Dermatologic Clinics
Volume 23 • Number 4 • October 2005
Copyright © 2005 W. B. Saunders Company
Psychosomatic Factors in Dermatology: Special
Perspectives for Application in Clinical Practice
Emiliano Panconesi, MD
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Department of Dermatology, University of Florence, Florence, Italy
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The identification of psychosomatic factors in dermatology has always been one
of the principal themes in the history of this field and in the personal
experience and research of the author. After a brief review of some of the
milestones in the area of psychosomatic factors in dermatology, the author
presents the criteria dictated by clinical experience, in the absence to date of
more precise scientific data, for the individuation of such psychosomatic
factors in clinical practice.
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Nothing is more profound than that which appears superficial.
—Hegel
A dermatologist's work would be incomplete if he/she did not consider and
examine the whole patient, not only the physical body with the skin and mucosae,
but also the individual's mind (the psyche or the psychologic aspects, “the
soul”). The term originally proposed by Heinroth in 1818 for such a situation is
“psychosomatic”—a term that is only relatively precise, but that presents the
advantage of clear understanding; later, Jacobi widened the field with the term
“somatopsychic.” The former term refers to the influence of the mind on the
body, and the latter refers to the influence of corporeal phenomena on the mind,
although actually the two must be considered clinically indistinguishable.
Today, there is a whole area of psychosomatic medicine, including, of particular
interest to dermatologists, psychosomatic dermatology. It is not necessary or
opportune to use separate neologisms, such as “psychocutaneous medicine,”
“emotional dermatoses,” “psychocutaneous disease,” or “psychodermatology,”
because psychosomatic medicine is a branch of medicine with a unified
epistemologic basis correlated with the various organs and systems.
To cite a historical example, their use of the term “psychosomatic” indicates
that the founders of the Journal of Psychosomatic Medicine (1939) had a similar
opinion, just as Weiss and English [1] must have had, shown by their choice of
the title Psychosomatic Medicine for their book, in which they noted that the
creation of the Journal of Psychosomatic Medicine and the emphasis on the topic
had been reported enthusiastically in the Journal of the American Medical
Association in an article that underlined the true origin of the psychosomatic
idea in the studies of Freud (and his followers, who more or less agreed with
him). One of the many possible references to his thought is Freud's significant
idea that no neurosis would be produced without some form of somatic connivance.
In a study on epistemology in psychosomatic dermatology, Panconesi and
Argentieri [2] agreed with the authors who followed Freud, including those of
the Chicago Psychoanalytic School, who concluded that “all medicine must become
(meaning is) psychosomatic medicine.” This is a sort of reply, over the
centuries, to Plato's phrase (presented as an epigraph in the book by Weiss and
English): “this is the great error of our times … physicians see the body
separate from the soul.”
These theories that make headway and develop and diversify in the field of
psychology/psychiatry do not make operational contact in other clinical
specialities, in either research or clinical activities. This situation seems to
be due to various factors, in particular the hybrid status of psychosomatic
epistemology, which is part of medicine with its empirical tradition and at the
same time refers to psychology, with all the related hermeneutic difficulties.
Experience (that of the author and many others) shows, however, that the
somatist's (the dermatologist in this case) simple referral of the patient to a
psychiatrist/psychologist is often unacceptable to the patient (who has chosen
the dermatologist to solve his or her problems) and may even be risky (owing to
the “delicate” patient's feeling that one has made an unfair, improper diagnosis
of mental disturbance).
This problem could be managed by formalized collaboration through
consultation-liaison psychiatry, a treatment method examined in depth by
Koblenzer [3], who emphasized possible strategies for its practical application.
She pointed out that it is helpful for the dermatologist to find a
psychologist/psychiatrist colleague with whom he or she relates well to discuss
or refer patients for specific psychologic problems. This collaboration provides
the patient with the necessary dermatologic expertise and treatment and
appropriate specialized psychologic/psychiatric management, while bypassing the
various risks of all-out referral, such as labeling the patient as mentally ill
and the specialists being played one against the other. In her discussion of the
method, Koblenzer [3] pointed out that the consultation-liaison clinic is the
ideal situation for such integrated care, and that such clinics operated
successfully in many cities (Florence, Paris, Ghent, Amsterdam, Stanford), with
varying organizational situations and different immediate objectives, but all
aimed at total, integrated care of patients. The specified ideal organization
requires space in a dermatology clinic, with regular liaison sessions, including
a minimum staff of one psychiatrist and one dermatologist. The optimal situation
is a team approach, however, including a clinical psychologist (to administer
psychologic tests) and psychiatric social workers, and facilities for
biofeedback training and other modalities. When the patient has been completely
evaluated, treatment is continued by the dermatologist, who consults when
necessary with the psychiatrist, who may begin biofeedback training, if
indicated, or psychotherapy, in which case the psychiatrist consults with the
dermatologist, who in the meantime continues the necessary dermatologic
treatment. The advantage of establishing the liaison clinic in the regular
dermatology clinic is that the patient sees that his or her choice of
specialist, the dermatologist, is recognized, and evaluations, laboratory tests,
and treatments are done there in the clinic with all dermatology patients who
undergo various other examinations (eg, allergologic tests) or treatments (eg,
phototherapy).
