Artículos / PsicoDermatología

By: Alberto Lavieri, M.D. Cecilia Daireaux

The concept of the human body—historical perspective

Hippocrates, Greek philosopher and ancestor of Western medicine remarked that "Man is a part of the whole cosmos and, therefore, only nature can deal with his complaints." From this quote it can be con- cluded that Hippocrates understood diseases to be a consequence of disturbances of the human organism and not as a punishment from the gods. This conception by Hippocrates can be interpreted as the first step towards a concept of diseases that is based on etiology. Today, that conception has been incorporated largely in our understanding of the human body and of diseases of it.

In the 18th century, the concept of the human organism was influenced by the French philosopher and mathematician René Descartes. He interpreted the human body as a machine that consisted of parts, each of which had a specific purpose. Descartes proposed that "Understanding the whole requires to study each part of it." That conception leads us to study in depth all the different parts of the human organism by methods of macroscopy, microscopy, physiology, and biochemistry.

As a result of studies by Wolfgang Köhler, Kurt Koffka, and Max Wertheimer, the concept of the human body has changed again in more recent years. The so-called "Gestalt theory" was developed from studies on visual perception of figures and backgrounds and was later applied to the processes of thinking, in general, the new concept being that "the whole is more than the sum of its parts."

The concept of the human body—current thinking

In the daily practice of medicine, we make diagnoses based largely on the results of complementary stud- ies such as laboratory procedures, radiological imaging, or pathology reports. Most of our colleagues believe that if we sum up the results of all these studies, we will arrive at the correct diagnosis and will determine the right treatment. This way of thinking is useful for a physician who wants to delegate responsibility for diagnosis and treatment to the pathologists, the radiologists, or to the laboratory. Profes- sional responsibility, however, requires a more philosophical approach. All complementary methods for diagnosis need to be assessed critically in every instance and need to be set into the broader context of each patient's specific situation. Keeping in mind the thoughts of Hippocrates, Descartes, Köhler, Koffka, and Wertheimer, we are well advised to rethink our process of decision making in the daily practice of medicine.

It is a common in medicine in general and in dermatology in particular that physicians do not view their patients as whole human beings. They regard themselves as specialists, sub-specialists, and "super-spe- cialists" who accumulate very specific knowledge about a circumscribed part of the human body. All too often, the human being as an unsplittable whole is not in the focus of our interest, i.e., a medical specialty for the whole human being does not exist. Patients, however, have a very fine sense of how they are treated by a physician, and they recognize full well when no attention is paid to their specific and individ- ual needs as a whole person. That is probably one reason why people who practice "alternative medicine" or "miraculous healing" are attractive for an increasing number of patients and specifically for those who suffer from diseases that are chronic or life threatening.

Psychodermatology—Our method

Much has been written about the interactions between mind and body and about the influences of them on sickness and health, but little of the findings have been integrated into the daily practice of medicine. When a patient seeks consultation with a dermatologist the following steps take place:

  • interview by the dermatologist
  • examination by the dermatologist
  • diagnosis and differential diagnosis rendered by the dermatologist
  • decision about treatment and ancillary procedures made by the dermatologist
  • in rare cases, recommendation to consult a psychologist if the dermatologist suspects "emotional fac- tors" to be involved in the pathologic process

Usually, when a patient leaves the consulting room, it is left to their decision whether or not to seek the advice of a psychologist. The dermatologist's job is finished—a diagnosis has been made, indications have been given, and medicines have been prescribed.

During the last five last years we introduced a systematic approach to patients who suffer from psoriasis, vitiligo, pruritus, and "atopic eczema." Many factors have been claimed to cause all of these conditions, but in the case of individual patients we often do not know specifically what the cause is. Practicing evi- dence-based medicine is extremely difficult with these patients. "Evidence" as defined by the Oxford Dic- tionary is "anything that gives reason for believing something." In our experience, evidence that is repeatable in the specific situation of our patient is more trustworthy than statistics cited from large, dou- ble-blind, multicenter studies. At our institute as well as in our private practice we have sought to develop a holistic approach to assess and to treat patients with skin diseases.

In our setting the patient experiences the following:

  • interview by the dermatologist
  • examination by the dermatologist
  • diagnosis and differential diagnosis rendered by the dermatologist
  • decision about treatment and ancillary procedures made by the dermatologist
  • in every case, assessment by the dermatologist of the requirements and options for psychological aid in the intended treatment
  • if psychological aid is indicted, the dermatologist explains to the patient that the success of treatment will depend to a large extent on his or her commitment to the suggested treatment in its entirety, consisting of medical treatment and psychological aid
  • if psychological aid is recommended, the dermatologist personally puts the patient in contact with a psychologist on our team.
  • the patient is interviewed and if warranted short-term interventional psychological treatment is given.

