Gereon Heuft and Gudrun Schneider
THE HISTORICAL DEVELOPMENT OF PSYCHOSOMATIC DERMATOLOGY
Embryologically, skin and the central nervous system (CNS) have the same origin in the ectoderm and are functionally closely related. One speaks of the skin as 'reflecting the soul'. Skin is a communication organ and plays an important role in the development and socialization over a whole life span. Skin is sensitive to tactile stimuli and responds to emotional stimuli. Skin diseases have a direct influence on communication, physical experience, as well as sexuality. Since skin is subject to one's own perception as well as those of others, skin diseases provoke reactions from the social environment and have an influence on self-confidence as well as relationships to other people culminating in either real or alleged stigmatization. Because of the immediate availability of their skin manifestation, patients have access to their lesions at all times, so that behavioural aspects (such as scratching, touching, exaggeration or neglect of the required skin care) may lead to new lesions and complications in the course of the disease. Personality aspects, certain coping strategies as well as mechanisms, lifestyle, support, and acceptance through the social environment also play an important role.
Psychosomatic aspects of different skin diseases have a long tradition in the scientific literature. Since 1933, when Sack1 founded psychosomatic dermatology in Germany with his article 'Skin and Psyche', papers have been published describing individual clinical case reports, approaching the subject, e.g. through psychodynamic/psychoanalytic interpretations ('anecdotal phase') (e.g. MacKenna 1944; Kalz 1945; Engels 1982).2-4 First psychophysiological measurements may be found in Deutsch (1952).5 A phase of systematic investigations in larger samples in some cases applying psychometric instruments and with control group design followed. The question was researched as to whether certain skin diseases may be associated with certain conspicuous personality traits and intrapsychic conflicts (hypothesis of conflict or personality specificity), also whether certain life events ('life-event-research') or stress trigger skin diseases or their exacerbation; the influence of skin disease on self-perception and quality of life was also researched. In the past 20 years, research has led to important insights into the psychophysiological and psy-choneuroimmunological relationship of many dermatoses because of the apparent close relationship between psyche, neuroendocrine, and the immune system.6-8
Atopic dermatitis (AD) is a frequently found skin disease characterized by chronic or chronic relapsing itching lesions; in children these are especially eczematous-exudative with a scratch effect, crusts, and lichenification. The frequency in the population has increased in recent years, and hereditary disposition has been proven.9 In atopics, disorders of the humoral and cellular immunity (raised serum IgE, defect of the T-suppressor cells, low natural killer cell activity), vegetative regulation disorders with a reduced sebaceous gland production, and a disorder in perspiration have been verified. At present, a multifactorial pathogenesis is assumed,10 whose course may be decisively influenced by psychic factors.
Rook et al11 introduced their chapter 'Psychocutaneous Disorders' in the 'Textbook of Dermatology' as follows: '... the role of emotional factors on diseases of the skin is of such significance that, if they are ignored, the effective management of at least 40% of the patients attending departments of dermatology is impossible.' Obermayer12 reported 66% and Medansky et al13 even 80% of derma-tologic patients as 'psychogenically influenced'.
