DERMATOLOGY
of
Psychological Aspects A
Atopic Dermatitis
Viewpoint
Gregory
K.
Fritz, M.D. An overview of
existing research
the
on
psychological aspects
of
atopic
dermatitis is presented. Conclusive evaluation of specificity hypotheses, relatyet these theories ing to emotional conflicts or personality types, is lacking, continue to exert their influence. A reactive-interactive model is elaborated the whereby a number of psychological processes exacerbate andaremaintain disorder. Management strategies and psychiatric involvement discussed.
XTHOUGH dermatologjc blushing, blanching
argue the relevance of psychological factors to atopic dermatitis. The appropriate question is how do emotions and the atopic skin interact. Three possibilities, not mutually exclusivei exist. ~ i. ~ Specific emotional conflicts or personality structures may cause atopic dermatitis alone or in combination with other factors. (2) Preexisting, unrelated elements of the individual personality or family structure may become entangled with the dermatitis, serving to ag-
literature, few clinicians
manifestations
or pile of emotion, such as the existare erection, universally recognized,
literature dealing with psychological aspects of atopic dermatitis reflects the arduous and uneven development of modern ’ psychosomatic medicine. In recent years, workers in this field’ have increasingly at-
ing
go beyond anecdotal reports, and pronouncements of studies simplistic toward thorough, rigorous scientific opinion of the psychoof various aspects investigations
tempted
to
gravate the condition or impede its treatment.
(3) Atopic dermatitis may lead to reactive emo-
somatic process. Yet the available literature on atopic dermatitis and the psyche still reflect the meth64010gic difficulties that have always
’
research. These include, biased samples, lack of appropriate controls, use of research instruments that are either too subjective or too superficial and
pla , 9 ued psychosomatic
,
tional problems for the child or his family. With these framework, it ’is possible to review representative studies from
.
the literature on atopic dermatitis and synthesize a reasonable model.. Management suggestions follow. .; . ’ . ;/ ’~.~ ~
.-
.,
laxity with regard.. ...~
l%p©©lfl©I?y ~h~©rlws ~ In the t94Qs,~Al€.xan.der
the lack of ~~~~~~~~ m the Clinical Assistant Professor
of Child Psychiatry in the
;
BehavioralStanford, Sciences, Stanford DepartmentUniversity School of Psychiatry andoftheMedicine,
California; Director, Consultation-Liaison Service, Department of Psychiatry at the Children’s Hospital at
Stanford, 520 Willow Road, Palo Alto, California 94304. Received for publication November, 1978; revised
March 1,1979 and accepted March 15, 1979.
360
now
an
and French’ led of school influential psychosomatic thought
which held that for each of ..
seven
classical
psychosomatic illnesses there was a specific, causative emotional conflict between an individuaps msttnctual drives and the perceived demands of external reality. In the case of
.;.;
this conflict was felt to revolve around the child’s expression or suppression of anger stemming from maternal rejection. A number of studies explored this
atopic dermatitis,
behavioral paradigm to approach the question of common characteristics among patients with atopic dermatitis. In an unusually well designed and quantified conditioning study, the patients suffering from atopic dermatitis formed and maintained a conditioned scratch response (to a neutral tone stimulus) significantly more easily than did healthy controls. The authors conclude that, for whatever psychological reasons, atopic patients scratch more readily to more signals from the environment. Summarizing available evidence, it a
most influential was Miller and Baruch’s work comparing 90 atopic children and 53 normal controls.~ Denning maternal rejection in terms of clinician judgment as well as direct verbal expression of rejecting attitudes, they found that in 98 per cent of the atopic group, the mothers were rejecting of their children while this was true for only 24.3 per cent of the control group. However, these striking results must be seen in the light of two methodologic flaws: the evaluator was not blind to atopic status of the subjects, and no effort was made to differentiate preexisting maternal rejection from those attithat evolved as a result of the dermatitis. Williams6 to intervene in the pat-
hypothesis.2-4 Perhaps
appears that (1) there is no specific personality type that causes, or is unique to, atopic dermatitis, but (2) many patients, on either an innate or acquired bas~s~ se~rm to share broad tendencies to suppress emotions, especially aggression, and to react with scratching to multiple environmental cues.
of maternal rejection to improve the of atopic dermatitis. His subjects were 53 children with atopic dermatitis and their mothers, 33 of whom received counseling around parenting issues. Follow-up, after two.. years revealed, clear. skin in 45. per cent of the. .children whose, mothers were counseled cc~r~pared to only. 10 per cent.. in the control group. This. study ~~~c~ had. serious F~~~~; specifically,. details of patient assignment the n~~.u~~ c~~~~~ ~c~ur~s~~in~ e~r ~~~e therapists involved were not monitored and the. mnucncc of .fathers .was..
~as~~i~ Dermatitis and Pre-Existing Problems
tern
course
.
