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Biofeedback, cognitive-behavioral methods, hypnosis: “alternative psychotherapy?”
Biofeedback, Cognitive-Behavioral Methods, Hypnosis: “Alternative Psychotherapy?” EMILIANO PANCONESI, MD FERDINANDO GALLASSI, MD MARIO G. SARTI, MD MARY ANN BELLINI, MA
“P
sychotherapy is in its broadest sense the systematic effort of a person or group to relieve distress or disability by influencing the sufferer’s mental state, attitudes and behaviour.”1 Actually psychosomatic dermatology can make use of all the branches of psychotherapy, but best if the decision is assumed in liaison-consultation with psychiatrists and/or psychologists. The first essential step of psychotherapy, counseling, is the task of the dermatologist and can be repeated usefully in numerous sessions. This is not the place to define and classify the term psychosomatic medicine from epistemological and clinical points of view, nor to discuss the use of the less justified synonyms psychodermatology and psychocutaneous medicine. Our group2 for clinical work and research by-passed the problems of definition and classification of psychosomatic cutaneous affections by dividing them into three distinct groups: cutaneous affections with high incidence of psycho-emotional factors (Table 1), dermatologically expressed psychiatric syndromes (Table 2), and somatopsychic reactions. It is superfluous to list the cutaneous affections with more or less somatopsychic rebound. In fact the visibility of the skin frequently comports alteration of one’s body image, with variable degrees of psychological influence, depending on the subject, with development of true psychopathological features in extreme cases, caused by unaesthetic lesions (alopecia, for example early balding, hypertrichosis, vitiligo, multiple melanocytic nevi, angioma, adolescent and adult acne, rosacea, striae cutis, cellulitis, etc.). In psychosomatic dermatology one can use any of the psychotherapeutic techniques, specifically those outlined by Kaplan and Sadock:3 I. Psychoanalysis and psychoanalytic psychotherapy From the Department of Dermatology, University of Florence, Florence, Italy. Address correspondence to Emiliano Panconesi, MD, Professor, Dept. of Dermatology, University of Florence, Via Alfani, 37, Florence, Italy. © 1999 by Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010
A. Psychoanalysis B. Psychoanalytically oriented psychotherapy C. Brief dynamic psychotherapy II. Behavior therapy A. Token economy B. Aversion therapy C. Systematic desensitization D. Flooding III. IV. V. VI.
Cognitive therapy Family therapy Interpersonal therapy (IPT) Group therapy A. Alcoholics Anonymous (AA) B. Milieu therapy C. Multiple family groups (MFGs)
VII. Couples and marital therapy The opinion that biofeedback, hypnosis, and cognitive-behavioral techniques are branches of alternative medicine in this particular case in dermatology is surely debatable, but also interesting. We believe that these techniques are now a well accepted part of official, western, scientific medicine, even in relation to dermatology. Leaving aside discussion of the boundaries between official and alternative medicine, let us focus on the main problem, the patient, in our case the dermatologic patient who, in cases involving psychosomatic affections, as we define them,1 can benefit greatly from the techniques outlined in this section. These techniques require the specific competence of experienced psychologists and/or psychiatrists (and we have called on three experts to illustrate the different types of technique), but knowledge of the various techniques and methods available and their underlying principles is useful to dermatologists, as well as to all other physicians. In fact, counseling, the first fundamental step in psychotherapy, is a task for and must be undertaken by, in the case of our patients, the dermatologist: he or she is the partner, caretaker chosen by the patient who, at 0738-081X/98/$–see front matter PII S0738-081X(98)00060-1
Clinics in Dermatology
710 PANCONESI ET AL.
Table 1. Cutaneous Affections Reported to Have High Incidence of Psycho-emotional Factors Hyperhidrosis Dyshydrosis
Telogen effluvium Alopecia areata
Pruritus sine materia Urticaria Lichen simplex
Psoriasis Seborrheic dermatitis Nummular dermatitis Lichen planus Herpes Warts
Atopic dermatitis
Acne Rosacea Perioral dermatitis
Table 2.
Y
1998;16:709 –710
Psychiatric Syndromes with Dermatological Expression
Self-Inflicted Dermatologic Lesions-SIDL Dermatitis artefacta (cutaneous pathemimesis) Neurotic excoriations Trichotillomania Onychotillomania
Hypochondria and So-Called Phobias Hypochondrias Dermatologic phobias Venereophobia Oncophobia Dysmorphophobia (dermatological non-disease) Bromidrosiphobia Glossodynia/Glossopyrosis Vulvodynia/Vulvopyrosis
Vitiligo
least initially, does not want to be referred to other specialists. The basic cultural and operant information about the three types of psychotherapy can be of valid assistance to the dermatologist in his counseling activity. For example, observe the items suggested in the phases of rational restructuring (article on “CognitiveBehavioral Techniques”, pages 715–717) and compare them with the results of a good anamnesis and useful conversation with a patient; you will discover, as with
the other techniques, analogies and some very useful indications and suggestions.
References 1. Encyclopedia Britannica, Vol. VII, 1982:275. 2. Panconesi E. Stress and Skin Diseases: Psychosomatic Dermatology. Clin Dermatol 1986;2:1–282. 3. Kaplan HI, Sadock BJ. Pocket Handbook of Clinical Psychiatry. Baltimore: Williams & Wilkins, 1996;266 –72.