The prevalence of anxiety and depression was mostly investigated. Depression scores and suicidal reflections were mostly found in the cases of disfiguring skin diseases; Gupta et al14 found suicidal thoughts in 7.2% of the inpatient psoriatic patients, in 5.6% of the patients with (non-cystic) acne, in 2.1% of AD and outpatient psoriatic patients, while alopecia areata patients reported no suicidal thoughts at all. In an investigation in German departments of dermatology, 23.2% of the heads of the departments found psychotherapeutic therapy to be a necessary requirement in addition to dermatological treatment.15
The relevance of developmental psychology and personality for atopic dermatitis
Cutaneous stimulation during childhood seems to be an important factor in cell growth and CNS maturation; this has been shown both in animal models as well as for premature children.16 Dermatosis influences tactile stimuli early on; it stands to reason that primary objects develop a special relationship to those babies who suffer from dermatosis, who are being 'tortured' by the chronic itching and who cannot be calmed down. This puts into perspective earlier 'discoveries' on the pathology of a mother-child relationship especially in the context of 'rejecting' mothers.17 It is possible that such a possible rejection may also develop due to the illness the child has developed, so that a disturbed parent-child relationship may in turn worsen the dermatosis, the child ending up in a circulus vitiosus by scratching excessively to compensate non-fulfilled needs.18 Qualitative evaluation of interviews in 5 families with neurodermatitis children demonstrated illness-related burdens for the family; however, family-typical and not illness-typical coping patterns could be found.19
Even controlled studies have presented inconsistent results for mothers with distinct psychological traits and with neurodermitis children: mothers of babies and small children with atopic eczema described themselves as more depressed, more hopeless, more anxiously over-protective, and their child as being less positive in its emotional behaviour than mothers of a control group with healthy children. Pauli-Pott et al20 and Ring et al21 described 14 mothers of neurodermitis children as being 'less spontaneous, more controlled and less emotional than a normal collective'. 'Strictness' as a method for raising children was described by the neurodermitis children as being more evident in mothers, while the fathers were less conspicuous. These results, however, could not be replicated in the controlled investigation carried out by Langfeldt22 with 50 mothers in each group. Absolon et al23 also found no striking differences.
A child may also be influenced in its further development: e.g. itching may lead to sleeping disorders, may reduce concentration, and may lead to a worsening in school achievement. The altered physical appearance may also lead to an altered self-perception and a lowering of self-awareness.24 Whereas Ring et al21 found no psychometric differences in school children with AD when compared to a control group, Absolon et al23 found psychically conspicuous behaviour twice as often in children with an average or severe case of atopic eczema than was the case for children with only a slight case of neurodermitis or a healthy control group.
Conspicuous personality behaviour has been repeatedly reported for neurodermitis patients: raised values for neuroticism, raised values for anxiety and depression have been found,25,26 raised excitability, and inadequate coping with stress;27 however, these may also be found in other psychosomatically determined illnesses as well and are therefore not specific for neurodermitis. Considering the burden involved in pruritus and the obvious skin disease, visible to all, as well as the early beginnings of the disease, there is every reason to believe that certain personality traits develop in the course of the illness and may interact with the course of the disease. All in all no specific personality types could be consistently described for neurodermatitis patients.28 However, there are indications that subgroups may be found that are psychically conspicuous.25,29
Atopic eczema and life events and/or stress
The basis of life-event-research in the 1960s was the model that the sum of 'critical' life events (without taking the context and the person involved into consideration) leads to illness. The 1970s and 1980s emphasized the inclusion of subjective burdens due to situations/ events, the role of personality aspects, and the experienced social support in coping; this was expanded in the 1990s to include the salutogenetic perspective. Today, the sum of everyday burdens is considered to be a chronic life-event. Chronic psychosocial burdens influence the activity of the hypothalamus-hypophyseal-adrenal cortex system and the sympathic nervous system30,31 and lead to molecular and structural changes in the brain.32 In the present life-event and stress research the following question is considered: 'Which life event influences which person with what characteristics at which point in time under the impact of what factors in what way, i.e. which disorders are evoked in what way and which mechanisms play a role?' (Seikowski et al, p. 5733).
