Mindfulness and Psoriasis

strawberries_strawberry_fruit_214340I often teach mindfulness to the people I work with. People who are struggling with painful and distressing symptoms find it a useful tool in helping them to cope.

Our brains are so complex and so busy and our thoughts can have a powerful physical affect on our bodies.  Remembering a stressful incident at work can raise your blood pressure, thinking about the presentation we have to do in a months time can cause a surge in adrenaline.  We have amazing brains.  A picture of a delicious cake or juicy strawberries can make us salivate, a photograph can physically arouse us.  But there are times when we need to quieten it down a bit.  To have a rest from our thoughts.  Mindfulness can help with that.

There are many great apps and podcasts to help you practice.  I would recommend watching anything by Mark Williams on youtube.  Try this video if you have spare hour.

I would also recommend Palouse Mindfulness  This is a fantastic resource which takes you through a six week course.  It’s free and there are no catches.  Try listening to the Body Scan exercise.

If you want to start with something simple, try a mindful minute.  You can do it whilst waiting for the kettle to boil.  Please comment below and let me know how you got on.

Advertisements

CBT and Psoriasis

Cognitive Behavioural Therapy (CBT) is a commonly used psychological approach to treating a wide variety of conditions such as depression, anxiety, phobias and more recently has been used in physical health conditions. The basic idea behind this therapy is that the way we think affects how we feel and our behaviour (what we do or don’t do).

For example:

Situation A

It’s the second week of July and so far it has been a great summer. Up until this point Rebecca has been wearing long sleeves and trousers to hide her psoriasis but today she can take the heat no longer and has decided to wear a skirt and t-shirt to her friend’s house. She catches a bus there and on the way a group of school children behind her start laughing. Rebecca thinks, “Those kids are laughing at my skin. It looks so awful. They must think I’m disgusting. I shouldn’t have worn a skirt and short sleeves.” She blushes and feels hot and embarrassed. She jumps off at the next stop, walks home in tears and changes into trousers.

 

Situation B

It’s the second week of July and so far it has been a great summer. Up until this point Rebecca has been wearing long sleeves and trousers to hide her psoriasis but today she can take the heat no longer and has decided to wear a skirt and t-shirt to her friend’s house. She catches a bus there and on the way a group of school children behind her start laughing. Rebecca thinks, “Teenagers seem to find everything so funny. I wonder what they are laughing about. I bet they are talking about boys. I can remember being like that.” Rebecca starts to daydream and remember happy times from her youth. She arrives at her friend’s house feeling happy.

 

Situation C

It’s the second week of July and so far it has been a great summer. Up until this point Rebecca has been wearing long sleeves and trousers to hide her psoriasis but today she can take the heat no longer and has decided to wear a skirt and t-shirt to her friend’s house. She catches a bus there and on the way a group of school children behind her start laughing. Rebecca thinks, “I wonder if they are laughing at me. I doubt it. They wouldn’t even see my legs from the back of the bus and anyway I don’t suppose psoriasis is that funny.” She turns on her MP3 player, reads her book for the rest of the journey forgetting all about the girls at the back. She arrives at her friend’s house feeling relaxed.

It’s the same situation but because the thoughts are different, the feelings and behaviour are different too. Who knows what the teenagers were laughing at? They might have found the sight of Rebecca’s arms and legs hilarious. They might not have.

Which one of those examples would have been most like you? If it is A, then is there anything you can do about it? CBT could be the solution.

We all think all the time. It’s often boring stuff, thinking about what to cook for dinner or who said what to whom at the office. One thought leads to another and to another. Suddenly you find yourself thinking about someone you met on holiday ten years ago and you don’t know what led you there. There would have been a chain of thoughts that led to this one but it’s often hard to back-track as we don’t plan the thoughts. They just pop up, unbidden, automatically, one after another. The first step in CBT is learning to identify these automatic thoughts, spot the unhelpful ones and challenge them. Rebecca in situation A didn’t stop to question her thoughts. She believed her thoughts as if they were the truth. If she had been able to stop her thoughts and challenge them with something like this – “hang on a minute am I jumping to conclusions, could they be laughing at something else?” then she might have been able to carry on with her journey without feeling so ashamed and bad about herself.