For the child troubled by separations from parent, competition in the school setting, rivalry with a sibling or any of a number of problems initially unrelated to the atopic . dermatitis, the skin condition can: consciously ~r~ unconsciously l~~c~me in~rc~l~~~ in attempts to effect desired outcome. The dermatologic symptoms may come to,function for the child as substitutes for behaviors that are not tolerated at h~m~~ Troubled families are especially prone to project multiple problems onto the dermatitis and often ap~~arr tc~ cli~~ to the disorder. ~9Cir~~~~~r~~~ has examined m detail the ~ ~psychosomatic family. constellation and the ’~: persistent. need for the, fa~al~r to, have an a
’
ignored. To ~~~e, ~th~ rnaterri~.l ~-~~e~c~i~n~ suppressed’anger...hypothesis.. has not~been ’ ~cau~~usa~~I~ ~v~lu~.~~c~. ~~ ~rs~~~* unproven . ’. but alive and apparently/useful in reports: by :. Y competent ~ciMtcians. in: v~:~~u~’,~is~i~lir~~s.~~ ’: &dquo;~’~e ~~~~ch .&)!&dquo;/spcci6c per~n~~i~~ types identified patient to avoid directly addressing associated’ ~with atoptc ~~r~n~.~i~i~ ~~~ ~~n other problems’. Application,of s y -stems theory f’ ’arduous :.::and ~.r~r~~~rdi~~r ~ nu~~~r ’ ~~‘ to family interactions where the ~ fariiily group ;
’
:
.
.
..
:.
~
.~mcMdes’ ’Sj’eMM~ with , fluctuating physical .~
’
~~~i~r~~~,
..
b~~ ~~ r~~~~~~~. ~r~~~~~ ~~i~ ~~~~ ~~’ ~’
approacli. syrn, p~I~iIn~ appears’to be’ promi!;ing studi~!s,,lnd
:~
a
~~~da~~&weye~~~~y’~.c~~~ very ropor,ts are available, and none . preiiminary ..~/: ~~~~~ , ~~~~ ~~~~ ~~a ~i~~~~.~i~,~~ 1~~~~ ~. .~ ~ ~ has specifica~lly ~ d-ermatitis. ~i~‘~ ~i~u~.~i~~s ~~d ~&dquo;~ll~~~~. u~ 99 ~~ai~n~~ ’. ’ ~ Pl~yphological Readdons ~ ..~~ ~ ’.’ ~.’ ~,~~ ~ ~..’;.. ;
.
.
’
’
..
:-
~~rn~ ~r ~~~~i~~~~~ ~i~~~~~~i~~ ~~~~
~~~r~d i~ ,:;!~:~’~~~€?Oe
of
Psychological Aspects A
Atopic Dermatitis
Viewpoint
Gregory
K.
Fritz, M.D. An overview of
existing research
the
on
psychological aspects
of
atopic
dermatitis is presented. Conclusive evaluation of specificity hypotheses, relatyet these theories ing to emotional conflicts or personality types, is lacking, continue to exert their influence. A reactive-interactive model is elaborated the whereby a number of psychological processes exacerbate andaremaintain disorder. Management strategies and psychiatric involvement discussed.
XTHOUGH dermatologjc blushing, blanching
argue the relevance of psychological factors to atopic dermatitis. The appropriate question is how do emotions and the atopic skin interact. Three possibilities, not mutually exclusivei exist. ~ i. ~ Specific emotional conflicts or personality structures may cause atopic dermatitis alone or in combination with other factors. (2) Preexisting, unrelated elements of the individual personality or family structure may become entangled with the dermatitis, serving to ag-
literature, few clinicians
manifestations
or pile of emotion, such as the existare erection, universally recognized,
literature dealing with psychological aspects of atopic dermatitis reflects the arduous and uneven development of modern ’ psychosomatic medicine. In recent years, workers in this field’ have increasingly at-
ing
go beyond anecdotal reports, and pronouncements of studies simplistic toward thorough, rigorous scientific opinion of the psychoof various aspects investigations
tempted
to
gravate the condition or impede its treatment.
(3) Atopic dermatitis may lead to reactive emo-
somatic process. Yet the available literature on atopic dermatitis and the psyche still reflect the meth64010gic difficulties that have always
’
research. These include, biased samples, lack of appropriate controls, use of research instruments that are either too subjective or too superficial and
pla , 9 ued psychosomatic
,
tional problems for the child or his family. With these framework, it ’is possible to review representative studies from
.
the literature on atopic dermatitis and synthesize a reasonable model.. Management suggestions follow. .; . ’ . ;/ ’~.~ ~
.-
.,
laxity with regard.. ...~
l%p©©lfl©I?y ~h~©rlws ~ In the t94Qs,~Al€.xan.der
the lack of ~~~~~~~~ m the Clinical Assistant Professor
of Child Psychiatry in the
;
BehavioralStanford, Sciences, Stanford DepartmentUniversity School of Psychiatry andoftheMedicine,
California; Director, Consultation-Liaison Service, Department of Psychiatry at the Children’s Hospital at
Stanford, 520 Willow Road, Palo Alto, California 94304. Received for publication November, 1978; revised
March 1,1979 and accepted March 15, 1979.
