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
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
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
Guilt and shame
Absence of positive attitudes and beliefs
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
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
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
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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