Psychiatry & Psychotherapy Podcast - An Introduction to Psychodermatology: "The Mind-Skin Connection"

Episode Date: July 20, 2019

What is Psychodermatology? At the most basic level, Psychodermatology encompasses the interaction between mind and skin. It is the marriage between the two disciplines of psychiatry and dermatology, uniting both an internal focus on the non-visible disease, as well as an external focus on the visible disease. This tight interconnection between mind and skin is maintained at the embryological level of the ectoderm throughout life. According to this article, although the history of psychodermatology dates back to ancient times, the field has only recently gained popularity in the United States. More specifically, Hippocrates (460-377 BC) reported the relationship between stress and its effects on skin in his writings, citing cases of people who tore their hair out in response to emotional stress. By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video. Instagram:dr.davidpuder Twitter:@DavidPuder Facebook: DrDavidPuder Youtube channel

Hello and welcome to the psychiatry and psychotherapy podcast with over 32,000 mental health professionals listening in every episode. Why? Because we need to stick together to survive the mental off field. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. So welcome back to the podcast. I am here with a graduating Loma Linda medical student, Chloe Walker. Chloe Walker, welcome to the podcast. Thank you very much, Dr. Peter. It's an honor to be here. And today we are going to be talking about the interplay between psychiatry and dermatology. Yes. Psycho dermatology. That's correct.

And Chloe has aspirations to become a psychodermatologist. And tell me a little bit about your journey and how you got interested in this. Sure. So as Dr. Peter said, I am a recent graduate of Loma Linda University School of Medicine, class of 2019. and my interest in psychodermatology developed during my high school and college years, actually, I suffered from a very emotionally distressing battle with severe resistant acne, and that cultivated a deep desire to reach out to other individuals. I'm going through a similar experience to mine.

Wow. So when you were a teenager, you had really bad acne, and then you felt like some sort of emotional, response to it? Absolutely. You know, a lot of people when they would see me, they would really just kind of focus in on my skin without even asking my name first. And that caused me to feel an immense sense of shame and guilt and really feeling vulnerable to their opinions of me. Did you ever get comments or did people like say things? Yeah, a lot of times in an indirect way, like today your face looks a lot better or, you know, have you seen a dermatologist and, you know, some very, very hurtful

remarks at a lot of times. Yeah. Definitely. Okay. And so your interest in psychodermatology, kind of interplay between, you know, mental health and our conditions of the skin that affect us. Sure. really sort of was sparked by this time. And then did you know that you would be interested in dermatology before you applied to medical school? Yeah, that was definitely an interest that I had, but I didn't have any formal exposure until I received a lot of my clinical training in dermatology. And I was immediately drawn because of its hands-on focus. And my joy of creativity and using my hands was definitely.

immediate draw for me. In addition to that, I've always had a very intuitive gift, and I love emotionally engaging with my patients. So when I figured out that I could marry those two specialties, I knew I had found my calling. Yeah. And just a little bit of my background in this. So I run a day treatment program, an intensive outpatient program and a partial program. So, you know, intensive outpatient three hours a day, three days a week, partial program, you know, seven hours a day, five days a week, and we see people with medical and psychiatric issues. So the gauntlet of, you know, from neurology issues to dermatologic issues, and some of the dermotelogic issues are, yeah, some people who have had skin issues that all of a sudden

even feel suicidal because of the intensity of how difficult it is to feel like that is the only thing that people are seeing, that people are no longer seeing them. And then they kind of identify with their skin issue where like I am this skin issue. And they become very, very focused and obsessive about treatment, about getting help. And, you know, often it turns into a full, you know, depression episode, whereas before they were living a pretty normal life. Or sometimes, you know, people have had other traumas in their life. And for some reason, this derm issue kind of stimulates the trauma. So in the program, you know, we do intensive therapy and help people be congruent with

their emotions, help people express the meanings that they attribute to their diseases, help them work through family dynamic issues that develop through medical illnesses. So that's kind of my background. Okay, so define for me, what is psychodermatology in your definition? So I like to think of psychodermatology as this marriage between two fields. We have psychiatry, which is looking at kind of this internal focus on the disease, the invisible disease. And then we have dermatology, which is the external focus looking at the visible disease. And the basic sense, the mind-skin connection.

Okay. Yeah. And so we've spent a couple months together looking at articles. you've done an amazing job, one of the best medical students have had. Thank you so much. Digging into probably about 100 articles, and we're going to go through a lot of them and kind of summarize them in this. And we'll put in our show notes a link to all the hard work that she's done,

and you can look at each individual article. There will be hyperlinks to it. So in the show notes, you'll go to the resource library and you can get the full list of the articles. So tell me a little bit about the beginning, the ectoderm. Sure. So from the literature, there is this tight interconnection at the embryological level through the actoderm actually, which from that we have the brain that's developing, the spinal cord that's developing, hair, skin, nails that's developing.

