Synopsis of training programme for dermatologists in non-pharmacological (Psychological) interventions in dermatology

Sudhir Nayak, Shrutakirthi Shenoi

 Department of Dermatology, Kasturba Medical College and Hospital, Manipal University, Manipal, India

Correspondence Address:
Sudhir Nayak
U.K., Department of Dermatology, Kasturba Medical College, Manipal University, Manipal-576 104
India

The Department of Dermatology, Kasturba Medical College and Kasturba Hospital, Manipal of Manipal University along with the Special interest group (Psychodermatology) of the Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) conducted a two days training programme on Non-pharmacological (psychological) interventions in Dermatology at Manipal on 17 ^th and 18 ^th November, 2012.

Dr. Mahendra Sharma from NIMHANS, Bangalore began the programme with a lecture on the relevance and application of cognitive behaviour therapy (CBT) in dermatological conditions. Psychodermatology is a super-speciality of medicine that deals with the complex interaction of the mind (psyche) and the skin. This inter-relationship between both is best illustrated by the numerous skin disorders which have got a psychological component and those skin disorders which are manifestations of psychiatric disturbances. Dermatological patients often tend to have low self-esteem, changing body image, anxiety, feeling of helplessness, high prevalence of psychiatric problems and negative psychosocial experience. The psycho-social distress is dependent on the skin disease, personality of the patient and cultural attitudes. Depressive patients often tend to have heightened sensitivity to itch sensation. Limited mother-child relationship often results in dermatological adverse effects, as studies have found that physical and psychological communication of mother and child are important and the lack of it can lead to dermatoses like atopic dermatitis. Atopic patients generally tend to be anxious and depressed. Psoriatic patients often tend to be depressed, anxious and have stress induced flares. Acne vulgaris is associated with poor self-esteem, depression, social phobia and anger. CBT is a cost effective, problem solving, short-term self- management approach with a collaborative relationship with the health staff. In CBT, patient′s cognitions or maladaptive thinking is tackled thereby bringing about a behaviour change as that is always influenced by our thoughts. Patient′s perception of the disease is assessed and the negative, dysfunctional irrational thoughts are challenged by the clinical psychologist. It is necessary to provide evidence of the irrationality of these thoughts in bringing about the success of this form of therapy. There are evidence based trials of CBT in psoriasis, atopic dermatitis and vitiligo.

Dr. Paulomi Sudhir, a clinical psychologist from NIMHANS continued the discussion on CBT. Cognitive therapy teaches patients to identify, evaluate, and respond to their dysfunctional thoughts and beliefs. CBT includes a variety of techniques like problem-solving, stress-inoculation, cognitive/rational restructuring and coping skills training. Therapist and patient together establish an agenda with specific target problems to focus on during each session. Key behaviors are focused upon and assertiveness and communication skills are taught. Cognitive restructuring, graduated exposure to feared situations, imagination of worst case scenario and brain storming sessions are held. Therapy is scheduled bi-weekly or more frequently, and may be individual or group formats. This may be applied to a variety of behavioral and medical conditions and itchy skin disorders where patients′ beliefs and negative thoughts can adversely affect the disease.

Dr. Paulomi Sudhir′s next talk was focused on "social skills training and assertiveness", a skill which everyone needs in their day to day life; whether professional or personal. Dr. Sudhir started with the definition of social skills as, "the ability to express both positive and negative feelings in the interpersonal context, without suffering consequent loss of social reinforcement" and is to be situation and culture specific. The five important principles of this are modeling, reinforcement, shaping, overlearning and generalization. Assertiveness on the other hand was defined as ability to express oneself and ones right without violating the rights of others. Acting assertive leads to self-confidence, gaining respect of others, increases chance of honest relationships, better self-control and improved decision making ability. On the other hand, assertiveness may not yield happiness, solve personal problems or achieve what we want. The various types of assertiveness are refusal assertiveness, request assertiveness, commendatory assertiveness. The procedures for assertiveness training include behavioural rehearsal and feedback (groups), developing a hierarchy and cognitive techniques (cognitive restructuring). Communication skills are important for promoting clear expression and reception of meaning, training individuals in reflective listening, promoting effective problem solving skill, learning appropriate communication in varied social contexts and providing positive feedback when desired behaviour occurs.

The talk on application of mindfulness based on intervention by Dr. Mahendra Sharma was an eye opener. Meditation is one of India′s contributions to the world. "Meditation (attention without tension) is form of mental exercise that is an effortless effort that is not against the mind, is non-doing, is not control and is not repression." It can be broadly classified into two categories viz., concentrative meditation and mindfulness meditation. In concentrative meditation, the attention is focused on one object or word (mantra) to achieve stillness of mind and then allowing awareness and clarity to emerge. Mindfulness meditation or insight meditation or awareness meditation or ′vipassana′ is one of the ancient meditation techniques with origin in India. Mindfulness meditation involves expanding the attention to become aware of own′s surroundings without being involved in thinking about them. The various mechanisms in mindfulness is exposure, minimization of experimental avoidance, acceptance, cognitive changes, self-management and relaxation. Mindfulness based approaches tend to produce long lasting reduction in physical and psychological symptoms, increased ability to effectively deal with short and long term stressful situations, enhanced spiritual, physical and psychological well-being.

