There is a relatively new subspecialty within dermatology that is of interest to therapists. Psychodermatology, the study of the connection between the “mind” and the skin—or an understanding of the psychosocial context of skin diseases—is giving many patients a new lease on life. While we’ve always known that there is a connection between mental health and certain skin conditions, we’re now finding that this connection runs much deeper than scientists first believed.
For example:
So, what can psychotherapists do to recognize patients who could benefit from seeing a psychodermatologist or drawing connections between their skin conditions and their mental health? Continue reading for tips to guide your recognition and treatment of psychodermatologic conditions.
How to Identify and Treat the Symptoms
Symptoms to look for in patients include any skin condition, including severe acne, eczema, pruritus (itching), psoriasis, vitiligo, and others, that may arise at the same time as particular mental health challenges. If you notice a skin condition, ask your patient to tell you about it. Find out what makes it worse or better and when they notice flare-ups.
You have to become a bit of a detective at first until you can teach your patient how to start connecting dots for themselves. Certain patterns may be obvious, while others will require further investigation. But once you discover a connection between the brain and skin, you can dig deeper to better understand the nature of the connection.
The goals of psychodermatology are:
With patient-centered approaches to explore the patient’s feelings, concerns, and experience regarding the impact of their condition and with cognitive behavioral therapy, you can begin to reveal a clearer picture of what stimuli and stressors contribute to the physical manifestations of a patient’s emotional condition.
For example, suppose you have a patient who you’re treating for depression and social anxiety. During one therapy session, you notice eczema on the back of your patient’s hands. You enquire—just as you would when assessing any physical behavior. Your patient discloses that ever since they started a new job, their eczema has gotten worse.
Armed with this new information, you can have your patient jot down when flare-ups occur and bring their notes to sessions with you. Together, you can collaborate to spot patterns, which can help you create a timeline. From here, it’s time to focus on healing from the inside out.
Working with Other Health Professionals
While many conditions can be eliminated through psychotherapy alone, patients experiencing any of the above symptoms often benefit from an interdisciplinary approach. Many dermatologists understand that while they can treat the physical manifestations of a patient’s mental health condition, patients often also need mental health professionals, like psychologists, psychiatrists, or psychiatric mental health nurse practitioners, to target the source of the skin condition. One good strategy may be for therapists to seek out partnerships with dermatologists in the know.?
Also, if you see patients who suffer from compulsions or skin conditions, such as skin picking or hair pulling, which you know have a psychological component, referring them to a psychodermatologist can be especially productive. While any dermatologist can prescribe drugs to treat the physical skin condition, working with someone who understands the deeper connection can be the ticket to deeper healing for particular patients.
Ultimately, psychodermatology is all about improving quality of life by healing the skin condition and enhancing the patient’s emotional state. When we give our clients the tools they need to find true healing from the inside out, we show them that the journey to healthy skin and mental stability is a path they can walk.
Case Application
Glenda, a 21-year-old-woman, was referred to my office by her dermatologist because of anxiety that heightened when asked questions about her visibly red, scaly and raw-appearing rash on her hands and forearms. She insisted that she must be allergic to the soap she had been using and possibly the prescription cream that her primary care physician (PCP) had prescribed. Glenda had been examined by her PCP for her rash three times over the past few months and diagnosed with contact dermatitis, allergic dermatitis, and possibly eczema. Her PCP also prescribed a steroid cream and instructed to wash her hands with hypoallergenic soap and apply Aquaphor healing ointment daily.
Glenda’s dermatologist took a thorough medical history and asked her about having repetitive thoughts that may be causing her distress. Glenda started to talk about the stress she has been experiencing over the past year due to COVID. She talked about staying up late at night worrying about getting infected with COVID and spreading it to others. She began to wash her hands multiple times a day. She shared that she had always frequently washed her hands, but now felt compelled to carry out a hand washing ritual—hand washing, turning the cold water on and off four times, then washing her hands, scrubbing until she counted to 30, turning the cold water on and off four more times, then applying hand sanitizer and rubbing it into her skin for 30 seconds. Lately she had been washing her hands every half hour and had been applying extra hand sanitizer to make sure her hands were clean, since washing her hands made her feel less anxious about getting COVID. She believed that carrying out this ritual had the additional benefit of protecting her family.