And so that suggests that there is this interconnection between mind and skin that continues to exist. throughout life. Yeah. So it's really, and I think it's interesting because there's different layers in the, you know, sort of the embryological connection. Sure. And the ectoderm is really linked to both the neurons in our brain, right? Mm-hmm.

And the skin. Absolutely. And so there's that connection, which is really, really amazing. Quite fascinating. Tell me a little bit about Hippocrates and the stuff that he was seen. Yeah. So from ancient times, we see kind of this existence of psychokutaneous disease.

We don't have the label of psychoderm, so to speak. But for example, Hippocrates had writings of people reporting pulling out their hair from stress. Yeah. So trichotillomania existed centuries ago. It's not a creation of our modern, you know. Exactly. Our modern world. Yeah.

And so tell me about this, 2008 article by Mars at all and what they found? Sure. So like Dr. Peter was saying, this 2018 article really looked at psychosomatic medicine, and they specifically said that the origins, meanings, and underpinnings of disease, which cannot easily be made sense of under the reigning biomedical understanding of health and illness. So just kind of getting at what are some of these underwriting.

issues affecting the skin. Yeah, so psychosomatic, it's kind of like we can't make sense of the illness from just pure pathophysiology. Exactly. And there seems to be, they stated, you know, there's this sort of repressed emotion, repressed anger, hostility at times. And that, here's a quote, in the skin, we see not just our internal physical. physical state, but all our physiologic processes and reactions.

Pressure from within and pressure from without reveals itself in the skin. And so the way that I see this, because I study all psychosomatic illnesses, is that everyone has a weak link. So some combination of genetics, epigenetics, we have a part of our body that's going to be affected by stress first. and so when we have chronic stress and we're constantly in the fight and flight state and sometimes we're going to shut down, dorsal vagal state,

we get in this sort of chronic ongoing stress state in our body and then that gets represented in one sort of area of our body, one organ system. And so skin is just another one of those organ systems that we're going to take a deep dive into today. And for some people, skin will be the first place where their stress shows up. Right.

Like when I first started medical switzerland, school, I developed this rash. Where was this rash? Oh my, it was on my chest. It was on my arms. And I was really freaked out. And I had some old steroids because I tried some of that and it didn't seem to go away. I had some old antifungal.

Tried some of that. It didn't go away. And so I ended up going to a dermatologist. Uh-huh. And a really bad interaction with this dermatologist. just actually. He comes in, looks at it. I tell him, look, I've tried steroids. I've tried antifungal. He's like, well, you're going to need a biopsy. And then he walks out. And I like, follow him out. And I'm like, wait, wait, what do you think's going on? He's like, oh, we just need a biopsy to know what's

going on. And so I go over to scheduling and it was going to take literally three months to get into a biopsy. But I was like, I had already diagnosed myself with Paget's disease of the nipple, which I later found out only occurs in women, which is why medical students shouldn't self-diagnose themselves. That's right. Or people in the general public, you know. And anyways, I end up paying for this private practice dermatologist. He takes one look at it and he says, oh, that's eczema.

Take the steroid and it'll get better. And I'm like, oh, like maybe I just didn't put enough steroid on it. But then it occurred to me, you know, I was only sleeping like four hours a night. I was literally studying every waking. moment, I was so stressed that I was not going to survive medical school. And it was that first like four months when you don't really know how to study. And so you're like totally overdoing it. And I wasn't, I was like in this weird sleep cycle where I would stay up to like three every morning studying. And then I was also eating like really poorly. I was eating. Oh gosh, it was so funny.

because I thought Loma Linda was like this epic center of nutrition, right? The health message, right? The health message, right? So I thought, like, anything that they fed me was, like, obviously very nutritious. So they had haystacks, which was, like, basically fritos with every fried beans and cheese on top. So I was eating all these really bad, like oils that I normally wasn't accustomed to. Sure. So maybe that contributed.

But anyways, my overall stress response. And by the way, people at Lomelinda really do eat healthy. that's just a very small piece of, maybe not the most healthy thing. So you came to these conclusions on your own about your diet and sleep. The dermatologist didn't mention any of those factors. No, the dermatologist, well, the dermatologist mentioned that it's dry weather here. That's the main thing that he mentioned. But I've never had eczema since.

Wow. Because I've never had that level of stress since the first. couple months of medical school. And I can tell you that not knowing the diagnosis was extremely stressful for me. Wow. It was extremely stressful. And once I knew what it was and I knew it had a treatment, it's like I calmed down so much. And then, you know, it was just a matter of figuring out how to do medical school, which is brutal. Absolutely. Okay, well, let's go on. What are the different ways, Oh, this was an interesting study. Another 2018 study, Chung et al, and they found what?

