Recurrent Suicide Attempt in Two Sisters with Non-segmental Vitiligo and Obesity: A Rare Case Report

According to our knowledge, the case reports about the Suicide behaviors in patients with vitiligo and obesity are rare. The chronic diseases like vitiligo and obesity are two risks factors that may have a synergistic effect for hopelessness and suicide ideation and attempt. The skin is the outer covering of the body and face, and the defects in skin can cause some psychological problems. Two sisters with vitiligo and obesity were referred to psychiatrist. They were depressed, hopeless and helpless with recent and previous history of suicide attempt. Psychiatrist started psychotherapy, counseling and pharmacotherapy, but, the therapeutic response was poor.


Introduction
Vitiligo is a chronic dermatological disorder that is characterized by depigmentation of skin and mucosa [1]. Vitiligo affects approximately 0.5-2% of the general population worldwide, and occurs in all races [2]. It is divided into two types of segmental vitiligo (SV) and nonsegmental vitiligo (NSV). Non-segmental vitiligo (NSV) is the most common type of vitiligo [3]. In non-segmental vitiligo, new white patches appear over time [4]. The clinical guidelines have represented that the major impact of vitiligo is the psychological problems of the disease [5]. It is reported that approximately one-third of patients with vitiligo suffer from psychological disorders as an outcome of the disease [2]. Owing to its chronic nature, unpredictable path of remissions and relapses, long term treatment and or no curable treatment, it's often disturbs the patient's quality of life in various aspects such as social activities, job, family relationships, and marriage [6].
The association between obesity and psychological disorders is a noteworthy public health problem. Both these status have main consequences for health care systems [7]. Weight and image concerns, weight-based teasing, and body uneasiness have been reported in suicidal individuals [8].
The psychological conditions of patients with vitiligo and obesity have often been investigated [9], but, according to our knowledge, the case reports about suicidality in individuals with vitiligo and disturbed weight status are rare. Therefore, in this case report, we describe two sisters with vitiligo and obesity, and recent and previous history of suicide attempt.

Case Presentation
We intend highlight the effects of dermatologic diseases and obesity on some psychological disturbances. Two young sisters were referred to psychiatrist because of suicide ideation, guilt feeling, hopelessness and depression. Two sisters were 34 and 23 years old, were unemployed, and their level of education was high school diploma. Their family socioeconomic level was below average. They were whitey and obese, and had beautiful faces. They felt disfiguration and difference with others. Both sisters had been diagnosed with nonsegmental vitiligo (NSV). The depigmentation was extended nearly in all of part of body with onset in late childhood about two sisters. The disease had expanded in adolescence, and had been more severe after love failure in marriage. The family discord and love failure were positive for both of them. Their parents were nice to them, but they persecuted by one of their brothers. Both of sisters were obese (81 and 76 kg, respectively). The both had impaired fasting glucose (IFG); Fasting plasma glucose levels in older sister and younger were 132 and 128, respectively. Their mother was a diabetic patient from 15 years ago. The history of suicide was negative about their family. The both had previous suicide attempt as drug poisoning be benzodiazepine drugs. The older sister had self-cutting on her forearm. The narcissistic personality traits were positive for both of them. They attempted for self-cutting and suicide attempt by drug poisoning. They were admitted in psychiatric service because of risk of suicide. The routine laboratory tests were normal (except fasting plasma glucose test). The beck anxiety, depression and suicide scale questionnaire showed high scores for these items for both patients. We started psychotherapy, counseling and pharmacotherapy. The therapeutic response was poor. Since the disease duration and severity of two sisters had been intensified, two sisters were severely affected psychologically and did not respond to psychological therapy and abandoned treatment process. Although, vitiligo was major risk factor for suicide, but obesity as a chronic disease with impaired fasting glucose had an additive effect for booster of suicide ideations. are reported to have depressive disorder, social phobia, high scores of anxiety, obsessive symptoms and hypochondria, impaired self-esteem, limited personal or sexual relationships, high rates of sleep disturbances, and suicidal ideation [9,11,12]. The key factors in this condition are how society interprets vitiligo, how vitiligo patients interpret themselves, and how they interpret and react to society attitude and behavior [5]. Psychological impacts of vitiligo may differ from person to person, depending on the natural color of skin, affected areas and severity of the disease. Factors such as female gender, being in adolescence or young adulthood, and low socioeconomic status negatively affect mental status of patients with vitiligo [13].The psychosocial problems of vitiligo are often more noteworthy for females, with negative effects specially on sexual relationships and marriage [5]. The chronic nature of disease, its unpredictable course, long term treatment and or nonexistence of uniform effective treatment are typically very demoralizing for patients with vitiligo. Vitiligo beginning in childhood can be correlated with important psychological disturbance that may have long lasting outcomes on the self-esteem of these children. Children affected by vitiligo are adapted with the disease well or be destroyed by it, often depending on attitude of the persons around them such as their parents, teachers, relatives, and friends [14]. Another important risk factor in women's negative attitude to the disease in some societies and cultures is that although vitiligo is a non-contagious disease but it can be grounds for divorce. For example, in India, women with vitiligo are often discriminated against in marriage; if it progresses after marriage, it can be legal grounds for the dissolution of marriage [10]. The first documented case study of psychodermatology disorder was found in 1155 AD, when the physician to the prince of Persia guessed that psoriasis of his patient was caused by the anxiety of young man about prospering his father to the throne [13]. In an Iranian study on some dermatologic diseases, it suggested that there is a close relationship between these disorders and psychological disturbances. The suicide ideation and attempt, and depression are more prevalent, significantly [15]. Suicide can occur because of various risk factors including psychological, biological, genetic, cultural, social, environmental and physiological [16]. Of all psychological morbidities threatening suicide, depression plays a key role. Because of chronic nature of dermatological diseases, their negative impacts on the self-image, losing hope of remission and their frequent relapses, they are considered as one of the most significant risk factors causing depression and suicidal behaviors [15].
The psychodermatological disorders should be treated by the liaison therapy; it is a multidisciplinary approach including cooperation of dermatologist, family physician, psychologist and psychiatrist. The collaboration of the dermatologist and a psychiatrist increase the life quality of the patients [12]. Psychological/counselling services should be offered to patients and their parents [5]. Patients with vitiligo have to cope with their skin disease [17]. Coping skills are vital protective factors against suicide behaviors. Religiosity and social support are other significant protective factors against suicide [18]. Some of the NGOs are active for the support of these patients worldwide. They offer a common platform for such patients to discuss their problems, to exchange opinions, to learn scientific information about the disease and to improve their self-image. Popular media like Films can also help to solving this problem. For example, the Marathi Film "Nital" depicted the life of a young woman with vitiligo and reflected the disturbance and contradiction related to the disease [19]. Therefore, a combination of the above processes will help to treat vitiligo and related psychiatric comorbidities.
The psychiatric disorders, particularly major depressive disorder, have also been connected to obesity. But, the evidence on the relationship between suicide and obesity has been very limited. Obese individuals commonly suffer from low self-esteem, depression, and related problems. Studies are typically reported that psychiatric disorders are more common in obese persons than in general population. Women are under higher societal stress than men to be thin. Obese females have reported higher levels of body image dissatisfaction than men. Consequently, it is not surprising that obesity has higher negative psychosocial impacts in women than in men [20].

Conclusion
Vitiligo and obesity are two risks factors that may have a synergistic effect for hopelessness and suicide attempt. The depression and suicide in patients with vitiligo is a serious concern that dermatologists should be aware and link with psychologists and psychiatrists in the beginning of this chronic and often progressive disease. Also, it is necessary a liaison-psychiatry service for dermatologic patients.