PSORIASIS AND COMORBIDITIES – Psychological and Psychiatric Disorders – PART 3

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The last in our 3 part series addressing psychological and psychiatric disorders associated with psoriasis.

   Psychological and Psychiatric Disorders –

   Sleep Disorders

   Somatoform Disorders

   Substance dependence of abuse

1, 2, 3

Sleep Disorders

It is thought that psoriasis has a direct effect on the development of sleep disorders due to the cutaneous (skin) symptoms of the condition. The skin is the primary circadian mediator of core body temperature (CBT), and a decrease in CBT in the late evening is an important mechanism for sleep initiation. Psoriasis has been associated with problems with thermoregulation and researchers have indicated that the reduced ability to dissipate heat is one factor in the inability to initiate sleep. Pruritus (itch) is another contributor to sleep disturbance and it is also regulated by circadian mechanisms. The threshold for pruritus is lowered in the evening due to complex circadian-mediated factors such as lower cortisol levels, decreased epidermal barrier function, and increased distal-to-proximal (distant limbs-to-body centre) gradient in skin temperature. Thus pruritus in psoriasis typically manifests or exacerbates mainly in the evening and worsens at night. 4,5,6

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The inflammatory biological mechanism(s) that lead to initiation and exacerbation of psoriasis, also contribute to the development of systemic diseases e.g. depressive disease, hypertension (blood pressure), adverse cardiac events, diabetes, metabolic syndrome and obesity. All of these conditions are known to indirectly give rise to sleep-disordered breathing. The heightened pro-inflammatory state in conditions such as obstructive sleep apnoea syndrome (OSAS) and insomnia could in turn lead to exacerbations of psoriasis.4,5,6

A systematic review of the literature on the relationship between psoriasis, PsA, and formal sleep disorders identified an increased prevalence of OSAS with a 36-81% prevalence in psoriasis versus 2% for women and 4% for men in the general population.4,5  In one study researchers found that some patients with chronic psoriasis and concurrent OSAS showed improvement of their psoriatic lesions while on nasal continuous positive airway pressure (CPAP).6 OSAS leads to severe physical and, possibly, psychological stress to the body, e.g., by hypoxemia (low blood oxygen levels), increased blood pressure, tachycardia (fast or irregular heart rate), sleep fragmentation, reduction of deep sleep, reduction of REM sleep, hypersomnia (excessive sleepiness), and insomnia. It is known that OSAS also dysregulates the function of the patient’s autonomic nervous system and hormone system. It is felt that this might alter the homeostasis of the immune neuroendocrine network in the skin and may cause the initiation of psoriasis in the genetically predisposed individuals.4,5,6

Somatoform Disorders – psychosomatic symptoms

Somatization is the manifestation of psychological distress by the presentation of bodily symptoms such as feeling nausea due to anxiety, stress headaches, falling ill after a trauma and inability to cope with a disease. 

Patients with psoriasis exhibit higher scores of hypochondriasis, hysteria, and somatization. As previously exposed hypochondriasis and hysteria may be connected with specific personality traits of patients with psoriasis of late-onset. Psychosomatic factors, namely stressful life events, lack of social support, and attachment insecurity, may explain why patients with psoriasis have greater scores of somatization. Moreover, the presence of depression in psoriasis may modulate itch perception and then exacerbate symptoms of pruritus.7 (Refer to Part 1 of this series) A systematic review of the psychosocial burden of psoriasis found that social stigmatization, high stress levels, physical limitations, depression, employment problems and other psychosocial co-morbidities experienced by patients with psoriasis are not always proportional to, or predicted by, other measurements of disease severity such as body surface area involvement or plaque severity. Some psoriasis patients had, even when their lesions were small and mild, levels of stress and loss of confidence that was not in keeping with the severity of their condition – which leads to the conclusion that they had maladaptive coping mechanisms in play e.g. self blame, blaming parents, social phobia, avoidance behaviours, substance and alcohol abuse etc. 9

Substance – Dependence of Abuse

In our previous blog Psoriasis and Alcohol (ethanol), we stated that patients with psoriasis experience considerable emotional distress, depression and social isolation due to the visibility of skin lesions, especially when the lesions are widespread and severe. Whilst it would be demeaning to state that all psoriasis patients with mild to severe psoriasis suffer from alcoholism, it has been confirmed in several Quality of Life studies that the percentage of psoriasis patients who admit to having a drinking problem may be as high as 32%. Research indicates that men are more likely to use alcohol excessively as a coping mechanism with the psychosocial burden of psoriasis. Consequently they are at a higher risk of developing depression – with the alcohol misuse and psoriasis as underlying causes. 4 Another study indicated that for women, excessive alcohol intake above a certain threshold (?30.0 g/d), may be associated with a significantly increased risk of Psoriatic Arthritis (PsA).5

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Alcohol is known to inhibit inflammation and immune responses; however acute and chronic alcohol consumption have opposite effects on inflammatory cell activation. Results indicate that acute alcohol exposure is inhibitory, whereas chronic alcohol exposure leads to an increase in inflammatory cell responses.6

Research has confirmed that alcoholics are more susceptible to infections, as streptococcal infections are trigger factors for psoriasis, this increased susceptibility may be involved in the onset and progress of the disease. It is also known that measurable quantities of ingested ethanol are secreted through human skin. Transdermal ethanol derives from two processes: active secretion by eccrine glands, primarily sweat glands, and passive diffusion through the lipid layers of the skin. Ethanol disrupts the dermal barrier enhancing skin permeability for numerous chemicals and increases the solubility of penetrating chemical compounds.6

Research into the the use of illicit drugs and psoriasis is extremely limited. Methylenedioxymethamphetamine (MDMA), also called Ecstasy, has been reported to initiate Guttate Psoriasis. The researchers theorized that “While MDMA [the main ingredient in ecstasy] is taken for its psychomimetic effect, pharmacologically it increases the level of noradrenaline, serotonin and dopamine by inhibiting the reuptake mechanism. It is known that Patients with psoriasis already have increased levels of noradrenaline.”7 There are also anecdotal stories on support websites where psoriasis sufferers have spoken about the exacerbation of their psoriasis with the use of “meth” (Methamphetamine, Ice). Within our clinic we have had several patients whose psoriasis was initiated and exacerbated by the use of cannabis (street not medicinal), once they ceased the use of cannabis their psoriasis resolved. As long as they did not use cannabis they remained free of any psoriatic lesions.

