People with skin problems are at high risk of developing psychological problems, and they can linger even after the skin gets better. Psychodermatology is especially helpful at erasing the psychological scars left by skin disorders. The psyche-skin conversation goes both ways. Just as signals of psychological and emotional stress can lead to skin disorders, skin disorders often lead to psychological distress. Skin disorders rarely kill people, but they have a menacing ability to chew them up and spit them out.

Here are some findings from the American Academy of Dermatology and other skin groups:

• Major depression is one of the main results of chronic skin disorders.
Suicidal thoughts are another consequence. Consider some statistics on psoriasis. About 5% of the 4.5 American adults with psoriasis have suicidal thoughts - three times the rate of the general population.
• Other psychosocial side effects of skin conditions are social withdrawal, anger, frustration, and lack of confidence.
• 26% of people with moderate to severe psoriasis have been forced to change or discontinue their normal daily activities.
• Adults with acne face higher rates of unemployment than the general population.
• Kids with skin disorders suffer, too. Two out of five of these children have some psychosocial impairment.

Psychosocial distress is a natural, normal response to skin symptoms, especially in our society. Americans spend more on their appearance than on social welfare, health, and education combined. It's tempting to disparage our emphasis on appearance as hopelessly shallow. In fact many of my patients beat up on themselves for their vanity, and this adds to their psychosocial anguish.
But it's more than vanity that drives people's desperation to look good. Your body image accounts for about one-quarter to one-third of your self-esteem, and your self-esteem is a major influence on your overall psychological health. So, when you have a skin disorder, your self-esteem and psychological health take a hit.

What's surprising is that the severity of this psychosocial toll is only weakly related to the severity of the skin disorder. Someone with mild symptoms may suffer worse psychologically than someone with severe symptoms. It all depends on an individual's perception. That's why clinical improvement in a skin disorder does not necessarily make you feel better inside. I see patients who suffer from a kind of skin post-traumatic stress disorder - their skin looks better, but they don't feel better. The dermatological scars are gone, but the psychological ones remain. We treat the psychological scars.

Fear, Loathing, and Rosacea


Donna, a 41-year-old painter and technical writer, developed rosacea, a painful rash on her face. Though her condition was usually mild enough to be concealed with makeup, Donna thought it was terrible. Her distress about her skin contributed to the development of depression and anxiety. When I saw her, she was taking medication for rosacea and an antidepressant for her depression and anxiety, but neither treatment was doing its job.

Donna's depression and anxiety stemmed in part from her tendency to focus on worst-case scenarios. She discovered that rosacea could make the nose red and bulbous, like W. C. Fields'. Even though her condition was nowhere near this severe and probably never would be, she kept dwelling on the possibility. In doing so, she was practicing "negative self-hypnosis." Also fueling her anxiety and depression was a feeling that plagues many people with skin disorders - a feeling of being dirty and unlovable.

Other factors came into play. As an artist, Donna was exceptionally attuned to aesthetic matters, so any flaw in her appearance dealt an especially hard blow to her self-esteem. Coincidentally, her mother was dying of ovarian cancer and Donna's relationship with her partner of 10 years was in trouble. The prospect of these losses, combined with her rosacea, fed Donna's fears that she would end up alone, unloved and unlovable.

We used therapeutic hypnosis as an antidote to her own brand of 'negative hypnosis.' She came to see that her tendency to focus on worst-case scenarios was actually a form of self-punishment. Then she connected this need to punish herself to her upbringing - her parents' warning against being too proud of her personal accomplishments and becoming arrogant. Fixating on worst-case scenarios went well beyond keeping her pride in check; it kept her pride imprisoned.

Donna and I worked together on treating her depression, her anxiety, and her skin. Gradually, each of them got better. As her anxiety and depression subsided, she realized that her rosacea was manageable and would not destroy her life. And the rosacea responded better to treatment once her anxiety and depression improved. She also grew more resilient in facing the reality of her mother's illness and eventual death. She and her partner started couples therapy, which helped them communicate better. Over all, her quality of life improved dramatically.

For more information see my site and my book Skin Deep: A Mind/Body Program for Healthy Skin.  You can download the free e-book edition there.


About the Author

Ted Grossbart Ph.D.

Ted Grossbart is on the faculty at Harvard Medical School and the author of the book Skin Deep.

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