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Transcript
Copyright 2004 by the American Society of Clinical Hypnosis
American Journal of Clinical Hypnosis
46:3, January 2004
Using Hypnosis to Facilitate Resolution of
Psychogenic Excoriations in Acne Excoriée
Philip D. Shenefelt
University of South Florida College of Medicine
Hypnotic suggestion successfully alleviated the behavioral picking aspect of acne
excoriée des juenes filles in a pregnant woman who had been picking at the acne
lesions on her face for 15 years. Acne excoriée is a subset of psychogenic or
neurotic excoriation. Conventional topical antibiotic treatment was used to treat
the acne. Compared with other treatments for uncomplicated acne excoriée,
hypnosis is relatively brief and cost-effective and is non-toxic in pregnancy.
Keywords: Acne excoriée, habit, hypnosis, Obsessive Compulsive Disorder
(OCD), suggestion
Introduction
Hypnosis has also been used successfully for multiple skin conditions such
as alopecia areata, atopic dermatitis, congenital ichthyosiform erythroderma, dyshidrotic
dermatitis, erythromelalgia, furuncles, glossodynia, herpes simplex, hyperhidrosis,
ichthyosis vulgaris, lichen planus, neurodermatitis, nummular dermatitis, post-herpetic
neuralgia, pruritus, psoriasis, rosacea, trichotillomania, urticaria, verruca vulgaris, and
vitiligo (Shenefelt 2000). This article reviews the causes and treatment of acne excoriée
and presents a case example in which hypnotic suggestions were used for the effective
treatment of a patient with acne excoriée.
Acne Excoriée
Acne excoriée des juenes filles is a special subset of psychogenic or neurotic
excoriation, typically beginning in adolescent women, which is superimposed on mild
Request reprints from:
Philip D. Shenefelt, M.D.
Division of Dermatology and Cutaneous Surgery, MDC 079
College of Medicine
University of South Florida
12901 Bruce B. Downs Blvd.
Tampa, Florida 33612
E-mail: pshene[email protected]
239
Resolution of Psychogenic Excoriations
to moderate acne vulgaris. Clinically it is seen as acne lesions on the face that have
been worsened by habitually scratching or picking at them. It was initially described in
the French literature by Brocq (1898). Acne excoriée was first mentioned in the English
medical literature by Adamson (1915). He grouped acne excoriée together with acne
urticata and neurodermatitis under the concept of “neurotic excoriations”. Wrong (1954)
noted a prevalence of excoriated acne among 12,000 consecutive private patients of
0.63 percent, with 0.6 percent female and 0.03 percent male. Age distribution for females
was 27 percent at 11 to 20 years old, 47 percent at 21 to 30 years old, and 26 percent at
31 to 40 years old. Average duration of the condition was 6.5 years with a range of 3
months to 21 years. The lesions were located on the face only in 70 percent, on the face
and back in 20 percent, and on the face and other parts of the body in 10 percent.
Typical acne was present in addition to the excoriations in 33 percent while only
increased oiliness and no clear-cut acne lesions were present in 67 percent. The latter
probably had mild acne initially but continued picking after resolution of the acne. The
picking produces excoriations which crust and may heal with hyperpigmentation,
hypopigmentation, or scarring.
Acne Excoriée: Stress-Relieving Habit, Psychosomatic Symptom, or Indicator of
Serious Psychiatric Problems?
Habit with Psychogenic Overlay
In general many of the treatment approaches to situations in which dermatologic
conditions are worsened by skin picking and irritation are those used for habit control.
The acne excoriée is hypothesized to be a self-soothing habit that may serve other
psychological tasks as well. Azrin and Nunn (1973) described a treatment of
neurodermatitis that they called habit reversal. The four techniques involved were:
1.)
2.)
3.)
4.)
awareness training,
practice of a competing response,
motivation for habit control, and
generalization training.
Kenyon (1966) discussed psychosomatic aspects of acne, including brief
mention of acne excoriée. According to Plewig and Kligman (1975), these young women
may have disturbed psychosexual adjustments, low self-esteem, and emotional lability.
They believed that these patients confirmed their flawed self-image by excoriating their
faces and consequently reducing their attractiveness. The habit of excoriating the acne
may go on for decades. Vogel (1974) studied two female patients in their mid-twenties
who had acne excoriée and histories of acne since puberty. Both had stressful
childhoods. One had been forbidden to criticize her mother and the other had lost her
father in war and was raised in unhappy circumstances as a stepchild. What had started
as the commonplace teenage behavior of squeezing and picking at acne papules and
comedones (blackheads) developed into a form of stress relief with greatly increased
frequency and duration of picking at and manipulating the acne papules and comedones.
The stress relief through picking became a ritual or habit, a conditioned reflex in response
to stress. Suppressed aggression toward others became self-directed aggression and
self-punishment. Aggression was expressed psychosomatically as picking at acne
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Shenefelt
lesions on the skin rather than through direct verbalization.