Psychodermatology—Our experience

For the process to work it was highly important that the dermatologist personally arrange for the initiation of psychological treatment. Most of our patients had long histories of interviews with specialists and non-specialists, and they all had heard many times that their skin conditions could possibly be associated with emotional factors. Despite that, very few of them had visited a psychologist prior to coming to our institu- tion. In our approach, the dermatologist guided and encouraged the patient to follow the recommenda- tions—the imperative advice of the physician. In our opinion it is fundamental that the patient entrusts his condition entirely into the hands of the dermatologist, who should be both expert in the skin disease and highly committed to the individual needs of the patient.

When recommending psychological aid the dermatologist needs to communicate to the patient that the psychological interview and intervention are indispensable parts of the treatment. Otherwise patients will want to wait until their pills, tonics, or ointments work because they perceive treatment with drugs to be the only way to get over their suffering. Patients with skin diseases often try to dissociate their disease from emotional factors and develop a rather "biological" attitude towards their disease. In our practice, the dermatologist who has the first contact with a patient needs to be skilled in assessing whether a patient has a real need for complementary psychological support.

Although many patients were aware of emotional factors that seemed to interact with their skin condition, most of them had no insight into the mechanisms that accounted for that experience, and they did not know how to deal with it. The major concern of patients who arrived in the psychologist's consulting room was the physical appearance of their disease. They often expressed that their skin condition had a negative impact on their daily life, on relationships, and on their self-image and self-esteem. Frequently they stated concern about how they were perceived by others. They imagined that others were afraid of acquiring an infectious disease from them and that those they came into contact with would want them to be quarantined. Many patients, for example, with severe psoriasis, felt ashamed of their appearances and tended to hide themselves not only from strangers but also from friends and sometimes even from closest relatives. Most patients appeared to be extremely watchful to the slightest signs of their disease process and especially to worsening of it. That was the case particularly for patients with vitiligo, whose disease could turn up any time and in whom the condition increasingly became a source of anxiety and fear.

We observed also that skin diseases affect the relationship between parents and their children. Parents of little patients often have a catastrophic perception of the disease of their children. They often feel that they are "faulty" and it was their "bad condition" inherited to their children that was responsible for their responsible for their disease. We experienced that children learn very quickly how to make believe that they have severe signs and symptoms, they also feel stigmatized, tend to isolate themselves, and refrain from social relationships.

We learned from our experience that it is preferable to use short-term intervention as the primary approach for supportive psychological treatment. The prospect of a definite and limited time frame increased the possibility of acceptance of therapy by the patients, and it motivated them to sustain it.

Our patients tended to report to us only the obvious problems caused by their skin disease in their daily lives, and they usually did not reveal longstanding sources of emotional problems rooted in their psyches and not in their skin diseases. Most patients had not given much thought to problems in life that caused them difficulty and that served as unique sources of stress. In our approach, the therapist attempted to detect specific characteristics of an individual patient including events that seemed to have caused trouble repeatedly. The therapist was advised to deal with these subjects cautiously and with care.

The main aim of the treatment was to guide the patient to identify and understand stressful events and to develop tools to deal with those situations effectively. At the same time, the psychologist tried to address issues unrelated entirely to the skin diseases, the aim being to widen the patient's horizon and to turn the patient's attention to issues other than skin disease. Distracting patients from their skin disease and its evolution usually proved to be beneficial for the therapeutic process in both the skin disease and its psy- chological effect. When the patients worried less about their diseases, their anxiety dwindled, and their perceptions of themselves and their responses to stress also changed. That alone was perceived by our patients as a marked improvement to the quality of their lives.

Critique of our approach

In our setting, patients were referred to the psychologist by the dermatologist, and did not make the deci- sion on their own. The therapist then reinforced what the dermatologist had told them, namely, that sup- portive psychological therapy is likely to be useful and beneficial. Ideally, for a psychological treatment to succeed the patient him or herself should seek consultation of a psychologist. Such a patient has a greater awareness of his problems psychologically, and he or she usually has a vague idea of how a psychologist might be of help to him. Nevertheless, we think that our approach is justified because it encourages many patients who might not otherwise seek treatment from a psychologist.


In this article we have attempted to share our experience with a systematic approach of offering psycho- logical support to patients with chronic skin diseases. Our patients usually have visited many profession- als over the years trying to deal with their diseases, and they come to us with high expectations. In our experience, even those who have lost hope or seem resigned to coping with their diseases can be moti- vated to engage in this new approach to treatment. We are highly convinced that our efforts are worth- while and we strongly suggest to our colleagues a more wholistic perspective when treating patients with chronic diseases of the skin. In the future we plan to evaluate the success of our method by means of sta- tistical analysis using psychological questionnaires that assess an individual patient's quality of life.

Alberto Lavieri, M.D., is a dermatologist and pediatric dermatologist at the Dr. Ignacio Pirovano Hospital, in Bue- nos Aires, Argentina. Cecilia Daireaux is a psychologist and specialist in systemic family therapy and in short-term therapies at the Belgrano University in Buenos Aires, Argentina. Contact corresponding author via email: