CONTENT

INTRODUCTION
ROLE OF STRESS AND ANXIETY IN PSYCHODERMATOLOGICAL CONDITION

VARIOUS PSYCHODERMATOLOGICAL CONDITIONS

Psychophysiologic (psychosomatic) disorders

 Atopic dermatitis.
 Urticaria.
 Acne Excoriee.
 Herpes Simplex Virus.
Primary psychiatric disorders
 Trichotillomania.
 Obsessive-compulsive disorder.
 Dermatitis artifacta.
 Psychogenic excoriation.
 Neurotic Excoriations.
 Delusions of parasitosis.
 Dysmorphophobia.
 Psychogenic pruritus.
Secondary psychiatric disorders
 Psoriasis.
 Alopecia areata.
 Vitiligo.
Miscellaneous
 Cutaneous Sensory Syndromes.
 Psychogenic Purpura Syndrome.
 Pseudopsychodermatologic Disease.

 Suicide in Dermatology Patients.

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BIOPSYCHOLOGICAL MODEL OF ITCH
PSYCHOLOGICAL INTERVENTIONS

 Cognitive-behavioral Therapy
 Behavior Therapy
 Group therapy
 Muscle Relaxation
 Hypnosis
 Biofeedback
 Meditation
CONCLUSION
REFERENCES

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 DERMATOLOGY

INTRODUCTION
As an easily noticed and touched organ, the skin has a special place in psychiatry. With its
responsiveness to emotional stimuli and ability to express emotions such as anger, fear, shame,
and frustration, and by providing self-image and self-esteem, the skin plays an important role in
the socialization process, which continues from childhood to adulthood (Domonkos, 1971;
Koblenzer, 1983). Psychodermatology describes an interaction between dermatology and
psychiatry and psychology. A relationship between psychological factors and skin diseases has
long been hypothesized. Psycho dermatology addresses the interaction between mind and skin
Psychiatry is more focused on the ‘internal’ non-visible disease, and dermatology is focused on
the ‘external’ visible disease..

ROLE OF STRESS AND ANXIETY IN PSYCHODERMATOLOGICAL CONDITION

Stress and other psychological factors trigger the formation and exacerbation of many
dermatological diseases (Van Moffaert, 1992; Koo and Pham, 1992). Every person has a shock
organ that is sensitive to stress, which is defined by environmental and genetic factors, and this
shock organ is the skin in people who display dermatological symptoms under stress. Panconesi
suggested naming dermatological diseases that are activated and whose symptoms are
exacerbated by emotional stressors a “dermatological stress disorders” (2000).
There is much research on the role of stress in dermatological diseases, and they are categorized
as:

I. Environmental factors that cause stress;

II. Subjective experiences towards specific situations
III. Biological responses to stress (Cohen, 1995)
Studies define stress along three general categories: 1) Major stressful life events (e.g., change of
employment, major personal illness and financial problems) 2) Psychological or personality difficulties,
and 3) Lack of social support.

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Research has shown that the subjective experience of stress is more important than the actual
stress and the conditions that cause stress. Stress is the first reason that comes to mind, excluding
in the formation of gastrointestinal ulcers and various studies has shown that gastrointestinal
ulcers and hemorrhages occur more frequently in situations that cause social stress, such as
earthquakes and economic crises. This can be explained by the decrease in regional blood flow
and increase in gastric acid secretion following stress (Levenstein, 1999). In the same way, in a
controlled study with 1500 people following the great earthquake in Japan Kodama found that
atopic eczema had increased when compared with normal controls (1999).
Biological responses to stress vary from person to person; vasoactive peptides, lymphokines, and
chemical mediators are secreted after stress and inflammation develops as a result of their
influence on the immune system.
Stress sets off several physiological reactions in the body that can affect the skin. It causes the
release of hormones like cortisol that thicken hair follicle cells and increase oil production—the
perfect recipe for acne. Stress can also trigger neuropeptide, chemicals unleashed from nerve
endings in the skin that leave it red or itchy, and encourage T cells (the skin's infection fighters)
to overreact, making the skin turn over too quickly and flake or scale. Then there are the blood
vessels: Under stress they become more reactive, either clamping shut (so skin looks pale or
sallow) or opening too widely (causing the skin to flush).

Stress, emotional trauma, bereavement, divorce, redundancy, depression – all these have a
psychological effect on the brain and the nervous system which, in turn, affects the skin.
Actually having a chronic skin condition like eczema or psoriasis can, in itself, create
psychological fluctuations via anxiety and depression which can make the skin condition worse.
An estimated 20 per cent of psoriasis sufferers also have depression. During periods of anxiety or
stress, the adrenal gland produces more of a hormone called cortisol, which affects the body’s
immune system. This in turn can cause the skin’s own defenses to either weaken, as in the case
of eczema, or go into overdrive, as in the case of psoriasis. There is growing scientific evidence
to prove that psychology and skin conditions are directly linked-

-A study published in the British Journal of Dermatology found that almost 40 cent of psoriasis
sufferers recalled stressful events in the month before their condition got noticeably worse,
though in some cases it could take just two days to bring on an attack.