At that point, the dermatologist explained that her skin rash and anxiety were interconnected, prescribed a hand ointment that promoted healing, and referred her to my outpatient mental health practice for an evaluation.
After taking her medical and psychological history, I asked Glenda “What is your story?” to provide her with an opportunity to construct her personal narrative and share her experiences and beliefs about her current psychosocial circumstances. She opened up about her repetitive hand washing behaviors and worries about COVID that “hijacked” her brain.
As a first-line intervention, cognitive behavior therapy for OCD directed at her behavior (compulsions) and cognitions (obsessions) made good sense. Sessions with Glenda included cognitive restructuring, psychoeducation, imagery exposure, self-monitoring, relaxation training, coping skills development, and self-care to alleviate her OCD-related distress. Relapse prevention was used to reduce the occurrence of initial lapses and to prevent any lapses that might escalate into a full-blown relapse. For homework, journaling was used to help Glenda identify harmful patterns of thoughts, emotions and actions and to develop techniques to help her better cope with uncomfortable feelings.
File under: The Art of Psychotherapy
For example:
- Among patients with disfiguring, chronic skin conditions, the prevalence of psychiatric disorders is 30% to 40%.¹
- Significant stress and anxiety have been reported in 44% of patients before the initial flare of psoriasis, and recurrent flares have been attributed to stress in up to 80% of individuals.²
- The prevalence of psychiatric disorders among patients with skin conditions is greater than in patients with brain disorders, cancer, and heart issues combined.³
So, what can psychotherapists do to recognize patients who could benefit from seeing a psychodermatologist or drawing connections between their skin conditions and their mental health? Continue reading for tips to guide your recognition and treatment of psychodermatologic conditions.
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How to Identify and Treat the Symptoms
Symptoms to look for in patients include any skin condition, including severe acne, eczema, pruritus (itching), psoriasis, vitiligo, and others, that may arise at the same time as particular mental health challenges. If you notice a skin condition, ask your patient to tell you about it. Find out what makes it worse or better and when they notice flare-ups.
You have to become a bit of a detective at first until you can teach your patient how to start connecting dots for themselves. Certain patterns may be obvious, while others will require further investigation. But once you discover a connection between the brain and skin, you can dig deeper to better understand the nature of the connection.
The goals of psychodermatology are:
- To investigate the emotional impacts of a patient’s skin condition,
- To help the patient work through these emotional impacts,
- To reduce the threats posed by these emotional impacts,
- To help the patient develop coping mechanisms for if and when a recurrence occurs
With patient-centered approaches to explore the patient’s feelings, concerns, and experience regarding the impact of their condition and with cognitive behavioral therapy, you can begin to reveal a clearer picture of what stimuli and stressors contribute to the physical manifestations of a patient’s emotional condition.
For example, suppose you have a patient who you’re treating for depression and social anxiety. During one therapy session, you notice eczema on the back of your patient’s hands. You enquire—just as you would when assessing any physical behavior. Your patient discloses that ever since they started a new job, their eczema has gotten worse.
Armed with this new information, you can have your patient jot down when flare-ups occur and bring their notes to sessions with you. Together, you can collaborate to spot patterns, which can help you create a timeline. From here, it’s time to focus on healing from the inside out.
Working with Other Health Professionals
While many conditions can be eliminated through psychotherapy alone, patients experiencing any of the above symptoms often benefit from an interdisciplinary approach. Many dermatologists understand that while they can treat the physical manifestations of a patient’s mental health condition, patients often also need mental health professionals, like psychologists, psychiatrists, or psychiatric mental health nurse practitioners, to target the source of the skin condition. One good strategy may be for therapists to seek out partnerships with dermatologists in the know.?