REFERENCES

  • Susskind W. and McGuire R.J.: The Emotional Factor in Psoriasis; Scot. med, J., 1959,4:503
  • Kessler R. C. et al.; Epidemiology of Anxiety Disorders; M.B. Stein and T. Steckler (eds.), Behavioral Neurobiology of Anxiety and Its Treatment, Current Topics in Behavioral Neurosciences 2, DOI 10.1007/7854_2009_9, # Springer?Verlag Berlin Heidelberg 2009, published online 3 September 2009
  • Nasreen S. et al.; Frequency and Magnitude of Anxiety and Depression in Patients with Psoriasis Vulgaris; Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (7): 397-400
  • Brenaut E. et al.; Alcohol consumption and psoriasis: a systematic literature review. J Eur Acad Dermatol Venerol. 2013 Aug;27 Suppl 3:30-5. doi: 10.1111/jdv.12164.
  • Shaowei Wu et al.; Alcohol Intake and Risk of Incident Psoriatic Arthritis in Women; J Rheumatol. 2015 May ; 42(5): 835–840. doi:10.3899/jrheum.140808.
  • Farkas A, Kemény L.; Psoriasis and alcohol: is cutaneous ethanol one of the missing links?; • British Journal of Dermatology 2010 162, pp711–716
  • Tan B., Foley P.; Guttate psoriasis following Ecstasy ingestion; Australasian Journal of Dermatology45(3):167-9 September 2004?

ATOPIC DERMATITIS (ECZEMA) AND COMORBIDITIES

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Atopic dermatitis (AD), also known as atopic eczema, is a chronic inflammatory disorder that causes significant morbidity and has a wide range of allergic and non-allergic comorbid disorders.

Comorbidity is a concurrence of multiple diseases or disorders in association with a given disease. The patient with AD has an increased risk of developing one or more of a number of other diseases/conditions that share many immunological features with AD.

 CHART 1: Comorbidities Associated with AD

Cutaneous (skin) infections including:-

Bacterial – Staphylococcal   / Impetigo contagiosum

Viral – eczema herpeticum

Fungal

 

Other Skin Conditions:

Vitiligo

Psychological and Psychiatric Disorders – Depression

Anxiety

Attention Deficit/Hyperactivity Disorder (ADHD)

Autistic spectrum disorder (ASD)

Food Allergies/Intolerances Cardiovascular Disease – Arterial hypertension/ Atherosclerosis

Stroke

Prediabetes

Diabetes

Obesity

Fatty Liver

Dyslipidemia (Raised cholesterol)

Allergic conjunctivitis

Cataracts 

Atopic keratoconjunctivitis (AKC) 

Allergic rhinitis

Hayfever

Asthma

Acute upper respiratory infection

Acute pharyngitis

Fatigue, insomnia  

1, 2, 3, 4, 5, 6, 7

Most cases of AD begin in childhood or adolescence, with more than 80% of pediatric patients having persistent symptoms of itch and dry skin in adulthood. The early age of onset and disease chronicity, plus impaired quality of life, secondary to AD weigh heavily on a child’s psychological and behavioural development, with delayed social development throughout life and very high rates of psychological and behavioural disorders and quality-of-life impairment.6 Various studies have consistently indicated an association between AD and ADHD which is independent of environmental exposures and other comorbidities. Particularly infant AD appears to be associated with later development of ADHD symptoms. Sleeping problems due to AD are suggested as playing an important role for the observed association between AD and ADHD. Children with previous or prevalent AD have an approximately 43 % increased risk to be diagnosed with ADHD or to display clinical ADHD symptoms.8

Researchers have found that adults with AD have higher rates of cigarette smoking, consumption of alcoholic, lower rates of exercise, and higher classification of obesity with category II / III consistently indicated in children and adults, hypertension, prediabetes, diabetes, and high cholesterol.6, 7

staph-infection

Bacterial superinfection by staphylococcal aureus is the most common complication in atopic dermatitis and is almost always present in AD flares.  S. aureus is an important human pathogen that causes a variety of  infections ranging from localised skin and soft-tissue infections (SSTIs) to severe necrotising fasciitis and life-threatening infections.7 , 8  S. aureus can be isolatedfrom 55–75% of unaffected AE skin, 85–91% of chronic lichenified lesions and 80–100% of acute exudative skin lesions.9 The correlation between AD severity and colonization with S. aureus has already been well documented, and it is generally known that this colonization is an important mechanism involved in the continued aggravation of the disease in patients.

S. aureus has shown a capacity to develop resistance to antimicrobials that were originally active against the species. In 1961, there were reports of strains that were methicillin resistant, and they were called methicillin-resistant Staphylococcus aureus (MRSA). By 1980, MRSA strains became an endemic problem in hospitals in several countries. Reports on MRSA infections in AD patients have been published since 2005. Some authors suggest that MRSA should be considered when patients with AD present with more intense and generalized erythemas (redness of the skin), and with the predominant location of infection in these patients being the face, and a fetid (fishy) odour present. Studies worldwide suggest that the prevalence of MRSA in the population with AD varies from 0 to 30.8% depending upon the country of research.10

Colonization by streptococcus generally precedes the development of impetignized lesions (by about 10 days). Group A streptococci often colonize the pharynx of asymptomatic people, especially school-age children. In cases of infected atopic dermatitis lesions, a high prevalence of co-infection by staphylococci and streptococci was reported, and these bacteria were present in about 70 to 85% of patients. B-hemolytic streptococci are the main cause of impetigo and are more commonly isolated on the skin of people with AD than on the skin of healthy individuals or of those with other skin diseases.11

Eczema herpeticum (EH) is caused by Herpes simplex virus-1 (HSV-1), Herpes simplex virus-2 (HSV-2), Herpes zoster virus, Coxsackie virus, etc. Also, EH may occur in children who have AD after smallpox vaccination. If corticosteroid therapy is used in these patients because of misdiagnosis, the lesions may worsen. Therefore, if skin lesions or another pre-existing dermatitis is aggravated after varicella (smallpox) infection then EH must be considered and antiviral therapy must be started immediately.11

AD, is an immunoglobulin E (IgE)-mediated disease with a complex etiology (cause) that is accompanied by superficial inflammation and itchy rashes. An association with asthma and Allergic rhinitis (Hayfever) is well documented. Fifty percent of all those with AD develop other allergic symptoms within their first year of life. In the International Study of Asthma and Allergies in Childhood (ISAAC), among the 56 countries, the prevalence of AD in children varied significantly from 0.3% to 20.5% but shows consistent trends in increasing disease prevalence over time. The main risk factors for progression and persistence of asthma are early onset, IgE sensitization, and severity of AD. Approximate 70% of patients with severe AD develop asthma compared with 20-30% of patients with mild AD and approximately 8% in the general population. Epidemiologic studies have consistently demonstrated strong associations between rhinitis and asthma. Recent clinical and basic science evidence indicated that the two diseases share anatomical, physiological, immuno-pathological, and therapeutical factors. Allergic rhinitis is an inflammatory condition affecting nasal mucosal membranes. In sensitized individuals, allergens such as pollens, moulds, and animal dander provoke this allergic response.12, 13