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- A study in the “The International Society of Dermatology” found that people with psoriasis
reported a lower quality of life and higher than normal stress levels.

- A study in the American Journal of Pathology. Researchers found that the immune cells in skin
can over-react when levels of stress rise, resulting in inflammatory skin diseases.
Psycho dermatology is divided into three categories according to the relationship between skin
diseases and mental disorders.
VARIOUS PSYCHODERMATOLOGICAL CONDITIONS AND ROLE OF
STRESS AND ANXIETY IN PSYCHO DERMATOLOGICAL CONDITION

PSYCHOPHYSIOLOGIC (PSYCHOSOMATIC) DISORDERS

Caused by skin diseases triggering different emotional states (stress), but not directly combined
with mental disorders (psoriasis, eczema).
Here psychiatric factors are instrumental in the etiology and course of skin conditions. The skin
disease is not caused by stress but appears to be precipitated or exacerbated by stress.

 Atopic dermatitis

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The onset or exacerbation of atopic dermatitis often follows stressful life events. Symptom
severity has been attributed to interpersonal and family stress, and problems in psychosocial
adjustment and low self-esteem have been frequently noted. Adults with atopic dermatitis are
more anxious and depressed compared with clinical and healthy control groups. Children with
atopic dermatitis have higher levels of emotional distress and more behavioral problems than
healthy children or children with minor skin problems.
Psychosocial morbidity in atopic dermatitis
Psychological stress may be an acquired factor affecting the expression of atopic dermatitis.
Atopic individuals with emotional problems may develop a vicious cycle between
anxiety/depression and dermatologic symptoms. In one direction, anxiety and depression are
frequent consequences of the skin disorder. The misery of living with atopic dermatitis may have
a profoundly negative effect on health-related quality of life (HRQOL) of children and their
families. Teasing and bullying by children and embarrassment by adults and children can cause
social isolation and school avoidance. The social stigma of a visible skin disease, frequent visits
to doctors and the need to constantly apply messy topical remedies all add to the burden of
disease. Lifestyle restrictions in more severe cases can be significant, including limitations on
clothing, staying with friends, owning pets, swimming or playing sports. The impairment of
quality of life caused by childhood atopic dermatitis has been shown to be greater than or equal
to that of asthma or diabetes.
 Urticaria
Severe emotional stress may exacerbate preexisting urticaria. Increased emotional tension,
fatigue, and stressful life situations may be primary factors in more than 20% of cases and are
contributory in 68% of patients. Difficulties with expression of anger and a need for approvals
from others are also common. Patients with this disorder may have symptoms of depression and
anxiety, and the severity of pruritus appears to increase as the severity of depression increases.
Cold urticaria may be associated with hypomania during winter and recurrent idiopathic urticaria
with panic disorder.
While the etiology is unknown in 79% of urticaria patients, it is also known that psychological
factors have a direct effect on the development of the disease in 11%-21% of the patients and
plays a facilitating role in 24%-68% (Champion, 1969; Michealsson, 1969). Whatever the reason
is, severe emotional stress exacerbates urticaria and traumatic events such as earthquakes may

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cause the disease (Arnold, 1990, Stewart, 1989). While 51% of urticaria cases begin with
stressful life events, this percentage is 77% in cholinergic urticaria and 82% in dermographism
(Czubalski, 1977). Depression is also frequent in these patients and it was reported that as the
severity of depression increases, scratching of urticaria plaques increases (Gupta, 1994). When
personality type and disease are matched, it was reported that these patients can not express their
anger and hostility sufficiently and that they seek approval from others (Juhlin, 1981). While
Unal et al. (1991) reported that, anxiety and depression are three times more frequent in chronic
urticaria patients than the general population.
Acne Excoriee
The habitual act of picking at skin lesions, apparently driven by compulsion and psychological
factors independent of acne severity, has been reported in the perpetuation of self-
excoriation. Most patients with this disease are females with late onset acne. Psychiatric co
morbidity of acne excoriee includes body image disorder, depression, anxiety, obsessive-
compulsive disorder (OCD), delusional disorders, personality disorders, and social phobias.
Immature coping mechanisms and low self-esteem have also been associated.

Herpes Simplex Virus, Herpes Zoster, and Human Papillomavirus Infections

There is increasing evidence that stress has a role in recurrent herpetic infection. In one
study, experimentally induced emotional stress led to herpes simplex virus reactivation. Other
studies have demonstrated an inverse correlation between stress level and present CD4 helper/
inducer T lymphocytes, thus contributing to herpes virus activation and recurrences. It has also
been suggested that stress-induced release of immunomodulating signal molecules (e.g.,
catecholamine, cytokines, and glucocorticoids) compromises the host's cellular immune response
leading to reactivation of herpes simplex virus. Relaxation treatment and biofeedback may
reduce the frequency of recurrences. Herpes zoster has been associated with chronic child abuse,
and severe psychological stress of any sort may depress cell-mediated immune response.
PRIMARY PSYCHIATRIC DISORDERS RESPONSIBLE FOR SELF-INDUCED SKIN
DISORDERS.
Primary psychiatric disorders are encountered less often than psycho physiologic disorders.
These disorders have received little emphasis in the psychiatry or dermatology literature, even
though they may be associated with suicide and unnecessary surgical procedures. Most of these