This is a very brief outline of CBT but it seems to me to make sense that this kind of an approach would be helpful to people with psoriasis. Some hospitals have started to use CBT with people with psoriasis and a few research papers have been published. You can read more about this in a future post.

Psoriasis. Good for your soul?

I was at a paediatric psychology network conference and listened to a very interesting presentation on positive personal growth following trauma or illness (Green 2009) and I wondered if this linked to psoriasis in any way.

This presentation highlighted the surprising evidence that many people do well after ill health or having something traumatic happen to them. In some cases, they do even better than those who have not had a similar traumatic experience.

The speaker gave lots of evidence. Of a group of adults who had been abused as children, 45% were classified as resilient and had no psychological problems. When compared to a group of adults who had not been abused they were actually functioning better. The same story was seen in a large sub group of children and adults who were involved in the ferry disasters, Herald of Free Enterprise and The Jupiter, in the 1990s. The same pattern is seen in survivors of cancer and heart attacks, women with impaired fertility and even in those who have lost a child.

So what does this mean? I don’t think the evidence suggests that people ‘benefit’ from these awful events. They are affected and no doubt those who have lost loved ones or even aspects of their own functioning still grieve, but these events and illnesses have helped them to reflect and perhaps value the good things in life. We heard a very moving quote from a father who had lost two daughters in the Hillsborough disaster “It sounds ridiculous, I know, but I think I have come out of it a better person. But I’ll always be a chipped cup…..” (Times Online)

So how does this relate to psoriasis? Can we find anything good from this condition? I did struggle with this at first being so focussed on the negatives (flaking, itching, soreness, embarrassment). But thinking away from the immediate symptoms I do think of myself as a caring person, I don’t judge a book by its cover and I am empathic. Would I have chosen to be a clinical psychologist had I grown up blemish free? I don’t know the answer to that. I would quite happily give my psoriasis away (any takers? No?) but it has taught me to cope with life’s challenges and it has taught me not to worry about the small things. A bad hair day would not have me diving under the duvet like many people I know. It has made me think about the connection between alcohol and psoriasis in a new light too. Perhaps we are not drinking to forget, maybe we are just enthusiastic party animals!

Depression and psoriasis

Many of us with psoriasis feel down about our skin. The research evidence looking at the link between depression and psoriasis is itself quite gloomy. One recent study conducted in Italy found that over 60% of people with psoriasis have symptoms of clinical depression (Eposito, 2006). Compare that to approximately 10% of people in the general population.

But how do you know if the way you are feeling is clinical depression? We all get low from time to time but feeling low is considered to be clinical depression when five or more symptoms from the following list have been present over a two week period, and at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure*:

  • Depressed mood most of the day, nearly every day;
  • Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day;
  • Significant weight loss when not dieting or weight gain (e.g., a change of more than 5 of body weight in a month), or decrease or increase in appetite nearly every day;
  • Insomnia or hypersomnia nearly every day;
  • Psychomotor agitation or retardation nearly every day;
  • Fatigue or loss of energy nearly every day;
  • Feelings of worthlessness or excessive or inappropriate guilt nearly every day;
  • Diminished ability to think or concentrate, or indecisiveness, nearly every day;
  • Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Feeling depressed about psoriasis is tricky because as we all know there is no cure for psoriasis. If someone could wave a magic wand and rid you of this disease then this is likely to be an effective cure for your low mood. Sadly there is no magic wand (or cream or tablet) to cure your skin so what can you do instead?

The symptoms of depression can be treated using anti-depressant medication and/or a psychological therapy. However a treatment that only aimed to improve the symptoms of depression would miss the bigger picture. It would be hard to treat depression without tackling the root cause: psoriasis. It is a Catch 22 situation because we know that treating psoriasis is not so easy. Perhaps equally important is to learn to cope with psoriasis so that it has less of an impact on your mood. If you can’t get rid of it then you need to learn how to live with it. How well you cope with this condition can determine how happy and fulfilled your life is. Learning to identify negative or unhelpful thoughts, changing behaviour and relaxation may be the tools to coping. Look out for tips relating to these strategies in future posts.

If you have read the list of symptoms above and think that you are depressed then please visit your GP to discuss treatment options.

* Taken from the DSM IV – The Diagnostic and Statistical Manual of Mental Disorders- Fourth Edition (American Psychiatric Association, 1994) – the current reference used by mental health professionals and physicians to diagnose mental disorders.