Koblenzer [3] pointed out that the aims of the various liaison clinics differ.
The clinic in Stanford had a specific educational approach—to teach young
dermatologists how to recognize and discover psychologic problems in patients.
The clinic in Florence performed more fully developed activities, with a staff
of dermatologists, psychologists, and psychiatrists who did separate
dermatologic and psychiatric evaluations, with psychodiagnostic tests and
treatments including biofeedback training, psychotherapy, and liaison
consultation. All the data were stored for future reference and comparative
studies, leading to therapeutic projection and the establishment of an index of
psychosomaticity [4], a practical guide to assist dermatologists and
psychologists/psychiatrists in their evaluation of dermatologic patients with
psychosomatic and somatopsychic problems. Economic and organizational problems
make it extremely difficult to establish such an integrated clinic, but the
individual dermatologist can dedicate more time to needy patients and
individuate one or more psychiatrist colleagues with whom consultation-liaison
is possible for specific cases.
The times were not yet ripe when Freud performed the first biologic and
histologic studies on biologic psychosomatics. The pioneer studies were those of
Lewis (1930), who described the phenomenon of the triple response observed in
human skin in response to an injury, with morphologic manifestations of wheals,
local erythema, and flare reactions in response to external stimuli (and release
or injection of histamine). In 1946, Selye proposed his general adaptation
syndrome, introducing the concepts of stress and stressors, identifying them
also with many substances (eg, endocrines, steroids, catecholamines), especially
neuropeptides, that were identified in blood and tissue, even in the skin and
mucosae. Since then, continuously more sophisticated research has supplied an
enormous mass of data of unquestionable scientific importance.
The rapid proliferation of important findings, as often happens in science, led
in the field of dermatology to expectations that soon information would be
available that would provide valid epistemologic definitions of clinical
pertinence for classification purposes in the field of psychosomatics,
information that would allow dermatologists to individuate with scientific
precision the various psychosomatic factors that influence specific dermatologic
presentations. This expectation is not yet a reality. Dermatologists still must
resort to practical, operational strategies.
RESEARCH ON THE INDIVIDUATION OF PSYCHOSOMATIC FACTORS IN DIAGNOSTIC AND
CLINICAL DERMATOLOGY
Research in psychosomatics began in the Department of Dermatology and
Venereology at the University of Florence, Italy, in the 1950s and developed at
various levels. Laboratory studies in the metabolic and endocrinologic sectors
of clinical pharmacology that involved investigation of hypophyseal and surrenal
substances studied by Selye were fairly easy to organize. It was not possible
until the 1970s, however, to organize and conduct research in medical
psychology, with the collaboration of experts in that field, on site. These
experts all worked on a volunteer basis because the administration could not
include them in the budget. It was important that the work be done on site in
the department of dermatology because the subjects, inpatients and outpatients,
had to undergo dermatologic examination (when necessary with laboratory tests,
including allergologic tests, mycologic and bacteriologic examinations, and
histologic investigations) and psychologic investigation (attentive anamnesis
and, when necessary, specific psychodiagnostic tests, such as the Rorschach
test, which require specially trained personnel). Many of these subjects would
not have accepted referral to dedicated psychiatric institutions because they
felt branded by the idea or did not believe they needed such evaluation.
At the author's institution, a psychosomatic dermatology team (three to five
dermatologists and three to five psychologists and psychiatrists) was organized
that met regularly once a week with an agenda that included consultation
liaison. The dermatologists all were University or National Health Service
personnel, and the psychologists/psychiatrists (all volunteers) were on call to
examine and talk with inpatients and outpatients at the request of the
outpatient service and the ward physicians. The dermatologists and
psychiatrists/psychologists all wore similar white hospital coats with a name
badge, without reference to their specific specializations, to avoid emphasis on
the presence of a psychiatrist, which some patients might not have welcomed.
Inpatients who required follow-up after their release from the hospital
continued therapy with the same personnel through the dermatologic outpatient
clinic. The weekly meeting served for programming research projects,
consultation and discussion regarding particular cases, and teaching
undergraduates and residents the aims and tactics of psychosomatic
investigations.