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disorders occur in the context of somatoform disorder, anxiety disorder, factitious disorder,
impulse-control disorder or eating disorder.
 Trichotillomania (The pulling out of one’s own hair)
In dermatological terms, trichotillomania is the pulling out of one’s own hair; in terms of a
psychiatric definition, impulsiveness accompanies the hair pulling behavior (Stein, 1995). It was
reported that in trichotillomania patients, a severe distress forms immediately before the hair
pulling behavior and distress decreases, while pleasure and satisfaction is felt afterwards.
Generally, hair on the forehand and temporal regions, eyebrows, eyelashes, beard, and pubic
hairs are pulled, and these may then be sucked on and swallowed (Gupta, 1987). It was
categorized among not otherwise defined impulse control disorders in DSM IV; the etiology of
trichotillomania is accepted to be variable and it is known that the rate of comorbidity with other
diseases is high, the most frequent being obsessive-compulsive disorder, and sometimes it may
not meet DSM - IV criteria (Mc Elroy, 1994). Among other causes of Trichotillomania are
simple habit, reaction to stress, mental retardation, depression, anxiety, and delusions in rare
cases. Childhood trauma and emotional neglect may play a role in the development of this
disorder. In delusional cases, patients believe that there is something in the hair root, and when
pulled out, it will disappear and normal hair will grow. This rare condition is called trichophobia.
The identification of the underlying etiology and designing the treatment accordingly is essential.
Trichotillomania is one of the rare dermatological diseases that show diagnostic symptoms in the
histopathological examination of the skin. This change is called trichomalacia and is only
observed in Trichotillomania patients (Lachapelle, 1977). Forty-three percent of the cases deny
that they pull out their hair and with his to pathological examination the correct diagnosis can be
made in these cases (Cristenson, 1991).

 Obsessive-compulsive disorder

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Patients usually present to dermatologists because of skin lesions resulting from scratching,
picking, and other self injurious behaviors. They typically have an increased level of psychiatric
symptomatology compared with age and sex matched controls taken from the general population
of dermatology patients, and many patients experience negative stigmatization in their daily life.
Common behaviors include compulsive pulling of scalp, eyebrow, or eyelash hair; biting of the
nails and lips, tongue and cheeks; and excessive hand washing. It has been found that OCD in
child and adolescent dermatology patients most commonly presents as trichotillomania,
onychotillomania and acne excoriée.
 Dermatitis artifacta (Factitial dermatitis)
Artifact dermatitis are the lesions entirely by the actions of the fully aware patient on the skin,
hair, nails or mucosa caused by the patient using nails, the butt of a cigarette, sharp objects, or
chemicals (Gupta, 1987a; Fabish, 1980), no rational motive for this behavior. Although patients
deny it. Lesions separate from the surrounding normal tissue with exact geometrical borders and
may replicate many skin disorders. Severe personality disorders, obsessive-compulsive disorder,
depression, psychosis, mental retardation, and Munchausen’s syndrome are among the
psychiatric disorders that accompany artifact dermatitis (Gupta, 1993a; Stein, 1992). As these
patients cannot control their self-images and moods, they have difficulty in maintaining
interpersonal relationships. They engage in self-mutilating behavior with feelings of emptiness
and anger. These lesions are a cry for help in response to the stress associated with undeveloped
coping mechanisms. It was reported that the rate of manifestation of the lesions after situations
that cause severe stress, such as illness, accident, and bereavement, was 19%-33%, and that the
lesions regress as the stressful situation disappears (Sneddon, 1975). In addition to mutilating
their skin, suicidal tendency, substance use, or compulsive eating are frequent in borderline
personality disorder patients.
Diagnosis: The peculiar looks of the lesions and the fact that patients cannot explain how they
were formed make the diagnosis easy (Hollender, 1973). Direct confrontation of the patient is
not suggested (Spraker, 1983). Early diagnosis can prevent the illness from becoming chronic.
This is an artifactual skin disease caused The condition is more common in women than in men
(3 : 1 to 20 : 1). The lesions are usually bilaterally symmetrical, within easy reach of the
dominant hand, and may have bizarre shapes with sharp geometrical or angular borders, or they
may be in the form of burn scars, purpura, blisters and ulcers. Erythema and edema may be

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present. Patients may induce lesions by rubbing, scratching, picking, cutting, punching, sucking
or biting or by applying dyes, heat or caustics. Some patients inject substances, including feces
and blood. Reported associated conditions include OCD, borderline personality disorder,
depression, psychosis and mental retardation. And most of the patients with factitious dermatitis
have some sort of personality disorder and they often use some means to damage his or her own
skin, such as burning cigarettes, chemicals or sharp instruments.

 Psychogenic excoriation
Psychogenic excoriation occurs in 2% of dermatology patients mostly in women. It is an
uncommon psycho dermatological condition, which responds well to serotonin reuptake
inhibitors and behavioral therapy. It is characterized by excessive scratching or picking of the
skin. The lesions are usually found on face, upper limbs and upper back. It is a chronic disorder
with a high rate of psychiatric co morbidity. Major depressive syndrome was the most common
psychiatric disorder found in the PE group.