Basically, they looked at these patients with chronic idiopathic urticaria, and they found an association with PTSD and how that's related with how are these patients coping. And so they actually talked about this conversion phenomenon in which you have these traumatic emotions that are converted into more acceptable physical dermatological symptoms. And that conversion process is actually facilitated by how these patients are escaping, avoiding, or other emotion-focused types of coping. Yeah, that's really fascinating. I was actually talking to some doctors who have been in the VA for like 50 years, you know, they've been doctors there. and they said that after World War II, there was a lot of people coming with PTSD

that was represented in their body because PTSD as a psychological disease wasn't socially okay. So people were feeling it in their body a lot more and as the stigma has changed, people are more experiencing the traditional PTSD symptoms. But what I liked about this study in particular was the escape avoiding type of ways of dealing with psychological trauma and stress, right, led to more of the

physical manifestations. Right. So this is what we've seen, like people who have no ability to state that they have psychological conflict or to process it. So they have to repress it. They have to push it down. They have to deny it. these are the patients that tend to have a harder time with somatic issues.

Wow. So the first step that we do in our treatment program is actually getting them to talk congruantly about their psychological things. And with my microexpression training that I teach people how to do, I show people how to read the emotions. And so when I'm talking with someone, I'm looking for their emotions and that helps me guide what I'm going to try to pull out. in someone. So I might see a micro expression of anger. And yet they have no way of representing that

consciously because they don't allow themselves to. Because for whatever reason, maybe when they were young, they were told they weren't allowed to express anger in a thousand ways. And so now they have to deny any anger. How did those micro expressions of anger, how do you see that maybe a tightening of a fist or pressure of speech? No, no. So micro expressions are like one-tenth to one-th30th of a second. flashes on the face. And so anger is a quick down and together of the eyebrows. Okay. And I do a series on my podcast.

Interesting. Three parts on how to use the micro expressions. And then I created an app to sort of help people read them. Thank you. But it's helpful in guiding what is actually there. Because you know if someone has a micro expression of anger, something they feel angry about. Maybe it's me. right when they're talking to me.

Did they express micro expression of anger? It may be, you know, towards me. And so it's helpful for me to tap into that there's some pocket of emotion there. I see. Okay. So here we have this nice 2007 article. And tell me how they break down the different dermatologic issues. Sure.

So, you know, there's a lot of different ways that we can actually classify these psychokutaneous disorders, but the most widely accepted system really looks at three different categories. So the first one, we have psychophysiologic disorders. These are disorders where the skin disease is precipitated or exacerbated by the psychological stressor. So this could be seen in acne, alopecia area, or tachyria, or psoriasis, for example. The second area includes psychiatric disorders with dermatologic symptoms. So there's really no underlying physical pathology here. This is everything seen on the skin is self-inflicted or self-induced by the patient.

So this would include things like body dysmorphic disorder. And the last category includes dermatologic disorders with psychiatric symptoms. So these would include emotional problems that are more prominent as a result of having the skin disease. So chronic eczema, vitiligo, resulting in, you know, major depressive disorder, for example. Yeah. Okay. And so the three categories, the psychophysiologic, which is your symptoms are worsened by stress. Correct. And so stress, sometimes there's a a temporal relationship with this with these types of issues

so that when someone has gone through in a stressful event, they'll get an outbreak. Like herpes is a good example. Often when a patient goes through something really stressful, they have an outbreak of herpes. Then number two, psychiatric diagnoses

or psychiatric disorders with dermatologic symptoms. So the primary issue is the psychiatric issue. Exactly. So I think like OCD, sometimes they'll have like skin picking or like hair pulling

or different things that they're doing it to themselves. Exactly. And then the third category, dermatologic disorders with psychiatric symptoms. So now you have the primary pathology of the dermatologic issue, which could be influenced by stress, but it also can cause stress by having it.

Right. So for me, I think, you know, although eczema is on this list, like having the eczema and the worry of the diagnosis and the worry of, you know, was this going to kill me because I thought it was a cancer, that created secondary psychological manifestations, but it was also due to the stress. So it's all, to me, it kind of blends together as well.

A lot of overlap, definitely. There's a lot of overlap. but there's these three categories which are helpful. And then there's other ways of thinking about it, which I think are also helpful to talk about. In this one 2009 comprehensive review, there was direct association and indirect association. So can you explain what those things mean?

Right. So in a direct association, we're looking at, so this is the psychiatric disorder, you know, directly causing, the dermatologic manifestation, and there's no secondary cause that's involved. But an indirect way, that would involve a secondary condition. So, for example, if you are having this phobia of dirt, that is going to cause you to continually wash your hands, and because you're continually washing your hands, you're causing trauma and damage to your skin.