Dr. Paulomi Sudhir′s talk on habit reversal training with description of technique and applications was one of the highlights of the programme and is used to treat habit disorders like trichotillomania, skin pinching, nail biting, Tourette′s syndrome etc. The main steps of habit reversal training include habit awareness, deep muscle relaxation, deep muscle relaxation with breathing control and competing response practice.

Another interesting talk was on a clinician′s perspective on patients saying, "I feel depressed and self-conscious because of my skin" by Dr. Paulomi Sudhir. Skin is most visible organ of the body and skin disorders often are associated with intrusive questions or inquisitive glances and are thus associated with self-consciousness, dejection, depression, poor self-image, low self-esteem, avoidance, guilt, self-blame, social withdrawal and stigmatization. Psychological and psychiatric disturbances are noted in nearly 30% of dermatological patients. The talk was inter-spread with role plays on the topic. The various treatment components include identifying the risk factors associated with disease exacerbation, assessing current mood state, life events and stressors, providing rationale for interaction between stressors and aggravation and presenting a cognitive model for maintaining factors. The cognitive methods include identifying negative automatic thoughts and dysfunctional assumptions, systemically challenging them, providing evidence and counter evidence and connecting behavioural and cognitive methods to change mood. The behavioural methods used include:

• anticipatory and avoidance behaviours
• training in relaxation
• exposure
• mood
• improve self-image- focus on positive images of self
• self-acceptance-assertiveness, communication skills- enhance interpersonal effectiveness
• coping with illness and adaptation- self acceptance
• remove behaviours that maintain self-consciousness and negative evaluation
• reduce self-criticality and increase positive feelings for self

The methods of preventing relapse include:

• owing responsibility for change
• identifying potentially high risk and challenging situations
• reviewing coping skills (including social support) and keeping a blue print for future
• increasing use of self- instructions positive self-statements and reducing avoidance, while being assertive

Dr. Abdul Lateef from Kozhikode enthralled the delegates with a breathtaking and relaxation talk on the application of hypnotherapy in dermatology. He started with the definition of hypnosis as the intentional induction, deepening, maintenance and termination of natural trance like state. The stages of hypnosis are induction phase and suggestion (trance) phase. The trance phase is characterized by deep relaxation, altered consciousness, narrow awareness, restricted and focused attentiveness, selective wakefulness and heightened suggestibility. The benefits of hypnotherapy include calming mind and body, normalization of sleep, decreased pain, breaking itch-scratch cycle, decreasesd anxiety and depression and rapid clearance of disease. It helps to strengthen coping mechanisms, enhance self-esteem, break ill habits, increase concentration and memory and development of positive attitude. The types of trance are summarized in [Table - 1]. Dermatological conditions in which hypnotherapy has been tried include atopic dermatitis, acne excoriee, alopecia areata, erythromelalgia, glossodynia, herpes simplex infection, hyperhidrosis, lichen planus, neurodermatitis, nummular dermatitis, penodynia, pompholyx, rosacea, post herpetic neuralgia, pruritus, psoriasis, trichotillomania, urticaria, vasculitic ulcer, verruca and vitiligo. He also demonstrated painless introduction of a needle into a volunteer thereby implying the use of hypnosis in minor procedures and also in people who have injection /needle phobia.

An interesting talk on "Biofeedback" was presented by Dr. Shwetha Rai. Biofeedback is defined as a self- regulation technique used to voluntarily control physiological processes of the body by means of physiological information (feedback) provided to the patient in the form of audio/visual cues. The feedback responses monitored include skin surface temperature, electrodermal response, blood pressure, heart rate, muscle tension and brain wave activity. It is an active process of learning where the participant takes an active role and is taught how the signals generated are related to normal physiology. The role of mental stress in altering normal physiological process can be well elicited by biofeedback. The various types of biofeedback are electromyography, finger temperature, sweat gland activity, electroencephalogram and pelvic floor disorder sensors. Biofeedback in dermatology is particularly useful in management of Raynaud′s disease, hyperhidrosis, dyshidrosis and psoriasis.

Talk on imagery training was given by Mr. Dinesh, Head of Department (HOD) of clinical psychology. Imagery is strongly linked to emotion process and is one of the new frontiers of CBT. Imagery reveals underlying schemes, scripts, beliefs, about self and world and imagery training involves alteration, modification of mental images. The therapeutic importance lies in the fact that images are flexible, easy to manage, condense a large amount of information, equivalent to real perception and enable to construct reality. The general features of imagery are controllability, multidimensional, accuracy, positive or negative. The objectives of imagery training are to decrease frequency, vividness and distress of intrusive imagery, unhelpful positive imagery, change the perspective and develop adaptive imageries.

The programme concluded with an interactive panel discussion which was moderated by Dr. Koushik Lahiri. The panel discussion featured excellent discussion with panelists and the audience and Dr. Lahiri queried the panelists with commonly encountered situations which one encounters in their practice.

The two day programme served as a platform for bringing to fore the holistic approach to treating a patient especially in those with chronic dermatological disease. It was an eye opener for the treating physicians for managing patients using alternative and holistic approach. The psychology of the dermatologic patient is an under-researched area and there is a need for better understanding of certain psychological factors, associated stigma and role of stress in exacerbation of skin disorders, rather than a limited focus on the skin lesions only.

The take home message is to have a multidisciplinary approach to treat a patient and to liaise with psychiatrists and /or clinical psychologists especially in chronic dermatoses.