The relationship between food allergy and AD is complex and the presence of food sensitization and allergy earlier in life predicts a prognosis of severe AD. Around 50–70% of children with an early onset of AD are sensitized to one or more allergens. These are mainly food allergens (cow’s milk, hen’s egg and peanuts being the foods most frequently involved). Food allergy is actually much more common in children with AD with studies reporting ranges from 20 to 80% of children being affected.12,13

Allergic conjunctivitis (AC), either seasonal and/or perennial, is one of the most common types of ocular inflammation which causes redness and swelling of the eyes. Estimates vary, but these types of allergy are said to affect at least 15–20% of the population and higher incidences in those with AD. Its pathophysiology also involves a type I IgE-mediated immune reaction triggered by allergens contacting surface of the eye.2 Atopic keratoconjunctivitis (AKC) is a bilateral chronic inflammatory disease of the ocular surface and eyelid. Its pathomechanism involves both a chronic degranulation of the mast cell mediated by IgE, and immune mechanisms mediated by Th1- and Th2-lymphocyte derived cytokines. It is considered the ocular counterpart of AD. Eczematous lesions may be found on the eyelids, or any place on the body. Skin lesions are red and elevated. They often occur in the antecubital (inner elbow) or popliteal (behind the knees) regions. Typically, eczematous lesions are itchy, and scratching them makes them itchier. Ocular findings vary. The eyelid skin may be chemotic (inflamed eyelid) with a fine sandpaper-like texture. There may be mild, or severe, red and swollen eyes.14

If you have any questions please do not hesitate to contact our clinic by either emailing us at info@goodskincare.com.au or message us on our Facebook page https://www.facebook.com/PsoriasisEczemaClinic/

 

 REFERENCES

  • Simpson EL.; Comorbidity in Atopic Dermatitis; Curr Dermatol Rep. 2012 March 1; 1(1): 29–38. doi:10.1007/s13671-011-0003-5
  • Augustin M. et al.; Epidemiology and Comorbidity in Children with Psoriasis and Atopic Eczema; Dermatology 2015;231:35–40 DOI: 10.1159/000381913
  • Deckert S. et al.; Nonallergic comorbidities of atopic eczema: an overview of systematic reviews; Allergy 69 (2014) 37–45 © 2013
  • Ellis CN. et al.; Validation of Expert Opinion in Identifying Comorbidities Associated with Atopic Dermatitis/Eczema; Pharmacoeconomics 2003; 21 (12)
  • Gradman J. et al.; Allergic conjunctivitis in children with asthma, rhinitis and eczema in a secondary outpatient clinic.
  • Silverberg J.I.; Eczema and cardiovascular risk factors in 2 US adult population studies; J Allergy Clin Immunol 2015;135:721-8.
  • Silverberg J.I. and Silverberg N.B.; Atopic Dermatitis: Update on Pathogenesis and Comorbidities
  • Baviera G. et al.; Staphylococcus Aureus And Atopic Dermatitis: Which Came First, The Chicken Or The Egg?; EMJ Dermatol. 2015;3[1]:92-97.
  • Leung DYM.; The role of Staphylococcus aureus in atopic eczema; Acta Derm Venereol 2008; Suppl 216: 21–27
  • Petry V. et al.; Bacterial skin colonization and infections in patients with atopic dermatitis; An Bras Dermatol. 2012;87(5):729-34.
  • Celtik C. et al.; A Life-Threatening Condition In A Child With Chicken Pox: Eczema Herpeticum; Open Journal of Pediatrics 1 (2011) 1-3
  • Tao Zheng et al.; The Atopic March: Progression from Atopic Dermatitis to Allergic Rhinitis and Asthma; Allergy Asthma Immunol Res. 2011 April;3(2):67-73. doi: 10.4168/aair.2011.3.2.67
  • Nutten S.; Atopic Dermatitis: Global Epidemiology and Risk Factors; Ann Nutr Metab 2015;66(suppl 1):8–16
  • La Rosa M. et al.; Allergic conjunctivitis: a comprehensive review of the literature; Italian Journal of Pediatrics 2013, 39:18 http://www.ijponline.net/content/39/1/18

Itch (Pruritus) & Eczema

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Scratching is the natural response to itch (Pruritus) and, by definition, inseparable from it. The act of scratching not only diminishes itch, but it has been found to be rewarding and addictive. The itch-scratch cycle is a complex phenomenon involving sensory, motor and emotional components. The urge to scratch can be remarkably intense because the reward provided by scratching brings such intense relief and may also be associated feelings of pleasure and enjoyment. Recent studies have shown that rating scratching as a pleasurable experience is correlated with the intensity of the underlying itch, both in patients with chronic itch and healthy individuals.1 Various functional brain imaging studies have discovered that the itch-scratch cycle in humans can be tracked to specific regions of the brain, including areas related to reward, pain sensation, and addiction.1,2

The Itch-Scratch-Rash cycle is commonly used to describe this ongoing, never ceasing, always constant itch that makes eczema very different from many other skin condition. Eczema has often been called the “Itch that Rashes” rather than the “Rash that Itches”.3 

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The itchier a patient feels, the more scratching of the skin that occurs and which ultimately lead to skin damage and the appearance of a red rash. Often, in chronic presentations it becomes a completely unconscious habit and patients are often not even aware that they are scratching. When a patient scratches, the skin becomes inflamed, this inflammation then causes the skin to itch even more, thus making it even harder for the patient to resist the urge to scratch. This vicious circle can become so severe that it causes sleeplessness, irritability, anxiety and stress. In extreme cases it can lead to significant excoriations (open, bloody and deep scratch wounds) on the skin or even severe lichenification (thickening of the skin) and pain. 

The Practitioner and Patient need to recognize and address various aspects of itch, including:

(1) Identification and elimination of trigger factors;

(2) Maintaining the skin barrier through emollients – Oil based and Water Based;

(3) Targeting inflammation through topical medications and systemic (oral) medications

(4) Addressing psychological and behavioural components; and

(5) Education – understanding the condition.