 Neurotic Excoriations

As per DSM-IV-TR classification an impulse-control disorder not otherwise specified, neurotic

excoriations are self-inflicted lesions that typically present as weeping, crusted, or lichenified
lesions with postinflammatory hypopigmentation or hyperpigmentation. The preferred term for
this disorder is pathologic skin picking. Usual sites are the extensor aspects of extremities,
scrotum, and perianal regions. Repetitive scratching, initiated by an itch or an urge to excoriate a
benign skin lesion, produces lesions. The behaviors of these patients sometimes resemble those
with OCD.

 Delusions of parasitosis ( Ekbom’s syndrome)

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The most common form of monosymptomatic hypochondriacal psychosis encountered among
patients with skin problems is called delusions of parasitosis. Delusional parasitosis is a
syndrome in which the patient has the false belief that he is infested by parasites or organism;
and they often elaborate on how these organisms reproduce, move and spread under their skin or
even exit the skin. It may occur as the sole psychologic disturbance, or it may be associated with
an underlying psychiatric disorder or physical illness. The psychiatric differential diagnosis
include schizophrenia, psychotic depression, psychosis in patients with florid mania or drug-
induced psychosis, and formication without delusion, in which the patient experiences crawling,
biting and stinging sensations without believing that they are caused by organisms. Patients with
delusion of parasitosis often present with the matchbox sign, in which small bits of excoriated
skin, debris or unrelated insects or insect parts are brought in matchboxes or other containers as a
proof of infestation.

 Dysmorphophobia
This condition is also called body dysmorphic disorder or dermatological non-disease. Patients
with this condition are rich in symptoms but poor in signs of organic disease. Self-reported
‘complaints’ or ‘concerns’ usually occur in three main areas: Face, scalp and genitals. Facial
symptoms include excessive redness, blushing, scarring, large pores, facial hair and protruding or
sunken parts of face. Other symptoms are hair loss, red scrotum, urethral discharge and herpes
and AIDS phobia. Strategies to relieve the anxiety due to the perceived defects may include
camouflaging the lesions, mirror checking, comparison of ‘defects’ with the same body parts on
others, questioning/ reassurance seeking, mirror avoidance and grooming to cover up ‘defects’.
Women are more likely than men to be preoccupied with the appearance of their hips or their

11
weight, to pick their skin, to camouflage defects with makeup and to have comorbid bulimia
nervosa. Men are more likely than women to be preoccupied with body build, genitals and hair
thinning and to be unmarried and to abuse alcohol. Patients with body image disorders,
especially those involving the face, may be suicidal. Associated comorbidity in
dysmorphophobia may include depression, impairment in social and occupational functioning,
social phobias, OCD, skin picking, marital difficulties and substance abuse.
Psychogenic pruritus
In this disorder, there are cycles of stress leading to pruritus as well as of the pruritus
contributing to stress. Psychologic stress and comorbid psychiatric conditions may lower the itch
threshold or aggravate itch sensitivity. Stress liberates histamine, vasoactive neuropeptide and
mediators of inflammation, while stress-related hemodynamic changes (e.g., variation in skin
temperature, blood flow and sweat response) may all contribute to the itch-scratch-itch cycle.
Psychogenic pruritus has been noted in patients with depression, anxiety, aggression, obsessional
behavior and alcoholism. The degree of depression may correlate with pruritus severity.
SECONDARY PSYCHIATRIC DISORDERS CAUSED BY DISFIGURING SKIN
Ichthyosis, acne conglobata, vitiligo, which can lead to states of fear, depression or suicidal
thoughts.
This category includes patients who have emotional problems as a result of having skin disease.
The skin disease in these patients may be more severe than the psychiatric symptoms, and, even
if not life-threatening, it may be considered ‘life-ruining’. Symptoms of depression and anxiety,
work-related problems and impaired social interactions are frequently observed.
 Psoriasis
Stress has long been reported to trigger psoriasis. Psoriasis is associated with a variety of
psychological difficulties, including poor self-esteem, sexual dysfunction, anxiety, depression
and suicidal ideation. Psoriasis is associated with substantial impairment of health-related quality
of life (HRQOL), negatively impacting psychological, vocational, social and physical
functioning. The most common psychiatric symptoms attributed to psoriasis include disturbances
in body image and impairment in social and occupational functioning. Quality of life may be
severely affected by the chronicity and visibility of psoriasis as well as by the need for lifelong
treatment.
Five dimensions of the stigma associated with psoriasis have been identified:

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(1) Anticipation of rejection
(2) Feelings of being flawed
(3) Sensitivity to the attitudes of society
(4) Guilt and shame
(5) Secretiveness.
Depressive symptoms and suicidal ideation was frequently associated in psoriasis. In general,
psychological factors, including perceived health, perceptions of stigmatization and depression
are stronger determinants of disability in patients with psoriasis than are disease severity,
location and duration. In a recent prospective study of patients with psoriasis, the frequency of
psychiatric disturbance decreased with improvement in the clinical severity and symptoms of
psoriasis. The emotional effects and functional impact of the disease are not necessarily
proportionate to the clinical severity of psoriasis.
 Alopecia areata
The role of psychological factors in the pathogenesis of alopecia areata (AA) has long been the
subject of debate. The influence of psychologic factors in the development, evolution and
therapeutic management of alopecia areata is well established. Acute emotional stress may
precipitate alopecia areata, perhaps by activation of over expressed type 2b corticotrophin-
releasing hormone receptors around the hair follicles, and lead to intense local inflammation.
Release of substance P from peripheral nerves in response to stress has also been reported, and
prominent substance P expression is observed in nerves surrounding hair follicles in alopecia
areata patients. Substance P degrading enzyme neutral endopeptidase has also been strongly
expressed in affected hair follicles in the acute-progressive as well as the chronic-stable phase of
the disorder. Comorbid psychiatric disorders are also common and include major depression,
generalized anxiety disorder, phobic states and paranoid disorder.
 Vitiligo
Vitiligo is a specific type of leukoderma characterized by depigmentation of the epidermis. In
some studies, patients with vitiligo have been found to have significantly more stressful life
events compared with controls, suggesting that psychologic distress may contribute to onset.
Links between catecholamine-based stress, genetic susceptibility and a characteristic personality
structure have been postulated. Psychiatric morbidity is typically reported in approximately one-
third of patients, but, in one study, 56% of the sample had adjustment disorder and 29% had

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depressive disorders. Patients with vitiligo are frightened and embarrassed about their
appearance, and they experience discrimination and often believe that they do not receive
adequate support from providers. Younger patients and individuals in lower socioeconomic
groups show poor adjustment, low self-esteem and problems with social adaptation. Most
patients with vitiligo report a negative impact on sexual relationships and cite embarrassment as
the cause.

MISCELLANEOUS

This group includes disorders or symptoms that are not otherwise classified.

Cutaneous Sensory Syndromes

Patients with these syndromes experience abnormal skin sensations (e.g., itching, burning,
stinging, and biting or crawling) that cannot be attributed to any known medical condition.
Examples include glossodynia, vulvodynia, and chronic itching in the scalp. These patients often
have concomitant anxiety disorder or depression.

 Psychogenic Purpura Syndrome

This condition, also known as auto erythrocyte sensitization syndrome (Gardner-Diamond

syndrome), is seen primarily in emotionally unstable adult females. These patients present with
bizarre, painful, recurrent bruises on extremities, frequently after trauma, surgery, or severe
emotional stress. The exact mechanism is unclear; however, hypersensitivity to extravasated red
cells, autoimmune mechanisms, and increased cutaneous fibrinolytic activity has been implicated
in the pathogenesis. These patients may have overt depression, sexual problems, and feelings of
hostility, obsessive-compulsive behavior, borderline personality disorder, and factitious
dermatitis. Without a correct diagnosis, these individuals can receive treatments that are neither
necessary nor effective. The diagnosis can be made in a patient who has atypical history and
clinical picture of the syndrome and in whom a skin test with use of the patient's blood reveals a
positive reaction.

 Pseudopsychodermatologic Disease

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These patients may have bizarre skin symptoms without obvious physical findings or a
subclinical skin disease that has been eradicated or modified by scratching. Psychodermatologic
disease can mimic other skin disorders, and medical disorders can mimic psycho dermatologic
conditions. Localized bullous pemphigoid lesions, for example, have been mistaken for
dermatitis artefacta; multiple sclerosis, folliculitis, hypothyroidism, and vitamin B12 deficiency
have been initially diagnosed as delusions of parasitosis.

Suicide in Dermatology Patients

Suicide has been reported in patients with longstanding debilitating skin diseases and must be
considered when evaluating these patients. Even clinically mild to moderate severity skin disease
may be associated with significant depression and suicidal ideation. Cotterill and Cunliffe
reported suicides in 16 patients (7 men and 9 women) with body image disorder or severe acne.

Itch is a major feature of many skin diseases, which adversely affects patient’s quality of life.
Besides disease severity, psycho physiological factors have been proposed to influence the itch
sensation. Ex: atopic dermatitis, contact dermatitis, urticaria and psoriasis
Apart from the severity other factors have also been proposed to influence itch intensity such as
sweating, skin dryness, or physical effort, psychological factors have regularly been described to
influence itch intensity.
One of the most striking examples of the influence of psychological factors on itch came from
the observation that itch (and the scratching response) could be aggravated by showing
individuals itch-related pictures of fleas, mites, scratch marks, allergic reactions, etc. high among
patients suffering from itch and that negative emotions can increase the level of itch.
Biopsychosocial factors can best be shown in a diathesis-stress model, which is based on the
hypothesis that internal vulnerability factors (diathesis), such as personality, interact with
external environmental factors (such as major life events and other stressors) to trigger a disease
or itch.