“P
sychotherapy is in its broadest sense the systematic effort of a person or group to relieve distress or disability by influencing the sufferer’s mental state, attitudes and behaviour.”1 Actually psychosomatic dermatology can make use of all the branches of psychotherapy, but best if the decision is assumed in liaison-consultation with psychiatrists and/or psychologists. The first essential step of psychotherapy, counseling, is the task of the dermatologist and can be repeated usefully in numerous sessions. This is not the place to define and classify the term psychosomatic medicine from epistemological and clinical points of view, nor to discuss the use of the less justified synonyms psychodermatology and psychocutaneous medicine. Our group2 for clinical work and research by-passed the problems of definition and classification of psychosomatic cutaneous affections by dividing them into three distinct groups: cutaneous affections with high incidence of psycho-emotional factors (Table 1), dermatologically expressed psychiatric syndromes (Table 2), and somatopsychic reactions. It is superfluous to list the cutaneous affections with more or less somatopsychic rebound. In fact the visibility of the skin frequently comports alteration of one’s body image, with variable degrees of psychological influence, depending on the subject, with development of true psychopathological features in extreme cases, caused by unaesthetic lesions (alopecia, for example early balding, hypertrichosis, vitiligo, multiple melanocytic nevi, angioma, adolescent and adult acne, rosacea, striae cutis, cellulitis, etc.). In psychosomatic dermatology one can use any of the psychotherapeutic techniques, specifically those outlined by Kaplan and Sadock:3 I. Psychoanalysis and psychoanalytic psychotherapy From the Department of Dermatology, University of Florence, Florence, Italy. Address correspondence to Emiliano Panconesi, MD, Professor, Dept. of Dermatology, University of Florence, Via Alfani, 37, Florence, Italy. © 1999 by Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010
A. Psychoanalysis B. Psychoanalytically oriented psychotherapy C. Brief dynamic psychotherapy II. Behavior therapy A. Token economy B. Aversion therapy C. Systematic desensitization D. Flooding III. IV. V. VI.
Cognitive therapy Family therapy Interpersonal therapy (IPT) Group therapy A. Alcoholics Anonymous (AA) B. Milieu therapy C. Multiple family groups (MFGs)
VII. Couples and marital therapy The opinion that biofeedback, hypnosis, and cognitive-behavioral techniques are branches of alternative medicine in this particular case in dermatology is surely debatable, but also interesting. We believe that these techniques are now a well accepted part of official, western, scientific medicine, even in relation to dermatology. Leaving aside discussion of the boundaries between official and alternative medicine, let us focus on the main problem, the patient, in our case the dermatologic patient who, in cases involving psychosomatic affections, as we define them,1 can benefit greatly from the techniques outlined in this section. These techniques require the specific competence of experienced psychologists and/or psychiatrists (and we have called on three experts to illustrate the different types of technique), but knowledge of the various techniques and methods available and their underlying principles is useful to dermatologists, as well as to all other physicians. In fact, counseling, the first fundamental step in psychotherapy, is a task for and must be undertaken by, in the case of our patients, the dermatologist: he or she is the partner, caretaker chosen by the patient who, at 0738-081X/98/$–see front matter PII S0738-081X(98)00060-1
Clinics in Dermatology
710 PANCONESI ET AL.
Table 1. Cutaneous Affections Reported to Have High Incidence of Psycho-emotional Factors Hyperhidrosis Dyshydrosis
Telogen effluvium Alopecia areata
Pruritus sine materia Urticaria Lichen simplex
Psoriasis Seborrheic dermatitis Nummular dermatitis Lichen planus Herpes Warts
Atopic dermatitis
Acne Rosacea Perioral dermatitis
Table 2.
Y
1998;16:709 –710
Psychiatric Syndromes with Dermatological Expression
Self-Inflicted Dermatologic Lesions-SIDL Dermatitis artefacta (cutaneous pathemimesis) Neurotic excoriations Trichotillomania Onychotillomania
Hypochondria and So-Called Phobias Hypochondrias Dermatologic phobias Venereophobia Oncophobia Dysmorphophobia (dermatological non-disease) Bromidrosiphobia Glossodynia/Glossopyrosis Vulvodynia/Vulvopyrosis
Vitiligo
least initially, does not want to be referred to other specialists. The basic cultural and operant information about the three types of psychotherapy can be of valid assistance to the dermatologist in his counseling activity. For example, observe the items suggested in the phases of rational restructuring (article on “CognitiveBehavioral Techniques”, pages 715–717) and compare them with the results of a good anamnesis and useful conversation with a patient; you will discover, as with
the other techniques, analogies and some very useful indications and suggestions.
References 1. Encyclopedia Britannica, Vol. VII, 1982:275. 2. Panconesi E. Stress and Skin Diseases: Psychosomatic Dermatology. Clin Dermatol 1986;2:1–282. 3. Kaplan HI, Sadock BJ. Pocket Handbook of Clinical Psychiatry. Baltimore: Williams & Wilkins, 1996;266 –72.