Psychosocial Effects and Nursing Interventions for Dermatological Disease and Psychodermatoses
Fiona Cowdell
Steven J. Ersser
OBJECTIVES
After studying this chapter, the reader will be able to:
Identify the functions of the skin that are related to psychosocial well-being.
Describe the psychosocial effects of dermatological disease.
Describe the classification of psychodermatological disorders.
Identify holistic approaches to consultation that support recognition of psychodermatoses and enhance the therapeutic nature of dermatological consultations.
Select appropriate measures that assess skin-related psychological status accurately and measure learning and support needs.
Assess when patients have psychodermatological conditions that are amenable to nursing intervention and when specialist psychodermatology referral is required.
Explain the principles of three evidence-based behavioral interventions that may be used by nurses to support patients with psychodermatological conditions with a focus on promoting effective self-management.
KEY POINTS
The skin is the largest and most visible organ of the body, and changes to the skin can have a major impact on psychosocial well-being.
Skin diseases cause alterations in appearance and thereby affect body image.
Psychodermatoses or psychocutaneous diseases are skin diseases with a psychological origin.
People with skin conditions may suffer physical and psychosocial discomfort as well as being stigmatized by others because of their appearance.
It is important to integrate psychosocial assessment into dermatological consultations.
Patients presenting with dermatological symptoms should be assessed for dermatological and systemic disease before a psychological or psychiatric cause is diagnosed.
A long-term skin condition can be very challenging for patients to cope with, and poor self-management can increase psychodermatological suffering and the quality-of-life impact.
Many psychodermatological issues are amenable to nursing intervention, while others need specialist referral.
INTRODUCTION
This chapter is divided into four sections. The first section examines the effects of dermatological disease on health and well-being. The second provides a summary of psychodermatological disease classification. The third examines how assessment of psychodermatological health and well-being can be integrated into nursing consultation and offers some measurement tools for assessment and evaluation. Recognition of conditions that are responsive to nursing intervention and those that require specialist referral is also considered in section 2. The final section outlines three evidence-based approaches for psychodermatological disorders that are amenable to nursing intervention through promotion of health and well-being and effective self-management.
EFFECTS OF DERMATOLOGICAL DISEASE ON HEALTH AND WELL-BEING
I. PSYCHOSOCIAL FUNCTIONS AND IMPACTS OF THE SKIN
A. The skin is the largest and most visible organ of the body that serves as the barrier between the individual and the external environment, including the interpersonal and social environment.
1. As a society, we tend to place a high value on flawless skin and can be quick to judge people on their appearance.
2. The visual appearance of skin disease may lead to the development of disruption of normal interpersonal relationships.
3. Rejection by others frequently occurs.
4. Interpretation of outside stimuli is adversely affected.
5. Expression of enjoyment from outside stimulation is adversely affected.
6. Sensory pleasure is adversely affected.
B. The skin affects the mind.
1. The skin acts as a sense organ for touch, cold, heat, and pain and is an erogenous organ.
2. The skin separates us from the outside world but provides an interface with the psychosocial environment.
3. The skin may be a source of anxiety and stress.
4. Early experiences of skin contact may have far-reaching impact on physical and emotional development.
5. The skin’s condition is influenced by the “look good-feel good” factor. If the skin has imperfections, this can have a detrimental effect on psychosocial well-being and body image, depending on the individual reaction.
C. The mind affects the skin.
1. The skin acts as a facade that displays us and serves as a means of nonverbal communication with the outside world.
2. The skin involuntarily communicates to others some of our emotional states.
3. The skin acts as an intermediary between the individual’s inner self and the external environment.
4. The skin is an organ of emotional expression.
5. The skin conveys varied external stimuli, including temperature differences, pain, affection, tenderness, and sexual identity and stimulation.
6. There is complex interplay between stress, anxiety, and depression in the skin; these factors can precipitate or worsen skin conditions. Living with skin conditions can cause or exacerbate stress, anxiety, and/or depression.
D. The skin is one of the most important psychosomatic organs.
1. The impression an individual makes on another person depends partly on their skin condition/health.
2. Unsightly skin typically provokes negative feelings in the observer.
3. Unsightly the skin may trigger feelings of revulsion, shame, and inferiority.
CLASSIFICATION OF PSYCHODERMATOLOGICAL DISORDERS
I. OVERVIEW
A. The skin has multiple functions and plays a crucial role in psychological and social well-being.
B. The concepts of psychological and social well-being are two distinct but related states but are often unhelpfully merged.
C. Psychological well-being refers to issues related to the mind, how the person copes with their experiences and surroundings.
D. Social well-being is concerned with how effectively the person interacts with others in society.
E. Several factors can precipitate psychodermatological disorders including stress, the impact of mood and anxiety, the presence or absence of social support, and, in some cases, mental ill health.
F. The visibility of the skin conditions can have a negative impact on body image, that is, the mental picture of how individuals view their bodies including their perception of how their body looks and the feelings, attitudes, and their emotions toward it.
G. If body image becomes very negative, the person may become obsessional about the appearance of their skin; this may lead to misperceptions of delusional proportion. People with dermatological conditions and those undergoing dermatological treatments often experience uncomfortable and unsightly skin.
H. Treatment for skin conditions may be time consuming and require expensive and unpleasant topical medications.
I. Dermatological treatments may be slow to show an effect, and their use may be required over prolonged periods of time; this may impact on motivation and thus well-being.
J. There is often a high self-management burden when living with chronic dermatoses.
K. While skin conditions present physical problems, they elicit emotional reactions as well, both for the person living with the disease and their significant others.