Reference

Esposito M, Saraceno R, Giunta A, Maccarone M, Chimenti S:An Italian Study on Psoriasis and Depression.Dermatology 2006;212:123-127

Psoriasis and Stress

It’s usually taken as read that stress makes psoriasis worse but in actual fact there is very little research evidence to suggest that this is the case. To date no-one has been able to track stressful life events in a large enough group of people with psoriasis to see whether an increase in their symptoms followed on from an increase in stress. A recent study by Berg et al (2008) used daily diaries to try and link stress to psoriasis flare-ups. They found no pattern between the two factors.

The strongest form of evidence is found in research studies that have asked people whether they think stress makes their skin worse. And although most people tend to say yes, what’s not clear is how accurate a judgement people can truly make. For a start most people are quite likely to have been told by their GP or dermatologist that stress makes psoriasis worse, and this is most definitely going to influence any reply. On top of that, like the straw that broke the poor camel’s back, people may be more bothered by their skin when under stress. Their psoriasis may be the same all the year but it’s only when work is going badly and the kids have all got winter vomiting virus and the in-laws have arrived for three weeks over Christmas that they begin to notice and be bothered by their skin more than usual.

An additional problem is that people who are finding life stressful may not lead the healthiest of lifestyles. They might not find the time to apply their creams properly, might drink the odd glass (or bottle) of wine, eat take-away food for ten days in a row and may be getting less sleep. All of which may result in a flare of symptoms.

Believing that stress is responsible for your psoriasis may not be that helpful either. I found in a research study that the people who believed stress was a causal factor in their psoriasis were more likely to be anxious, depressed and stressed out than those who didn’t believe that stress was related, despite no differences in the level of psoriasis. In other health conditions researchers have found that if people believe stress is causing the problem then they feel less in control and this low self-efficacy results in low mood.

What we do know for sure is that having psoriasis is stressful and therein lies an additional compounding problem. If your psoriasis is bad you will probably feel stressed: but which came first? It’s a classic chicken and egg situation.

So there is no firm medical evidence to suggest that stress causes psoriasis, but given that psoriasis causes stress and stress in itself is bad for you, it might be wise to take measures to relax and de-stress.

Some people find this easier than others but for most of us relaxation is a skill that has to be learned and practised. Good relaxation is not about getting an extra hour in bed on a Sunday morning or spending a fortune on designer shoes.   Instead it’s about learning to become aware of your body; your muscle tension, your breathing and your thoughts, and learning to reverse the signs of stress and tension. A bit of stress is not bad for us. It helps us to perform and get though difficult situations. It’s when it becomes prolonged that it becomes a problem. The key is to practice relaxation regularly and at times when you are not stressed or tense. Then when you do come under fire those skills should come in to play like second nature. Watch out for tips on how to relax in future posts.

References

Berg M; Svensson M; Brandberg M; Nordlind K (2008) Psoriasis and stress: a prospective study. Journal of the European Academy of Dermatology and Venereology : JEADV ;22(6):670-4.

O’Leary, C.J., Higgins, E. and Creamer, D., Weinman, J., (2004). Perceived Stress, Stress Attributions and Psychological Distress in Psoriasis. Journal of Psychosomatic Research 57(5):465-71.

Dealing with Disgust

image

A paper published in the Psychological Bulletin examined the emotion disgust.   The authors suggest that disgust is an innate emotion designed to protect an individual from disease. Humans are instinctively disgusted by something that looks like it might be harmful. In the case of disease, the feeling of disgust is triggered by visible symptoms and it leads the disgusted person to keep their distance and hence avoid catching it. They suggest that feelings of disgust are more strongly aroused when the person with symptoms is a stranger.

This paper could make quite depressing reading for those of us with psoriasis and might explain the extreme reactions some psoriasis sufferers have experienced. If strangers can’t help feeling disgusted and we can’t help having psoriasis, how can we deal with it? Well, we could hide away – wear long sleeves, avoid swimming or the hairdressers, never use shop changing rooms or wear a bikini on the beach.

An alternative solution might be to learn to manage the reactions of others instead. The charity Changing Faces has great advice. They suggest using an Explain-Reassure-Distract method to deal with comments or questions. For example:

 

Explain: “I have psoriasis.”

Reassure: “It’s not catching. Don’t let it bother you.”

