The role of psychological factors in certain dermatologic conditions is not disputed. The various ways in which psychological factors impact the skin have been thoroughly explored in the adult dermatologic literature. Conditions studied in this literature include those that are primarily psychiatric (trichotillomania, parasitosis, dermatitis artefacta), those in which psychogenic factors are reportedly involved in the etiology and maintenance of the disorder (alopecia, urticaria), and those caused by an interaction of genetic predispositions and stress factors (atopic dermatitis, psoriasis, acne). In addition to these categories, one might add problems adjusting to a chronic medical regimen and psychological problems resulting from a severe or disfiguring condition.
Compared to the adult literature the psychological factors in child skin disease have not been well explored. Although much can be learned from the adult literature, children with dermatologic conditions are unique owing to the need to focus assessment and treatment on both the child and the family system. Because psychological problems related to a child's medical condition can have long-term implications (e.g., social development, stress management), treatment of these problems may be even more important for children than it is for adults. Despite the acknowledgment of a relationship between certain dermatologic conditions and psychological factors, treatment of these psychological problems rarely occurs.
Sabbath and Stein point out the significant barriers for children with a chronic medical condition to receive mental health treatment. The authors categorize the barriers into those contributed by the family, those brought by the medical team, and those contributed by mental health providers. Among barriers to effective referral, Sabbath and Stein discuss the likelihood that parents may become defensive at the mention of psychological or behavioral factors and interpret any such discussion by medical staff as a judgment of their ability as parents. They may also be sensitive to the perceived stigma associated with their child or family difficulties.
Barriers that hinder pediatricians include a failure to recognize behavioral aspects of an illness, lack of belief in the efficacy of mental health treatment, and concern about sharing their patient with another professional. In addition, frequent experiences with parents' resistance to mental health referrals may make physicians reluctant to initiate a discussion of behavioral issues, because of a concern with disrupting their relationship with the parents and child. This family resistance may be due in part to the physicians' difficulty in explaining the referral.
It can be difficult for physicians to articulate the connection between the medical treatment of the dermatologic condition and psychological factors, and therefore their referral for psychological treatment may seem unrelated to the family's presenting problem. The psychological explanations familiar to pediatric dermatologists, often psychoanalytic descriptions of hostile-dependent parent-child relationships, are unacceptable to most families.
Finding less pathologic ways in which to conceptualize the dermatologic-psychological interface may increase the acceptance of a referral and the likelihood of successful treatment. There may also be few mental health professionals with significant experience in treating children with medical conditions available to accept referrals, and third party reimbursement of these services can be limited, causing a financial disincentive to the family. Understanding how to discuss the role of psychological/behavioral factors with families and building relationships with competent mental health providers can make an important difference in the successful treatment of dermatologic conditions in some cases.
Traditional medical treatment of dermatologic conditions can be significantly improved by the inclusion of behavioral health strategies by medical providers or mental health professionals, if the families' problems exceed the resources of the primary provider. This article will review relevant research literature on the psychological-dermatologic connection, particularly those conditions in which genetic predispositions and stress interact and in which adjustment to long-term regimens is necessary. The goal of the article is to provide the physician with empirically based explanations that are acceptable to the patient/family and help move them to accept psychological interventions as needed. Further attention to principles of psychological management within the dermatology context may prove beneficial to the treatment as well as make referral to a mental health provider ultimately more acceptable.