BIOPSYCHOLOGICAL MODEL OF ITCH

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Internal Mediating factors
factors
-personality -cognitive factors
Helplessness
Worrying Physiological ITCH
factors
-behavioral factors
External Scratching
factors Avoidance behavior
-stressors
-social factors
Perceived support
Social network

TREATMENT

PSYCHOLOGICAL INTERVENTIONS OF PSYCHO DERMATOLOGICAL

CONDITION

Nonpharmacologic management of psycho dermatologic conditions includes both structured and

unstructured interventions that may ameliorate skin disorders, reduce psychological distress, and
improve the functional status of the affected individual. Many approaches are available.
Cognitive behavioral psychotherapy, behavior modification, insight-oriented psychotherapy,
family therapy, and supportive psychotherapy are common interventions used for dermatologic
disorders; it can be accomplished in a one-to-one relationship setting or can be carried out in a
group setting. Psychotherapeutic interventions have demonstrated improvements in eczema,
psoriasis, neurotic excoriation, BDD, and trichotillomania.
Cognitive-behavioral Therapy

Cognitive–behavior therapy (CBT) is a treatment approach that aims to change maladaptive

ways of thinking, feeling and behaving through the use of cognitive and behavioral interventions.
This model takes the view that it is not situations in and of themselves that are stressful, but
rather the perception that one takes of them that makes them so. According to the cognitive
model, the beliefs that patients hold about their condition often influence how they cope with and
adapt to it. A common feature in the beliefs of people with emotional difficulties is that they

16
have negative and irrational content. These perceptions are often the result of distortions in
processing, such as ‘cognitive errors’ (Beck, 1976, 1993).

CBT focuses on examining and trying to challenge dysfunctional beliefs and appraisals which
may be implicated in a person’s low mood or avoidance of certain situations or behaviors’.
Consequently, targeting cognitions and maladaptive behavior are the key areas of CBT
interventions for facilitating change. According to this approach, beliefs are considered as
hypotheses to be tested rather than assertions to be uncritically accepted. Therapist and client
take the role of ‘investigators ‘and develop ways to test beliefs, such as ‘Others do not like me
because of my eczema’ or ‘I won’t be happy anymore because of my vitiligo’. Success at
challenging these beliefs involves providing evidence that they are erroneous, and underscored
by anxiety and depression (Beck, 1993).

CBT has been successfully applied to various skin conditions. For example, Horne et al. (1989)
used cognitive–behavioral therapy along with standard medical treatment in treating three
patients suffering with atopic eczema. All three showed a post-treatment reduction in symptom
severity, an increase in their ability to control the disorder and a decrease in their reliance on
medication. Four controlled studies have also used a cognitive–behavioral approach with
psoriasis patients (Price et al., 1991; Zacharie et al., 1996; Fortune et al., 2002; Fortune et al.,
2004). Findings have shown adjunctive cognitive–behavioral interventions result in a reduction
of psychological distress and in the clinical severity of the condition. Additionally, Papadopoulos
et al. (1999) compared two matched groups of vitiligo patients, one of which received CBT
while the other received standard medical treatment alone. Results suggested that patients could
benefit from CBT in terms of coping and living with vitiligo. There was also preliminary
evidence to suggest that gains made through CBT influences the progression of the condition.
Finally, Ehlers et al. (1995) employed CBT with patients with atopic dermatitis and found
significant reductions in anxiety, frequency of scratching and itching as well as cortisone use.

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 Behavior Therapy

Behavior therapy incorporates applications derived from learning theory (classical and
operant conditioning) and employs them to the treatment of persistent, maladaptive, learned
habits. It is based on the assumption that since autonomic responses can be learned, they can also
be unlearned via different methods. Among behavior therapy techniques are systematic
desensitisation, assertiveness and social skills training, behavior analysis, relaxation training (e.g.
autogenic and progressive muscle relaxation, biofeedback) habit-reversal training and imagery.
The aim of these techniques is to progressively diminish maladaptive behavioural responses by
repeatedly inhibiting the anxiety by means of competing responses (Wolpe, 1980). A behavior
analysis is conducted where the clinician collects information about the relationship between
stimuli and behavioral responses in order to understand the role of anxiety.

Diverse behavioral therapeutic strategies have been applied, either separately or in combination
with other psychological techniques to dermatological conditions.

Systematic desensitisation is an appropriate technique for the treatment of dermatoses which

feature anticipatory anxiety (Van Moffaert, 1992). The fear and apprehension that patients
with skin disease may feel about them may be challenged by this technique. Through graded
exposure, the patient enters situations that they may fear and avoid. The habit- reversal
technique is a common strategy used to inhibit scratching and it has been reported to have some
success with skin disorders, such as eczema and psoriasis (Ginsburg, 1995). It involves self
monitoring for early signs and situational cues of scratching and practicing alternative responses,
such as clenching the fists (Ehlers et al., 1995). Relaxation has beneficial effects on skin
disorders because it reduces stress levels. It is a useful way to help patients prepare for anxiety-
provoking situations or to cope with stressful social predicaments. Relaxation can be used on its
own as a means to reduce anxiety or tension or can be paired with imagery. There are various
different techniques, such as progressive muscle relaxation or autogenic relaxation training.
Imagery with skin disease patients is employed in order to help them cope with anxiety relating
to their condition. Imagery is a useful technique for helping the patient to visualise the feared
situation while in a relaxed state (Papadopoulos & Bor, 1999). Assertiveness and social skills
training is appropriate for patients with cutaneous conditions that attract attention from others,
such as staring or personal questions. Interventions focus on improving social skills and ways of

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expressing emotions, thus helping patients deal more effectively with the reactions of others and
learn a more positive mode of social functioning (Robinson et al., 1996).
Many techniques used for stress management program: self observation, relaxation
training, time management and problem-solving etc.