360
now
an
and French’ led of school influential psychosomatic thought
which held that for each of ..
seven
classical
psychosomatic illnesses there was a specific, causative emotional conflict between an individuaps msttnctual drives and the perceived demands of external reality. In the case of
.;.;
this conflict was felt to revolve around the child’s expression or suppression of anger stemming from maternal rejection. A number of studies explored this
atopic dermatitis,
behavioral paradigm to approach the question of common characteristics among patients with atopic dermatitis. In an unusually well designed and quantified conditioning study, the patients suffering from atopic dermatitis formed and maintained a conditioned scratch response (to a neutral tone stimulus) significantly more easily than did healthy controls. The authors conclude that, for whatever psychological reasons, atopic patients scratch more readily to more signals from the environment. Summarizing available evidence, it a
most influential was Miller and Baruch’s work comparing 90 atopic children and 53 normal controls.~ Denning maternal rejection in terms of clinician judgment as well as direct verbal expression of rejecting attitudes, they found that in 98 per cent of the atopic group, the mothers were rejecting of their children while this was true for only 24.3 per cent of the control group. However, these striking results must be seen in the light of two methodologic flaws: the evaluator was not blind to atopic status of the subjects, and no effort was made to differentiate preexisting maternal rejection from those attithat evolved as a result of the dermatitis. Williams6 to intervene in the pat-
hypothesis.2-4 Perhaps
appears that (1) there is no specific personality type that causes, or is unique to, atopic dermatitis, but (2) many patients, on either an innate or acquired bas~s~ se~rm to share broad tendencies to suppress emotions, especially aggression, and to react with scratching to multiple environmental cues.
of maternal rejection to improve the of atopic dermatitis. His subjects were 53 children with atopic dermatitis and their mothers, 33 of whom received counseling around parenting issues. Follow-up, after two.. years revealed, clear. skin in 45. per cent of the. .children whose, mothers were counseled cc~r~pared to only. 10 per cent.. in the control group. This. study ~~~c~ had. serious F~~~~; specifically,. details of patient assignment the n~~.u~~ c~~~~~ ~c~ur~s~~in~ e~r ~~~e therapists involved were not monitored and the. mnucncc of .fathers .was..
~as~~i~ Dermatitis and Pre-Existing Problems
tern
course
.
For the child troubled by separations from parent, competition in the school setting, rivalry with a sibling or any of a number of problems initially unrelated to the atopic . dermatitis, the skin condition can: consciously ~r~ unconsciously l~~c~me in~rc~l~~~ in attempts to effect desired outcome. The dermatologic symptoms may come to,function for the child as substitutes for behaviors that are not tolerated at h~m~~ Troubled families are especially prone to project multiple problems onto the dermatitis and often ap~~arr tc~ cli~~ to the disorder. ~9Cir~~~~~r~~~ has examined m detail the ~ ~psychosomatic family. constellation and the ’~: persistent. need for the, fa~al~r to, have an a
’
ignored. To ~~~e, ~th~ rnaterri~.l ~-~~e~c~i~n~ suppressed’anger...hypothesis.. has not~been ’ ~cau~~usa~~I~ ~v~lu~.~~c~. ~~ ~rs~~~* unproven . ’. but alive and apparently/useful in reports: by :. Y competent ~ciMtcians. in: v~:~~u~’,~is~i~lir~~s.~~ ’: &dquo;~’~e ~~~~ch .&)!&dquo;/spcci6c per~n~~i~~ types identified patient to avoid directly addressing associated’ ~with atoptc ~~r~n~.~i~i~ ~~~ ~~n other problems’. Application,of s y -stems theory f’ ’arduous :.::and ~.r~r~~~rdi~~r ~ nu~~~r ’ ~~‘ to family interactions where the ~ fariiily group ;
’
:
.
.
..
:.
~
.~mcMdes’ ’Sj’eMM~ with , fluctuating physical .~
’
~~~i~r~~~,
..
b~~ ~~ r~~~~~~~. ~r~~~~~ ~~i~ ~~~~ ~~’ ~’
approacli. syrn, p~I~iIn~ appears’to be’ promi!;ing studi~!s,,lnd
:~
a
~~~da~~&weye~~~~y’~.c~~~ very ropor,ts are available, and none . preiiminary ..~/: ~~~~~ , ~~~~ ~~~~ ~~a ~i~~~~.~i~,~~ 1~~~~ ~. .~ ~ ~ has specifica~lly ~ d-ermatitis. ~i~‘~ ~i~u~.~i~~s ~~d ~&dquo;~ll~~~~. u~ 99 ~~ai~n~~ ’. ’ ~ Pl~yphological Readdons ~ ..~~ ~ ’.’ ~.’ ~,~~ ~ ~..’;.. ;
.
.
’
’
..
:-
~~rn~ ~r ~~~~i~~~~~ ~i~~~~~~i~~ ~~~~
~~~r~d i~ ,:;!~:~’~~~€?Oe