Kent and Drummond (1989) used habit reversal behavior modification to treat a
case of acne excoriée in a 32-year-old woman with a 20 year history of picking at her
facial skin that began when she developed acne at age 12 years. She spent about 2
hours a day examining her skin in a mirror and picking at it, primarily early morning and
evening. She was asked to record the frequency and duration of each episode of picking.
Then she was instructed that whenever she felt the urge to pick her skin, she was to
hold her arms straight by her sides and clench her fists until the urge had passed. After
a month of practicing these techniques at home, she noted a dramatic reduction in
picking to less than 10 minutes a week. This improvement was maintained at 2 and 4
month follow-ups.
Hypnosis has not been used often in the treatment of acne excoriée. Hollander
(1959) described using posthypnotic suggestion to achieve control of acne excoriée in
two cases. The patient was instructed under hypnosis to remember the word “scar”
whenever she wanted to pick her face and to refrain from picking by saying “scar”
instead. The excoriations resolved, but not the underlying acne.
Psychiatric Issues
A different kind of treatment approach was used by Sneddon and Sneddon
(1983), one of whom was a dermatologist and the other a psychiatrist. They described
eight female patients with acne excoriée ranging in age from 21 to 43 years, with onset of
the picking starting at puberty for most, but ranging from childhood to age 33 years. All
but one of their patients had underlying active acne. The dermatologist tended to focus
on treating the acne and suggesting that the patient stop picking. Simple suggestion
was insufficient to stop the habit. With this population the psychiatrist focused on
what was inducing and perpetuating the habit. Their histories disclosed neurotic traits
and various kinds of phobias since childhood. For most, the self-mutilation by picking
seemed to provide a defense or excuse for not dealing with some issue in their life.
Bach and Bach (1993) discussed psychiatric issues in acne excoriée. They
studied 12 patients with acne excoriée. Two patients exhibited dysthymia and two
patients had a personality disorder, but eight of the 12 did not fulfill DSM-III-R criteria
for any disorder. There was no evidence of any underlying obsessive-compulsive
disorder or body image disorder. Fried (1994) presented psychogenic causes of pruritus
and self-excoriation. He classified acne excoriée under neurotic excoriations. According
to Fried, neurotic excoriations are often accompanied by underlying anxiety or
depression. Frequently these individuals are perfectionistic, obsessive-compulsive, and
have a strong uncontrollable impulse to rid themselves of a perceived imperfection by
scratching at it. Many of these individuals are in need of psychological intervention
but refuse psychiatric referral. In those cases he advocated for psychopharmacologic
intervention by dermatologists using antidepressants, anxiolytics, and antipsychotics.
Arnold, McElroy, Mutasim, Dwight, Lamerson, and Morris (1998) described
characteristics of 34 adults with psychogenic excoriation. Most of their subjects were
women with a mean onset at age 38 years and a chronic course averaging five years.
They excluded individuals younger than 18 years and did not specifically note any
patients with acne excoriée. All 34 of their patients had at least one DSM-IV comorbid
psychiatric disorder. Forty one percent had undifferentiated somatoform disorder, 32
241
Resolution of Psychogenic Excoriations
percent body dysmorphic disorder, 21 percent impulse control disorder, and 6 percent
obsessive-compulsive disorder.
Arnold, Auchenbach, and McElroy (2001) included acne excoriée as a subset
of psychogenic excoriation. They proposed diagnostic criteria for psychogenic
excoriation and described three subtypes:
1.) impulsive,
2.) compulsive, and
3.) mixed.
Psychiatric comorbidity was common and included mood and anxiety disorders,
obsessive-compulsive disorder, body dysmorphic disorder, and various impulse control
disorders. They discussed treatment options including pharmacotherapy with selective
serotonin reuptake inhibitors (SSRIs), doxepin, clomipramine, naltrexone, pimozine, and
olanzapine. Behavioral treatment and psychotherapy were also discussed.
Gupta and Gupta (2001) reported a case of a 28 year old woman with acne
excoriée for 16 years who had a significant decrease in her excoriations after 4 weeks of
therapy with olanzapine 2.5 mg at bedtime. She continued on the olanzapine 2.5 mg
daily for 6 months while undergoing psychotherapy to deal with psychosocial stressors
arising from childhood abuse and her feelings of anger and helplessness toward the
perpetrator. These memories had previously flared her picking behavior. After stopping
the olanzapine her excoriations had not recurred on followup extending to 4 months.
Fried (2002) reported that the picking component of acne excoriée in a young
adult woman responded to cognitive-behavioral therapy coupled with biofeedback,
minocycline, and sertraline. A multimodal approach such as this is often beneficial in
resistant cases.
Case Report
A 32-year-old pregnant Caucasian female presented with mild to moderate
papular (raised lesions) acne with multiple excoriations. She said that she had been
picking at her acne for 15 years. Treatment with 2 percent erythromycin ointment was
instituted and she was instructed to stop scratching at her acne. Other acne treatments
were omitted due to her pregnancy. The papular component of her acne improved
gradually over several weeks, but she continued to pick at her acne. After some
discussion she consented to medical hypnosis for her excoriating habit. A Hypnotic
Induction Profile was performed and she scored 9 on the newer scale of 16 (Spiegel,
Greenleaf, & Spiegel, 2000), or 7 on the older scale of 10 (Spiegel & Spiegel, 1978). That
placed her in the moderately hypnotizable group. The eye roll induction was performed
and she was instructed to descend to a safe place as I counted to 10, and to enjoy the
sights, sounds, fragrances, feelings, and other sensations.
