Decoding the psychology of skin disorders

Shriyal Sethumadhavan delves deeper with experts in explaining the psychological complexities behind dermatological disorders, shedding light on coping mechanisms, treatments, and the path to reclaiming patient confidence and well-being.

Ever thought of the intricate connection between the psyche and the skin? Can you imagine the scenario where psychological intricacies intertwine with dermatological disorders and the resulting impact? From the relentless pursuit of perfection to the distressing impact of compulsive behaviours, conditions like Body Dysmorphic Disorder (BDD), skin-picking disorders, and hair-pulling disorders manifest and significantly affect individuals’ lives, and how!

Dr Komal Manshani, Clinical Psychologist, Department of Mental Health &Behavioural Sciences, Artemis Hospital, says, “Certain disorders like BDD, skin-picking (Dermatillomania), or hair-pulling (Trichotillomania) have psychological factors, which may contribute to the symptoms and their presentation.” She adds, “These could include difficulty in coping with stress, anxiety-related concerns, and poor self-esteem. Trouble in regulating one’s emotions is also commonly seen, and boredom is occasionally seen as a trigger for hair-pulling.”

Laharika Arasu, Counseling Psychologist, Lissun, (a mental health startup), highlights the impact of Body Dysmorphic Disorder (BDD), emphasising, “BDD is a mental health condition where a person obsesses over perceived flaws, impacting self-esteem and daily life, affecting relationships and work.” She stresses the importance of psychotherapy, medication, and support groups as solutions. Arasu also addresses delusional disorders, noting, “Treatment involves therapy and sometimes medication to manage symptoms.” Additionally, she discusses the effects of skinpicking and hair-pulling disorders, stating, “People often feel a strong urge to pick at their skin, causing distress and impacting self-esteem,” and acknowledges the challenges faced by individuals with hair-pulling disorders, known as Trichotillomania, saying, “It can affect their self-image, leading to shame and embarrassment.”

These disorders can also lead to obsessive thoughts and behaviours, impacting daily life and relationships. Individuals may struggle with intrusive thoughts about their appearance or the urge to engage in harmful behaviours like picking or pulling. It is important to address these issues with therapy, medication, and support to help manage symptoms and improve quality of life. Understanding these psychological effects can help those affected to seek the help they need to cope with these challenges.

Agreeing that these disorders often manifest with distorted perceptions of looks, obsessive thoughts, compulsive behaviours, and full-size misery, Dr Pavana S, Consultant Psychiatrist, Relationship Expert, and Sexologist, Bengaluru, says, “Patients with BDD, for instance, revel in obsessive preoccupation with perceived flaws in their look, leading to compulsive behaviours consisting of immoderate grooming or searching for beauty tactics. Delusional disorders may additionally involve constant false beliefs about skin conditions, despite proof to the contrary. Skin-selecting and hairpulling disorders frequently function as maladaptive coping mechanisms for pressure or tension.”

Patient’s mental health and wellbeing

Most skin disorders including those with cosmetological concerns have comorbid anxiety and depression.

According to Dr Sudipta Roy, MA, MPhilb (NIMHANS), Ph D, Consultant Clinical Psychologist, Director, Psy Lens Centre, “The types of anxiety seen are generalised, social, and illness anxiety, and the types of depression seen are dysthymia and major depressive disorders.” With the emergence of skin disorders, the patients may feel self-conscious, nervous about appearing in public, fear negative appraisals, and have low selfconfidence which falls in the spectrum of anxiety. “Over a while,” she adds, “the patients begin to feel helpless and hopeless about their condition, which is the setting of depression. Some patients also develop adjustment disorder or post-traumatic stress disorder around their condition. Many skin conditions begin to impact relationships and occupational functioning as well.”

In addition to anxiety and depression, dermatological disorders can also precipitate a range of other mental health challenges.

Dr Swapna Bondade, Professor & HOD, Department of Psychiatry, The Oxford Medical College Hospital &Research Center, and Consultant, Narayana Multispecialty Hospital, and Apollo Clinic, HSR, Bengaluru, says, “Patients may experience heightened levels of stress, frustration, or irritability as they grapple with the chronic nature of their condition and its impact on their daily lives. Sleep disturbances, including insomnia or hypersomnia, may also occur, further compromising the individual’s overall well-being and ability to cope effectively with their symptoms. Moreover, in severe cases, individuals may experience suicidal ideation or engage in self-harming behaviours as a means of coping with their emotional pain and distress.

The impact of these disorders on intellectual fitness and wellbeing may be profound, says Dr Pavana. “Individuals may experience heightened tension, despair, social withdrawal, and impaired quality of life. Consistent preoccupation with perceived flaws or uncontrollable urges to pick or pull can result in significant emotional distress and functional impairment.”

According to experts, individuals striving for an idealised beauty often resort to harmful behaviours like excessive skin picking or hair pulling, intensifying their distress. These perceived flaws can detrimentally affect self-perception and confidence, resulting in social withdrawal and isolation. Moreover, the time and energy dedicated to these disorders can disrupt daily activities, relationships, and work performance.