Also, if you see patients who suffer from compulsions or skin conditions, such as skin picking or hair pulling, which you know have a psychological component, referring them to a psychodermatologist can be especially productive. While any dermatologist can prescribe drugs to treat the physical skin condition, working with someone who understands the deeper connection can be the ticket to deeper healing for particular patients.
Ultimately, psychodermatology is all about improving quality of life by healing the skin condition and enhancing the patient’s emotional state. When we give our clients the tools they need to find true healing from the inside out, we show them that the journey to healthy skin and mental stability is a path they can walk.
Case Application
Glenda, a 21-year-old-woman, was referred to my office by her dermatologist because of anxiety that heightened when asked questions about her visibly red, scaly and raw-appearing rash on her hands and forearms. She insisted that she must be allergic to the soap she had been using and possibly the prescription cream that her primary care physician (PCP) had prescribed. Glenda had been examined by her PCP for her rash three times over the past few months and diagnosed with contact dermatitis, allergic dermatitis, and possibly eczema. Her PCP also prescribed a steroid cream and instructed to wash her hands with hypoallergenic soap and apply Aquaphor healing ointment daily.
Glenda’s dermatologist took a thorough medical history and asked her about having repetitive thoughts that may be causing her distress. Glenda started to talk about the stress she has been experiencing over the past year due to COVID. She talked about staying up late at night worrying about getting infected with COVID and spreading it to others. She began to wash her hands multiple times a day. She shared that she had always frequently washed her hands, but now felt compelled to carry out a hand washing ritual—hand washing, turning the cold water on and off four times, then washing her hands, scrubbing until she counted to 30, turning the cold water on and off four more times, then applying hand sanitizer and rubbing it into her skin for 30 seconds. Lately she had been washing her hands every half hour and had been applying extra hand sanitizer to make sure her hands were clean, since washing her hands made her feel less anxious about getting COVID. She believed that carrying out this ritual had the additional benefit of protecting her family.
At that point, the dermatologist explained that her skin rash and anxiety were interconnected, prescribed a hand ointment that promoted healing, and referred her to my outpatient mental health practice for an evaluation.
After taking her medical and psychological history, I asked Glenda “What is your story?” to provide her with an opportunity to construct her personal narrative and share her experiences and beliefs about her current psychosocial circumstances. She opened up about her repetitive hand washing behaviors and worries about COVID that “hijacked” her brain.
As a first-line intervention, cognitive behavior therapy for OCD directed at her behavior (compulsions) and cognitions (obsessions) made good sense. Sessions with Glenda included cognitive restructuring, psychoeducation, imagery exposure, self-monitoring, relaxation training, coping skills development, and self-care to alleviate her OCD-related distress. Relapse prevention was used to reduce the occurrence of initial lapses and to prevent any lapses that might escalate into a full-blown relapse. For homework, journaling was used to help Glenda identify harmful patterns of thoughts, emotions and actions and to develop techniques to help her better cope with uncomfortable feelings.
***
The collaboration between two specialties, dermatology and mental health, enabled this patient to have her psychological and physical needs treated holistically and simultaneously.
References:
1. Goldin, D. (2020). Concepts in Psychodermatology: An overview for primary care providers. The Journal for Nurse Practitioners, 17(1), 93-97.
2. Jafferany M. (2007).Psychodermatology: A guide to understanding common psychocutaneous disorders. Prim Care Companion J Clin Psychiatry, 9(3), 203-13.
3. Ghosh S, Behere R.V., Sharma P, & Sreejayan K. (2013). Psychiatric evaluation in dermatology: An overview. Indian J Dermatol., Jan;58(1), 39-43.
4. Azambuja R. D. (2017). The need of dermatologists, psychiatrists and psychologists joint care in psychodermatology. Anais brasileiros de dermatologia, 92(1), 63–71.
File under: The Art of Psychotherapy