Chronic Recurrent Psoriasis - Essay Example

Introduction A case study of a young woman with chronic, recurrent psoriasis is presented. In addition to the standard treatments for psoriasis, the nursing care mainly consisted of patient education, counselling and specific psychological therapies. Patient background and history A 24-year-old woman presented in the skin department in July 2005 with a history of progressively worsening psoriasis for the past eleven years with frequent remissions and exacerbations. The complaints had increased since the past one-month. The patient gave a history of intense itching of her skin and scalp, which was worse during winters and during the night. She also complained of pain in the joints of her fingers, feet and ankle. This was associated with swelling in these joints. She had tried both allopathic as well as homoeopathic treatment in the past for a long time but did not feel any significant improvement. There was a history of frequent exacerbations and remissions of her condition. This was especially severe during periods of stress and anxiety. The surgical history included an operation for appendicitis in childhood. The family history was significant with a history of psoriasis in her maternal uncle, who was also undergoing treatment for the same at present. Other than this person, nobody else in her family had this condition. She was also experiencing irregular periods since the past one month with occasional abdominal pain. There was no history of any other medical illness. In her personal history, she said her appetite was decreased since two to three months and she had lost some weight over the past two months. She was also having trouble falling asleep. She was a non-smoker but only used to consume alcohol occasionally. Since the past one month, however, she reported taking alcohol frequently, about 100-200 ml in quantity, with a frequency of about two or more times a week. She experienced one episode of blackout, after a heavy bout of drinking. She was married for five years and had no children. She had just started college five months back and was extremely distressed about her appearance. She felt very self-conscious. She knew that psoriasis was a chronic condition and that it required prolonged treatment. However, lately she was experiencing a lot of stress because of her condition and the fact that her husband had recently lost his job. She was from a middle class family, now they were facing a lot of financial difficulties, and her condition was adding to this problem. She was feeling very depressed. Although she liked the company of her friends, since the past few months, she had begun to feel uncomfortable in their company due to her skin problem and would get panic attacks with excessive sweating and palpitation. She was especially very concerned about the pruritis because it caused her a lot of embarrassment. It gave her a low self-image about herself. She often felt that she was not clean enough and was dirty. She also felt guilty about neglecting her family and that her condition was somehow infectious, and would spread to others. She was also not enthusiastic about going to college, and suffered from poor concentration. She preferred being alone, and generally avoided being seen in public places. Because her husband himself was trying to cope with his own problems, she was not able to express her feelings and share her grief with him. She had the tendency to suppress her grief and often cried alone. The patient also reported getting into the habit of consuming alcohol regularly, which concerned her very much. Recently, she has also been very irritable with easy provocation and would get into arguments with her husband over trivial issues. Although her husband wanted her to get pregnant, she felt that this would only aggravate her present condition, and was not interested in the idea. This was also a reason for frequent quarrels with her husband. Of late, she used to feel so much depressed that she even contemplated suicide. She felt that her stress had significantly contributed in aggravating the psoriasis. On examination, the patient was tall and of an average built, and well nourished. The skin examination showed large, dry, well-defined macules, papules, and plaques of erythema with numerous layers of silvery scales, predominantly on the back of her elbows, front of the knees and legs. These lesions measured about 6-12 cm in diameter. The surface was glazed with crusting, especially around the periphery. She had similar but much less pronounced lesions on the palms and on the arms. Lesions in the palm consisted of well-defined patches of hyperkeratosis and fissures, on erythematous bases. The lesions were bilaterally symmetrical. The scalp also showed thick, scaly papules discretely distributed with intervening areas of normal skin. The lesions were dry with no matting of hair or hair loss. The lesions covered around 30% of her total body surface area. Examination of the nails of both hands showed mild dystrophic changes and pitting. There was also mild tenderness and swelling of the joints of the fingers, feet and ankle. She also appeared very depressed and agitated. She would often breakdown and cry when relating her history. Other than the standard treatments for psoriasis, additional psychological care was given, in view of her acute anxiety and depression. Initially, she was educated about the clinical nature about the disease. The chronic nature