The sensation of pruritus can be triggered by endogenous (internal) and exogenous (external) stimuli, which activate specific peripheral nerve endings in the epidermis and dermis layers of the skin.3

Trigger Factors3

Allergies                                   House dust mites, food allergens, air-born contact dermatitis (pollen, etc.), animals (e.g. cat                                                        dander), jewellery, certain cosmetic ingredients.

Infections                                 Staphylococcus aureus, viral infections (herpes, molluscum), yeasts (eg, Trichophyton,                                                                malassezia).

Exogenous                               Soaps, solvents, wool, sweat, chemicals, toxins, cigarette smoke, smog.

Physical stimuli                       Temperature: humidity, cold dry air, clothes rubbing on the skin.

Emotional                                Anxiety/Stress /Anger/ Depression.

How to rate your Itch4

Based on the Eppendorf  Itch Questionnaire.

Rate each of the following from 0 to 4

The following describes your Itch………

 01234
  Painful     
  Pulsating     
  Throbbing     
  Prickling     
  Hurting     
  Tickling     
  Stinging     
  Worse when Cold     
  Less when Cold     
  Worse when Hot     
  Less when Hot     
  Dull     
  Sharp     
  Burning     
  Feels like ants     
  Comes in waves     
  Unbearable     
  Annoying     
  Physical urge to scratch     
  Numbing     
  Relentless     
  Cruel     
  Tormenting     
  Tiring     
  Numbing     
  Severe     
  Uncontrollable     
  I only can think of the Itch     

When do you feel the need to Itch?

 01234
  In the Morning     
  In the Evening     
  At night     
  At rest     
  Worse in Bed     
  After a hot shower     
  After exercise     
  After being outside     
  After being in the Sun     
  After gardening     
  After Dusting, Sweeping/Vacuuming/ Changing beds     
  After eating certain foods

  Specify

     

How would you describe the need to Scratch?

 01234
  I find it enjoyable     
  It is a physical urge     
  It is compulsive     
  I forget when I do it     
  I always want to scratch     
  I find it satisfying     
  I find it pleasurable     
  It hurts but I cannot stop     
  Other –     

What action do you take when you feel the urge to scratch?

 01234
  I rub     
  I scratch with my nails     
  I scratch with my fingertips     
  I scratch with my knuckles     
  I use a pencil/pen/ruler/stick     
  I rub     
  I pinch     
  I use a cold pack     
  I use a heat pack     
  I take a cold shower     
  I take a warm shower     
  I take a hot shower     
  I put the air conditioner on     
  I turn down the ducted heating     
  I dig my fingernails in     
  I bite my lip     
  I scratch until I bleed     
  I apply pressure     
  Other –     

Which areas of the body do you scratch the most?

                              Front                                                           Back

What distracts you from the urge to scratch?

 01234
  Company distracts me     
  Watching Television     
  Reading a Book     
  Using a Computer/IPhone/IPad     
  Listening to music     
  Applying heat pack     
  Applying ice pack     
  Exercising     
  Doing something with my hands   (hobby)     
  Other –     

When you understand your itch, when you itch, what you do when you scratch and what distract you from scratching, you may be able to plan your approach to your itch more methodically and with more control. You may decide that you need to start a meditation or behavioural therapy class to help you control the need to scratch. You may find that you will learn the best times to apply your creams so that you circumvent the urge to scratch e.g. applying creams before gardening or mowing the lawn or doing housework etc.

What can a Patient do to avoid or control the urge to itch?

Scratching is difficult to resist because it gives the mental impression of easing the itch – but this is only for the short-term. Eventually the sensation to itch comes back – even worse that before you scratched. 

Basic tips to control the urge to itch:- 

  • Keep nails short to avoid tearing the skin when scratching. 
  • Keep cool. Over-heating can trigger the itch. Try to keep your body temperature as constant as you can, wear light layers of cotton clothes.
  • Avoid overheated rooms, keep ducted heating to a minimum, and at night keep the bedrooms cold.
  • Avoid heavy blankets and doonas – use cotton blankets if possible. 
  • Gently rub with the back of the fingers, place pressure or gently pinch the area instead of scratching. 
  • Use a cold compress 

Parents of children often ask “How can I stop my child from scratching?” And as scratching is an instinctive reaction to itching which can become a compulsive/unconscious habit, that question is not an easy one to answer. Parents can help by keeping their child’s nails short and, especially at night, by covering their hands with cotton mittens. 

With older children, it is important that you explain to them how scratching will actually make them feel worse, not better. And that their skin will become redder, more cracked and feel itchier and sorer. 

Become aware of any habits of scratching that your or your child may be developing and take especial note as whether it is at a particular time of day, or during a particular activity, such as playing sport or just watching television. If you or the parents of a child become aware of these types of habits then it is important to try to break the habit.

Nonpharmacological Treatments for the Management of Atopic Dermatitis Itch

 Cognitive-behavioural methods3,5,6

Cognitive-behavioural methods alter dysfunctional habits by interrupting and altering dysfunctional thought patterns (cognitions) or actions (behaviours) that damage the skin or interfere with dermatologic therapy. e.g. Itch-coping Training Programme or Habit Reversal Training, cognitive-behavioural methods for the reduction of itch and scratching behaviour, including self-monitoring, guidance in skin care and coping skills to manage itch- and scratch-triggering factors, stress-management methods with relaxation techniques and habit reversal. The habit reversal technique teaches patients to recognize the habit of scratching, identify situations that provoke scratching, and train them to develop a competing response practice, for example, a child who unconsciously scratches can be taught to recognize the early signs of the sensation of itch and instead of scratching be taught to clench his/her fists or place his/her hands underneath his/her legs as soon as they feel the sensation of itch.

Biofeedback5,7

Biofeedback can enhance the patient’s awareness of tension and help them to relax; improving skin disorders that flare with stress or that have an autonomic nervous system aspect. Biofeedback is a mind-body therapy that uses electronic instruments to assist patients to gain awareness and control over psychophysiological processes. The patient is connected to a machine that measures muscle activity, skin temperature, electrodermal activity, respiration, heart rate, heart rate variability, blood pressure, brain electrical activity, and brain blood flow and visually gives the patient feedback as they go through various “game” like tasks. Chronic itch, which may be somatic, emotional and cognitive, may be treated with therapies that can modulate the autonomic nervous system stress response. Behavioural biofeedback techniques that reduce stress and anxiety have been used to treat chronic pain and itch and could potentially alter the sympathetic over-activity noted in patients with AD.