L. Significant others and the public often do not understand skin diseases and are typically repulsed at the site of their appearance.
M. A common fear is that the diseases are contagious and communicate their thoughts and feelings, both verbally and nonverbally, to the individuals with the diseases. The public may also misinterpret skin lesions as a sign of poor personal hygiene.
II. CLASSIFICATION
A. Primary psychiatric disease presenting to dermatology health care professionals
1. Delusional disorders
a. Olfactory syndromes
b. Dysmorphic syndromes
c. Others
2. Obsessive-compulsive disorders (OCD)
a. Body dysmorphic disorders
b. Other obsessive-compulsive disorders, for example, excessive hand washing
c. Health anxieties
d. Skin picking disorders
e. Trichotillomania
3. Dysesthesias, for example, burning syndrome, vulvodynia, and scrotal dysesthesias
4. Anxiety disorders
a. General anxiety disorder
b. Specific anxieties
i. Syphilis phobia
ii. Cancer phobia
iii. Others
5. Chronic pruritus
a. Psychogenic pruritus
b. Nodular prurigo
6. Factitious disorders
a. Dermatitis artefacta
b. Factitious and induced illness
c. Malingering
d. Abuse (sexual/emotional)
B. Dermatological disorders with potential psychosocial comorbid conditions: for example, acne, eczema, psoriasis, vitiligo, and others with psychiatric disorders such as anxiety, depression, suicidal ideation, and social phobia
C. Suicidal ideation associated with skin disorders
D. Psychopharmacologically related disorders
1. Medication which dermatologists use that may lead to psychiatric disorders (e.g., isotretinoin and depression)
2. Psychiatric medication that may lead to skin disorder (e.g., lithium and psoriasis)
E. Skin disorders that may be induced by stress (e.g., psoriasis)
F. Site-specific skin disorder that may have a site-specific psychosocial comorbid condition, such as the following:
1. Alopecia areata and hair appearance-related comorbid condition
2. Genital dysesthesias and psychosexual comorbid condition
III. CLINICAL FEATURES OF FREQUENTLY SEEN DERMATOLOGICAL DISORDERS
A. The clinical features, etiology, and treatment of the most frequently seen dermatology-related primary psychiatric conditions are summarized in Table 7-1.
B. These psychiatric disorders require more specialized care and are beyond the scope of this chapter.
TABLE 7-1 Clinical Features and Treatment of Common Dermatology-Related Primary Psychiatric Conditions | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
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IV. DERMATOLOGY-RELATED PSYCHOSOCIAL COMORBIDITIES
A. Psychological and social experiences in dermatological disease
1. Patients with dermatology-related psychosocial comorbid conditions may encounter one or more of the psychological and/or social experiences listed in Box 7-1.
2. Any of these experiences and feelings can hinder people’s ability to self-manage effectively; this can lead to a downward spiral, as self-care diminishes skin condition and quality of life deteriorates.
3. This may result in impaired ability to self-care and everworsening skin condition; this in turn can impact on psychosocial well-being and self-care ability.
4. Experiences listed in Box 7-1 may be considered within the realms of “normal” reactions and are likely to be amenable to nursing intervention.
HOLISTIC APPROACHES TO NURSING CONSULTATION AND ASSESSMENT
I. OVERVIEW
A. Dermatology-related psychosocial comorbid conditions are amenable to nursing care through effective assessment, consultation, and psychological interventions.
B. Accurate, holistic patient assessment is essential in identifying and understanding psychosocial health in patients with skin conditions in planning appropriate care and referral.
C. Most nurses will already have an extensive skill set that will inform consultations. There are additional techniques that may be integrated into consultations to enhance communication, develop therapeutic effectiveness, and ensure that psychosocial issues are identified and addressed.
BOX 7-1. Experiences of People with Dermatology-Related Psychosocial Comorbid Conditions
Anger
Anxiety
Avoidance
Bullying
Concealment
Depression
Embarrassment
Exhaustion
Frustration
Guilt
Helplessness
Increased alcohol intake
Irritability
Low confidence
Low self-esteem
Performance issues
Poor body image
Relationship issues
Resentment
Secretiveness
Self-consciousness
Sexual problems
Sleep deprivation/sleeplessness
Social isolation
Social phobia
Stigmatization
Stress
Suicidal thoughts
Suicide
Teasing
Unemployment
Withdrawal
II. NURSING CONSULTATION
In any nursing consultation, the patient must have the opportunity to express their thoughts and feelings. The consultation should take place in a quiet, comfortable environment in which there are no disturbances. This information below is not intended to be a checklist but rather a number of ideas that may be introduced in the course of consultations using a mixture of open and closed questions as appropriate.
A. Objectives of the nursing consultation:
1. To provide support and education to patients with skin disease to aid their adaptation and promote well-being and quality of life.
2. To enhance their mental health and well-being and so enable patients to manage their condition as effectively as possible.
3. To identify patients with psychiatric conditions or complex clinical psychological needs who require specialist care and so referral to psychological or psychiatric services.
B. The four-stage therapeutic consultation
A four-stage therapeutic consultation approach allows the person to be examined holistically and provides a basis for effective care planning:
1. The clinical observation: global evaluation
a. How does the patient behave?—for example, do they appear worried, relaxed, and defensive?
b. How are they talking?—for example, do they provide a concise or a long and complex history?
c. What about nonverbal language?—for example, do they exhibit signs of stress?
d. How do they look?—how are they dressed; what is the first impression of their skin condition?
e. How are they interacting with others?—For example, are they accompanied by a friend or relative, who talks first, and are they able to listen to and understand information?
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