Dermatologic Therapy, Vol. 21, 2008, 409–411 Printed in the United States · All rights reserved
© 2008 Wiley Periodicals, Inc.
DERMATOLOGIC THERAPY ISSN 1396-0296
Blackwell Publishing Inc
HOT TOPICS
Indications for psychological intervention in patients with psoriasis KONRAD JANOWSKI* & ALDONA PIETRZAK† *Department of Adult Clinical Psychology, John Paul II Catholic University of Lublin, Lublin, Poland, †Department of Dermatology, Venereology and Pediatric Dermatology, Medical University of Lublin, Lublin, Poland
ABSTRACT: Various forms of psychological interventions have since long been proposed as potentially helpful adjuncts to standard pharmacological therapy of psoriasis. All studies investigating the effectiveness of psychological intervention in psoriasis reported its positive impact on the patients’ psychological well-being and some studies also reported improvements in the skin condition as a result of psychotherapy. When making a decision about the referral of a given patient to the psychologist, both clinical (psoriasis-specific) and general (psychotherapy-specific) indications should be taken into consideration. This can allow a better identification of those psoriasis patients who are in real need for psychological intervention and who are most likely to benefit from it. KEYWORDS: guidelines, psoriasis, psychological intervention, psychotherapy
Introduction
Specific indications
Various forms of psychological interventions have since long been proposed as potentially helpful adjuncts to standard pharmacological therapy of psoriasis, contributing to the patients’ improved psychological well-being and faster skin clearance (1). However, the cost-effective approach favors a selection of the patients referred to psychological intervention according to the pre-established indications maximizing the likelihood of a potential benefit rather than random or “for anybody” referrals. Here, we would like to propose some guidelines that may help clinicians in taking decisions concerning such referrals.
Ample evidence exists that psychiatric and behavioral disorders, particularly depression and anxiety disorders, often co-occur with psoriasis. Their comorbidity with psoriasis should be considered as an indication for a psychological intervention. Suicidal ideation was also reported to be significantly more frequent in the population of inpatients with psoriasis (1), and it constitutes an important reason for psychological intervention. It should also be remembered that when mental or behavioral disorders are suspected, a psychiatric consultation may be necessary, prior to a referral for a psychological intervention, and this is crucial when the patient manifests suicidal ideation (2). In some cases a combination of both psychopharmacological and psychological treatment may prove most successful.
Address correspondence and reprint requests to: Dr Konrad Janowski, Department of Adult Clinical Psychology, John Paul II Catholic University of Lublin, Al. Raclawickie 14, 20-950 Lublin, Poland, or email:
[email protected].
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Another group of psoriasis patients who may potentially benefit from psychological intervention involves those whose history clearly reveals psychological stress as a psoriasis-triggering or aggravating factor. Some preliminary findings suggest that psychological treatment may be particularly beneficial for these patients as compared to those who do not report associations of the disease course with stress (3). However, it should be realized that the mere presence of a stressful life situation does not constitute an absolute indication for psychological intervention, particularly if no connection can be traced between the stressful event and exacerbation or changes in the course of psoriasis. Significantly decreased quality of life constitutes another indication for psychological treatment in patients with psoriasis. Since quality of life assessment becomes more and more common in clinical practice, its results may serve as a robust criterion when considering the need for psychological help. Most probably, primarily those patients should be referred to a psychologist whose quality of life is seriously affected in such domains as social relationships, sexual functioning, and self-esteem. In this context, it is also worth noticing that decreased quality of life may be a considerably stronger indication for psychological intervention than objective disease severity such as that reflected in the Psoriasis Area Severity Index (PASI) score. Increased pruritus should also be viewed as an indication for psychological intervention. Research on pruritus in psoriasis showed that this symptom is modified by a range of psychological factors such as increased depression, higher stress levels, and lower quality of life, therefore shows promise to be responsive to psychological influences (4). Specific psychotherapeutic approaches are available targeting at psychophysiological symptoms such as pruritus (5). Another clinical characteristic of psoriasis patients, suggestive of the need for psychological help, are increased feelings of stigmatization. Feelings of stigmatization involve cognitive factors, such as sensitized attention to potential rejecting behaviors of others, biased interpretation of others’ behaviors and intentions, or anticipatory expectations of unfavorable reactions from others. Certain psychological approaches can offer effective ways of dealing with such cognitive beliefs or enhance social skills to be used in coping with real rejection situations. Psychological intervention may turn out particularly helpful in those patients, whose psoriasis is