of the disease and the contribution of stress in aggravating psoriasis were emphasized to the patient. A psychological counselling for the patient and family counselling session was arranged with the patient’s husband. Her husband was counselled on the nature of psoriasis and the various psychological aspects of the disease. The fact that the patient required his support, especially at this juncture, was explained to him. He was counselled on how the psoriasis was affecting his wife and the psychological problems that she was facing. Her husband appeared to have significantly appreciated these facts and both were willing for the necessary therapy that was required. In view of her extreme distress and panic attacks, drug treatment with imipramine 100 mg per day was started immediately. This was then gradually tapered and stopped over four weeks. After a few days of treatment, she reported feeling significantly better, and appeared more cheerful. She did not report any adverse effects from the drug. Psychological therapy was started concurrently, and mainly consisted of hypnosis and cognitive behaviour therapy. The importance and benefits of these therapies were clearly explained to the patient. Two sessions of hypnotherapy, once in the morning and once in the evening was started. Hypnosis was combined with three sessions of cognitive behaviour therapy (CBT). Both therapies were continued for a week, till her condition stabilized, followed by once a week sessions. The nursing team also encouraged her to join a support group, consisting of other psoriasis patients. The nursing team encouraged them to interact with each other and discuss their feelings about the disease and guided all the members towards a more optimistic outlook. The support group met frequently. Initially, they met every day and then once a week. The group was limited to only about ten people in order to encourage more interaction with each other. Patients who had shown improvement in the past were specifically included in the group because they could convey and spread positive thoughts amongst the group members. She was also asked to give regular feedbacks about how her therapy was helping her. In addition to this, she was also asked to do some simple aerobic exercises everyday and read some books and magazines to divert her mind. She was able to complete the treatment in three weeks and showed marked improvement in both her physical and mental condition. A trial termination of therapy showed no adverse effects. Nurses with special knowledge and skills in dealing with alcoholism were utilized to educate and counsel her about alcoholism. An open communication about the problems of alcohol with the patient and with her family was adopted. She was also given the option of joining Alcoholic Anonymous, and the benefits of doing so were clearly explained. Relaxation techniques, which included simple muscle relaxation techniques and yoga, were explained to the patient, and this was to be followed regularly at home to maintain the improvement seen during treatment. She was also advised to exercise regularly at home and take up some hobby in her spare time. She was counselled on the importance of continuing her college education and to develop a harmonious relationship with her husband. She was advised that the effect of pregnancy on psoriasis was variable, and that in fact, some studies have shown a beneficial effect on the condition. This allayed her fears to a significant extent and she said that she would consider the facts. She was discharged from the hospital after three weeks. The patient was advised to follow-up immediately after one month with a regular follow-up every two months for a year or more, depending on her progress. Review of literature As in most skin disorders, the psychological problems in psoriasis can arise from the patient’s perception about their appearance, social rejection, guilt, embarrassment for self and family, and emptiness. A number of studies have shown that psychological stress is often caused by psoriasis, and can be a factor in flare-ups of psoriasis. Pruritis in psoriasis contributes to stress and the stress in turn can lead to more pruritis. This vicious cycle can contribute to psychological problems including depression, anxiety, aggressive behaviours, obsessional behaviour, and alcoholism (Gupta MA, Gupta AK, 1996). The other psychological problems can include poor self-esteem, sexual dysfunction, and suicidal ideation. (Russo PA, Ilchef R, Cooper AJ, 2004.) The mechanisms by which psychological stress can make pruritis worse are not clearly understood. These mechanisms may include activation of itch-inducing neurochemical pathways, variation in skin temperature and blood flow, and sweating (Koblenzer CS, 1994). Stress and its effect on the autonomic nervous system and the immune system may play a significant role in the onset and course of psoriasis (Winchell SA, Watts RA, 1988.) Psychological counselling may be helpful in some patients with psychosocial problems (Zachariae R, Oster H, Bjerring P, Kragballe K, 1996). A family counselling session may also help the family members to understand the nature of the disease better and realise the role that family members can play in reducing psychosocial stress. Case reports have indicated that psychologic treatments may have a beneficial effect on psoriasis activity (Zachariae R, Oster H, 1996). This has been confirmed by other studies also (Capoore HS, Rowland