Hypnosis / Meditation8

With proper training, an individual can intensify this trance state in himself or herself and use this heightened focus to induce mind-body interactions that help alleviate suffering or promote healing. The state of altered consciousness known as a “trance state” may be induced using guided imagery, relaxation, deep breathing, meditation techniques, self-hypnosis or by a trained medical practitioner. Researchers have used relaxation, stress management, direct suggestion for non-scratching behaviour, direct suggestion for skin comfort and coolness, ego strengthening, posthypnotic suggestions, and instruction in self-hypnosis. Their results were statistically significant for reduction in itch, scratching, sleep disturbance, and tension. Reported topical corticosteroid use decreased by 40% at 4 weeks, 50% at 8 weeks, and 60% at 16 weeks. For milder cases of atopic dermatitis, hypnosis along with moisturization can suffice as a primary alternative treatment. For more extensive or resistant atopic dermatitis, hypnosis can be a useful complementary therapy that reduces the amounts required of other conventional treatments.

Read also our Blogs for Psoriasis …. The same techniques can be used for Eczema

Simple Mental/Mind Relaxation Techniques Part 1 – For Psoriasis Patients

Simple Mental/Mind Relaxation Techniques Part 2 – For Psoriasis Patients

Itch_4 Itch_5 Itch_6

References

 

  • Papoiu A. D. P. et al.; Brain’s Reward Circuits Mediate Itch Relief. A Functional MRI Study of Active Scratching; PLOS ONE, www.plosone.org 1 December 2013, Volume 8, Issue 12, e82389
  • Mochizuki H. et al.; Chapter 23Brain Processing of Itch and Scratching; http://www.ncbi.nlm.nih.gov/books/NBK200933/?report=printable
  • Hong J. et al.; Management of Itch in Atopic Dermatitis; Seminars in Cutaneous Medicine and Surgery; Elsivier; doi:10.1016/j.sder.2011.05.002; Pg 71-88
  • Darsow U. et al.; New Aspects of Itch Pathophysiology: Component Analysis of Atopic Itch Using the ‘Eppendorf Itch Questionnaire’; Int Arch Allergy Immunol 2001;124:326–331
  • Shenefelt PD.; Psychological interventions in the management of common skin conditions; Psychology Research and Behavior Management 2010:3 51–63
  • Evers Et al.; Effectiveness of a Multidisciplinary Itch-coping Training Programme in Adults with Atopic Dermatitis; Acta Derm Venereol 2009; 89: 57–63
  • Tran BW. Et al.; Effect of Itch, Scratching and Mental Stress on Autonomic Nervous System Function in Atopic Dermatitis; Acta Derm Venereol 2010; 90: 354–361
  • Shenefelt PD. ;Hypnosis in Dermatology; Arch Dermatol / VOL 136, MAR 2000

 

Stress, Anxiety, Depression – Atopic Eczema (AE)/Atopic Dermatitis (AD) and associated Itch

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Atopic dermatitis may be caused by genetic predisposition and environmental conditions, including hereditary factors, allergens, and neurogenous (arising from the nervous system, or from some lesion of the nervous system) and immunological factors. However, the major contributing cause remains unknown. AD may cause psychosocial problems such as anxiety, depression, sleep disorders, emotional excitability, stigmatization, social isolation, and discrimination and on the other hand, all of these factors may also contribute to and exacerbate the symptoms of AD. Of the many factors related to atopic dermatitis, psychological stress is considered to be among the most important.1

 The psychological, physical and social impact of AD is complex and varies among different ages. The relationship of stress, anxiety, depression, not to mention feelings of stigma, shame, embarrassment, and low self-esteem all impact upon a person who is suffering from a skin condition such as AD. Research has confirmed that adults with AD exhibit high levels of anxiety, depression, and emotional excitability. Children with AD also have higher levels of emotional distress and more behavioral problems than healthy children or children with minor skin problems. Psychosocial factors contributed in the form of exacerbating factors in as high as 94% of AD hospitalized patients. Clinically, it has long been appreciated that both acute stress (stressful life events) and chronic psycho-emotional stress can trigger or enhance pruritus.2, 3, 4,5

Pruritus, or itching, is a main symptom of AD and is often one of the first presenting symptoms.

Itching leads to scratching, which leads to and exacerbates the skin lesions.

  • AD has been referred to as the “itch that rashes.”
  • The cycle of itching and scratching is considered an important factor in the maintenance of AD symptoms and is believed to be one of the first symptoms of an impending AD flare.
  • Scratching tends to cause further itching, leading to the so-called “itch-scratch cycle.” 6

Results of one study found that in patients with AD the itching intensity played an important role in determining the patient psychosocial well-being and that a relationship between pruritus and depression was also found.6

 Scratching often begins automatically in association with stress and emotions, and becomes habitual, being performed many times every day. In addition to the psychological factors, such as anger, irritation, impatience, relief, anxiety, etc., many patients say that they somehow find themselves scratching even when they do not feel itchy. Research has identified that habitual scratching is involved in the formation of the lesions of AD. The scratching is patterned, with the rash exhibiting a bilaterally symmetrical distribution over the back and normal skin remaining in the middle where the hands cannot reach, producing a “butterfly” sign. The prominent red face can also be explained by this scratching behavior.4

 This vicious cycle can cause sleeplessness in over 65% of AD sufferers leading to sleep deprivation which leads to tiredness, mood changes and impaired psychosocial functioning of the sufferer and their family, particularly at school and work. Embarrassment, comments, teasing and bullying frequently cause social isolation and may lead to depression or school/work avoidance. The sufferer’s lifestyle is often limited, particularly in respect to clothing, holidays, staying with friends, owning pets, swimming or the ability to play or do sports. For parents caring for a child with eczema, restriction of normal family life, difficulties with complicated treatment regimens causing an increased work load together with disturbed sleep can lead to parental exhaustion and feelings of hopelessness, guilt, anger and depression. And so the whole family is impacted by the condition.5,6,7

Research has suggested that some AD patients might benefit from certain psychological interventions: patients showing psychological characteristics that comprises high depression, low agreeableness and high public self-consciousness would probably benefit from psychological interventions, such as cognitive restructuring, anger management and self-assertiveness training, because these interventions might be able to modulate the extent of the personality characteristics that are associated with induced itch.8

Recent emerging research indicates that mindfulness meditation training may have beneficial effects across a spectrum of health conditions, but the mechanisms linking mindfulness meditation training with health are unknown. One striking feature of the mindfulness training literature to-date is that mindfulness training effects on disease outcomes have been observed in diseases where stress is known to trigger the onset or exacerbation of disease symptoms and pathogenesis (e.g., HIV, psoriasis, depression, pain, chronic inflammation).9   Research has indicated that relaxation techniques appear to be helpful in the treatment of patients suffering from chronic itch in patients that are open to it. And it is becoming a standard recommendation by many Practitioners and hospitals that relaxation training be considered clinically in patients who report that their itch increases during periods of heightened stress.10

The challenge for sufferers of AD is, with the aim of improving their quality of life, to help themselves to find, together with their practitioner, the best personal treatment plan and then sticking to it. The main challenges in the effective management of AD, comes down to patient adherence to the treatment plan and their emotional resilience.