This collaboration led to numerous publications over the years as the study of
psychosomatic dermatology became more profound and better recognized, accepted,
and authorized by public institutions (in Europe, most individuals have access
to some form of public health service, and acceptance by such national health
services, public hospitals, and state universities to underwrite the costs of
specific programs and services is paramount). In a relatively short time
(mid-1950s–1970s), this group acquired remarkable experience and collected a
large quantity of data. Another source of information was participation in
meetings and congresses in Europe and the United States, although during those
years and into the 1980s, with few exceptions, psychosomatic dermatology was
generally ignored in US universities and at major dermatology congresses.
Finally, in the early 1980s,there were signs that psychosomatic medicine was
becoming a topic of interest in the United States. The Clinics in Dermatology
published an issue dedicated to the subject [5], and shortly before the
publication of this issue, the New York Times published a brief article on the
skin and emotions [6]. This was une ideé qui était dans l'air or, as Parish
wrote in his Foreword to the Clinics in Dermatology issue, “a rekindling of
interest in psychosomatic medicine is currently in progress” [5].
SPECIFIC CUTANEOUS CONDITIONS AND SYMPTOMS WITH PSYCHOSOMATIC ASSOCIATIONS
The Clinics in Dermatology issue [5] was based on the author's then more than 25
years of experience and the body of the existing literature on the subject;
clinical pictures represented the most significant mind-body relationships, with
reference to the current acquisitions in the field of
psychoneuroendocrinoimmunology, including pruritus and prurigo, urticaria,
contact dermatitis, atopic dermatitis, rosacea, acne, alopecia (in particular
alopecia areata), telogen effluvium, vitiligo, purpura, seborrheic dermatitis,
and psoriasis; cosmetologic alterations; and psychiatric syndromes with
dermatologic expression, such as self-inflicted lesions, trichotillomania, and
certain so-called phobias (eg, dysmorphophobia, glossodynia, delusions of
parasitosis, venereophobia/syphilophobia, AIDS-phobia). Myriad observations
refer to numerous different psychosomatic factors, where psychic problems seem
to predispose, trigger, accompany, or exacerbate various dermatologic patterns,
and to somatopsychic factors, where various dermatologic conditions or symptoms
seem to trigger or exacerbate psychologic/psychiatric problems (Tables 1 and 2).
This information remains valid today.
Table 1 . Dermatologic conditions that may involve somatopsychic rebound in
childhood, adolescence, and adulthood Children Adolescents Adults
Ichthyosis Acne Rosacea
Alopecia Alopecia Alopecia
Epidermolysis bullosa — Seborrheic dermatitis
Nevi — Psoriasis
Angioma — Skin aging
Table 2 . Examples of psycho–somatic and somato–psychic influence in
dermatologic affections Body (soma) Influence Mind (psyche)
Acute urticaria ← Emotions
Chronic relapsing urticaria ← Anxiety
Psoriasis ↔ Stress
→ Depression
Atopic dermatitis ← Deep psychic conflicts
Androgenetic alopecia → Psychic problems
Telogen effluvium ↔ Stress
Alopecia areata ← Stress
← Psychic conflict
→ Psychic problems
Trichotillomania (hair-pulling tic) ← Psychic disease
Acne in adolescence → Psychic problems
Acne in adults ← Psychic problems/disease
Research, the literature, and the author's own experience lead the author to
reconfirm today that there is no physical pathology that does not influence the
mind and vice versa. While waiting to be able to individuate other methods of
classification—harmonizing etiopathogenetic criteria in the two fields of
research, one related to psychology and the other to clinical dermatology, the
only modus vivendi that is acceptable is to base one's considerations on
epistemologic empiricism, but closely related to the statistics of clinical
observations of the various groups of conditions studied.
Box 1 lists cutaneous conditions reported to have a high incidence or evidence
of psychoemotional (psychic factors influence the body) factors. Table 1
presents cutaneous conditions with frequent, strong somatopsychic rebound
(somatic conditions influence the psyche). Box 2 lists psychiatric conditions or
syndromes with clinical dermatologic expression (correlated with psychogenic
factors that are revealed clinically prevalently on the skin or mucosae).
Box 1. Dermatologic conditions with high incidence of psychoemotional factors
Hyperhydrosis
Dyshydrosis
Pruritus
Urticaria
Lichen simplex
Atopic dermatitis
Acne
Rosacea
Telogen effluvium
Alopecia areata
Psoriasis
Seborrheic dermatitis
Perioral dermatitis
Lichen planus
Herpes
Nummular eczema
Box 2. Psychiatric syndromes with dermatologic expression
Self-inflicted dermatologic lesions
Dermatitis artefacta
Neurotic excoriations
Trichotillomania
Hypochondriasis (the so-called phobias)
Venereophobia
Dysmorphophobia
Bromhidrosiphobia
Glossodynia
Delusions of parasitosis (Ekbom's disease)
The aforementioned paths of thought and method are useful in individuating
psychosomatic (and somatopsychic) factors in the individual patient who presents
to the dermatologist, with the dermatologist deciding case by case regarding the
necessity for collaboration (or even close consultation-liaison) with a
psychologist or psychiatrist. It is important for the dermatologist to find one
or more psychologist/psychiatrist colleagues with whom he or she relates well to
discuss cases and to whom the dermatologist can refer patients for specifically
psychologic problems, even while continuing to manage the dermatologic aspects.