Psychosocial stressors like burdening life-events and psychic burdens are regarded to be important factors triggering exacerbations of AD. To research the relation between stress and neurodermitis, retrospective interviews, life-event research, experimental stress reactions, and chronologic serial analyses as well as psychotherapy evaluation studies were applied. Despite the many published papers on the relation between neurodermitis and emotional factors, only a few papers actually satisfy scientific methodology standards.34 The largest sample up to now (1457 patients with AD) was investigated by applying a questionnaire after the earthquake in Hanshin, Japan on January 17, 1995. 38% of the neurodermitis patients from the area most severely affected (A) and 34% from the area less severely affected (B) reported worsening of their skin disease as compared to 7% in the control group. Improvement was reported by 9% from A, 5% from B, and 1% in the control group. Subjectively felt stress was reported by 63% from A, 48% from B, and 19% from the undamaged area. In the multiple logistic regression analyses, subjective stress was the best predictor for the exacerbation of the skin disease.35
In serial analyses the explicit influence of stress factors on the severity of skin alterations and different immunological parameters could be demonstrated.36 It was interesting that 24 hours later an increase in psychic burdens was associated with a distinct worsening of dermatologic symptoms; however, patients also reported an increase in burdens 24 h after skin exacerbation. This could refer to the fact that in the sense of a circulus vitiosus psychosocial burdens were both the cause as well as the result of dermatologic illness. Correlations between the degree of severity of the self-evaluated itching and the level of depression for the different itching dermatoses, among others the atopic eczema, could be shown.37
Psychophysiological and psychoneuroimmunologic aspects of atopic eczema
As serial analyses have proven, the relationship between stress and skin alterations is conveyed by different neuroendocrine, immunologic, and vegetative regulation mechanisms.8 In a meta-analysis, clinical depression went hand in hand with a variety of relevant alterations of cellular immunity.38 Embryologic development (both the epidermis as well as the CNS develop via the neural tube from the neural plate) already accounts for the close functional connection between CNS and the skin organ. Deformation syndromes quite often concern both skin and CNS. Emotions trigger skin reactions: to blush, to pale, to perspire, etc. Many common function systems such as hormones, neuro-transmitters, and receptors correspond both in skin and CNS.39 Numerous neuropeptides have been found in the skin, e.g. substance P (SP), calcitonin-gene-related-peptide (CGRP), vasoactive intestinal peptide (VIP), neuropeptides Y (NPY), neurokinin, neurotensin, etc. Neuropeptides are found in the myelinized A-fibres and the non-myelized C-fibres both in sensitive as well as autonomous nerve fibres. The skin organ is extensively supplied with various nerve fibres the sensoric nerves not only conduct afferent nerves from the skin to the CNS but also fulfil efferent neurosecretory functions. Ascending conduction pathways supply information to the thalamus, where the switching to the higher cortical centres takes place, which are responsible for the transformation of cognitive information. Descending pathways lead the sensoric information back to the spinal cord to effect the peripheral autonomous answers (perspiration, vasodilatation, etc.) The effect of some neuropeptides (SP, CGRP, VIP, NPY) are known: SP, for example, is a potent vasodilator and raises the permeability of blood vessels; intradermal injection of SP leads to reddening of the skin and urticaria, whereby the effect of SP is 100 times more potent than hista-mine. SP-induced secretion from cutaneous mast cells raises the leukocyte count in the tissue, strengthens the phagocytosis through macrophages and neutrophils, increases the in-vitro production of IgA through lymphocytes of Peyer plaques by more than 300%, potentiates the activity of other mediators, etc. It has been discussed that through the mechanism of the axon reflexes, in emotional stress neuropeptides are released in the skin that lead to neurogenic inflammations. Effects of emotional stress on the skin physiology could thus be explained; however, up to now, raised concentrations of certain peptides could be proven for experimental stress in the CNS but not for the skin. Psychophysiological comparative investigations on experimental stress between patients with neuroder-mitis and healthy probands have led to contradicting results: Faulstich et al40 have determined significant differences, with a raised reactivity of heart frequency, EMG, and fluctuation of the skin resistance in patients with neurodermitis. Arnetz et al41 and Kohler et al42 found no general psychophysiological hyperreactivity in patients with neurodermitis compared to healthy individuals. Possibly there are subgroups in patients with AD concerning the psychophysiological irritability.