 

References

  • Kwon1 J.A. et al.; Does Stress Increase the Risk of Atopic Dermatitis in Adolescents? Results of the Korea Youth Risk Behavior Web-Based Survey (KYRBWS-VI); PLOS ONE, www.plosone.org; August 2013, Volume 8, Issue 8, e67890
  • Han-Ting Wei et al.; Risk of developing major depression and bipolar disorder among adolescents with atopic diseases: A nationwide longitudinal study in Taiwan; Journal of Affective Disorders 203 (2016) 221–226
  • Buske KIrschbaum Hellhammer et al.,; Endocrine and immune responses to stress in chronic inflammatory skin disorders; 992. 231-240 (2003)
  • Sang Ho Oh et al.; Association of Stress with Symptoms of Atopic Dermatitis; Acta Derm Venereol 2010; 90: 582–588. The Journal of Clinical Investigation; http://www.jci.org; Volume 116, Number 5, May 2006
  • Kamide R.; Atopic Dermatitis: Psychological Care; Journal of the Japan Medical Association (Vol. 126, No. 1, 2001, pages 59–62).
  • Brown T.M. et al.; Assessing Pruritus Among Patients With Atopic Dermatitis: Targeted Literature and Instrument Review; https://www.rtihs.org/sites/default/files/Brown_isporposter_May2012.pdf
  • Lewis-Jones S. Quality of life and childhood atopic dermatitis: the misery of living with childhood eczema. Int J Clin Pract. 2006;60(8):984-992.
  • Schut C. et al.; Personality Traits, Depression and Itch in Patients with Atopic Dermatitis in an Experimental Setting: A Regression Analysis; Acta Derm Venereol 2014; 94: 20–25
  • Creswell J.D. et al.; Brief mindfulness meditation training alters psychological and neuroendocrine responses to social evaluative stress; Psychoneuroendocrinology (2014) 44, 1—12
  • Schut C. et al.; Psychological Interventions in the Treatment of Chronic Itch; Acta Derm Venereol 2015 Preview

Simple Mental/Mind Relaxation Techniques Part 2

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Are you having trouble controlling your thoughts and finding it difficult to let yourself float in the Full Body Scan Meditation or the Releasing Troubles and Worries Exercise?

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WELL DON’T WORRY!!!!!!!

Here is a “Thought-Stopping” Exercise that can be used during either the Full Body Scan Meditation or the Releasing Troubles and Worries Exercise or when trying to get to sleep.

In thought-stopping, you would do this exercise FIRST. So lie on a yoga bed for the exercises or in bed to get to sleep.

Think about something that you know is worrying you and will keep you awake …… something troubling you that you will know your mind will churn over and make it difficult to relax or go to sleep.  Force your mind to concentrate on that issue or person e.g. the project at work is in trouble and you know your boss is going to get angry at you and the team. Turn this over in your mind again and again and then suddenly in your mind “Shout Out” STOP!!!!!!. Breath easily and try to relax …… if you feel the issue creeping back into your mind ….. repeat the STOP exercise again and again until your mind releases the thought.

This STOP exercise basically is forcing your brain to recognize when to stop thinking about something …. It abruptly interrupts the thought process and makes the brain shift its focus … this is where the relaxation technique, that you have chosen should now be used.

A number of sites on the internet offer some wonderful guided meditations, and alternative Relaxation Techniques. Below we have listed some of the techniques and their links:-

SAFE HAVEN” – VISUALIZATION – Page 19 http://www.mirecc.va.gov/visn16/docs/Franklin_Relaxation_Therapist_Manual.pdf

QUICK RELAXATION STRATEGIES

https://www.k-state.edu/paccats/Contents/Stress/Quick%20Relaxation%20

Strategies.pdf

 

ABC GUIDED AUDIO MEDITATIONS

http://www.abc.net.au/radionational/programs/lifematters/features/meditation-toolkit/audio-practice/4326674

 

Also read our blog “Stress, Anxiety, Depression and Psoriasis, Stressed about Psoriasis – Identify Your Stressors and Yours Stress Responses, Simple Physical Relaxation Techniques for Psoriasis Patients, Simple Mental/Mind Relaxation Techniques Part 1 – For Psoriasis Patients, Simple Mental/Mind Relaxation

 

REFERENCES

  1. National Center for Health Promotion and Disease Prevention (NCP); Manage Stress Workbook; http://www.prevention.va.gov/mpt/2013/docs/managestressworkbook_dec2013.pdf
  2. Relaxation Techniques for Health: What You Need To Know; National Institutes of Health; U.S. Department of Health and Human Services; https://nccih.nih.gov/sites/nccam.nih.gov/files/Get_The_Facts_Relaxation_Techniques_02-06-2015.pdf
  3. Progressive Muscle Relaxation; http://www.cci.health.wa.gov.au/docs/ACF3944.pdf
  4. Manzoni G.M. et al.; Relaxation training for anxiety: a ten-years systematic review with meta-analysis ; BMC Psychiatry 2008, 8:41 doi:10.1186/1471-244X-8-41
  5. Franklin C.L. et al.: Relaxation Enhancement Therapist Manual; http://www.mirecc.va.gov/visn16/docs/Franklin_Relaxation_Therapist_Manual.pdf

Simple Mental/Mind Relaxation Techniques Part 1

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As we indicated in the Simple Physical Relaxation Techniques blog, it is important that you take control and find some relaxation techniques that best assist you to relax and to control your stress levels and increase your emotional resilience. Once you have mastered the 4 exercises that you found or will find in our Physical Relaxation Techniques blog it is time to combine any one of these with some simple Mental/Mind Relaxation Exercises and find the one that works for you:-

RELEASING YOUR TROUBLES AND WORRIES

 Create a Picture in Your Mind

Think of a view or a place or an object that you find simple, quiet and inspiring or use one of the following.

simple_mental_part1_2simple_mental_part1_1simple_mental_part1_3simple_mental_part1_4

Study every minute detail in your mind.

