Dr. Sergio Lanari, D.ssa Maria De Federicis
Dermatologi – Falconara (An)

Psoriasis is a skin disease whose relationship to the psyche has already been extensively described… …in few other pathological skin complaints does this intersection of psychic element with the spreading of cutaneous manifestations, appear so clear and consequential. Many authors today classify Psoriasis among pure psychosomatic disease.

Skin disorders such as those that occur in patients suffering from psoriasis can change the relationship both with themselves and with others.

Consequently, the person may withdraw from society, experience states of depression and disordes of bodily image as well as developing a feeling inferiority (1).

According to Bahnson’s psychodynamic interpretative model, the Psoriatic patient tends to deny his inner conflict, his anxieties, distress and suffering, channelling them through his body, and expressing them by sketching a symptom on his skin.

Didier Anzieu observed (2) that every time there was a psychosomatic conversion sustained by the skin, the extent of the cutaneous alteration was proportional to the extent of the mental trauma.

We decided to investigate the psychodynamic aspects present in Psoriatic patients with the purpose of outlining some sort of parallel between Psoriasis and psychosis.

If it is true, as Biond observed (3) that the actual concept of psychotic personality is not always equivalent to a psychiatric diagnosis, but rather to a pattern of mental behavior, in as much as the psychopathological way of living is in a certain sense, accepted by the psychotic patients, who rather than fighting lives with his illness; we cannot help observing how the same way of living with the illness is found in most Psoriatic patients, who end up showing more pathophilic traits than pathophobic ones concerning their dermatosis.

In the personality profiles of the Psoriatic patients we observed, we often discovered psychic rigidity, “that inability to feel emotions, develop personal experiences and communicate with oneself”, which are also so frequently verifiable in the psychotic patients. This disharmony, this conflict, this mechanical feeling, devoid of life and warmth, is common to both personalities.

We examined a group of 33 Psoriatic patients (24 male and 9 female) aged between20 and 83 years who underwent a two-year observation.

Regarding the patients’ school education: there were eighteen patients who had attended only the Primary school (leaving age 11), seven had Primary and Middle school (leaving age 13), two had obtained their Senior school Diploma. One patient had a degree. Four patients had left school during the first years of Primary school, one patient was illiterate. A low academic level itself produces a personality more inclined to express himself through his body than verbally. The patients were first interviewed for their case history: the projective tests MMPI (or Minnesota), Rorschach’s test and the Machover test were then carried out. Only a few managed to complete the MMPI test, probably due to their low academic standards and intrinsic difficulty of the test itself. The Rorschach test evoked so few answers to render an evaluation of the results difficult. However all patients responded to Machover’s “human-form” test. We found this test particularly useful for the advantages the figurative activity afforded us in individuals such as Psoriatic patients who are so little disposed to verbal communication.

The deeper subconscious functions of the individual are often expressed through a figurative or graphic activity, which is more archaic than the verbal one and therefore nearer to psychosomatic thought.

Somatic regression expresses a change from a more differentiated structural level to a more disorganised and undifferentiated state (4).