The psychophysiological differences found at first for atopic, psoriatic patients, and healthy individuals may be due to the differences in coping, mood, or cognition. If these factors were controlled then the only difference found was a significantly lower secretion of growth hormones under stress in the skin patients. Functional changes in the hypothalamus-hypophyseal-adrenal cortex axis are discussed. Scheich et al27 reported on relations between level of serum IgE and irritability/excitability in patients with neuroder-mitis. Psychophysiological relations were demonstrated for a raised self-perception and leukocyte count and for the influence of cognitive evaluation of the investigative situation on skin reaction;43 this was valid for both healthy individuals and patients. Of 30 inpatient neurodermitis patients, 90% reacted after dramatizing instructions in a standardized histamine prick test with increased itching and/or urticaria as opposed to a more soothing instruction. The influence of sensoric nerves on allergic inflammations has been presented by Undem et al.7
Psychosocial burdens due to atopic eczema and chronic dermatoses
Chronic skin diseases lead to severe psychosocial burdens that are quite frequently underestimated, since as a rule these diseases are not life-threatening.44 Specific dermatologic burdens are itching, and a visible impairment in the case of atopic eczema. The itching may be extensive, so that a reflexive scratching may be the case which then leads to a circulus vitiosus of tissue damage and subsequent itching. This itching-scratching circle is perceived as a loss of control and is often accompanied by extensive feelings of guilt. The visible skin alterations may be experienced as a stigma, which may contribute to a negative self-concept and to avoidance and social withdrawal to reduce the anxiety of being stigmatized by the social environment.45 The feeling of being stigmatized correlates with the extent of brooding, i.e. a strong inner preoccupation with the dermatosis.46 Women are more influenced by skin diseases than men; patients with an atopic eczema or psoriasis had a more impaired sex-life than healthy individuals, and here psoriatic patients more than neurodermitis patients. Localization and morphology of skin appearance have an influence on the reactions of healthy individuals; however, for the extent of the subjectively felt disfigurement cognitive coping processes are more important than the extent of the symptoms. Neurodermitis patients with emotion-related coping strategies (avoidance of negative emotions, high self-acceptance, low stress vulnerability, avoidance of generalizations and brooding) were less impaired by the skin disease whereas a high disposition of personal self-attentiveness contributed to a higher burdening through the disease. In a longitudinal study, coping behaviour that included expressing emotions, looking for social support, and diversions led to a reduction in anxiety and depression; less medical treatment was necessary, and better physical health could be found 1 year later. Coping strategies explained higher variance in psychic health and life quality than in physical health.
These empirical results show that skin diseases themselves may be seen as psychosocial stressors that demand coping possibilities from the individual and that these may also be overtaxing. As a result, clinically relevant adjustment and depressive disorders, anxiety, etc., may develop. In the context of comorbidity, these must be diagnosed with care and must be treated in addition to the AD.
PSYCHOSOMATIC THERAPY OF CHRONIC SKIN DISEASES
Psychosomatic therapy of AD includes promotion of coping processes as well as the treatment of the psychic comorbitidy (e.g. anxiety or depression).
The problems of coping are also defined as somatopsy-chosomatic disorders. On a symptom level, one speaks of an acute stress reaction (ICD-10: F43.0) if the psychic symptoms last no longer than 4 weeks. A longer duration of problems in coping is, according to ICD-10 (F43.2), defined as adjustment disorders: for example, a 25-year-old patient with neurodermitis since childhood, who has not left her home for 4 months because of an exacerbation and is therefore socially isolated. These psychosocial symptoms may be related solely to the severity of the skin disease, since no further (neurotic) conflicts could be found.
Such burdens quite often overtax the individual's regulation systems that would otherwise regulate the individual coping competence and the demands made on the individual from the environment: the patient experiences the limits of his personal and social resources. The world is no longer as it once was and the individual is no longer the same person he once was prior to the illness.
Coming to terms with such a situation may be doomed to failure because the patient, according to the model of learned helplessness47 (Figure 11.1), experiences the skin phenomena, for example, as something he cannot control and thus allowing negative future expectations to arise. The objective of psychotherapeu-tic treatment in such cases should be to support the patient and his family in their endeavours to adapt; these endeavours may in turn be subdivided into inner psychic processes and psychosocial coping processes. The goal of both is to maintain the capability to act or to re-attain this capability. As Figure 11.1 demonstrates, subjective illness concepts play an important role (external attribution: 'That what is happening to me, comes uninfluenced from the outside').
Every illness also signifies a narcissistic insult; if self-esteem problems have already existed prior to the illness, then an adaptive reaction to the illness may prove difficult. For example, a 33-year-old neuroder-mitis patient was enraged every morning when looking into the mirror; however, at the same time she was also
Negative events are experienced as uncontrollable
- no behaviour warrants control
- negative expectations
- cognitive deficits
Figure 11.1 Model of learned helplessness. (Adapted according to Hautzinger M. Depression im Alter. Weinheim: Psychologie Verlags Union, 20 00.55)
someone who reacted angrily when she was challenged during the times without visible skin problems. Such repetitive dysfunctional conflict patterns make it necessary to take other treatment possibilities, e.g. psychody-namic psychotherapy, into consideration (see below).
