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Sufian Agwani, M.D.
Child and Adolescent Psychiatry Fellow
University of Toledo Medical Center

Theodor Rais, M.D.
Associate Professor
Child and Adolescent Psychiatry
University of Toledo Medical Center


A fifteen-year-old Caucasian male with no prior psychiatric hospitalization was referred to our inpatient adolescent unit because of depression and suicidal ideation.

The patient reported feeling depressed for 2 weeks, reportedly due to finding out that his friends were talking about him “behind his back” and saying he has changed. 2 days prior to this, patient’s girlfriend (via internet) indicated to the patient that she may break up with him. This news greatly increased his depression to the point of experiencing suicidal ideations but no definite plans.

On the day of his admission he posted a picture on “my space” of himself with a toy gun up to his head and sent it to more than 300 “friends,” expecting no reply because “people never pay any attention” to him. Someone who received this message called the police. Later he denied access to any real guns.

On further evaluation he admitted feeling hopeless and having poor self esteem. However he denied any neurovegetative symptoms. There was no history of any appetite change, weight loss or sleeping difficulties. He denied manic, hypomanic, psychotic symptoms or homicidal ideations. He also denied anxiety symptoms, substance use or any legal problems.

According to the parents, patient showed increased angry behavior for the past 6 months and was progressively more oppositional for the past year. The patient felt lonely, as he didn’t have any friends. He was always in conflict with his siblings and also stated his parents annoyed him and were “always yelling at” him. He stated that his oldest brother and younger sister always try to tell him “what to do.” His sister also disdained for and “bad-mouths” his girlfriend. The two had verbal altercations on the telephone. He said that he can’t “stand” his 18 year-old brother. Parents did not approve of his girlfriend because she dresses “Goth,” She was pulled out of school for fighting and she threatened the patients’ parents and sister. The parents tried to keep patient’s contact with his girlfriend only supervised by parents, but that was unsuccessful.

Patient had no prior psychiatric hospitalization or suicidal attempts but had history of psychiatric treatment. He was diagnosed with ADHD in 2nd grade and was treated by a pediatrician. Two years prior, he was switched from Ritalin to Concerta, for an unknown reason. Despite this switch, he continued to perform poor in school and grades continued to decline, as he showed no real efforts to improve.

The patient took part in family group therapy with a therapist pertaining to his oldest brother, who was diagnosed of Bipolar disorder.

I n terms of developmental history, patient’s mother was 37 at the time of his birth and smoked less than a pack of cigarettes per day during the pregnancy. The pregnancy, labor, and delivery were reportedly uncomplicated. The patient began walking and talking at age 1 and was toilet trained at age 3.

Beginning at ages 6-12 until the present, he exhibited poor attention and poor concentration. Beginning at age 13 until the present, he exhibited temper tantrums, aggression to others and property destruction.

He was in the 10th grade and attended regular classes. He was never been held back or suspended. School performance was poor. He didn’t work hard at school – he did a minimum amount of work as possible. The patient’s motivation appeared to be very low. He served only minor detentions for chewing gum. His behavior at school didn’t seem to be a major problem.

His family consisted of his biological parents, two brothers (21 and 18), and a younger sister (14). All lived together in the same house. There was no history of substance abuse. Interests and activities included music, Internet, and basketball. He was unemployed. No history of physical, sexual, or domestic abuse/violence to patient or witnessed by patient. No delinquency. Dating history included the girlfriend at the time of admission and he was not sexually active.

His support system consisted mainly of his parents, with whom he often has conflicts with and sees them as aggressive towards himself. Because his relationship with his siblings is relatively poor, they didn’t serve as an important supportive role. Patient felt that his siblings tend to bully him. He was close to his girlfriend and didn’t want her to break up with him.

Family history was positive for depression and bipolar disorder on maternal and paternal side. One brother had bipolar, the other brother and sister were diagnosed with ADHD. No family history of suicidal attempt.

Patient suffered from Psoriasis and refused treatment. He also had history of Asthma. Upon admission he was treated with Concerta, Acetaminophen and Zoloft.
Past meds included Ritalin.

On the mental status exam, the patient was 15 years old Caucasian male with very dark apparently dyed, black, long hair that often covered his eyes. He worn thick black bracelets, a black T-shirt, and had multiple psoriatic lesions on his forearms, face, and neck. The worst lesions are on his forehead, which he kept covered by his hair. Hygiene, nutrition, and grooming all seemed to be good for someone his age. He maintained very poor eye contact during the interview. He was cooperative, but somewhat guarded. His mood was sad. Affect was appropriate to content and flat. Speech was normal. He denied hallucinations. He had mild suicidal ideation at the time of interview but no plan and stated that he wasn’t going to kill himself at the time he posted the suicide note. There was no evidence of gross delusions, obsessions, thought insertion, or homicidal ideation. Thought process was linear and intact. Memory was intact. Oriented X 3. He was unwilling to participate or even try to spell WORLD backwards. Information and Intelligence appeared to be below average. Abstract thinking ability was concrete with similarities and interpretation proverbs may be limited by intelligence. Judgment was poor. Insight level was fair in some areas but limited in others.