If you are sitting on the sand on the beach, feel the aetting sun warming your face, feel the breeze on your skin, smell the ocean air, taste the salty tang on the breeze, hear the waves washing right up to you and as you hear each and every wave, release all of your stress and throw it onto the waves to wash out into the ocean …… take a bad feeling and do the same with this feeling and just release it to the waves, repeat with a troubled thought, or a person who riles you or who has upset you … do it with everything that has angered, troubled, annoyed, worried or upset you until you are totally relaxed and free from all troubles and worries.

When using the sunset …. Do the same as you imaging the colour changing and fading until you are free from all troubles and worries and looking at a beautiful starry night.

When using the rainbow … do the same as you climb higher onto the rainbow ……. with each step leave another thing behind you. Climb right to the top of the rainbow and view the world free from all troubles and worries and as you begin to make your way down the rainbow know that you remain free from all of you troubles and worries as you step into a field of beautiful flowers and lush grass.

When using the garden …. Smell the flowers, hear the bees, watch the sun glint on dragon fly wings, and as you go through the gate leave all of your troubles behind you and imagine yourself walking along a golden path into beautiful warm, fern forest. Wind the path back to the garden but notice that when you walk back into the garden your troubles and worries have all gone and you a free to enjoy the garden with a feeling of peace and serenity.

RELEASING PAIN AND DISCOMFORT

Body Scan Meditation

To practice the Body Scan Meditation, get into a comfortable position, by lying on a yoga mat on the floor or on a bed. You can use a pillow under your head. You can also sit in a chair on in the Yoga position. Use the Controlled Breathing or the Progressive Relaxation exercise from our Simple Physical Relaxation Technique blog and gently bring your awareness to the present.

1. Concentrate on a specific body part, e.g. your right arm. As you breathe deeply, scan that part of your body for sensations – heat, pain or burning. Notice the sensations but try not to get lost in thought and feel the heat, pain or burning. Repeat in your mind – “ALL HEAT, PAIN, or BURNING IS GONE”…………. Repeat three times

Gradually let your focus move to different body parts—each leg, your hips, stomach, chest, hands, arms, and head. And do the same.

simple_mental_part1_5

2. Practice the Body Scan Meditation and do not worry if you become aware of your mind’s tendency to drift to other thoughts. When you notice this happening, just let the thought go and gently bring your attention back to your body. If you have any pain or discomfort, just notice it, accept it, and release it using the mantra and continue scanning

The more you do this exercise the greater control you will achieve over your pain or discomfort.

Also read our blog “Stress, Anxiety, Depression and Psoriasis, Stressed about Psoriasis – Identify Your Stressors and Yours Stress Responses, Simple Physical Relaxation Techniques for Psoriasis Patients, Simple Mental/Mind Relaxation Techniques Part 2 – For Psoriasis Patients, Simple Mental/Mind Relaxation

 

 

REFERENCES

  •  National Center for Health Promotion and Disease Prevention (NCP); Manage Stress Workbook; http://www.prevention.va.gov/mpt/2013/docs/managestressworkbook_dec2013.pdf
  • Relaxation Techniques for Health: What You Need To Know; National Institutes of Health; U.S. Department of Health and Human Services; https://nccih.nih.gov/sites/nccam.nih.gov/files/Get_The_Facts_Relaxation_Techniques_02-06-2015.pdf
  • Progressive Muscle Relaxation; http://www.cci.health.wa.gov.au/docs/ACF3944.pdf
  • Manzoni G.M. et al.; Relaxation training for anxiety: a ten-years systematic review with meta-analysis ; BMC Psychiatry 2008, 8:41 doi:10.1186/1471-244X-8-41
  • Franklin C.L. et al.: Relaxation Enhancement Therapist Manual; http://www.mirecc.va.gov/visn16/docs/Franklin_Relaxation_Therapist_Manual.pdf

Simple Physical Relaxation Techniques

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It is important that you and you alone take control – find the solution that best helps you and ensure that you keep doing it – remember it comes down to your adherence to not only your treatment plan but also in your efforts to control your stress and increase your emotional resilience.

The next step is to test some simple Physical Relaxation Techniques and find the one that works for you:-

Use the following to help you release muscle tension.

YOGA STRETCH

 1.         Stand relaxed with your arms hanging at your sides and place your feet comfortably apart.

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2.       Tilt your head back and count slowly to five.

3.       Roll your head forward and count slowly to five.

4.       Exhale as you curl your body forward and bend at the waist; arms dangling down and slowly count to five.

5.       Inhale slowly through your mouth as you slowly straighten up whilst raising your arms overhead – stretching as far as you can. Then            drop your arms slowly to sides as you exhale though your mouth.

Repeat several times.

CONTROLLED BREATHING

1.        Use a yoga mat or a folded blanket – lie down with your back flat on the floor and place a book or large magazine on your                          stomach.

2.        Bend your knees (you can close your eyes if this makes your more relaxed).

3.        Inhales and push your stomach upwards (but not you upper chest) as far as you can and slowly count to five, then exhale slowly.                You may also use the affirmative “I am relaxed” as you exhale.

Repeat several times.

Use the following after a physical reaction to a stressful situation to allow the physical changes of your stress reaction to subside and return to a non-stress state.

RELAXATION RESPONSE

simple_physical_2

1.        Sit (or lie) in a comfortable position in a quiet environment with eyes closed.

2.        Start with your feet and mentally relax each muscle group moving up to the head—calf, thigh, waist, stomach, arms, chest, neck,              face, and forehead.

3.        Breathe in through your nose gently pushing your stomach out (but not your upper chest).

4.        Breathe out through your mouth and let your stomach relax.

Repeat this exercise for 10-20 minutes.

When finished, open your eyes but remain seated or lying for several more minutes.

PROGRESSIVE RELAXATION

1.        Lie flat on a yoga mat or a folded blanket – with your eyes closed and knees bent.

2.        Beginning with your right foot, press foot firmly to the floor and count slowly to five, then relax for the count of five; repeat with the              left foot.

3.        Straighten legs out and press back of lower right leg firmly to the floor and count slowly to five, then relax for the count of five;                    repeat with left leg.

4.        Press each of the following areas firmly to the floor and count slowly to five, and then relax for the count of five. (one at a time):

             a.      Back of thighs and buttocks

             b.       Lower back and shoulder blades

             c.       Arms

             d.      Back of head

REMEMBER: – to breathe normally as you press and relax. Repeat several times.

There are many other forms of Relaxations Techniques including, exercise, meditation, yoga, Tai Chi etc. On the internet there are many sites that offer other tips for relaxation exercises and meditation techniques…

Walking is an excellent form of exercise that will cost you nothing.