Special programmes for patients to learn to cope with AD include behavioural therapeutic methods such as psycho-educative elements, training in handling stress, training in social competences, learning relaxation methods all with the following goal: assistance in coping with the illness, assistance in coping with the fear of losing control and penetration of the itch-scratch circle.48,49 These programmes are usually carried out as group programmes on an inpatient or outpatient basis. In practical experience, these programmes have proven to be quite useful50 and in controlled studies in patients with atopic eczema their efficacy with regard to derma-tologic findings and psychosocial parameters when compared to a solely dermatological treatment has also been well documented.51
Cognitive behavioural psychotherapy (CBT)
The indication for behavioral therapeutic measures is based on symptoms, disorders, and available resources. Changes are either achieved by learning or relearning processes or by active environmental changes. Figure 11.2 demonstrates the basic model of cognitive therapy according to Beck.52 In dealing with dysfunctional assumptions (e.g. 'I am ugly'), those thoughts that automatically come to mind ('no one wants to have anything to do with me') are changed with regard to the external trigger, e.g. the skin disease, so that depressive symptoms for example may be reduced. The afflicted learn to recover their feeling of internal control.
The sessions take place once a week; between the sessions 'homework' is assigned that is previously agreed on in the sessions. This may include practical exercises and may include e.g. phobic avoidance behaviour or changes in cognitive processes.
If in addition to AD, repetitive dysfunctional conflicts exist since early childhood development then the indication for psychodynamic psychotherapy (PDP) is given. As a rule, these sessions also take place once a week. Psychoanalytic treatment with a higher frequency (2-3/week) are more seldom and usually indicated in patients with an additional personality or ego-structural disorder.
Psychodynamic treatment procedures in dermato-logic patients have been described for smaller samples in an outpatient setting6 or, depending on the severity of the disorder, in an integrative inpatient setting.53 The pre-post evaluation of integrative inpatient treatment in 40 neurodermitis patients demonstrated satisfactory results.54 The advantages of inpatient treatment are:
• A continuous change between doctors/therapists and treatment concepts can be stopped.
• Patients are given a feedback in the intensive inpatient treatment programme through both the patient and the therapist group, thus experiencing an emotionally corrective experience ('I am not that repulsive at all') and are allowed new insights ('I can change something').
• Inpatient treatment allows a more 'external' perspective in cases of difficult personal or familial conflict relations and may thus be solved more easily.
Traumatic experiences in the biography of a patient present a special therapeutic problem. Even if the patients insist on speaking about these severe psychic burdens, it must be ensured that they are able to control their emotions. In these cases, an internal 'secure spot' is first practised with the patient. Only when the patient has gained enough confidence during treatment, should an extensive trauma-specific treatment follow.
In those problems that arise in coping with illness discussed here, antidepressive medication is only indicated if in addition severe depressive symptoms or anxiety persist. This medication must then be applied in an adequate dosage for at least 2-4 weeks before one can declare them to be effective or non-effective. If the psychic disorders are due to neurotic conflicts, then antidepressive medication is only helpful in those cases where severe psychovegetative symptoms such as sleep disorders or a severe inner unrest prevail.
In acute anxiety or agitated depression tranquillizers may be considered as a highly effective emergency medication; as a rule they have a swift effect and may be applied orally. They should, however, be applied no longer than 4 weeks because of the pronounced risk of dependency. This is also valid for a low-dose tranquillizer dependency often found in older people and leading to chronic dysphoria and lack of interest. Low-potent neuroleptic drugs are indicated in psychotic crises or severe states of unrest; they should however only be applied within the context of a psychiatric liaison service.
In summary it may be stated that we have a broad repertoire for both of the psychotherapeutic models addressed here (CBT and PDP) at our disposal depending on the differential indication for therapy and the goals aimed for (coping vs cognitive restructuring vs handling conflicts). These psychotherapeutic approaches may be supported by medication, in most cases antide-pressant drugs, where indicated.
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