On Medical assessment review of systems was negative except for psoriasis on face, arms and neck. His CBC and chemistry panel were within normal limits, with slightly increased monocyte (18.4). Urinalysis showed dark yellow, cloudy urine with a high specific gravity of 1.035, many mucous threads, occasional bacteria, 2-4 WBCs. He denies urgency, frequency, or dysuria. TSH was normal.


The differential diagnosis of this patient included depression, bipolar disorder, dysthymia, cyclothymia, schizophrenia, schizoaffective disorder, an anxiety disorder, and oppositional-defiant disorder or conduct disorder.

Because Bipolar disorder typically begins with an episode of major depression, it technically cannot be completely ruled out. However, the patient at the time didn’t exhibit symptoms of hypomania or mania. This also rules out cyclothymia. The patient didn’t have significant symptoms of dysthymia but he reports only being depressed for the past 2-3 weeks. A period of depression lasing 2 years is required for the diagnosis of dysthymia.

The patient didn’t have delusions or hallucinations, making the diagnosis of schizophrenia highly unlikely. Although some of the negative symptoms of schizophrenia may be present in this patient such as flattened affect, he didn’t show any disorganized speech or behavior. These symptoms are probably more a part of the neurovegetative symptoms of depression.

The patient never had a panic attack, didn’t experience severe trauma, and reported no phobias or generalized anxiety, which rules out all of the anxiety disorders.

The diagnosis of conduct disorder requires at least three acts within the past year including aggression, destruction of property, deceitfulness, or serious violation of rules. Although his parents indicated that his attitude has been angry and aggressive, he has not actually hurt anyone or destroyed property. Therefore conduct disorder would not be a proper diagnosis. A diagnosis of oppositional defiant disorder could be argued for in this case. This is indicated by negativistic, hostile, and defiant behavior for at least 6 months. The patient was said to have lost his temper, been in arguments with adults, and easily annoyed with anger. However, oppositional defiant disorder usually begins around the age of 8. These symptoms have been present in our patient only for the past 6 months. Also, depression in adolescents often takes the form of anger. This observation and the fact that he is suicidal make the diagnosis of depression more likely.




Axis I Attention Deficit Hyperactivity Disorder, Depression NOS.
Axis II Deferred
Axis III Psoriasis, History of Asthma
Axis IV Subjective feeling of poor social support: conflicts with parents and siblings, girlfriend recently threatening to break up with him, feeling that his friend no longer care for him.
Axis V GAF 30



Since the skin is the largest and most visible organ of the body, its integrity is vital for a well-developed positive self-image. Diseases of the skin tend to be unsightly, and often reduce a person’s self-confidence; adversely affect interpersonal relationships, and studies have shown that people with facial conditions are more at risk for depression with suicidal ideation. (1). Psoriasis is an example of a dermatologic condition that has been associated with psychological distress, morbidity and increased risk of suicidal ideation particularly in women (2).

Psoriasis is an autosomal dominantly transmitted disease with variable penetrance that arises in 1-3% of the population. Psoriasis usually begins in childhood and the first red scaling papules that combine to form plaques with silvery white scales. These plaques may bleed when removed (Auspitz’s sign) and cause pain and itching. The most common area for plaques to form are the elbows, knees, scalp, gluteal cleft, fingernails, toenails, and possible the genital area. Historically, the epidermis of a psoriatic patient contains a high number of mitoses, epidermal hyperplasia, and scales. In the dermis large and tortuous capillaries are seen near the surface, which imparts the erythematous appearance to these lesions.

Psychosomatic causes, particularly emotional distress, are also believed to play a role in precipitating psoriasis. However, there has been only modest validation of this theory in literature. Psychosomatic factors have been implicated with more evidence in the diffuse plaque type of psoriasis. Picardi et al, recently published a case-control study to investigate the role of stressful life events, social support, attachment, and alexithymia in precipitating exacerbations of diffuse plaque type of psoriasis. This study compared patients with diffuse plaque psoriasis with equally chosen patients with another skin condition. The patients were then evaluated for the above four parameters with standardized assessments. This study found that there was no an association between stressful life events and the exacerbation of psoriasis. However, it did find that psoriasis exacerbations were significantly associated with alexithymia, avoidance of emotional closeness and intimacy in attachment relationships, and poor perceived social support. There were two main limitations of this particular study. Only inpatients were studied and there were modest imbalance between socio-demographic factors between the two patient groups (3).

