Question 21. Psychotherapy: when and how?
- Vitiligo is a distressing disease because of its perceived stigma, cosmetic disfiguration and tendency to chronic relapse.
- In certain cases treatment of psychological rebound may both improve the self-esteem and clinical outcome: this must be started in the “liaison consultation” room where the subject will be simultaneously in contact with the dermatologist and the psychotherapist.
- Cognitive behavior therapy may be appropriate in certain cases.
Vitiligo is often considered to be emotionally triggered, both by the affected subjects and doctors.
An incubation period of 2-3 weeks between the stress event and the clinical manifestation of vitiligo patches is reported by over 70% of patients.
Even the localization of white patches has been anecdotally but significantly reported as related to specific affective relationships.
Thus, according to some reports, men who had been betrayed developed vitiligo on the genital areas and women who did not accept their pregnancy, developed vitiligo on their abdomens.
The case of a woman who developed vitiligo on hands in a few hours after cleaning the sheets where her son’s girlfriend had had a miscarriage, is also illuminating.
These are obviously anecdotal reports in medical literature, which are of very limited “per se” value, but are clearly disclosing possible general psycho-somatic paths, which could direct researchers toward the causes and to the cure of vitiligo, in as yet un explored psycho - neuro - immuno endocrine territories.
Nobody can ignore the burden of the somato-psychic rebound effect of vitiligo into the psyche of the affected subject. Vitiligo subjects may adopt (more or less consciously) different behaviors to cope with vitiligo.
Some will adopt the “mastery active” psychological mechanism consisting of reading, studying and researching actively the causes of the disease. Others will behave as “natural acceptors” showing good self-esteem and not trying to hide their skin lesions. Others instead will make heroic attempts to hide their white spots, will be always embarrassed and often depressed.
These subjects could limit their social contacts and could lose their jobs because of vitiligo. While examining any vitiligo subject and discussing therapeutic options, the skilled dermatologist will try to understand both the possible psycho-somatic mechanism inducing the appearance of vitiligo patches (if any) and the somato-psychic rebound effect of the disease on self-esteem and thequality of life of each individual subject.
Thus, should the dermatology always or often refer each and every vitiligo patient to the psychologist or the psychiatrist?
Hard to say no, but it is harder to say yes.
If the vitiligo patient has chosen the dermatologist for “superficial and deep” assistance regarding understanding of his/her surface and depths, the dermatologist cannot give up.
The dermatologist must always respond to the request of the patient by giving the complete care requested, including supplying proper counseling.
“Forcing” the patient to visit another (non-skin) specialist is, in fact, dangerous.
Immediate insensitive referral of skin patients to a psychiatrist can even lead to ideas of suicide in over sensitive subjects, as has already been reported in literature.
Thus, when a psycho-intervention is be considered “necessary”, the dermatology should use the “liaison consultation” practice of getting the patient into close collaboration with the psychiatrist-psychologist. It is direct connection of two to one: the vitiligo subject, the dermatologist and the psychiatrist.
Only later, can the two experts have the full right to treat the same patient separately, with expected excellent results. In this context, it seems that cognitive behavior therapy could give fair results in contrast to different psychiatric or psychological approaches.
Author: Prof. Torello Lotti, MD
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