Payne CM, Goldin D, 1998). Stress reduction techniques can thus be regarded as part of the treatment offered to some patients suffering from psoriasis. (Gaston L, Crombez JC, et al., 1991). Traditional psoriasis treatment regimens may be augmented with stress-reduction strategies. (Farber EM, Nall L, 1993). Biofeedback training, psychotherapy, and hypnosis are examples of adjuncts to traditional medical treatment (Kantor SD, 1990). Hypnosis may improve or resolve numerous dermatoses, including psoriasis. In addition, hypnosis can facilitate aversive therapy and enhance desensitization and other cognitive-behavioural methods (Shenefelt PD, 2003). Hypnosis may be a useful therapeutic modality for patients with psoriasis, and merits further testing in a larger patient population. (Tausk F, Whitmore SE, 1999.) Cognitive behaviour therapy combines two kinds of psychotherapy, cognitive therapy and behaviour therapy. CBT has been very thoroughly researched. Numerous studies have shown CBT to be as effective as drugs in treating both depression and anxiety. Although CBT is usually used alone without psychiatric drugs, in some cases, drugs are essential and may need to be continued indefinitely. For others, a short-term drug treatment may partially reduce the symptoms before CBT can be fully effective. Treatment of depressive symptoms may prove to be a helpful adjunct in the management of pruritis and sleep difficulties in psoriasis. (Gupta MA, Gupta AK, et al 1990). The tricyclic antidepressants imipramine and clomipramine are considered the first-line treatment options for panic disorder (Saeed SA, Bruce TJ, 1998.) Most CBT treatments can be completed in a few weeks or months. As a rule, however, most people can expect to begin their treatment with weekly visits. For those patients who are in a crisis, two or more sessions a week can be started till the condition is stabilized and then once a week. (Bush JW, n.d.) Conclusion Psoriasis is a chronic, relapsing and usually lifelong condition. Patients with psoriasis often lose hope that their condition can be managed. This may lead to poor treatment compliance. It is a well established fact that in addition to physical discomfort and disability, psoriasis can produce anxiety, depression and other psychological problems, which in turn can aggravate the disease. The degree of psychosocial distress experienced varies widely in individuals. The effective management of psoriasis includes considering the psychological and social impact of the disease on each individual as well as the physical symptoms. Patients affected with psoriasis also tend to suffer from low self-esteem and poor body image. They suffer guilt, embarrassment, and the fear of being thought dirty and infectious to others. When compared to other skin diseases, the level of stigmatization is greater in patients with psoriasis. Numerous studies have demonstrated the beneficial effects of psychological counselling and treatment in psoriasis. This can include hypnosis, cognitive-behaviour therapy and relaxation techniques. The role of counselling the family members is also important, and the support they provide can help the patient immensely. In addition, the increased psychological well-being generated by effective therapy makes future contact with the patient more rewarding, and may improve patient compliance. This case study showed that the patient had significant relief in both her physical and mental problems because of effective counselling and psychological therapies. *************************************************************************** References Bush JW, n.d. The CBT website. Retrieved November 14, 2005 from, http://www.cognitivetherapy.com/basics.html Capoore HS, Rowland Payne CM, Goldin D (1998). Does psychological intervention help chronic skin conditions? Postgrad Med J. 1998 Nov; 74(877): 662-4. Farber EM, Nall L (1993). Psoriasis: a stress-related disease. Cutis 1993 May; 51(5): 322-6. Gaston L, Crombez JC, et al (1991). Psychological stress and psoriasis: experimental and prospective correlational studies. Acta Derm Venereol Suppl (Stockh) 1991;156:37-43 Gupta MA, Gupta AK (1996). Psychodermatology: an update. J Am Acad Dermatol 1996;34:1030-1034 Gupta MA, Gupta AK, et al (1990). Some psychosomatic aspects of psoriasis. Psychodermatology: an update. J Am Acad Dermatol 1996. Koblenzer CS (1994). Psychological and psychiatric aspects of itching. In: Bernhard JD (ed.) Itch: Mechanisms and Management of Pruritis. New York: McGraw-Hill; 1994:347-356. Kantor SD (1990). Stress and psoriasis. Cutis 1990 Oct;46(4):321-2. Russo PA, Ilchef R, Cooper AJ (2004). Psychiatric morbidity in psoriasis: a review. Australas J Dermatol. 2004 Aug;45(3):155-9. Shenefelt PD (2003). Biofeedback, cognitive-behavioral methods, and hypnosis in dermatology: is it all in your mind? Dermatol Ther. 2003;16(2):114-22. Saeed SA, Bruce TJ (1998). American Family Physician. Retrieved November 14, 2005 from, http://www.aafp.org/afp/980515ap/saeed.html Tausk F, Whitmore SE (1999). A pilot study of hypnosis in the treatment of patients with psoriasis. Psychother Psychosom. 1999;68(4):221-5. Winchell SA, Watts RA (1988). Relaxation therapies in the treatment of psoriasis and possible pathophysiologic mechanisms. J Am Acad Dermatol. 1988 Jan;18(1 Pt 1):101-4. Zachariae R, Oster H, Bjerring P, Kragballe K (1996) Effects of psychologic intervention on psoriasis: A preliminary report. J Am Acad Dermatol 1996; 34:1008-1015. Read More