She was then given the suggestion that she is beautiful and that her beauty
contains slight imperfections, just as nature is beautiful with slight imperfections, and
that the imperfections add to her natural beauty. She was told that “perfection is the
enemy of good” and that perfection is less beautiful than natural beauty is. She was
also given the suggestion that she would visualize a scar and think of the word “scar”
every time she reached toward her face to pick at her skin. The trance was terminated
using a 10 count after giving her additional posthypnotic suggestions for a feeling of
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Shenefelt
calm and tranquility and for daily self-hypnosis for reinforcement.
When the patient was seen in clinic 6 days later, her facial excoriations had
already healed. She reported that she had stopped picking at her face the day of the
initial hypnosis and had used self-hypnosis for reinforcement. She still had mild papular
acne on the face. The eye roll induction was repeated and she was directed to her safe
place. She was then instructed to imagine herself sitting in a movie theater, seeing
herself in a movie on the screen picking at the acne, then seeing herself several weeks
later with scars where she had picked. Again she was told that she has a naturally
pretty face and that it is OK to be good, not perfect. The statement “perfection is the
enemy of good” was repeated. She was reminded to visualize a scar and think of the
word “scar” if she started to reach up to scratch her face.
The patient was seen again in follow-up in 2 weeks. She had continued to
refrain from picking and her acne was still mild. Because her insurance would not cover
medical hypnotherapy, she stopped follow-ups but continued for several months to do
the self-hypnosis. During a telephone contact with the patient 16 months after her last
visit, she stated that she had refrained totally from picking at her face for 8 months.
After giving birth, she had gotten out of the habit of self-hypnosis. She had then
gradually resumed some picking during stressful times but not nearly to the previous
extent. She felt that if the picking became a significant problem for her again that she
could bring it under control with self-hypnosis.
Discussion
Part of the art of being a dermatologist is being able to choose appropriate
therapeutic modalities for specific patients, and patient selection for particular treatments
is one of the most important aspects of successful medical hypnosis in dermatology. In
the case described there was no evidence of serious psychopathology or of other
possible manifestations of Obsessive Compulsive Disorder (Frederick, 2002) or other
co-morbid conditions such as depression. In keeping with Ginandes’ (2002) integrative
model of hypnotically facilitated therapy, a decision was made to begin with the simplest,
most clear-cut attempt to address the behavior with hypnotic suggestion directed at
the patient’s acceptance of her natural imperfections into which was incorporated some
of Hollander’s (1959) script. This treatment was effective (Amundson, Alladin, & Gill,
2003) in liberating her from her symptoms.
It is important to note that when patients with acne excoriée show any signs of
significant psychopathology that suggest that there is more than a stress-relieving
habit present, or are refractory to suggestive hypnotic treatment, it is necessary for
them to be referred to an appropriate mental health practitioner for diagnosis and further
treatment. Among the possibilities for such patients are obsessive compulsive spectrum
difficulties (Frederick, 2002) that exceed the scope of dermatologic expertise. Similarly,
hypnosis by a dermatologist would be contraindicated in the presence of mania, severe
depression, psychosis, or were there evidence of other kinds of self-mutilations such
as cutting or burning.
However, this case report, as well as that of Hollander’s (1959), suggest that
hypnosis can be an effective (Amundson, Alladin, & Gill, 2003) and appropriate primary
treatment for the excoriation aspect of acne excoriée when used with highly and
moderately hypnotizable individuals who have little or no other apparent
243
Resolution of Psychogenic Excoriations
psychopathology (Shenefelt, 2000). It must be accompanied by standard acne treatments
employed for the acneiform aspects.
Hypnotic intervention was successful in the reported case with fairly brief
visits and minimal utilization of resources. It is non-toxic and relatively safe, with few
side effects. In the above case, hypnosis was an ideal intervention since the patient
was pregnant. For individuals who fall within the low hypnotizable range, cognitivebehavioral therapy with or without biofeedback may be appropriate (Shenefelt, 2003) as
may insight oriented psychodynamic psychotherapy (Sneddon & Sneddon, 1983). With
resistant cases that are characterized by the patient’s refusal to accept a mental health
referral (Fried, 1994), the addition of SSRIs or low dose olanzapine may prove helpful.
Close observation of these individuals is recommended.
As for the issue of efficacy of hypnotic suggestion in acne excoriée, it would
be ideal to have a randomized controlled trial with measures of hypnotizability in each
patient and comparisons of the options of hypnotherapy, cognitive-behavioral therapy,
biofeedback, psychodynamic psychotherapy, and SSRI or olanzapine therapy. However,
the literature indicates that acne excoriée is seen with relative infrequency, and it would
be a challenge to find an adequate cohort of patients willing to enroll in such a trial.
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