Arasu shares, “Psychological therapy, such as cognitivebehavioural therapy (CBT), plays a vital role in treating disorders like BDD, delusional disorder, skin picking disorder, and hair pulling disorders.” She elaborates that in therapy, individuals can explore the root causes of their behaviours, learn coping skills to manage urges and challenge negative thought patterns associated with these disorders. “By addressing the psychological aspects through therapy, patients can gain a better understanding of their condition and develop healthier ways to cope with stressors and triggers.

This can lead to long-term changes in behaviour and improved emotional well-being.”

The collaboration between psychologists and dermatologists ensures that the patients receive holistic care that addresses both the physical and emotional aspects of these disorders. This combined approach maximises the effectiveness of treatment and supports patients in achieving better overall outcomes and a higher quality of life.

Challenges in diagnosis and treatment

One key challenge remains: Dermatological issues are visible, whereas psychological issues are not. And a correlation between the two is often not easily apparent.

“There may also be difficulty in accepting help for mental health issues due to the stigma associated with it, especially in our society,” points out Dr Manshani.

Diagnosing and treating disorders like trichotillomania, skin picking disorder, and BDD in dermatology practice can pose some challenges. Arasu elaborates, “One common challenge is that these conditions may not always be immediately recognised as psychological, leading to misdiagnosis or delayed treatment. Additionally, individuals may feel embarrassed or ashamed to discuss these issues, making it harder for dermatologists to address the underlying psychological factors.” The treatment often requires a multidisciplinary approach involving mental health professionals, which can, oftentimes, be a challenge to coordinate within a dermatology setting.

Dr Pavana points out overlapping signs and symptoms with commonplace dermatological situations as a challenge. “Patients can be hesitant to disclose their psychological misery or may not apprehend the underlying psychological components of their symptoms.” Furthermore, she adds that a powerful remedy requires a holistic approach addressing both the dermatological and mental factors, which might not continually be convenient to have.

On conditions going undetected also because the dermatologists do not ask questions to elicit the required information, Dr Roy says, “Some clinicians who routinely inquire for mental health issues may find that patients do open up and share their distress. The building of a safe place, trust, and good rapport is essential for patients to reveal their innermost feelings openly.”

The fact remains that patients may seek out aesthetic treatments in an attempt to alleviate their distress without addressing the underlying psychological issues. However, dermatologists may not always have the training or resources to identify and address these psychological factors effectively.

Here, Dr Bondade, says, “Treatment can be challenging due to the chronic and relapsing nature of these disorders, as well as the need for a multidisciplinary approach involving both dermatological and psychological interventions.” On finding the right combination of therapies, she responds, “This may involve medication, psychotherapy, and support groups.” The chronic nature of these disorders and the potential for relapse require long-term commitment and support.

Referring patients to a psychologist or mental health professional

When dermatological treatments alone fail to adequately address the patient’s psychological distress or functional impairment, collaboration with a psychologist or psychiatrist becomes essential.

Skin problems can often be affected or exacerbated by stress or anxiety. Dr Manshani says, “Many skin problems may also lead to concerns around one’s mood or self-esteem, or to an increased level of stress and difficulty in coping. Whenever either of the two conditions are evident to the dermatologist in their evaluation, then a referral to a mental health professional should be in order.”

Arasu emphasises the need for dermatologists to refer clients to psychologists when they suspect underlying psychological factors contributing to conditions like trichotillomania, skin picking disorder, and BDD. “If the dermatologist notices signs of distress, anxiety, or obsessive behaviours related to these disorders, it is important to involve a psychologist for a more comprehensive assessment and treatment plan.” It is all about ensuring that clients receive the best care possible to address both the physical and emotional aspects of these disorders.

So, how can dermatologists recognise these disorders as psychological based on certain signs and symptoms? Arasu points out that for body dysmorphic disorder, they may notice excessive preoccupation with perceived flaws in appearance, which causes significant distress or impairment in daily functioning. Delusional disorder may present with fixed false beliefs about skin issues despite evidence to the contrary. Skin-picking disorder is characterised by repetitive picking at the skin, leading to tissue damage. Hairpulling disorders like trichotillomania involve the urge to pull out hair, resulting in hair loss and distress. Dermatologists may identify these psychological disorders by observing patterns of behaviour, discussing symptoms with the patient, and considering the impact on mental health and well-being.

Refer patients to psychologists or mental health professionals when psychological distress significantly impacts daily functioning, treatment adherence, or while dermatological interventions alone show insufficient, says Dr Pavana. “Collaborative care guarantees complete evaluation and tailor-made remedy plans addressing both bodily and mental factors.”