So that would be kind of the... That's the indirect. So the indirect association are the things that you are doing to yourself. Right. People scratching themselves, pulling their own hair. So that would be like an OCD would be causing an indirect association with skin symptoms. And then the direct association is when you have maybe stress, which is causing hives. or you're having psychosis causing hallucinations of something on your skin.

But you're not actually seeing the skin pathology, so to speak. Yeah. Delusional disorder would be a direct, you know, and then there's some that could be both direct and indirect. Absolutely. So depression could be associated with indirect things like, scratching yourself, pulling your skin, agitation, and then it could be associated with direct stuff as well,

like psoriasis with inflammatory mechanisms. So, yeah, I think that's another good way of thinking about it in classification. Sure. And then we talked a little bit about the temporal relationship already, but I think that that's a really important thing to think about in terms of how we think through how these different skin, issues are coming up. Yeah.

Can you tell me any other skin issues that would be caused or would be associated with temporal timelines? Yeah. So I think you had mentioned the herpesy simplex infections. So acne as well, vitaleigo, alopecia areata, lichen plaintiffs, and even separate dermatitis, urticaria, atopic, eczema, quite a few examples. Yeah. So in one article they talked about.

about, you know, hey, asking the patient, do you, does your skin seem to look or feel worse when you're stressed? You know, that would be a simple question to sort of see if the patient has any conscious knowledge of if stress is associated with it. Right. Then there's another category of like, you know, do developmental sort of things influence our skin? That was really interesting to me. Yeah.

Because we talk about attachment styles at times in this podcast. So insecure versus secure. And Beatrice Beebe found that she could predict it to some degree at four months of life by watching the mother and the child interact. And then at one and a half or one year to one and a half, you can watch the child and how the child interacts with the mother and sort of classify them as secure or insecure attachment style. So how does this relate to skin?

Yeah. So this was actually a fascinating 2017. multi-center study conducted in Europe, actually. And so the conclusion of the study showed that participants who had secure attachment styles reported stressful life events during the last six months significantly less often than those who had insecure attachment styles. And also these dermatological outpatients were less able to depend on others, were less comfortable with closeness and intimacy, and experience similar rates of anxiety and relationships. Yeah. So it's, you know, how we perceive, stress depends on who we're in relationship with.

Yeah. And so, like, as a dermatologist, I would say, you know, having a relationship where the patient feels heard and understood. So key. You can provide a secure attachment with an insecurely attached person. Or, like, they may tend to be more anxious or avoidant in their attachment style, but you can still develop a secure attachment with that type of person. Now, that might be more difficult.

The study actually showed that patients with secure attachment styles tended to be. more satisfied with their dermatologist than insecure patients. And I think it can take a little bit more empathy to make someone who's insecurely attached, feel securely attached. So, yeah, even development influences the way that our skin is. That's fascinating. And then, you know, getting a history of the present and past traumas

can help someone in their sort of understanding of how these things are influenced. Right. on each other. So tell me a little bit about what that study found. Okay. So this was a 2013 study looking at some of these psychosocial factors such as dermatologic disease-related stress. And they actually found that up to 90% of patients who commit suicide may have a psychiatric disorder. And the majority of that percentage, 50% actually involves major depressive disorder and followed by 25% involving substance abuse and dependence.

Yeah, and also, you know, to a lesser degree, the PTSD and the body dysmorphic disorder. Yes. But I think with this study and the other studies kind of, the conclusion that I reach is that as a dermatologist, you really need to be kind of looking for psychiatric core morbidity. Yes. And so we talked about, you know, screenings. screening tools, you know, maybe in an outpatient setting, having your patients fill out a GAD 7 or a PHQ9, GAD 7 gives you the basic anxiety symptoms, and it would allow you to kind of get a quick

idea, oh, this is a big issue or this is a small issue. And then the second thing would be the pHQ9, which is a depression inventory, which looks at, you know, a bunch of different depression symptoms and would give you a quick idea of how much depression a person is suffering from. but also screening, screening out other like parasuocidal behaviors, I think can be important. We've talked about a couple of them. Any others that you want to highlight? Sure. So what we mean by a parasitocidal behavior is where there's no intention of dying.

It's an intentional self-injury rather. So this would, for example, include something called dermatitis artifacta, also known as neurotic excorations. So these are solely introduced by the patient. Typically, these are driven by psychological problems, and they may reveal themselves as these bizarre shapes with irregular outlines in a linear or geometric pattern. Other examples such as trichotillomania, this is basically where we get these irresistible urges to pull out one's hair. Yeah, and that's associated with OCD and kind of other sort of obsessive types.

behavior such as nail biting, skin picking. So let's talk a little bit about the psychiatric morbidity in dermatology. So how often are we seeing, you know, different psychiatric manifestations in this people group of people with dermatologic issues? So tell me about the study in India. Yeah. So according to Indian Journal of Psychiatry, the incidence of psychiatric disorders among these dermatological patients is actually all the way up to 60 percent, range of 30 to 60 percent. Yeah. And in another 2006 study, there were a lot of patients who were referred to a psychiatrist and, you know, a lot of depression and the most prevalent dermatologic issue with those with psychiatric comorbidity was chronic utericuria.

