Guest blog with future psychodermatologist Erica Aukerman!

Hello! My name’s Erica Aukerman, and I’m a fourth-year medical student at Indiana University School of Medicine. I recently matched into dermatology, and my interest in the field traces back to before medical school. The ability to have a profound impact on a patient’s quality of life drew me to dermatology originally. I also value the innovative nature of the field and the continuity of care. I want to establish longitudinal relationships with my patients and see them improve over time. Growing up with severe eczema, I understand firsthand the psychological toll that skin conditions can take. As a result, I am passionate about addressing the psychosocial impact of skin disease. Throughout medical school, I have collaborated with dermatologists, psychiatrists, and therapists from across the country on projects within the realm of psychodermatology and hope to continue contributing to this niche field in the future.

Can you tell the readers about what it took to get to this point and what it means for you to have matched at IU? What will the next few years of your career look like, and when do you finally get to claim the title of Dr.? 

I truly cannot put into words how excited I am to have matched at my home dermatology program, Indiana University. I am so grateful to continue training under my incredible mentors and alongside wonderful colleagues. It took a lot of hard work to get this point, but I’ve truly loved every step of the way. I worked hard to excel academically in medical school, and I devoted most of my time to learning how to best take care of patients as a physician. I spent any extra time I had establishing connections and exploring the field of dermatology. I will officially become a doctor at the conclusion of medical school (this May). I will complete an intern year in general medicine before entering my three years of dermatology residency. At the completion of residency, I will officially be able to call myself a dermatologist.

 2. How did you become interested in psychodermatology? Was there a personal component to your interest? 

 My interest in psychodermatology stems from my personal experience with eczema, but it has been fueled by my interactions with patients who suffer from life-limiting skin conditions. My involvement with Camp Wonder, a camp dedicated to empowering children with severe skin diseases, sparked my interest in the psychosocial impact of skin disease. Spending prolonged periods of time with children who have conditions like epidermolysis bullosa and harlequin ichthyosis opened my eyes to the daily hardships they face. I want to serve as a pillar of support for these patients and their families and learn as much as I possibly can during my training to provide them with the highest level of evidence-based, compassionate care.

 3. Can you name one or two of the most fascinating things you have learned about the mind/body/skin connection?

 One thing that fascinates me most about the mind/body/skin connection is the intimate link between mental stress and exacerbation of certain skin conditions.

 4. What research have you been involved in recently that you would like to share with my followers who are interested in body-focused repetitive behaviors? 

 I recently helped Stacy with a write-up focused on the benefits of psychodynamic therapy for patients with body-focused repetitive behavior disorders. We shared the story of a patient with multiple psychiatric comorbidities whose skin-picking disorder responded well to intensive psychodynamic therapy.

5. How do you hope to use your knowledge to advance the field of psychodermatology?

I hope to use my platform to draw more attention to the importance of this field. Skin conditions do not exist in isolation, and it’s important to address the mind/body/skin connection for comprehensive patient care. I want to find more ways to incorporate quality-of-life metrics into dermatologic care and continue researching ways to improve the everyday lives of patients who suffer from dermatologic conditions with strong psychological implications.

 6. Can you give a sneak peek of your thoughts about my book for your upcoming book review through Dermatologic Therapy?

It is an easy-to-read book that supports the efficacy of a psychodynamic approach in the treatment of body-focused repetitive behaviors. Stacy does a wonderful job weaving compelling case studies with the practicalities underlying her therapeutic approach. Her patients' treatment responses speak volumes to the work she does and her work warrants expanded use of psychodynamic therapy across the field of psychodermatology. This book not only benefits those who serve patients from a medical or therapeutic standpoint but also offers support and validation to those who personally struggle with body-focused repetitive behaviors.

Guest blog post with Pavitt Thatcher

Trichotillomania and Dermatillomania: The Relevance of an Integrative Approach to Treatment

In the UK, it is difficult for people struggling with body-focused repetitive behaviour disorders to find a therapist with any training or specialisation in working with these disorders. The comprehensive cognitive-behavioural approach designed to treat this population called ComB is seen as the gold standard amongst leading clinicians.

