How psychologists are helping patients with dermatological problems

CREDIT: REBECCA A. CLAY; American Association of Pschology

While psychodermatology is a well-established field in Europe, it has been slower to catch on in the United States, according to a history of the movement on the Association for Psychoneurocutaneous Medicine of North America (APMNA) website. There are just a few psychodermatology clinics in the country, the association reports.

What's more, the field consists primarily of dermatologists and psychiatrists, says Kristina G. Gorbatenko-Roth, PhD, a psychology professor at the University of Wisconsin–Stout. She became interested in psychodermatology when she developed the hair loss condition alopecia areata and discovered that depression, anxiety and other psychological issues were common among participants posting in an alopecia-related Internet chat room.

The APMNA is eager for psychologists to get involved in the field, says Gorbatenko-Roth, who is working with two European psychologists to develop training materials for those interested in developing a clinical competency in psychodermatology.

"The skin is the most noticeable part of our body that could be impacted by psychological factors, yet very few psychologists are studying it," she says. "It's classic health psychology, just in a different area."

Psychologists have roles to play in treating all three types of psychodermatology disorders, says Gorbatenko-Roth. The three types are:

• Skin problems affected by stress or other emotional states.
• Psychological problems caused by disfiguring skin disorders.
• Psychiatric disorders that manifest themselves via the skin, such as delusional parasitosis.

"Psychologists' service provision skills are highly applicable and relevant," she says. "Coupling this with the lack of psychologists with training in psychodermatology, and the growth potential for psychologists becomes more apparent."

Rick Fried is one of the few U.S. clinicians specializing in psychodermatology. Skin problems can be extremely distressing, he says. For one, flare-ups of psoriasis, eczema, acne and other conditions can be unpredictable. Unlike hypertension, diabetes or other health problems, skin problems are usually obvious to onlookers. Plus, patients may have psychological reactions that seem out of proportion to their actual skin conditions.

"We can never presume that the so-called objective severity of a dermatological disorder correlates with the psychological impact," says Fried. "I've see people who have nodulocystic acne who aren't happy but really aren't psychologically distraught; I've also seen patients with one zit on their chin who have attempted suicide."

 

Having a skin problem can prompt intense distress. In a 2014 National Rosacea Society survey of 1,675 patients with rosacea — a condition that causes facial redness and related symptoms — 90 percent of respondents reported lowered self-esteem and self-confidence, 54 percent reported anxiety and helplessness, and 43 percent reported depression, for example. More than half said they avoided face-to-face contact.

In a vicious circle, stress, depression and other kinds of psychological problems can exacerbate the skin problems. "The common dermatological issues that have been documented to be made worse by stress include acne, rosacea, psoriasis, itching, eczema, pain and hives, just to name a few," says Fried.

Fortunately, he says, treating psychological problems can also improve skin problems.

In a paper published in 2013 in Seminars in Cutaneous Medicine and Surgery, Fried reviewed the evidence for nonpharmacological management of psychodermatalogical conditions. Proven interventions — typically used as complements to traditional dermatological approaches — include hypnosis, support groups, biofeedback, meditation, guided imagery, progressive muscle relaxation, cognitive-behavioral therapy and other forms of psychotherapy.

The key, says Fried, is to give patients a sense of control over their conditions and their reactions to them. Cognitive-behavioral therapy, for example, can help patients manage stress and stop catastrophizing, such as saying they'll kill themselves if their psoriasis acts up on an important day.

Boston psychologist Ted A. Grossbart, PhD, a private practitioner who specializes in psychodermatology, uses a variety of therapies to help people with skin conditions, including imaging and meditation. Hypnosis can be especially helpful, he says. The key is to help patients focus on an image associated with the desired change, whether it's warmer, cooler, dryer, moister or less itchy skin, says Grossbart, who is also an assistant professor of psychology at Harvard Medical School. A patient with eczema, for instance, might zero in on the image of a tropical rainforest to counteract the drying the condition brings.

"Often, people are doing what I call inadvertent negative hypnosis anyway," says Grossbart. "If that very same mechanism can get used in a focused way and in a proper dimension, the results can be quite dramatic."

