Dr Robert London

Dermatology and the Psyche

Clinical Psychiatry News - Volume 34, Issue 1, Page 55 (January 2006)

When I was in junior high school, I remember a time when I suffered with a set of warts—on both feet. Walking to school day after day was excruciating as the warts grew larger. Finally, I complained to my parents, and my father took me to a doctor for an assessment.

The recommended treatment was a series of x-rays. Before we started that treatment and turned me into a Roman candle, my father—an ophthalmic surgeon—decided that a second opinion would be in order. So he found a well-known dermatologist in New York City.

After examining my warts, this doctor suggested that I think of them as getting smaller and smaller. Specifically, he encouraged me to close my eyes and visualize the warts shrinking.

He worked on this for about 20 minutes while my father watched. What was this guy up to, I thought? This was not my youthful idea of doctoring.

If nothing happened in 3 weeks, the dermatologist recommended, I should return for a second visit. On the drive home, I remember pelting my father with questions about the dermatologist's approach. My father calmly explained some of the ways in which the mind can play a significant role in helping the body heal.

I found myself becoming bored with my father's academic explanations. But that was just the beginning. Over the next several days, my father, who must have tapped into his medical school memories, continued to share the thinking behind the dermatologist's strategy.

My father even went beyond that. He brought home books by Dr. Franz Alexander of the Chicago Institute of Psychoanalysis and Dr. Helen Flanders Dunbar. Dr. Alexander proposed ideas about psychic stimuli mediated through the autonomic nervous system and leading to organ stress. While affiliated with Columbia-Presbyterian Medical Center, Dr. Dunbar published “Emotions and Bodily Changes” (New York: Columbia University Press, 1954), which made an important contribution to the developing field of psychosomatic medicine.

In the meantime, I focused on my assignment. For about 2 weeks, I practiced closing my eyes and trying to envision the warts becoming smaller. To put the shrinking into a context that my young mind could relate to, I imagined the warts as round. They started off as basketballs, then as baseballs, and finally as ping-pong balls. My visualizations did not go much further.

It wasn't until a month or so later that I noticed that the pain had subsided significantly and that the size of the warts had reduced substantially. Eventually, they disappeared. Neither the warts, nor the pain that often accompanied them, ever recurred.

This event left a lasting impression on me. In fact, experiencing this mind-body relationship in such a personal and powerful way undoubtedly had a strong influence on my choice of psychiatry and on my work in the areas of pain and mind-body disorders.

We know that the skin as an organ system mirrors our emotions. Sweating, blushing, gooseflesh, and temperature alterations during various emotional states are signs that our mind affects this organ system.

What these reactions symbolize remains debatable. However, the epidermis and nervous system originate from the ectoderm, which developed from a mesenchymal derivative of vascular tissue, making connections between skin and autonomic reactions a psychophysiologic reality.

According to Dr. Michele C. Pauporte, a dermatologist who practices at Juva Skin and Laser Center in New York City, the emotions do, indeed, have a significant role in several dermatologic problems seen in everyday clinical practice.

Usually, the well-rounded dermatologist is able to solve these kinds of problems with some conversation and insights.

But approaches encompassing these kinds of psychiatric and psychological techniques are valuable—and sometimes even necessary.

Furthermore, Dr. Pauporte points out, if a specific approach used by a psychiatrist enhances the dermatologist's work, that's all for the good. “If I had the time, I'd run some relaxation groups with my more psychologically stressed patients, trying to relieve some anxiety and slowing the scratching and picking at their skin,” Dr. Pauporte said.

My experience in treating dermatologic problems is related to eczema, psoriasis, and neurodermatitis. Using warm/cold imagery and glove anesthesia, I've had successes.

All the patients I've seen were referred by dermatologists who had had a difficult time getting a positive treatment result, who had suspected a psychological component, or who had responded to a patient's request of wanting a psychological examination.

Two examples of patients I've seen come to mind. Each patient responded well to warm/cold imagery and to a glove anesthesia technique, in order to control the itch accompanying the eczema.

In both cases, the constant itching appeared to be a major part of the patient's failure to get better with dermatologic care. The strategies I used were straightforward. I used the learning, philosophizing, and action techniques that I had developed at the New York University Medical Center short-term psychotherapy program.

The learning phase was usually done by the dermatologist, who spent a good deal of time explaining to the patient why she was not getting better.

Rarely did I need to offer any more learning than was already done.

My role came in at the philosophizing stage. Depending on the patient's interests and background, we often discussed some of the ideas in the field of psychosomatic medicine. I would tell the patient about thought leaders in the field such as Dr. Alexander and Dr. Dunbar.

I also used the action phase with the eczema patients to help resolve their problem. I began by teaching a relaxation/hypnosis technique (“Psychiatry and Medicine Working Together,” CLINICAL PSYCHIATRY NEWS, June 2005, p. 67).

After spending 10–15 minutes with a patient who was comfortable with the relaxation/hypnosis technique, I would have her envision herself on a large movie screen on a beach on a warm summer day, with the sun beating down on the patient.

I offered the patient the option of letting the sun focus directly on the areas of skin that were not healing well because of her continued scratching and picking.

Usually, the warmth this exercise produces brought the patient relief.

The key component is for the patient to practice this technique 6–10 times a day to gain consistent relief from the itch, while healing from the prescribed dermatologic remedies continue.

During the same visit, I offered a cold imagery technique that some patients find more acceptable. For a patient choosing this option, the cold provided the same relief by removing the stimuli that had driven the patient into excessive scratching and picking.

In this instance, the patient used the imagery of ice on the spots to be treated or thought of being outdoors ice skating or skiing, where she could visualize that ice-cold feeling.

In glove anesthesia, the patient made a fist and continued to tighten it until the hand felt numb.

The numb hand was then placed on the area to be treated. If the approach worked, the numbness from the hand moved into the treatment area, leading to symptom relief.

Dr. Pauporte agrees that this approach can work. “Breaking the itch-scratch-itch histamine cycle through imagery is superb therapy for these more difficult-to-treat dermatologic patients,” she said.

My visits with these patients lasted for one, two, or three visits. They were instructed to routinely practice these techniques, modify them if a different approach worked better, and, of course, share this information with their dermatologist.

The doctors who referred the patients to me were always supportive of my work—which is key. Too often, well-intentioned clinicians make a referral, are doubtful of the outcome, and inadvertently pass on that doubt to their patients. This is not a good referral model under which to gain a patient's confidence.

Given the power of the mind-body connection, psychiatrists and other mental health professionals have much to offer our colleagues in dermatology and other specialties. Using these techniques to empower the patient is in best interests of all involved parties.

If you have any other examples or ideas about the role of mental health in psychosomatic medicine, please drop me a line, and I will try to share them with my readers.

PII: S0270-6644(06)71135-3


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