That's correct. Okay. And so that was like chronic hives, right? Right. And some patients are so bad that they commit suicide due to their skin condition. Or the skin condition may be part of that or stress them out. So tell me a little bit about that study. Yeah.

So this was a 1998 questionnaire that was sent to all consultant dermatologists and the British Association of Dermatologist Members Handbook from 1996 to 96. 97. And interestingly, they found that 320, so about 78% of that sample said that they actually saw patients with psychological or psychiatric disturbance. And additionally, 86 participants were aware of 178 patients who had attempted suicide associated with their skin condition, skin disorder. So, you know, a lot of dermatologists already see this. They already know about it. They already have patients that they know, you know, some people's skin condition gets to a place

where they're like, you know, I don't really want to live anymore due to the severity of this. So part of, you know, my hope in this episode is to equip, you know, therapists, psychiatrists, mental health professionals, maybe even dermatologists on what to do when we have these patients. What can we do to help them? Before getting to that point. Yeah. Let's talk a little bit about acting. because you looked at some studies in particular on that.

Okay, sure. So around acne, there are a lot of fears around that, and I can attest to that suffering from acne myself. Interestingly, there was a 2015 cross-sectional observational study, and they eloquently said in the long run, acne may cause cutaneous as well as psychological scars. So they had a sample of 355 high school students. Basically, this was done in Brazil.

And the average age was 16, and they showed that 89.3% had a prevalence of acne vulgaris. And the most prevalent psychosocial issue was, quote, afraid that acne will never cease. Yeah. So you think about that as like a cognitive distortion. like if you were a therapist, you know, like looking at all or nothing thinking, over generalization, predicting the future. And this is why, like, thoughts like that, that increase anxiety, that increase distress, if we can maybe use cognitive behavioral therapy to approach those types of thoughts, it might help. And that's what they found and we'll get to those studies.

So anxiety and depression is higher. We know that in people with acne and severity of acne. and there was another study that we looked at for that. Let's jump into treatment modality. So the way that I thought through this was, you know, thinking through like, okay, if you're a dermatologist, how might you approach this? If you're an outpatient psychiatrist or psychotherapist, how might you approach this? So first of all, for the dermatologist, I think it makes sense to have a screening tool. Absolutely.

GAD 7, PHQ9, have every patient fill it out in the lobby. and then when you're seeing them, you know, getting the full history, right? Right. Getting a history of stressors going on in their life. Getting a history of are there other psychological, developmental aspects that are contributing to this? Family and personal history. And then, you know, screening for, is this person depressed?

Is this person anxious? Do they have OCD? You know, do they have obsessive thoughts? like that lead to damaging their skin in some way. Right. And it seemed like in the literature when we looked at this, a lot of dermatologists are already looking at this. They're already thinking through what medications they can use.

So we looked at various studies for that where, you know, there might be the use of antidepressants. They looked at, for example, Psychogenic excoriation, TCA's, doxipine, chlamypramine, prozac, and recommendations for trichycinamina, you know, chlomipramine, fluoxetine, olanzapine, even. So in the articles, it looks like there's some dermatologists who are already kind of like trying to treat them with medications. Right.

What I would say is the first line in my mind would be psychotherapy. Okay. And so, you know, we had this kind of discussion, okay, if you're a dermatologist in the future, it might be good to have a therapist in your office. You know, it might be good to build a relationship with a psychiatrist as well that you can refer patients to. You know, it's, you know, I refer out to a lot of therapists. When the patients come back, you ask them, how did it go? Do they feel connected to the therapist? Do they feel like it was helpful?

Eventually, you kind of figure out who the good therapists are. or who can be helpful for this disease. Sometimes it might be educating the therapist, like, hey, I'm referring you this patient. I think they're struggling with how they cope with stress. And I think that the data pretty much supports, you know, that therapy can be helpful as a way of decreasing stress long term. Absolutely.

So therapy, I think, would be first line. I think also exercise, sleep, diet. mindfulness, there's a bunch of studies on mindfulness that we looked at, spirituality. You know, I have an episode on forgiveness. There's a, you read a couple articles on the interplay of that. Yeah. Yeah, any other thoughts on treatment, combined treatment, medications, psychotherapy, any questions that you might have?