The findings in this study and the above patient do seem to be parallel. On questioning, the patient did not notice an exacerbation of his psoriasis during times of emotional stress, much like the patients in the study. In addition, one of the patient’s main complaints is his perception of having poor social support. The patient feels he has no real friends and that he is constantly at odds with other members of his family. He stated at one time that he feels there is no one he can talk to and no one pays attention to him. The threat of loss of his girlfriend, in addition to the perception of poor social support highly contributes to his insecurity, poor self-esteem, and consequently his depression. The finding of alexithymia and its relationship with psoriasis does not seem to be quite as important of an association in this case. Although he does seem somewhat limited in his ability to verbally express his emotions, it is unclear whether this is simply a nuance of a typical adolescent male or if it is true alexithymia. From speaking with the patient and available reports, the quality of fantasy life of the patient is unclear. In a related matter, the conclusion that poor intimacy in relationships is significant in patients with psoriasis is also less strong of a factor for the patient. Although his relationships with siblings, parents, and peers are reportedly quite weak, he does report closeness and an emotionally intimate relationship with his girlfriend. He states that he once “brought her out of her own depression.” The fact that the patient is so distraught over the possible loss of this person in his life exemplifies his perceived closeness to her and the vulnerability that comes from intimate relationships.

Picardi et al. also proposed a neruo-immuno-cutaneous-endocrine network explaining the connection of the mind to the body and skin. He states, “stress-induced release of neuroimmune substances, including neuropeptides, might adversely affect cutaneous homeostasis though activation of inflammatory processes in deeper skin layers’ (3). Stress can also influence the permeability of the epidermis, which allows for the continuance of inflammatory cytokines in the skin. Findings have also shown that stress may increase CD8+ T cells among psoriatic patients. Personality traits like hostility and a negative attitude have shown to cause an increase in cortisol and norepinephrine in response to stress, which may also affect skin. The patient in this case has been reported to have significant anger and hostility towards parents, siblings, and peers, so this may be a factor in his psoriasis and depression.

In conclusion, there is no cause and effect relationship between this patient’s psoriasis and his depression. However, studies have shown that certain personality traits, poor social support, and alexithymia are commonly found in patients with psoriasis – all of these factors may play a part in the patient’s depression.

It is also apparent that genetics most likely play a part in the patient’s condition. Numerous people in his family have mood disorders. A first degree relative, his eldest brother, carries a diagnosis of Bipolar. It has been determined in reliable studies that first-degree relatives of bipolar disorder are at increased likelihood of having either unipolar or bipolar disease.

There may be a structural component to his disorder as well; as previously stated, depressed patients have a high cortisol. Other endocrine abnormalities found in depressed patients include a blunted response of TSH to TRH stimulation and a blunted response of growth possibly a disturbance in the monoamine neurotransmitters (4). Most patients with depression show a decreased level of serotonin metabolites in the CSF, which would also correlate, with improvement of symptoms with selective serotonin reuptake inhibitors.

The psychological component of the patient’s depression has a cognitive component related to negative thinking and a misperception of events. When he heard that friends were talking about him, he automatically assumed that they no longer liked him. Interpersonal theories suggest that interpersonal losses are risk factors for depression. Although he has not list his girlfriend yet, the suggestion of losing her seemed to exacerbate his already depressed thoughts.

Psoriasis is prevalent in 2-3 % of general population and has the potential for significant psychological and social morbidity. It is therefore critically important to regularly assess and screen these patients for emotional problems to maximize Health related quality of life. (5), (6)


(1) Urpe, M., Pallani, S., & Torello, L., (2005) Factors in Dermatology.
Dermatologic Clinics, 23, 601-608

(2) Angelo Picardi, Eva Mazzotti, Paolo Pasquini, Prevalence and correlates of suicidal ideation among patients with skin disease, Journal of the American Academy of Dermatology - Volume 54, Issue 3 (March 2006)

(3) Picardi, A., Mazzotti, E., Gaetano, P., Cattaruzza, M.S., Balivia, G., Melchi, C.F., Biondi M., & Pasquini, P. (2005). Stress, Social Support, Emotional Requlation, and Exacerbation of Diffuse Plaque Posriasis. Psychosomatics, 46(6). 556-564

(4) Andreasen, N.C., & Black, D.W. (2006). Introductory Textbook of Psychiatry.
Washington, DC: American Psychiatric Publishing, Inc.

(5) Jochen Schmitt, Daniel E. Ford, Understanding the relationship between objective disease severity, psoriatic symptoms, illness-related stress, health-related quality of life and depressive symptoms in patients with psoriasis -- a structural equations modeling approach, General Hospital Psychiatry - Volume 29, Issue 2 (March 2007)

(6) Dónal G. Fortune, Helen L. Richards, Christopher E.M. Griffiths, Dermatologic Clinics - Volume 23, Issue 4 (October 2005)


First Published December 2008

Copyright Priory Lodge Education Ltd 2008

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