 Distract: “Have you been here before?” Or “Did you see the football last night?”

 

In this way, the person with psoriasis can take control of the conversation and limit its potential to cause upset.

There is an article in The Psychologist by James Partridge and Adam Pearson, two inspirational men with visible differences. They suggest that if you have a disfigurement you have to be more socially skilled to help manage the reactions of others.   Both James, who was badly burned in a car accident, and Adam, who has Type 1 neurofibromatosis, have learned to do this:

James:

I experimented with different levels of eye-contact, handshake, verbal energy and body language, and found out and eventually mastered the skills to deal with the scared-ness I met – ‘scared’ being an acronym for staring, curiosity, anguish, recoil, embarrassment and dread. These skills mediated the effect of my outside and boosted my inside too.

Adam:

I discovered too how to control a social situation – just going up to someone who is staring or acting funny and saying ‘Hi’ is a really good way of breaking the ice and showing your human side.

There is no doubt that facing the world, plaques and all, takes a great deal of courage. But, like all things, it gets easier with practise. Decide how you want to explain, reassure and distract. Choose your own words and try them out on your family or in the mirror.

If you have a child with psoriasis, practise it with them so they can use it at school. Instead of getting cross if someone asks what is wrong with your child, model an “explain, reassure, distract” response so your child can learn from watching you. Be prepared and then you won’t get upset, flustered or angry in the heat of the moment.

Stop hiding away. Take a deep breath and get out there!

 

References

Oaten, M., Stevenson, R.J. and Case, T.I. (2009). Psychological Disgust as a Disease-Avoidance Mechanism. Psychological Bulletin, Vol. 135 (2), 303–321.

Partridge, J. and Pearson, A. (2008). Don’t worry…it’s the inside that counts. The Psychologist, 21, 490-491.

Searching For A Cure For Psoriasis

I’ve been thinking about how the search for a cure affects our well being. In my twenties I found an ‘alternative’ treatment called Skin Cap. The online community was reporting great success and it contained nothing more harmful than zinc. I bought a few cans and was delighted. It was a spray, easy to use and cleared my skin in record time. I bought several more cans and sprayed away with joy. However it did all seem too good to be true. I was noticing side effects like thinning of my skin and bruising so I wasn’t surprised when it emerged that it contained an unlisted steroid. I stopped using it and had the worse rebound ever. But even worse than the flare in my symptoms was the horrible feeling of being let down and having my hopes dashed. Not surprisingly I became quite low and depressed. I thought I had found the answer to my psoriasis and had been ‘in control’ for the best part of a year. I felt cheated and let down and determined not to fall for a ‘miracle cure’ again.

I have had psoriasis for over twenty years and in that time have tried many ‘cures’. The disappointment I have felt when they fail always affects me deeply and more so than the waste of the money or time. In more recent years I have come to the decision that I won’t invest any hope, time or effort in a ‘miracle cure’ that costs money. I am prepared to try treatments that involve healthy lifestyles like cutting out wheat and processed food and taking vitamins, as I believe that it will probably do me some good even if it doesn’t clear the psoriasis. This is my personal decision but is it the best approach to take? What does the research suggest I should be doing? Should I accept my psoriasis or should I keep trying new potions and searching for a cure?

With this in mind I searched healthcare databases (Medline and PsychInfo) for research looking at acceptance and coping. I found one relevant paper by Zalewska et al (2007) that suggested factors such as higher levels of optimism and a lower conviction of others’ influence on one’s health were linked with acceptance. The authors also stated that a lack of acceptance is associated with poorer medical adherence and delayed clinical improvement. In other words, if I accept my skin as it is, I am more likely to follow doctor’s orders and get better, and I am more likely to accept it if I feel optimistic and don’t think that my health is dependent on someone else.

Whilst not specifically answering my question, this research would suggest that I should be optimistic that something will work (keep trying) and I should have belief in my own ability to cure it (don’t rely on someone else to find the cure for me). Whether or not I should invest any hope or money in a cure remains unanswered. If you know of any research that addresses this question I would be very interested to hear more.

References

Zalewska A,Miniszewska J,Chodkiewicz J,Narbutt J (2007). Acceptance of chronic illness in psoriasis. Journal of the European Academy of Dermatology & Venereology, vol./is. 21/2(235-42), 0926-9959