I guess just trying to gauge like, you know, how could we best approach this? So you said, you know, for the dermatologist, we would start. with getting a good history that coupled with using a very good screening tool. And so, like, is this based on the dermatologist's, like, professional opinion? If they see that there's a significant concern, would they at that point refer them to a psychiatrist or a derm site clinic and kind of go from there? It's kind of the process we're talking about. Yeah, and I think that's, I think that's already happening. What I would say is that the most difficult aspect is actually getting a patient from your office into treatment.

And so even I see patients often and outpatient, and it may take like six months to a year to convince them to go into psychotherapy. Right. So that's where I think as a dermatologist, like learning some of the basics of the medications, if they're not willing to do therapy, maybe start. there, continuing to see them, and really learning some motivational interviewing. Yeah, definitely. Because even through my clinical rotations on dermatology, I would see definitely a huge emotional burden associated with a lot of these derm disorders. And the dermatologist would acknowledge there are some stressors here, but they had no,

like, formal tool of like, you know, analyzing them. so that they could have the next step. It was just saying, okay, this is here. You may want to get plugged in with your psychiatrist, but there wasn't like this collaborative, joint, aggressive effort between both. I didn't see that consistently happening. Right.

And in your studies that you showed me, like, therapy will be much better than just psychoeducation. Yeah. Okay. And, you know, you're in a busy dermatology clinic. You don't have very long. But even like five to 15 minutes of motivational interviewing can sometimes be enough.

And I would also say like therapeutic alliance. If you have a stronger therapeutic alliance with your patient where patients trust you, they'll be more likely to follow your treatment recommendations. So I always start with therapeutic alliance teaching empathy, teaching psychological safety. And so when you give the information at first, let me kind of express how this plays out, some patients will resist the idea that something psychological is happening. So I always use words like stress. And, you know, like even diabetes is worsened by stress.

So I take like a very physical disease that everyone thinks is physical. And I say like, and even diabetes is, you know, improved by higher level ways of dealing with stress. And, you know, like most people are pretty resilient. But, you know, we can always learn better ways of dealing with stress and dealing with anxiety and the traumas of our life. And so having, for me, it's, I'm often referring to the men program, which is this sort of mixture of medical issues and psychiatric issues. So I, you know, I'll say to them like, hey, coming to the men program, it can help you learn advanced ways of dealing with stress. Now, some patients come in and they think they're going to get psychoeducation.

They're actually going to learn how to process the emotions in a more congruent fashion. Right. So what I mean by that is that we know from the evidence here that suppressing emotions, suppressing negative emotions, specifically anger, fear, disgust will lead to more physical manifestations of the stress. And so in our program, what we're going to do is we're going to help people be congruent, either in writing, in art, or in language, talking first. And once we can get one of those domains where they're congruent, where their inner experience matches their outer experience, Then we try to pull them in so that they can get all three.

Okay, so let's say they start out and the only place they can be congruent is in artwork. So you have them do self-portrait. They, you know, on one patient, black face, a little dark heart in the middle of the face. It's like, that's my soul and it's dark. Okay, then we get them to talk about that authentically. And that may be the first place where they're verbally congruent in expressing the art and defining the art and talking about the art. and then we may get them to write about it. So at least that writing of the art is congruence.

And now we're bridging them into the three domains of congruency. And the next thing we might do is we might look how their family reinforces the disease narratives, the narratives that they believe about themselves, that they're a victim, that they're not going to change, that this is going to, that they are the disease, right? Right. This is where people get. They get so focused on their disease that they are the disease. and whenever they define themselves,

I am Joe and I am, you know, I have a chronic rash. And it's like, I am, you know, it's like the first thing that they used to describe themselves whenever they meet anyone. So we get them to learn how the family reinforces that. And then we get them ideally to be congruent in their family structure. Okay? Okay.

So that they can then have a voice. that is consistent with their inner experience in their family so that they don't need the therapist ongoing to be the only place where they can be congruent. Now, that being said, a lot of patients can't even, they have a really hard time being congruent even with their therapist. Right. And that process of developing that congruency, what's kind of the timeline on that, or is it really different for each patient? Yeah, so in my program, it usually takes about 20 to 30 sessions. Okay.

Yeah. And to your knowledge, is that men program specific to Loma Linda? It is, but I do think that something similar can be developed. I mean, in the research that we already explored here, you know, cognitive behavioral therapy, mindfulness work. So there are other modalities that work. I'm just kind of explaining, like, when things go beyond outpatient, because we see people who have already seen psychiatrists, they've already seen psychotherapists for a while, and they're not making the progress still. So there's like another level like partial programs, day treatment programs. And there's partial programs and day treatment programs across the U.S.

Right. You know, and a lot of them are good. A lot of them are more cognitive behavioral therapy based, but that's still good. But ours is specific to the chronic disease. So I think it's really particular for this people group who are suffering from chronic dermatological issues. Absolutely. Okay. So if the patient was suicidal, you know, actively with a plan,

inpatient would probably be the best place. Okay. And if they were treatment resistant, you know, then I might, you know, they failed multiple antidepressants. They failed therapy. They failed partial programs. That's when you think more like ECT, TMS, ketamine as one of the treatments. Okay.