Although a drawing may be conditioned by the expressive ability of the individual, it represents a graphic form which is able to symbolically translate the inner contents of the patients.
The following data emerged from the case history and Machover test:
  • An insecure ego with a strong sense of inferiority;
  • Dependent personality, often very sensitive to social critisism
  • A very conflicting identification with sexual role;
  • Mental rigidity;
  • Very marked but inhibited aggressiveness;
  • Anxiety;
  • Difficulty in communicating and relating to the outside world;
  • Sometimes exhibitionism.
We found no dissociative traits, probably due to the fact that these patients have already carried out their dissociation through Psoriasis.
We have already pointed out the essence of psychosis could be characterized by an inability of adequate evaluation of what is real and an emotional detachment from reality.
What could be the essence of Psoriasis? The semiological element that best characterized Psoriasis are of course the scales. (The term Psoriasis itself comes from the Greak Psora meaning scale).
These scales cover and hide an underlying Erythema, caused itself by a capillary dilation to such a degree as to take the twisted capillaries of the dermic papilla nearly back to the stratum corneum, giving rise to slight bleeding after removal of the last lamella (Auspitz sign).
According to psychosomatic concept every cutaneous symptom can be read symbolically, what symbol could we attribute to the presence of the scales? On further examination of various symbolic cutaneous symptoms (5), we noted that desquamation brings to mind dryness, rigidity, defence; in the same way the Erythema would evoke anger, pain, aggressiveness, while the haematic seeping could stand for separation, a cutting off, difficulty in communicating with the surrounding world. Thus we can highlight symbolically how in a Psoriatic patch a situation of emotional rigidity hides an underlying aggressiveness, conditioned and determined in its turn by a difficulty in relating to the outside world. One could say that the fragile Ego of Psoriatic patients takes its defence behind this armour of scales so as in the ancient greek myth of Apollo and Daphne.
The soul Daphne, desperate and furious for the inability to communicate and feel affection, induced by the sorcery of the vengeful god Eros’s blunter arrow (6), shuns the life-giving embrace of Apollo the god of beauty and light, to hide peevishly inside the bark of a tree, covering herself with a thick scaly crust. As we saw previously, aggressiveness, mental rigidity and difficulty relating to the outside world, emerged from the personality profiles of our patients. For this reason we would suggest that the Psoriasis skin symptom represented the symbolic equivalent of a psychosis. It has also been observed how the first Psoriatic eruptions coincide with a particularly traumatic event for the Ego, loaded with emotion (a death, the end of relationship, work problems), situations where the Ego is put hard to the test. We well know from clinical experience that the same events are capable of sparking off a psychotic crisis, because the Ego cannot tolerate the frustrations and face the events that bombard it. In the psychotic mechanism, the fragile and insecure Ego, cannot keep control and becomes disorientated. The distress then invades the whole body. The patient, disorientated in time and space channels his distress through delirious expression.
Delirium therefore represents a form of liberation that solves his existential tragedy. In Psoriasis the patient channels his anguish and denied suffering through his body, expressing it by a parakeratosic patch on the skin that we can liberally call a cutaneous delirium or a delirium drawn on the skin.
We would go as far as to say that if he had not manifested a Psoriasis, the same patient could have suffered a psychotic crisis.
Finally we would like to mention a case, we observed in which the alteration seen in the Machover test appeared to a clinical symptomatological improvement.
The case was a 26 years old bachelor, a labourer with a school leaving age of 14. He showed an extensive Psoriatuc eruption which had exploded after a series of dramatic family events. The patient on admittance showed large patches on the body and limbs. In the Machover test he drew extremely poor, simple figures of modest dimensions, typical expressions of an insecure and inhibited Ego. After a one-month stay in hospital, in which the young man was made to feel welcome and built up a satisfactory relationship with the other patients and hospital staff, he was discharged clinically cured. On dismissal he sketched a drawing which showed that he had clearly recovered some aspects of his Ego (a larger drawing with more attention given to detail).
Finally we would like to mention how the local ointment cures, abundantly used especially in the initial phase of therapeutic cycle (in combination with the other cures), probably provided a further beneficial soothing effect.
With the removal of the scales of the anguish (that impedes contact with others) and with the attenuation of the Erythema, we remove the anguish which has been converted into a cutaneous symptom and are then able to blanch the repressed aggressiveness (due to lack of communication).
The patient will later have to be helped to take possession of his own psyche again: the soul Daphne, victim of Eros’s sorcery, which caused her to flee from Apollo’s love, hid herself behind a bark of scales. The soul Psyche fell into the underworld of the illness: only the god of Eros, moved by pity, descending into that darkness, will save her bringing her back to the light.

References

1 Williams, R., “The psychosocial aspects of Psoriasis”, Physiotherapy Canada 36/5, 257-260 (1984)
2 Didier Anzieu, “Le moi peau”, Bordas Paris (1985)
3 Grinberg, L., Sor, D., Tabak De Bianchedi, E., “Introducción a las ideas de Bion. Grupos, conoscimiento, psicosis, pensamiento, trasformaciones, práctica psicoanalitica”, Nueva Vision, Buenos Aires (1972).
4 Pancheri, P., “Medicina psicosomatica”, in Reda, G.L., “Trattato di psichiatria”, USES, Firenze, 216 (1968).
5 Cossidente, A., “Il sognificato psicologico della pelle”, in Panconesi, E., “Lo stress le emozioni e la pelle”, Masson Milan, 41 (1989).
6 Graves, R., “Greek Myths”[/vc_column_text][/vc_column]

9_-_Psoriasis

Dr. Sergio Lanari
D.ssa Maria De Federicis
Dermatologi – Falconara (An)

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