Self-Observation:

A daily diary format is used, with patients being asked to keep a record of how they
responded to challenging or stressful events that occurred each day. A particular stress
(e.g. argument with spouse) may precipitate a sign or symptom (e.g. pain in the neck).

Behavioral modifications include identifying triggers that lead to maladaptive behavior ex: hair
pulling behavior,scratching along with replacing the behavior with a competing activity such as
clenching fists or pulling on a Koosh Ball

Magnet stones (magnetite’s) to reduce tension

Self-monitoring: This involves systematically observing and discriminating when the behavior
occurs, recording the responses, and evaluating one’s own behavior.

Habit reversal: This is a set of procedures taught to a child that includes the following
components: increasing awareness of the habit; teaching a competing response to practice when
the child feels the urge to engage in the habit, in situations where the habit historically occurs or
for 1 minute after the occurrence of the habit; practicing stress and anxiety reduction procedures
on a daily basis; and support and encouragement from parents.

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Competing reaction training: This is a component of habit reversal that is occasionally used
alone; a child is taught a socially appropriate alternative behavior or response and encouraged to
practice it on a daily basis when they feel the urge to engage in the habit, in situations where the
habit historically occurs or for 1 minute after the occurrence of the habit

Group therapy
Understanding and addressing social factors can be extremely helpful for patients and their
families coping with skin disease. For example, atopic dermatitis can result in diminished quality
of life. Providing education regarding the etiology and pathogenesis of atopic dermatitis as well
as realistic expectations can improve adherence to treatment regimens while simultaneously
addressing the anxiety, frustration, shame, and depression that is frequently associated with the
disease.16 Weber et al demonstrated improvement of pruritus (decreased frequency of pruritus)
and improved quality of life (both leisure and personal relationships). Group therapy is a mode of
intervention that helps individuals with a common problem enhance their social functioning
though group exercises. Group members are given the opportunity to share their experiences,
feelings and difficulties in a safe atmosphere under the auspices of a group facilitator. Using a
combination of instruction, modeling, role-play, feedback and open discussion, members of the
group are encouraged to discover more about the interaction process. In most cases 6–12 clients
meet with their therapist at least once a week for about 2 hours. Usually groups are organized
around one type of problem (such as coping) or type of client (such as psoriasis patients).
Through group interaction, ineffective and immature ways of coping are discouraged, positive
attitudes are fostered and feelings, such as loneliness and isolation, that many patients
experience, diminish. Moreover, group members can bolster one another’ self-confidence and
self-acceptance, as they come to trust and value one another, and develop group cohesiveness.
Group therapy allows participants to try out new skills in a supportive environment and
members learn from one another. Thus this offers features not found in individual treatment.
Various approaches, such as social skills training to group therapy have been tried with patients
with skin disorders (Robinson et al., 1996). Patients with chronic skin conditions, such as
psoriasis or eczema are known to benefit from group therapy and such therapy has increased
their confidence in coping with them disease (Ehlers et al., 1995; Seng & Nee, 1997; Fortune et
al., 2002).

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 Muscle Relaxation

Numerous guided imagery and progressive relaxation programs are available. Their goal is to
reducing muscle and psychic tension and producing pleasant images and sensations.
Physiologically, the techniques are effective in reducing sympathetic reactivity and enhancing
parasympathetic activity. Relaxation therapy has been used to treat acne, acne excoriée,
psoriasis, eczema, hyperhidrosis, and neurotic excoriations. Edmund Jacobson in 1938 developed
a method called progressive muscle relaxation Patients were taught to relax muscle groups, such
as those involved in “tension headaches” When they encountered and were aware of situations
that caused tension in their muscles, the patients were trained to relax. A recent study has
confirmed a long-held belief that acne worsens under stress. Therefore, regular practice of a
stress management technique may decrease the occurrence and severity of acne.
Hypnosis

Early researchers in Psychodermatology experimented with the use of hypnosis (Van Moffaert,
1992).Hypnosis brings about changes in physiological parameters, such as skin conductance,
skin temperature and vasomotor reactions all of which can be decisive in the etiology of skin
diseases (Van Moffaert, 1992). Neurodermatitis, chronic urticaria and viral warts are skin
diseases with which hypnosis has been successfully used (Barber, 1978). Hypnotic techniques
and the trance state have been used since ancient times to assist in healing.. Hypnosis has proved
beneficial for some patients with eczema, alopecia areata, hyperhidrosis, verruca, urticaria,
rosacea, lichen planus, pain syndromes, and vitiligo. Benefits in reducing scratching in eczema
can be long-lasting, and more highly hypnotizable subjects may achieve greater benefits.
Hypnosis has been used to facilitate resolution of psychogenic excoriations in acne excoriée.
Recent studies in patients with alopecia areata (including several with ophiasis distribution)
demonstrated that hypnosis promotes excellent regrowth in approximately 50% of treated
patients and improvements in depression and anxiety in almost all patients. Efficacy has also
been demonstrated in treating warts. Hypnosis is best performed by qualified clinicians with
appropriate training.