In my opinion, some elements of ComB are essential for patients struggling with these behaviours. The program guides therapists to help patients get to know their triggers, to become aware of their sensory functioning, bodily movements and behavioural patterns that lead to body-focused behaviours. I have viewed this exploration as one of many pieces of the puzzle and a necessary component in discovering how a patient can reduce their picking or pulling. 

 The ComB model is an excellent starting point in one’s journey to recovery.  But I felt that I needed more tools in my clinical toolbox.  I found myself wondering about factors other than cognitive and behavioural may influence a patient’s picking or pulling. I have been pleased that the clinical community has advocated for the inclusion of Acceptance and Commitment Therapy and Dialectical Behavioural Therapy to create a more integrative treatment approach, adding in a focus on mindfulness skills, self-compassion and social skills. I have noticed other elements to consider re: how each person’s environment has impacted their behaviours.

When I considered the impact of psychosocial factors on an individual's emotional and mental well-being, I began to understand the world in which my patients live. It has become clear that trauma stored in the body is an important factor to consider, as it may be part of the clinical picture. Psychodermatologists believe that trauma may affect the body and skin and show up in a variety of different ways.  There is a need to understand and perhaps re-define the definition of what trauma means and how it is understood. Many people associate trauma with a traumatic event, a set of circumstances or that ‘something has happened’.  Some would argue that trauma can be seen as simply not having your needs met as a child, an unavailable parent, lack of love, lack of choices and freedom or being controlled. 

This perspective has led me to appreciate an integrative approach. I think that trauma-informed care should also be part of the clinical picture. The addition of somatic therapy has the benefit of addressing a patient’s nervous system. This work includes attention to breath work in regulating the nervous system. 

A psychodynamic approach to treating body-focused repetitive behaviours can complement traditional behavioural therapies. We cannot look at behaviours without asking the question ‘why’. Why do we have these behaviours erupt for some people at certain times in their lives? Psychodynamic approaches are relevant and necessary to in order to explore the conscious and unconscious mind and the stories we tell ourselves. 

The theory of psychotherapy has largely come from a Western perspective, and there are limits to this perspective. The culture we come from is a filter through which we see and perceive the world; it’s a lens that shapes our relationship with others.  Learning and growing up is a process of negotiation, of meeting others and of challenging our beliefs and our assumptions.  As therapists, a part of our job is to scrutinize ourselves and remove any unconscious bias.  Only then can we remain impartial, without prejudice or judgment. These intricacies are another part what I believe should be included in an integrative approach.

Through this wider lens, various factors come into view such as culture, religion, beliefs and core values. Ethnicity, nationality, cultural, religious, gender and diversity factors impact the particulars of each person’s engagement with picking and pulling behaviours, as do psychosocial and biosocial factors. Questions the therapist should ask include: Where did they grow up? What is their background? What are their influences? Where do they feel they belong?  What does hair and skin mean to them?  How do they see themselves?  What are the symbolic meanings behind hair and skin in their cultures? How are our patients using their own language and mannerisms to communicate with us and each other and what are the differences that we need to be aware of? 

Fundamentally, I aim to get to know each patient as a whole and understand their lived experiences, their social identity and how they understand the world around them. Ultimately, I hope that a patient will get to know themselves better and understand and reflect on themselves throughout our work together. My aim goes beyond the goal of helping people reduce picking or pulling, as I seek to address the wider issues that could influence these behaviours.

Pavitt is a UK trainee psychotherapist studying at University of London, Birkbeck.  She has an MSc in psychology and has completed The TLC Foundation’s Professional Training Institute on the comprehensive behavioural model for the treatment of BFRBs.  Pavitt is a co-founder of BFRB UK and Ireland.  She works with clients to create a safe space in a non-judgmental, protected environment to allow people to express themselves.  She is passionate and dedicated towards advocating and raising awareness for those with mental health issues. www.pavittthatcher.com