Such consultation-liaison also can be performed in private practice, as the
author has done since the 1970s. The greatest advantage to such collaboration is
that the patient receives the necessary dermatologic expertise and treatment and
appropriate specialized psychologic/psychiatric management. The schematic
information presented in Table 2 provides generic clues of what the
dermatologist might need to look for or at in deciding when some form of
psychologic/psychiatric assistance might be helpful or necessary in treating the
patient.
The criteria used relate well to the opinions on psychosomatic medicine
expressed by the psychiatrists Kaplan and Sadock [7]. In their Handbook of
Psychiatry for students, which refers to the general classifications established
in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
(DSM-IV), they dedicate a chapter to “Psychosomatic Disorders,” although the
DSM-IV seems to ignore psychosomatics. The subtitle of the chapter is
“Psychosomatic Factors Affecting Medical Conditions.” Bypassing the prevailing
position imposed by the DSM-IV, these authors offer their definition, ad usum
Delphini (the student): “The term psychosomatic disorder refers to a physical
condition1 …While many disorders are influenced by stress, conflicts or
generalized anxiety, some are more influenced than others” [7].
Regarding pathogenetic theories, basically the author agrees with Kaplan and
Sadock's [7] “nonspecific theory:” any prolonged stress, or even strong emotion
or conflict, can cause pathophysiologic changes that provoke pathologic
disorders or alterations. Most individuals have a “shock organ” (or even more
than one) that is genetically (or otherwise predisposed because of trauma or
other stimulus) vulnerable to stressors (“meiopragia” is the term used in the
past to refer to such organ vulnerability). Some subjects are cardiac reactors
(stress provokes cardiac damage), others are gastric reactors, and others are
skin reactors.
The advances in psychoneuroendocrinoimmunology based on neuropeptide research
led the author and colleagues to state that the future had begun [8], [9], but
since then the arrival of new information in this field has been slow.
Dermatologists are waiting for scientific data that show clearly the various
factors operative in this field, individuating their specific mechanisms of
influence in psyche–skin (skin–psyche) relationships.
Gabbard [10] reported on some new neurobiologic perspectives that he attempted
to connect directly with psychodynamic psychotherapy. His article closed with a
short list of clinical implications and limits of the studies presented,
including the fact that psychotherapy and pharmacologic treatment can have
similar influences on the brain in certain conditions, but that studies on
changes in the brain during psychotherapy still need further investigation and
confirmation.
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1 In the author's opinion, this should read “The term psychosomatic disorder
refers to a pathologic condition caused or aggravated by psychologic and
psychopathologic factors.”
SUMMARY
This article has been a series of notes, with references to certain milestones
in the long march to bring the mind and body closer together through
individuation of the factors involved in their intrinsic automatic relationship.
It is hoped that with this understanding of psychosomatics the dermatologist can
understand and treat his or her patients better.
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REFERENCES:
[1] Weiss E., English O.S., Psychosomatic medicine 1949. Philadelphia: Saunders.
[2] Panconesi E., Argentieri S., Epistemological aspects of psychosomatic
dermatology. J Dermatol Psychosom (2000) 1 : pp 53-55.
[3] Koblenzer C.S., Psychocutaneous disease 1987. Orlando (FL): Grune &
Stratton.
[4] Panconesi E., Lo stress, le emozioni e la pelle: spunti di dermatologia
psicosomatica per lo specialista e per il medico pratico 1990. Milan: Masson.
[5] Panconesi E. Clin Dermatol (1984) 2 : pp 1-282.
[6] Blumenthal D., Skin and emotions—one's mental state affects the body; stress
can precipitate or aggravate, skin disorders. New York Times Magazine (September
30, 1984) : pp 62-.
[7] Kaplan H.I., Sadock B.J., Handbook of psychiatry 1996. Baltimore: Williams &
Wilkins.
[8] Lotti T., Hautmann G., Panconesi E., Neuropeptides in skin. J Am Acad
Dermatol (1995) 33 : pp 482-496. Full Text
[9] Panconesi E., Hautmann G., Lotti T., Neuropeptides and skin: the state of
the art. J Eur Acad Dermatol Venereol (1994) 3 : pp 109-115.
[10] Gabbard G.O., A neurobiologically informed perspective on psychotherapy. Br
J Psychiatry (2000) 177 : pp 117-122. Abstract