I want to make sure we get a little bit to the mechanisms. Okay. But before we jump to the mechanisms, do you have any other questions that have come up in our discussion so far? No, I think you've done a great job of covering all the bases. I guess one other question, kind of looking at the pathology involved, whether it's anxiety, depression, OCD. There's so many treatment modality, like possibilities. How do you gauge, like, what to try? Is that based on kind of obviously their history and how they tolerate different side effects?

Yeah. So in my empathy episode, I talk a lot about therapist effect. So across modalities, there are commonalities within therapists that make them good at what they do. And there are some therapists that have better outcomes than other therapists. And I think it has a lot to do with empathy, social IQ. therapeutic alliance. So outside of modality, I would say that those things

are actually even more important than the modality in particular. Oh, wow. So a lot of people will say CBD, CBD, CBD, because it's so easy to run these studies, it's easier to train it, but there's also really good people who are practicing other forms of psychotherapy.

So when I refer someone to a psychotherapist, I have like a list in my head of about 20 different therapists. I kind of know who they might be a fit for. I see. Okay. And so if we're talking to individual outpatient therapist, I'm not so concerned with the type of therapy as the therapist in particular.

That being said, you know, like if they do have OCD, you might look at more of a behavioral approach. Or you might look at someone who's treated OCD. And if they do have something more like trauma, you might look at someone who's, you know, either does trauma work or has like EMDR certification. Okay, so that expertise. That expertise, yeah.

And then the other thought that I had in thinking about the medications and the kind of a common mistake that people make is like, let's say you're treating someone with really bad obsessions like OCD. And how do you treat them? Well, if you start them on a high dose of an antidepressant, they make it worse.

So you may need to start them really low. So we're talking instead of like, Prozac 20, you start them on like Prozac 5. And then you wait for a couple weeks and then 10 and then 20 and then 40 and then 60. And then you may even go up to 80. So usually Prozac we only go up, fluoxetine, we only go up to about 40. But in someone with really bad anxiety and obsessions, we may actually go up higher. Now that being said, I really want to emphasize for anyone listening to this, the importance of psychotherapy.

I would not just do medications on this group of people because they really need both. And the therapy will probably have a longer effect for OCD than the medications. As long as they're on the medications, their obsessions will decrease. But what I've found is that you want to allow them to do the therapy to make the long-term improvements. Therapy changes actually how the brain is structured. Right. They've shown that in studies of OCD. So we actually want to change the way that the brain instruction.

And I'll put in the resource library as well, my OCD handout that I give to people, which is there's three steps, basically. Step number one, they relabel the intrusive thought as an error message, a misfiring of the brain. Step two, they distract themselves for 15 minutes. So they set a 15-minute timer, and they do things that are pleasurable before they act upon the impulse. Okay, so instead of scratching themselves, they would. wait 15 minutes and while in that 15 minutes they would try to distract themselves and they would see hopefully by the end of the 15 minutes the obsession has decreased and then the third step is to

re-value what do I value do I really value this message in my brain that's telling me that if I scratch myself I'll protect myself I won't die or do I value my family my friends my job and the people with the most severe OCD, it's very hard for them to start doing this. But if they continue to do it every single day, the brain literally changes. And that's what Dr. Schwartz and his studies have shown. So I'll put that resource in the library as well. Thank you. And, you know, exercise, diet, sleep, all these things are important. So it's really the full package. Right. Okay. Let's talk about mechanism a little bit. Like, how do people get to this place? So let's say we had a stressor. What happens when someone has a stressor? What kind of chemicals are released? Right. So kind of in

the early stages to a stressor, kind of the natural way the body responds by that is activating the hypothelamic pituitary access system. And so basically what happens is the stressor is releasing corticotropin releasing hormone, and then that whole cascade. You get the adrenocortocotropic hormone, and then downstream from that, cortisol, nor epinephrine. And then from my understanding, at the same time, we're also in creating cytokines like IL-18, IL-6. These are very pro-inflammatory and immunomodulatory cytokines. So that, coupled with the cortisol, you're actually causing this negative feedback loop to kind of shut everything off. So when you have a chronic stressor, what you're doing is exhausting the HPA access. And so now your cortisol release is decreasing

and you're getting like this outpour of IL-18, IL-6, these pro-inflammatory cytokines. And so you shut off that feedback response. And so, you shut off that feedback response. And so, that basically just exacerbates kind of this pro-influen inflammation. Yeah, so we know that people, when they get just pure depression, they don't have a history of trauma, cortisol level will be higher. In patients with chronic early childhood trauma, they actually, and they look depressed later in life, their cortisol levels are actually lower. Right. Okay. And so, you know, the depressed, high cortisol person might have like a lot of fat in their midsection because that's what steroids do, whether you take them, you know, whether you take them by pill or whether you have a lot

