Psychotherapy Role in Treatment of Chronic Spontaneous Urticaria in a 32 Years Old Female Patient.

As indicated by the latest scientific evidence, the lines between different fields of medicine gradually blur and overlap more and more. Psychiatry and dermatology have seen this trend in the last decade as an ever-increasing number of studies suggest the strong connection of many dermatological syndromes and diseases with psychiatric conditions and vice versa. It seems that the relationship is more intertwined than previously believed and the effects of different multidisciplinary approaches to diagnostic and treatment are being considered. The aim of this case report is to highlight the effect of psychotherapy on chronic spontaneous urticaria which is tightly related to the maladaptive stress response. Copyright:

Introduction

As indicated by the latest scientific evidence, the lines between different fields of medicine gradually blur and overlap more and more. Psychiatry and dermatology have seen this trend in the last decade as an ever-increasing number of studies suggest the strong connection of many dermatological syndromes and diseases with psychiatric conditions and vice versa. It seems that the relationship is more intertwined than previously believed and the effects of different multidisciplinary approaches to diagnostic and treatment are being considered.

This case report aims to highlight the effect of psychotherapy on chronic spontaneous urticaria which is tightly related to the maladaptive stress response.

Case Presentation

A 32 years old female patient came into the psychiatrist office for an interview. This was the first interview, and she didn’t have any prior history of mental conditions. During the interview, she disclosed that her symptoms came about up three months ago when she got engaged to a man, she was dating for 3 years. The engagement triggered a memory of a traumatic event that happened early in their relationship when she was raped by an unknown man while under the influence of alcohol. The incident was not reported to the authorities, and she repressed the experience without further contemplation or seeking psychiatric help. She reported that, in the last three months, she started having recurring thoughts of the incident that produced severe anxiety followed by increased heart rate, muscle tension, dizziness, and acute urticaria, rash and lividity of the skin on the torso, arms and neck area. During this period, she had trouble sleeping with a recurring episode of night terrors, irritability, depressed mood and intense feelings of guilt, shame and unworthiness. Also, her ability to function in everyday tasks was, self reportedly, compromised. The novel skin condition caused her to feel more anxiety which in turn worsened the symptoms she had experienced so far. The acute urticaria seemed to be connected to her mental state as it dramatically flared up within 10 seconds of becoming anxious. She went for an examination to a dermatologist office, and upon completion, she was instructed to seek psychiatrist opinion on diagnosis and treatment for her condition.

- There was no family history of mental illness or skin diseases;

- GAD7 test score 18/21 which correlates to severe anxiety;

- HAMD test score 10 which correlates to mild depression;

- The blood test showed no abnormalities;

- Common allergy testing battery report came back negative.

The working diagnosis was generalised anxiety disorder (GAD) as she satisfied most of the DSM 5 criteria with consideration of post-traumatic stress disorder. The dermatological diagnosis was chronic spontaneous urticaria with no proposed treatment.

The patient refused proposed treatment for GAD in the form of SSRI since she was trying to conceive with her partner, so the treatment consisted only of psychotherapeutic interventions. The psycho-therapeutic approach used was rational emotive behavioural therapy (REBT) once per week over 4 months. The interventions used were: analysis of dysfunctional and irrational beliefs; empirical and functional dispute; formation of healthy, rational beliefs; discovering and refuting cognitive distortions; rational emotive imagination; behavioural exercises; home assignments to reinforce new insights and biblio-therapy. Throughout the treatment, the client and the doctor formed a satisfactory alliance and the patient actively participated. GAD7 test result on month two of treatment was 13 which correlates to moderate anxiety, on month three was 9 which correlates to mild anxiety and on month four 6 which also correlates to mild anxiety. During the last month of the treatment, the patient haven had a single flair of urticaria, and her level of life function and efficacy returned to normal. The flairs of urticaria continued to manifest over the first month in the situations when the patient got anxious. By the end of the treatment, and with gaining valuable emotional insight, the patient gradually started reporting fewer anxiety episodes and less urticaria flaring.

Discussion

Development of a comorbid mental condition in patients with chronic spontaneous urticaria is well documented [11], [12] and brief emotional arousal induced flare-ups [14] can, in turn, worsen the both mental and skin condition. As with our patient, scientific evidence suggests that psychological trauma and stressful life events often precede the development of chronic spontaneous urticaria [15], [16]. It is known that acute stress triggers the release of neuropeptides in the skin [18], [20]. Mast cells are an important target of cutaneous neuropeptides. Substance P as a neuropeptide stress mediator leads to enhanced mast cell response to IgE antibodies. This reaction is called neurogenic inflammation, and case studies suggest that it is especially potentiated with acute stress [14]. Therefore, acute stress can lower the threshold for urticaria and affect the severity of the disease. Acute stress triggers a typical stress reaction and Leeds release of hormones such as cortisol and adrenaline, while reducing stress lowers morning cortisol concentration and urticaria symptoms [13].

The effectiveness of psychotherapy is well documented when dealing with psychological stress and conditions such as generalised anxiety disorder. The scientific evidence also suggests that the effectiveness of psychotherapy is on par with the effects of psychotropic medication [1]. Psychotherapy is known to modulate stress responses and consequentially lover the excretion of adrenaline and cortisol [2]. Normalising the stress responses can, in turn, lead to reduced release of skin neuropeptides and thus raise the threshold for chronic spontaneous urticaria flareups. With our patient, irrational beliefs and cognitive distortions regarding the memory of the traumatic event were responsible for the intense emotional distress. It is safe to assume that this led to the development of the chronic spontaneous urticaria and periodic exacerbations as emotional stress repeated and got more severe. Physiological connections and interdependence of her body and her mental state led to the development of a somatic disease in the form of urticaria. Those same connections enabled the psychiatrist to successfully administer the taking-therapy cure that led to the satisfactory remission of both symptoms of GAD and urticaria. As an approach to human health and wellbeing inevitably evolves and becomes more holistic, psychiatry doctrine and psychotherapy interventions gain more traction and become an integral part of treating and curing diseases of the body and soul.