These kinds of interventions don't just help patients' distress, says Fried. They can also improve patients' skin and their responsiveness to treatment. In one study Fried cites in his literature review, for example, patients who listened to a mindfulness meditation program while undergoing phototherapy treatment for psoriasis needed 40 percent less exposure to ultraviolet light than others.

Fried refers his patients who need more intensive psychological assistance to psychologists, whom he calls "skin-emotion specialists" as a way of reducing stigma and overcoming patients' reluctance to seek mental health care.

In some cases, adds Grossbart, skin problems are the outward manifestation of an underlying mental disorder.

 

Take skin picking, for example. "Sometimes people would have perfect skin if they would just leave it alone," says Grossbart. "But they can't." Their picking may be a form of addiction, a symptom of attention-deficit disorder or the outward sign of obsessive-compulsive disorder, all of which require different treatment approaches. "You've got to do detective work first," says Grossbart.

 

Preventing problems

Psychologists are also helping prevent dermatological problems from developing.

Kasey Lynn Morris is investigating the best ways to prevent melanoma and other problems caused by excessive tanning, for instance.

"Excessive tanning is one of those areas where even though people know how bad it is for them, they still do it," says Morris, a graduate student in social psychology at the University of South Florida.

Research has shown that reminding people of tanning's potentially fatal consequences can help curb people's desire to tan, at least temporarily. But as thoughts of death slide into the unconsciousness, which happens very quickly, people's desire to tan actually increases if being tan is relevant to self-esteem, as is often the case for women, says Morris.

"The reason is that non-conscious thoughts of death motivate a desire to maintain self-esteem," Morris explains. "If a person's appearance is relevant to their self-esteem — and being tan is a part of that cultural appearance ideal — then non-conscious thoughts of death will motivate a desire to uphold that ideal by tanning one's skin."

Adding an appearance-related element to the intervention can "re-route" that self-esteem, Morris and colleagues found in two experiments described in a 2014 paper published in Psychology and Health. In the experiments, the researchers exposed women not just to a reminder of mortality via a funeral scene depicting a woman sunbathing on a beach but also to UV-filtered photos of their own skin, a technique that reveals sun damage. "If you've ever seen a UV-filter photo of yourself, you know you look terrible," says Morris. When the death- and appearance-related interventions were combined, they decreased participants' intentions to tan and increased the amount of sunscreen they took from the researchers.

"It relies on the assumption that people value their appearance — and research suggests the majority of women do — and the knowledge that unconscious thoughts of death motivate a desire to maintain self-esteem," says Morris. "If you prime thoughts of death, followed by a delay to give it time to no longer be conscious and then remind people how much sun damage can hurt their appearance, they are subsequently going to try to boost their self-esteem by maintaining their appearance through using sun protection."

Now Morris and her team are exploring whether participants follow through on their intentions in everyday life.

Other psychologists are working on interventions designed to prevent psychological problems from developing among dermatology patients.

 

Heidi Williamson, Health, Psychology, for example, has worked with young people to develop an online interactive intervention called YP Face IT. It's designed for youth ages 12 to 17 who are distressed because of conditions or injuries affecting their appearance, including skin issues such as acne, psoriasis, burns or scars. The seven-week program teaches kids coping strategies and social skills.

"What young people fear most is being judged negatively for their appearance," says Williamson, a senior research fellow at the Centre for Appearance Research at King's College London. And anticipating negative judgments can make young people anxious and self-conscious, which can mean that young people lose their social skills or fail to develop them in the first place.

YP Face IT teaches users how to overcome negative thoughts about their appearance as well as how to handle social situations, such as answering questions about their conditions, coping with teasing and bullying and making the most of their body language and verbal skills. Participants can also find support through a discussion forum. Throughout the program, a psychologist or other health-care professional monitors users' progress and can suggest more intensive help if necessary.

While Williamson and her colleagues are still evaluating YP Face IT, preliminary results suggest that it decreases social anxiety scores and increases assertiveness and social skills.

 

For Gorbatenko-Roth, all this activity by psychologists is a welcome change.

"Dermatologists and other health-care providers are out there doing the best they can for patients, but they're frustrated, because they see their patients' emotional distress but typically have neither the time nor the tools to fully address it," she says, urging psychologists to attend the APMNA's next annual conference in San Francisco in March. "This is a great role for psychologists."

 

Rebecca A. Clay is a journalist in Washington, D.C.

 

 

 

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