Dr Pradnya Manwatkar shares insights on stress management and dealing with patients who undergo stress due to PCOS.

Me: Currently, are you under any stress? I am certain that as dermatologists, we all ask this basic question to our patients. And, I am also sure that you too get a myriad of answers. Patient 1: I don’t have stress! Patient 2: I am fine! Patient 3: But is stress not a normal part of life? Patient 4: What has stress got to do with my condition?

And the answer that I usually get from my PCOS patient is not always simple either. Because this group of patients not only have underlying stresses that have gone unnoticed by them, but are stressed out due to their hair growth, hair thinning, and acne. It is a tough place to be in both for the dermatologist and the patient.

To classify PCOS or not!

PCOS has boggled many a Gynecologists, Endocrinologists, and Dermatologists. There has been a myriad of classifications that exist today, and as we have been trained – we diagnose a patient as PCOS with the criteria that are in those systems of classification. But the simple reason PCOS has been an enigma to all of us, especially dermatologists, is because it is difficult to club and classify patients. Because each patient comes to us with a different symptom. Some have only hirsutism, and some may have only acne. Some come with thinning of hair and some come with all of the above. They may or may not necessarily have any irregular menstruation or cysts that are so called ‘conclusive’ of PCOS. But as far as my experience goes, I don’t think classifying a patient has helped me treat them.

A girl, with PCOS or lean PCOS, may have symptoms of hormonal imbalance but need not have menstrual irregularity and it is the symptomatic treatment – both medical and emotional – that I have always focused on rather than giving importance to labelling a patient as PCOS.

Why?

Because these patients have come to you due to the stress associated with their hirsutism or androgenetic alopecia. Not because they want PCOS treated. These patients are troubled due to the sociological impact that these symptoms have on their psyche. Their aunties and mothers and neighbours are pointing it out to them with statements like – “Who will marry you?”, “You look fat”, “Pimples treat karo”, and the most infamous one: “Meri skin tumhari age mein bilkul saaf thi”.

That makes me inclined to treating them not only with all the medical, cosmetic, and laser therapies, that we have in our clinics, but also with emotional therapy – or emodermatology – because unlike psychodermatology, it focuses on illogical or irrational thoughts that lead to negative or harmful emotions, which further lead to PCOS (most of the skin diseases) that we encounter in our practices, rather than giving tricyclic antidepressant or a benzodiazepine pill and diagnosing a patient.

What is emodermatology?

Emodermatology deals with the application of a type of psychotherapy, called Rational Emotive Behaviour Therapy (REBT) that was developed by Dr Albert Ellis. It runs on the idea that your thoughts affect your behaviour that leads to negative emotions.

It differentiates between Eustress – that stress that helps the patient perform better – and distress that takes a toll on the patient by involving the Neuro Cutaneous Immune System (NCIS). With the changes in the cortisol and adrenaline levels that happen due to distress, repercussions are seen on the other hormones in the body, immunity and skin. This therapy helps us put the patient in a state of Thinking Awareness, where the patient tries to understand the thoughts that are running through the mind. There are as many as 60,000 (and this is but a rough figure), or even more thoughts that run through the mind throughout the day. Most of the times, these are Automatic Negative Thoughts or ANTs as they are called. And most of these are either running in the subconscious and have been suppressed or repressed.

Suppressed thoughts are those that keep coming up in the conscious mind now and again. These are the thoughts that lead to a continuous level of stress that leads to a consistent stimulation of Adrenalin in the system. Then there are the repressed thoughts which are buried deep down in the subconscious and rarely or may never come up to the conscious mind. These are better than suppressed thoughts, but nonetheless can be a source of unidentified distress in the patient. Emodermatology helps us make the patient aware of these thoughts thereby leading to thinking awareness. Only after the patient identifies these thoughts, can we change them and thereby improve the patients ability to deal with them in a more productive manner.

Common examples of suppressed thoughts are:

• “I am not good looking because of my acne,” every time the patient looks into the mirror; or

• “My skin is not perfect,” every time the patient looks at a girl with healthy skin or a model; or

• “I am not worthy of a partner because I am worthless due to thin hair,” and the list goes on.

These thoughts are not necessarily playing in the conscious mind but they crop up their ugly heads whenever possible. And what this result into is: changes in the NCIS and the adrenalin/ cortisol levels in the body.

Meet my patient!

I remember a young bright girl who was diagnosed as a PCOS patient consulting me for her acne. She sat there, and as she complained about how she was tired of having acne and hair fall, I noticed that she was also sweating profusely. I listened to her patiently as I wrote her prescription down, and while doing so l, I asked her the single most important question I always ask before handing over the prescription to the patient - “What is bothering you?”

She looked at me as if I was going bonkers. “The acne! And it doesn’t go away! Plus, that I have PCOS!”

I merely smiled and said, “Any big event that has happened or is happening?”

She stopped for a second. “How did you know? I am going to give my exam for MBA in the US.” “Is that stressful?” I questioned with concern. “Yeah, but stress has to be there na,” she retorted as a matter-of-fact. She belonged to that group of people who had normalised stress in their lives. “No, stress is not normal”, I said slyly. She looked at me with interest as I explained to her the different types of stress, how to identify ANTs, and to navigate through harmful emotions that students are engulfed with. She heard me out, and as she reached the door, she looked back and stopped. “Do you want to ask me anything?” I probed. “Just that… how did you know I was under distress?” she said. “Because you were sweating profusely in an air-conditioned room”, I replied with a wink. All this happened in the 15 minutes that she was with me. The notion that counselling is all about long sessions and patients laying on couches with the doctor becoming Freud is a thing of the past. With newer concepts of counselling like Emodermatology that applies REBT, it is becoming easier to communicate to the patient that you are not only there as a dermatologist who will give you results but also there to help them sustain those results through improving their emotional quotient (EQ).

By the way, the patient above – She ended up getting admission into Harvard Business School and that too with a healthy skin!

About the author: Dr Pradnya Manwatkar, Consultant Dermatologist and Cosmetologist, Skin Matra, is based in Mumbai and author of the book “How To Tell Your Skin To Heal Itself”. She has completed her training hours in REBT-Rational Emotive Behavioural Therapy, and actively counsels her patients to ensure better treatment outcomes. Her expertise lies in emodermatology, and latest treatments along with counselling that ensure long lasting treatment outcomes.