18
The New Psychopsoriasis

The psychological approach to psoriasis is now in the midst of a quiet revolution. The openness of mainstream dermatology is at an all-time high and research interest is growing. People with psoriasis are the fastest growing part of my practice, but although awareness and attitudes are changing, the disease itself is no different than it has been back through the ages.

Approaches to psoriasis have spanned the full range of human possibilities. In the Middle Ages, people with the disease were declared dead by the church or were burned at the stake. Yet at roughly the same time in Persia, psoriasis was successfully treated with psychotherapy.

Let's review new developments, remembering these two fundamental principles:

What you have inherited is the possibility of psoriasis. Having actual symptoms depends on your ability to negotiate with the triggers, which include emotional factors.

Every skin cell could be affected at every moment. Any area that is clear for any period of time is an affirmation of your body's ability to triumph over the possibility of psoriasis.

Let's look first at the emotional impact of having psoriasis. You don't need anyone to tell you how psoriasis makes you feel, but it is important to realize that you are probably suffering from normal reactions to an abnormal situation.

John Updike's beautifully written accounts ironically combine the definitive description of his inner experience with a puzzling disregard of the potential of psychological help:

Psoriasis keeps you thinking. Strategies of concealment ramify, and self-examination is endless. You are forced to the mirror again and again; psoriasis compels narcissism, if we suppose a Narcissus who did not like what he saw.

An over valuation of the normal went with my ailment, a certain idealization of everyone who was not, as I felt myself to be, a monster. Because it came and went, I never settled in with my psoriasis, never adopted it as, inevitably, part of myself: it was, instead, a constant rude awakening.

A study of one hundred long-term patients by Stanker noted that the majority considered embarrassment the worst feature of their disease. Stares, real or imagined, and fears of contagion among the uninformed took a severe emotional toll. Indeed, ignorance about psoriasis has long compounded its impact. The disease wasn't distinguished from leprosy in America and Europe until 1908.

Braughman and Sobel's patients also ranked "embarrassment over one's appearance" as the most severe consequence. (Dermatologists in the study ranked it the lowest!)

Ginsburg and Link used modern statistical techniques to tease out the essence of the feelings stirred up by psoriasis. They believe that stigmatization is pivotal. A stigma is any "biological or social mark that sets a person off from others, is discrediting, and disrupts interactions with others." (The original Greek stigma was a pointed instrument used to cut or burn marks into the flesh of people who were to be avoided.)

Which feelings contributed most to the stigmatization experience?

• Anticipation of rejection
• Feeling flawed
• Guilt and shame
• Absence of positive attitudes and beliefs
• Secretiveness

Other factors heightened or diminished feelings of stigma. On the positive side, people who were working, and whose psoriasis started later in life, were less vulnerable. The extent of bleeding most strongly predicted a tougher time with these feelings.

More important than the role of psoriasis in triggering emotional upset, the role of emotional upsets in triggering psoriasis has been recognized in the West for at least one hundred years. English physician R. H. Seville found that among sixty-two patients with psoriasis, the ones who did best were those who could identify the stressful events that triggered outbreaks. An understanding of provoking factors apparently improves, or at least accompanies, the ability to deal more effectively with the disease.6

Various research studies estimate that between 40 and 80 percent of people with the disease are "stress reactors." Who are these people versus those who don't report their psoriasis worsening with stress? The assumption is that stress reactors not only have a better prognosis but are more likely candidates for psychological techniques.

We may be looking at a useful conclusion arrived at by dubious logic:  in fact, the studies are not looking at stress reactivity as such but rather the ability to recognize the triggering factors. The "stress reactors" may well be people with more psychological awareness. This work underscores the importance of the Time Line and Micro Time Line exercises:  it suggests that your progress with them may enhance your ability to use the psychological treatment techniques effectively.

Good results have been obtained with most of the techniques, including hypnosis, psychotherapy, relaxation, and biofeedback. Group psychotherapy, support groups, and mutual help groups have proven helpful as well, particularly in cushioning the impact of the disease.

The psychological approach to psoriasis has been finding a more and more sympathetic ear in the mainstream of dermatology. In a major address to the thirtieth annual meeting of the North American Clinical Dermatologic Society, Dr. Eugene Farber, professor emeritus at Stanford University, asserted the central role of stress (especially anxiety, depression, and grief) as a trigger of psoriasis. He strongly endorsed a therapeutic role for clinical psychologists, stress reduction, biofeedback, discussion groups, and attitude change.

Winchell and Watts from Texas worked with a random selection of patients who were not being helped by medical treatment alone.11 Seven received weekly hypnosis and relaxation treatments augmented by daily use of a relaxation and imagery audio cassette. A second group of five did their hypnosis and relaxation in a group along with self-hypnosis and tapes. (All tapes used imagery of the treatment and cure as well as direct suggestion of resolution of lesions.) Everyone experienced the techniques as an important breakthrough; they saw both significant relief from their psoriasis and improvements in self-image.

Receptive dermatologists need options beyond referring people to mental health practitioners, giving them books like this one, or suggesting that they reduce their stress levels. Light treatments provide a good opportunity to add a psychological component. Many of my patients take individualized tapes into the light box. Bernhard and colleagues did a controlled study of a similar approach and were able to document quicker clearing with the tapes. Their audiotapes were not tailored to the individual but were varied for different light treatments; they included mindful focusing on breathing, muscles and body sensations, and music. The tapes also guided visualization of the mechanisms and cellular effects of the treatment.

I have seen some very rapid and dramatic improvements, usually in people whose psoriasis had arrived on the scene recently and was not too widespread. Psoriasis that has been entrenched for decades and involves a large part of the body may require several years of work, with the psychological techniques becoming a useful part of continuing treatment. The Time Lines are the most useful diagnostic technique. Most ideal imaginary environments emphasize sunlight and warmth. Visualizations on the cellular level are particularly helpful.

One personality pattern has emerged that is not mentioned in the literature but several dermatologist colleagues have noticed it as well. Fast, fast, fast:  many people with psoriasis seem to be always on the run. I've seen a series of people who were wonderfully bright, active, accomplished, energetic human beings, but they weren't just in high gear most of the time--overdrive or hyperdrive was more like it.

They varied widely in overall psychological health, and each had different emotional hot spots. A successful sales rep practically lived at the airport as she tried to generate more and more cash to buffer a deep sense of vulnerability and unlovability. A composer frantically produced four dozen film scores working with three computers and two synthesizers simultaneously. He was constantly remaining loyal to his parents' experience of the universe as a place where the sky was falling and only working like a maniac and being constantly sick could ensure survival. Another man, the son of a very intrusive and sexualizing mother, had to stay relentlessly sexually and professionally active for fear that if he let any degree of sexual tension build up, some unnamed disaster would strike. The daughter of an alcoholic couple spent her adult life trying to establish the control and predictability that had been terrifyingly absent when she was growing up.

These different individuals were all chased by personal "monsters" that they experienced as external but that actually lurked in their own hearts, brains, and expectations. They were all moving much too fast for their own good. Was their skin doing exactly the same thing? In psoriasis, skin cells look red and raw, having come up to the surface before they have the time to fully mature. Frantic overproduction causes constant flaking.

The exact link between slowing down emotionally and the skin's slowing down is not clear medically, but this connection helped each of these people make dramatic improvements. Slow down, see what monster catches up with you, then reevaluate if you and your skin really need to keep running. What are you so frightened of? What support will you need from the inside and the outside to hold your ground and face the monster? Be sure and ask these questions as you do the other diagnostic and treatment exercises.

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