in your body from chronic stress. But then what will happen is with people with the history of trauma, the events of high stress early on kind of build like a resistance to the release of the steroids. So the steroids are elevated early in their life and then that causes this sort of secondary resistance and a lower level. Now that being said, there's a big myth out there, like that's adrenal fatigue, like your adrenal systems get tired. That's not, that's not what we're talking about. So the adrenal systems never stop producing cortisol. But it's interesting for a lot of these diseases, what do we end up giving to the patients? Steroids. Steroids, yeah. And we give it topically, sometimes orally, if it's really systemic, right? Definitely. And so it kind of, it kind of,

fits into this idea of like we may need to dec – the cortisol shuts down the immune response, the innate immune response. Yes. So it says, you know, this – we can quiet down the inflammatory system, right? Naturally. Naturally. And interestingly, when we looked at other articles, we talked about the fight and flight system, right? And I think about that a lot with, like, trauma.

we're going into the fight and flight, but then whenever there's a trauma, the trauma is so overwhelming that you feel like you're going to die. And therefore, you shift from that fight and flight into more of a shutdown state is the dorsal vagal state. You have a couple articles that kind of touched on that a little bit. And I think that science may not be there completely for dermatologic issues, but I know that that's happening whenever trauma occurs, is that people are shifting into that dorsal vagal state, which is that shutdown play. which is a place where we're dissociating, we're feeling numb, we're feeling disconnected, maybe we have depersonalization, de-realization. So, okay, what from all of this information,

like what are some of your main takeaways? Like diving in, tons of journal articles. Wow, it was quite an experience, really enjoyable for me, and just so fascinating, how much, you know, our mind and our thoughts and all of that, how that can manifest in our skin. And just looking at, you know, how the prevalence of suicide from all of this and the prevalence of all the psychiatric comorbidities shows that this is a valid concern and it needs to be addressed and not ignored. Yeah, I would say my main takeaway was, it just reinforces to me the importance of equipping primary care doctors, dermatologists, with motivational interviewing to engage treatment. And I'm actually developing a series that I'm going to go around to do some grand rounds around my university, Lomelin University.

We're going to be talking about how do you help your patient engage treatment, you know. Right. Empowering them. Because we know if they engage treatment, like it's going to help. Like the effect size of the men program is like one to two, depending on if we're talking about physical issues versus psychological issues. And effect size of medications, just to give you an idea, pure medications can be somewhere from like 0.3 to 0.6. And psychotherapy, like 0.3 to 2, depending on the length and the intensity of the psychotherapy and the quality of the psychotherapy. So we know that it's really important to do the work, the psychological work, so that we're not just taking the emotions and then suppressing them in our sort of consciousness. And that was a mind opener.

That one study you found on how patients with dermatologic issues are stuffing their emotions more frequently. They're denying the emotions. They're stuffing them, which is something that I've seen clinically, but I hadn't seen in the literature, which is really fun. So that was a really nice one. And I'm looking forward to working with my dermatology colleagues here more. And I hope that this creates a bridge and maybe do some work with their department, integrate with their department a little bit better. Because I think it's something that it's a big issue.

Yeah. It's a big issue. And it could be done a lot better. And sometimes it is enough like it was for me as a medical student. Just be told like, hey, this is eczema. This medication is going to work. and then naturally reducing my stress by growing into medical school. Yeah.

What was the biggest win for you back then? In terms of... When you were a kid, adolescent, and you had the... Dealing with acne? Dealing with acne, yeah. Yeah. So the biggest win for me, I think, was, you know, partnering with my dermatologist, and it didn't feel like she was, you know, critical in any way that this was in any way, fault, but really patient with the process with me until we found something that worked

and worked specifically for me. So. Yeah. Yeah, that's good. So the patience, the lack of shame or judgment, right? That can be very powerful. That can be very powerful, especially from an authority figure, from a doctor, and then, you know, walking with you, right?

Absolutely. And I think having the confidence that, hey, we're going to try some different. things, we're going to find something that works. Right. There's always hope. That's really good. Okay. Well, thank you so much for coming on. It's been a pleasure, Dr. Peter. Thank you for having me. Yeah, and I will, once again, we'll put up a blog

with some notes from the show, and we'll put up, we'll create a separate document in the resource library. We'll put up the OCD handout for you guys. And if you have any questions, jump on one of my social media handles, links are in my show notes. I post a picture for every episode and then can correspond with different people, kind of see what they learn, what their takeaways were, and I love doing that. And I love hearing from you guys. And yeah, we'll leave it there.