The skin-mind connection
From the Editor
Dr. Schwarzenberger is the former physician editor of DermWorld.
By Kathryn Schwarzenberger, MD, March 1, 2020
There is rarely a day when I am not reminded of the fascinating and intimate relationship of the skin and the mind. Psychological factors are estimated to play a significant role in up to one-third of the diseases we see. The older I get, the more certain I am that this number significantly underestimates the number of people whose skin disorder has a strong mind-body connection.
But here’s the problem. While we are experts at recognizing these often-challenging conditions, their diagnosis and management requires a commodity that we all seem to be short on these days: time. Our office visits do not always allow enough time to flesh out both organic and psychological factors that may be at play for a given disorder. It takes time and, frankly, it’s hard work to be both analytical and empathetic enough to hear facts, recognize nuance, and synthesize them into a reasonable working diagnosis. It’s even harder when we ourselves are stressed or exhausted.
Over the years, I have encouraged my residents to accept the fact that they may not make everyone better on the first visit. What is important is to remain open to the possibility that there may be more to the situation than immediately meets the eye. Listen to that “doctor instinct” that nags at you when you enter the room, the one that makes you look up when your patient says something that is just not quite right. I vividly recall one patient I saw with a chronic ulcer on her face. She appeared to be highly functional in all the outward facing aspects of her life, so the possibility that she had an underlying psychiatric issue was not immediately on my radar. However, when I finally sat back and allowed her to to tell her story, she offered, in one revealing phrase, the clues that helped me focus on the correct diagnostic path.
Over the next few months, we are highlighting several dermatologic disorders in which psychological factors are key. We begin the series this month with our feature on body dysmorphic syndrome. This is a topic I suspect we should be well versed in, as patients with this condition are likely to frequent our offices. We all know “that patient” who insists there is an abnormality on the skin that we just cannot see. And those are the easy cases. The symptoms of body dysmorphic syndrome can be subtle, and as the demand for cosmetic services grows, it is crucial that we recognize patients in whom this might be an issue. While it may be tempting just to provide the services they request, it may lead to dissatisfaction for them and misery for us. Our feature article provides questions that may help identify those at risk. This will hopefully allow us to ensure these patients get the appropriate care that they truly need, rather than the quick fix they may be seeking.
I will close by sharing an interesting conversation I had recently with a colleague, who offered a perspective that really resonated with me. She misses the ritual of washing her hands in the patient room. Those few seconds spent with her hands in warm, soapy water provided a moment for reflection at the beginning and end of each patient visit. I thought of this as I rushed in and out of rooms today, slapping on cold, alcohol-based hand sanitizer which stung every time it hit the cat scratch on my finger.
So, I went to the sink and indulged myself with 15 seconds of a warm, soapy handwash. She was so right.