And of course other activities e.g. gyms and swimming pools will require membership fees to be paid.

Also read our blog “Stress, Anxiety, Depression and Psoriasis, Stressed about Psoriasis – Identify Your Stressors and Yours Stress Responses, Simple Mental/Mind Relaxation Techniques Part1, and Simple Mental/Mind Relaxation – Part 2

 

REFERENCES

 

  • National Center for Health Promotion and Disease Prevention (NCP); Manage Stress Workbook; http://www.prevention.va.gov/mpt/2013/docs/managestressworkbook_dec2013.pdf
  • Relaxation Techniques for Health: What You Need To Know; National Institutes of Health; U.S. Department of Health and Human Services; https://nccih.nih.gov/sites/nccam.nih.gov/files/Get_The_Facts_Relaxation_Techniques_02-06-2015.pdf
  • Progressive Muscle Relaxation; http://www.cci.health.wa.gov.au/docs/ACF3944.pdf
  • Manzoni G.M. et al.; Relaxation training for anxiety: a ten-years systematic review with meta-analysis ; BMC Psychiatry 2008, 8:41 doi:10.1186/1471-244X-8-41
  • Franklin C.L. et al.: Relaxation Enhancement Therapist Manual; http://www.mirecc.va.gov/visn16/docs/Franklin_Relaxation_Therapist_Manual.pdf

 

Stressed about Your Skin Condition – Identify Your Stressors and Your Stress Responses

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Whether you suffer from Psoriasis, Eczema / Dermatitis etc. stress is a recognized trigger that initiates and exacerbates fale ups. Being able to recognize what your Stress Triggers (Stressors) may assist you in modifying your responses and be part of the learning curve in managing your condition.

Identifying your Stressors

Use the list below to identify your stressors. For each item on the list, note whether or not it is important to you and whether or not you have control over it.

Changing Jobs/Promotion      Family Conflicts                      General Health   

Lack of Confidence                  Isolation                                     Money Worries

Pain/Fatigue                              Planning for Retirement         Public Speaking

Traffic to/from Work               Travel/Vacation/Holidays       Upcoming Wedding

Social Events                           World Events: War, Natural Disasters, Economy

Other:_______________        Other:_______________

 

 IMPORTANTNOT IMPORTANT
 

 

 

You are in Control

 

 

 

    
 

 

 

You do not have Control

 

 

 

  

 

 How Does Your Body Respond to Your Stressor?

Take note of what your body is telling you. Your body may constantly show a set pattern of response to stress and, as such, if you become aware of these responses you can then take the next step in trying to control these responses. These are classified as the following:

1) Physical

2) Behavioral

3) Emotional

4) Cognitive and

5) Spiritual

 

Physical symptoms include:- Shallow or rapid breathing, rapid heat beat, headaches, nausea or indigestion, hot flushes or sweaty palms, back pain, tight shoulders and/or neck or other unusual random aches and pains, insomnia and/or excessive fatigue, Psoriasis flare up.

tiredness-sets-in-1482054-640x480 backache-1620045-639x442

Behavioral symptoms include:- Excessive smoking, abuse of alcohol and/or compulsive eating.  Compulsive chewing of gum or inner cheek or grinding one’s teeth, especially at night. Aggressiveness, bossiness and/or being over critical of others;

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Emotional symptoms include:- Excessive impulse to laugh or cry, unhappiness for no reason and being easily upset. General boredom or nervousness and edginess. Extreme loneliness and/or overwhelming feelings of being powerless to change things. Over reacting and/or intense anger.

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Cognitive symptoms include:- Mental confusion/concentration – trouble thinking clearly or being able to do simple mental tasks e.g. adding numbers up or simply being able to read a book, forgetfulness, memory loss and loss of sense of humor.

Spiritual symptoms might include:- Loss of faith – doubt, martyrdom and just a general loss of direction in one’s life, being vulnerable to cult groups.

 

Identify Your Stressor Responses

When you know how your body responds to stressors, you can focus your attention on finding the best stress management technique for each one. Tick the box corresponding to your Body Responses as to when you feel stressed and identify what the stressor was.

SYMPTOMSSTRESSORSYMPTOMSSTRESSOR
Chest Pain

 

 Fatigue 
Chest Tightness

 

 Lack of Energy 
Heart Palpitations

 

 Difficulty Sleeping 
Headache/Migraines

 

 Depression/Anxiety 
Neck & Shoulder Pain

 

 Sadness 
Teeth Grinding

 

 Crying 
Backache

 

 Irritability/Anger 
Muscle Crams/Spasms

 

 Frustration 
General Muscle Tension Forgetfulness

 

 
Pain

 

 Worrying 
Upset Stomach/Nausea

 

 Restlessness 
Diarrhea / Constipation

 

 Lack of Motivation 
Increased Smoking

 

 Blaming Others 
Increased Alcohol Consumption Loneliness 
Excessive eating for the sake of eating, not when hungry Skin Flare-up (State the Condition) ________________

e.g. psoriasis

 

 

Now Rate the Severity of Your Stress Response

 

0       1        2        3       4        5       6       7        8        9       10

l____l____l____l____l____l____l____l____l____l____l

 

Not                        A little                   Somewhat                Very                        Extremely

troubled                troubled                 troubled                 troubled                    troubled

Date/TimeStress Level

(0-10)

What Did I Do?What Did I Think?
E.G.   9.30pm10Argument with Partner Yelled and stormed outI hated myself, I hated him/her, I hated life, I hated the way I felt
 

 

 

   
 

 

 

   
 

 

 

   
 

 

 

   
 

 

 

   
 

 

 

   
 

 

 

   
 

 

 

   

 

Also read our blog “Stress, Anxiety, Depression and Psoriasis”, Simple Physical Relaxation Techniques for Psoriasis Patients, Simple Mental/Mind Relaxation Techniques Part 1 – For Psoriasis Patients, Simple Mental/Mind Relaxation Techniques Part 2 – For Psoriasis Patients”

 

 

 

References

 

  1. Bamber, Petrina Nicole, “Quality of life for patients with psoriasis : more than skin deep” (2009). Master’s and Doctoral Projects. Paper 272. http://utdr.utoledo.edu/graduate-projects/272
  2. National Center for Health Promotion and Disease Prevention (NCP); Manage Stress Workbook; http://www.prevention.va.gov/mpt/2013/docs/managestressworkbook_dec2013.pdf
  3. Franklin C.L. et al.: Relaxation Enhancement Therapist Manual; http://www.mirecc.va.gov/visn16/docs/Franklin_Relaxation_Therapist_Manual.pdf