Medicine: Mind Over Skin
A young man is injured during his Israel Defense Forces service. Two weeks later, his wound is healing, but patches of skin all over his body are turning thick and red, then flaking off in silver-white scales.
A woman in her sixties loses a beloved nephew to cancer; within two months of burying him, her body is covered in red lumps that itch so intensely she can no longer sleep.
An apparently healthy man in his thirties suffers so much pain from the skin around his genitals that he has quit work and can scarcely stand upright.
Skin, the largest and heaviest organ in the human body, exposed to assault from within and without, is susceptible to many disorders—perhaps more than any other organ. Doctors have more recently realized, however, that this pliant organ, stretched over the body’s entire external surface, is a canvas on which we often display not only skin disorders, but also stress and psychosis.
During the past five years, this mind-skin connection has developed into the subspecialty of psychodermatology, the managing of skin disorders psychologically as well as dermatologically. While the specialty is new, Dr. Vera Leibovici, a senior dermatologist at the Hadassah–Hebrew University Medical Center at Ein Kerem, has through 32 years of practice always treated “the patient rather than the disease,” she says, “listening to them and spending longer with them than the clinic’s scheduled 15 minutes, to allow time to address underlying emotional issues.”
Psychodermatology made perfect sense to her, and in 2009 she trained at the European Academy of Dermatology and Venereology teaching center in Brussels. She returned to open Hadassah’s psychodermatology unit three years ago and today sees around 30 patients, aged 18 and up, every month.
The consultations can be emotionally painful, she says. A patient comes in with what he or she thinks is a skin disease to be told that it, in fact, is a different type of disorder.
“There are psychiatric conditions that present as skin complaints,” says Dr. Leibovici. “They are self-induced conditions—among them, pulling out hair [trichotillomania], skin picking [psychogenic excoriations] and psychoses, such as illusions of bugs crawling over the body [parasitic delusion]. We refer these patients to mental health professionals.”
Patients with skin problems that react to emotional states are being treated with great success in Hadassah’s psychodermatology unit; psoriasis, urticaria and eczema are prime examples. “When negative feelings—stress, fear, grief—are bottled up, they often find an outlet in and on our bodies, particularly on our skin,” says medical psychologist Uri Mandelkorn, who began working with Dr. Leibovici two years ago as a postgraduate and formally joined her team once he qualified. “The skin speaks for the psyche: It signals distress.”
Medical psychology is a relatively new specialty that focuses on this mind-body connection. In dermatology, its role is to help patients discover the underlying emotional factors contributing to their skin condition and learn how to manage them.
The soldier who developed psoriasis after his IDF injury came to the psychodermatology unit two years later, “looking,” as he put it, “like a leper with all the lesions on me.”
“Skin cells usually grow deep in the skin and rise to the surface about once in three weeks,” says Dr. Leibovici. “In psoriasis, this process is speeded up and dead skin cells build up on the skin’s surface. The etiology is unknown, but there’s some evidence it may be an autoimmune disease. It’s known to be exacerbated by emotional stress in at least half of those it affects. When the disorder fails to respond to treatment, we must ask whether psychological, social or occupational stress is playing a role.”
From among the psychologist’s arsenal of cognitive behavioral therapy—relaxation, meditation, hypnosis, self-hypnosis, biofeedback, focused psychotherapy—Mandelkorn selected the first for this patient. “We began treatment with a diary in which the patient noted when and in what situations the itching became most acute,” he says. “It was apparent that the attacks came when he got up each morning and before his nighttime shower. On a superficial level, it was simple to control this by habit-reversal techniques, which included changing his morning routine, and moving his shower from 9 P.M. to 5 P.M. On a deeper level, we worked to find the mind-body interface.”
During 12 sessions together—the usual duration of treatment—the patient recalled that in high school he used to hurt himself by cutting his hands. Mandelkorn helped him connect this at a psychodynamic level, and he realized the itching was linked to the old pattern of hurting himself.
For the grieving woman who developed itchy red lumps of urticaria (hives) after her nephew died, relaxation techniques along with talking about the time she spent with her nephew helped her deal with her loss. “Her skin complaint gave her an opportunity to talk about her deep grief,” says Mandelkorn. “I taught her focused breathing and progressive muscle relaxation, techniques she practiced with me over four weeks as well as at home between sessions.”
The man with skin pain in his genital area came to Hadassah after seeing a dozen urologists and surgeons in other clinics. He was convinced he had a sexually transmitted disease. When test results were negative, he came to Mandelkorn.
“We began therapy, and a pattern emerged,” says Mandelkorn. “He…told me he wanted a second child but his wife refused. As therapy evolved, childhood issues relating to shame and guilt around early sexuality surfaced. We worked through the impact of the past on the present. His genital pain began to subside, and he has resumed work. He’s still in therapy…to focus on his relationship with his wife.”
While some in the medical community claim that psychodermatology’s successes are anecdotal rather than scientifically proven, psychodermatologists and growing numbers of their medical colleagues have no doubts about its efficacy. Even the American Academy of Dermatology concluded that when dermatologists treat both skin and the source of stress, the skin clears more quickly.
“Skin disorders have many etiologies, from epidemiological to genetic, but mental stress is clearly linked with onset, exacerbation or preventing medical treatment from working properly,” says Dr. Leibovici. “Over half of patients who seek help for skin problems have emotional issues as well. Skin is a living tissue nourished by blood and traversed by nerves. Stress is known to act through different hormones and interleukins on the nerve endings of the skin.”
With some medical professionals skeptical about psychodermatology, it is very much a research topic of the moment. Among studies under way at Hadassah is one of psoriasis patients, in cooperation with the Illinois-based Abbott Laboratories.
“Patients with psoriasis seem more depressed than those with other dermatological diseases,” says Dr. Leibovici. “We are comparing them with patients with equally disfiguring atopic dermatitis, with depressed patients and with a control group. We are asking whether their depression results from the disease’s stigmatization or whether, as I suspect, it is integral to the disorder.”
Another research project concerns skin picking. Often misdiagnosed as a pruritic or itchy skin disorder, it is, in fact, a manifestation of an obsessive compulsive disorder. Dr. Leibovici is studying its prevalence in a population of 1,200 Jews and 1,200 Arabs, looking at familial skin picking to establish whether there is a genetic predisposition and examining its incidence in professionals who are burned-out from their high-stress jobs.
Group therapy, which Mandelkorn launched late last summer, will form the basis of a clinical study. It is helping hospitalized and day-care patients cope with the causes of their disease and its impact on their lives as well as deal with the stigmatization and stress it creates.
The biological mechanisms of psychodermatology are still unknown, but its practitioners and its many patients in Hadassah and worldwide have no doubts about its efficacy.