Biofeedback

Biofeedback is a pleasant and noninvasive intervention allowing the patient to gain control over
measurable physiological reactions that are often considered automatic and beyond voluntary

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control. Blood pressure, heart rate, skin temperature, galvanic skin response (sweating), and
muscle are frequent targets of treatment. Use of electromyography for measurement of muscle
tension and hand temperature for measurement of blood flow is common. The patient is given
feedback in real time, and simple techniques are taught to enable the patient to consciously
modify and control these physiological activities.
The physiological modifications learned during biofeedback training can lead to positive changes
in skin and emotional functioning. Virtually anyone can learn and benefit to some degree from
biofeedback training. The goal of training is to master self-regulatory techniques that can be used
quickly and inconspicuously throughout the day to manage stress and modulate physiological
reactivity. Biofeedback training typically uses auditory or visual feedback cues for the patients.
Structured breathing techniques (square-box breathing or deep and rhythmic breathing),
progressive muscle relaxation, and guided imagery techniques are often used to induce a more
relaxed state. This more relaxed and healthful state is accompanied by more relaxed musculature
and increased blood flow to the extremities. The patient is made aware of the more relaxed state
by slowing or quieting of auditory tones or decreased frequency of tones. Sometimes visual cues
are used with soothing color change or decreased height of histograms. Patients can actually
observe the physiological benefits of simple stress management techniques. This physiological
validation coupled with greater awareness of proprioceptive cues can be an excellent motivator
for use of the techniques outside the training sessions. Biofeedback is used widely throughout
medicine with success in the treatment of skin disease, hypertension etc. Benefits have been seen
in patients with rosacea, acne, eczema, urticaria, and psoriasis. Biofeedback of skin temperature
by temperature –sensitive strip or by thermocouple can be used for relaxation, dyshidrosis and
Reynaud’s syndrome.108-110 HRV biofeedback can also help reduce the stress response that
tends to exacerbate many inflammatory skin disorders
Biofeedback training is usually best performed by trained psychologis or other medical
professionals.
Meditation
Meditation describes a state of concentrated attention on some object of thought or awareness. It
usually involves turning the attention inward to a single point of reference. Concentrative type
medication focuses the attention on the breath, an image, or a sound (mantra) to still the mind
and allow a greater awareness and clarity to emerge. There is a centering or focusing on a single

22
thing. The simplest form of concentrative meditation involves sitting quietly and focusing one’s
attention on the breath. Both yoga and meditation practitioners believe that there is a direct
correlation between one’s breath and one’s state of mind. If a person is anxious, frightened,
agitated, or distracted, the breath will tend to be shallow, rapid, and uneven. On the other hand,
when the mind is calm, focused, and composed, breaths will tend to be slow, deep, and regular.
Counseling

 Information giving (psycho education)

 Supportive counseling to family

How can therapy help in the treatment and management of dermatology patients?

Therapy can help dermatology patients to:

 Come to terms with their conditions.
 Explore treatment options and facilitate decision-making.
 Examine difficulties they are experiencing with their condition and gain insight into
what factors maintain those difficulties.
 Explore and challenge dysfunctional appraisals, beliefs and assumptions.
 Identify useful coping strategies.
 Facilitate interaction skills.
 Examine issues that may be indirectly linked to the skin condition.
 Challenge and cope with anticipatory anxiety and depression.
Group therapy, especially social and assertiveness skills training can help dermatology
Patients:
 Encounter difficulties in social situations.
 Discuss their problems with others who can empathies.
 Develop a better understanding through the others’ experiences of their condition.
 Allow members to acquire and develop a variety of skills and put them in practice
with other members.
 Serve as a means of emotional and social support for skin patients.

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CONCLUSION
Psycho dermatologic disorders are conditions involving interaction between the mind and the ski
It is suggested to use a biopsychological model, which takes into account the psychological (e.g.
psychiatry comorbidity such as major depression and the impact of skin disorder on the
psychological aspects of quality of life) and social (e.g. impact upon social and occupational
functioning) factors. The treatment of psychodermatological disorders should be carried out
through the multidisciplinary approach, including family physician, dermatologist, psychiatrist
and psychologist. It is very important to educate dermatologists in the diagnostic procedures and
therapy of psychiatric disorders, which sometimes coexist with the skin disease. The cooperation
of the dermatologist, psychologist and a psychiatrist in order to increase the life quality of the
patients is of utmost importance. The management of psycho dermatologic disorders requires
evaluation of the skin manifestation and the social, familial and occupational issues underlying
the problem.

“Sickness is not just an isolated event, nor an unfortunate brush with nature. It is a form of
communication – the language of the organs – through which nature, society, and culture
speak simultaneously.” (Synnott, 1993)

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