For Dr Bondade: “Firstly, if psychological symptoms such as anxiety, depression, or obsessive-compulsive behaviours overshadow the physical manifestations of the dermatological disorder, it may indicate the need for specialised mental health intervention. These symptoms may manifest as excessive preoccupation with perceived flaws, avoidance of social situations, or difficulty functioning in daily life.” Secondly, she points out to suspicion of underlying psychiatric conditions, and says, “Body dysmorphic disorder (BDD) or delusional disorders warrants referral to a psychiatrist for further assessment and treatment. These conditions often require medications followed by specialised therapeutic approaches, to address distorted beliefs and alleviate distress.”

Dr Roy advises that dermatologists use screening instruments to rule out mental health conditions. PHQ 9 and GAD 7, DASS-21 are some rating scales that can be routinely used to screen comorbid mental health conditions. “I am happy to share that we have constituted a body ‘Psychodermatology Association of India (PDAI)’, which is three years old now and brings together dermatologists, psychiatrists and clinical psychologists to address skin conditions holistically. We have also developed an Indian tool for screening for psychological concerns which is currently being standardised.”

Mental health professionals can provide targeted interventions to address the emotional and cognitive aspects of the disorder, complementing dermatological interventions and promoting holistic recovery.

Collaboration for comprehensive care

Can mental health professionals and dermatologists work in collaboration, especially for complicated cases?

Dr Manshani suggests, “There can be a basic screening for psychological concerns in all prospective patients who visit a dermatologist, considering the common presentation of mental health issues in dermatological concerns. All patients, who show significant symptoms in the screening tool may be referred to a mental health professional.”

Collaboration is critical for complete care, says Dr Pavana. “Psychologists can conduct psychological tests, offer psychoeducation, and offer proof-based healing procedures such as CBT to deal with maladaptive thought styles and behaviours. Dermatologists can complement mental interventions via supplying scientific treatments, monitoring progress, and addressing dermatological issues.”

Collaboration is crucial for comprehensive care, says Dr Bondade. “Psychiatrists and Psychologists can help to assess the psychological aspects of the condition and provide therapy to address negative thoughts, emotions, and behaviours, and in severe conditions, medications will be provided by the psychiatrists. Regular communication and shared treatment plans ensure a holistic approach to patient care.

Sharing areas of collaboration, Dr Roy lists, “Knowledge sharing at webinars, seminars, conferences, case conferences, panel discussions; skill building through multidisciplinary workshops; organising inpatient integrative care for dermatology patients; and conducting research on the efficacy of psychotherapy techniques for different dermatological conditions.”

Developing treatment plans that address both the mental health and dermatological aspects of the disorders allows for a more holistic and effective treatment strategy, ensuring that patients receive the best care.

Role of psychological therapy in dermatology

Treating psychological symptoms can often lead to an improvement in the dermatological concerns.

Psychological therapy is an effective way to deal with complicating factors such as stress, anxiety, self-esteem, and self-image issues, says Dr Manshani. She confirms that therapy can go hand-in-hand with dermatological procedures as well as medications.

Listing various ways in which psychotherapy can help dermatological patients, Dr Roy, shares:

• “Reducing distress, and overwhelming feelings.

• Reducing anxiety through relaxation, training and mindfulness.

• Working on depression and anxiety by teaching skills for managing negative thoughts and emotions.

• Using behavioural techniques to bring about lifestyle changes.

• Using acceptance and commitments therapy for those conditions that cannot be helped.

• Using narrative therapy techniques to help build new narratives around the skin conditions.

• Building on resilience, coping skills, problem-solving skills to deal with a challenging situation.

• Counselling to ensure compliance with the treatment regime.

• Habit reversal training to deal with skin picking and hair pulling.

• Hypnotherapy for psoriasis and other chronic skills conditions.

• Psychoeducation to patients and their families.”

For Dr Bondade, psychological therapy, particularly CBT, relaxation therapy, RET, and many other individualised tailor-made therapies, can be effective in treating dermatological disorders by addressing cognitive distortions, reducing compulsive behaviours, and improving emotional regulation. These therapies complement dermatological interventions by targeting the underlying psychological factors contributing to symptom maintenance and promoting long-term recovery and resilience.

On her part, Dr Pavana says, “Particularly CBT performs an essential role in the treatment of dermatological issues. It facilitates sufferers to perceive and challenge distorted beliefs about their looks, expand coping techniques for distressing thoughts and urges, and gradually reduce compulsive behaviours.” Psychological interventions supplement dermatological treatments by addressing the underlying psychological factors contributing to symptom exacerbation and selling long-term symptom control.

While dermatological interventions focus on the physical symptoms, psychological therapy targets the emotional and psychological aspects of the disorders. Arasu adds, “By combining both approaches, patients receive comprehensive care that addresses the full spectrum of issues related to these disorders, leading to better outcomes.” Psychotherapy can help individuals understand the underlying psychological factors contributing to these conditions, develop coping strategies to manage urges and behaviours, and address any emotional distress or negative beliefs associated with the disorders.

All-in-all, understanding the psychological aspects of dermatological disorders is crucial for providing comprehensive care to patients. Collaboration between dermatologists and mental health professionals is essential for accurately diagnosing, effectively treating, and improving outcomes for individuals affected by these complex conditions.