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notoriously unresponsive to standard pharmacological treatments and in whom an underlying emotional cause of the recalcitrant course of the disease may be suspected. Psychotherapy was reported as a potentially helpful treatment option for intractable inflammatory dermatoses, including psoriasis (6). A referral to the psychologist is advised in the cases of children and adolescents with psoriasis. Psoriasis in childhood was reported to be particularly frequently precipitated by psychological stress (7), and in such situations, the psychologist may help to evaluate the potential stressful factors and ameliorate them. However, even if no psychological factors can be traced in the etiology of psoriasis, the occurrence of the disease in early childhood alone always poses a risk for disturbances of normal psychosocial development. The psychological intervention may help to shape appropriate parental attitudes and educational techniques, and prevent potential adverse effects of psoriasis on the child’s personality. The same is particularly true for adolescents, as body image and self-esteem in this developmental period are naturally fragile and may be easily devastated by an esthetically disfiguring disease such as psoriasis. It remains unclear if other subgroups of psoriasis patients can specifically benefit from psychological intervention. Studies in patients with other chronic diseases suggest that psychological intervention may not provide much significant improvement in patients who are already well adapted (8). It should be emphasized, however, that the so-called “difficult” patients, who during treatment reveal behaviors troublesome for the staff, including instigating conflicts, incompliance, disregard for medical staff, or rejection of the therapeutic cooperation, are not necessarily the group predisposed for psychological intervention. Although it is these patients who are frequently referred for a psychological consultation, the practice shows that they typically benefit little from psychological counseling. Having said this, however, certain psychosocial interventions have been reported in the literature aimed at enhancing the patients’ adherence to pharmacological treatment, though in samples other than psoriasis patients, and certain tips have been proposed useful in dealing with such patients (9). Finally, it should also be mentioned that apart from specific psoriasis-related indications for psychological intervention, there are also other, more universal factors, investigated thoroughly in basic research on psychotherapy, that are commonly considered to be predictors of psychological intervention effectiveness, largely irrespective of
Psychological intervention in psoriasis
Table 1. Summary of the indications for psychological intervention in patients with psoriasis Clinical Depression Anxiety disorders Suicidal ideation Other mental or behavioral disorders History of stress as a psoriasis-triggering/aggravating factor Significantly decreased quality of life Increased pruritus Feelings of stigmatization Recalcitrant disease course with a suspected emotional cause Psoriasis in childhood or adolescence General Average or higher motivation for participation in psychological intervention Average or higher insight Realistic expectations as to the results of psychological treatment
the clinical sample or treatment method. Good general predictors of successful completion of a psychological intervention are at least average motivation for the participation in the intervention and realistic expectations as to the results of the intervention, whereas at least average insight abilities are prognostic for achieving better psychotherapy results. Therefore, these factors should also be taken into account, beside specific clinical indications, when taking the referral decision with regard to psoriasis patients (Table 1).
Conclusions Many patients with psoriasis are in real need for a form of psychological intervention; however, no specific guidelines were available providing
reasonably justified criteria for the selection of patients who may best profit from such intervention. We believe that this brief review may at least partially complete this gap while suggesting specific clinical indications for psychological intervention in psoriasis patients.
Acknowledgments A part of this work was done when Dr Janowski was receiving a scholarship grant from Università Cattolica del Sacro Cuore, Milan, Italy.
References 1. Gupta MA, Schork NJ, Gupta AK, Kirkby S, Ellis CN. Suicidal ideation in psoriasis. Int J Dermatol 1993: 32: 188 – 190. 2. Gupta MA, Gupta AK. The use of antidepressant drugs in dermatology. J Eur Acad Dermatol Venereol 2001: 15: 512 – 518. 3. Niemeier V, Nippesen M, Kupfer J, Schill WB, Gieler U. Psychological factors associated with hand dermatoses: which subgroup needs additional psychological care? Br J Dermatol 2002: 146: 1031–1037. 4. Gupta MA, Gupta AK, Kirkby S, et al. Pruritus in psoriasis. A prospective study of some psychiatric and dermatologic correlates. Arch Dermatol 1988: 124: 1052–1057. 5. Grillo M, Long R, Long D. Habit reversal training for the itch-scratch cycle associated with pruritic skin conditions. Dermatol Nurs 2007: 19: 243–248. 6. Koblenzer CS. Psychotherapy for intractable inflammatory dermatoses. J Am Acad Dermatol 1995: 32: 609–612. 7. Benoit S, Hamm H. Childhood psoriasis. Clin Dermatol 2007: 25: 555–562. 8. Vos PJ, Visser AP, Garssen B, Duivenvoorden HJ, de Haes HC. Effectiveness of group psychotherapy compared to social support groups in patients with primary, nonmetastatic breast cancer. J Psychosoc Oncol 2007: 25: 37– 60. 9. Othmer E, Othmer JP, Othmer SC. Our favorite tips for “getting in” with difficult patients. Psychiatr Clin North Am 2007: 30: 261–268.
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