Atopic dermatitis in infants: a psychosomatic approach

Abstracts

A pele é a nossa fronteira com o mundo, fazendo trocas e contato com o meio ambiente. Sendo assim, não seria ela capaz de sinalizar, através de suas alterações, o nosso anseio pelo outro, a necessidade de "trocas afetivas"? Os autores apresentam a observação da evolução clínica e emocional de uma criança de 2 anos de idade, portadora de dermatite atópica, participante do Grupo de Apoio à Dermatite Atópica, com sua formação pioneira interdisciplinar, durante 9 meses de acompanhamento da criança no grupo. Como resultados, foram evidenciadas mudanças no comportamento da criança frente ao livre brincar, uma interação social mais concreta, com diminuição da irritabilidade e agressividade e, principalmente, maior e melhor vinculação entre a dupla mãe-criança, assim como marcada melhora do quadro dermatológico. Conclui-se que a abrangência, proporcionada pelo atendimento interdisciplinar, possibilita uma intervenção precoce na relação mãe-criança, podendo ser considerada como uma estratégia de prevenção em saúde mental materno-infantil, evitando possíveis patologias futuras.

Dermatite atópica; psicodermatologia; grupoterapia

CASE REPORT

Atopic dermatitis in infants: a psychosomatic approach

Dermatitis atópica en el niño: una visión psicosomática

Paulo T. L. Fontes Neto^I; Magda B. Weber^II; Suzana D. Fortes^III; Tânia F. Cestari^IV

^ISpecialist in Psychiatrist, Fundação Faculdade Federal de Ciências Médicas de Porto Alegre (FFFCMPA), Porto Alegre, RS, Brazil. MSc student, Graduate Program in Medical Sciences: Pediatrics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil

^IIDermatologist. Professor. MSc in Dermatology, Universidade Luterana do Brasil (ULBRA), Canoas, RS, Brazil

^IIIPsychiatrist, UFRGS, Porto Alegre, RS, Brazil. Psychoanalyst, Sociedade Psicanalítica de Porto Alegre (SPPA), Porto Alegre, RS, Brazil. PhD in Public Health, University of Illinois, Chicago, USA. Fellow in Child and Adolescent Psychiatry, Medical College of Wisconsin, USA

^IVDermatologist; Professor. PhD in Dermatology, UFRGS, Porto Alegre, RS, Brazil

^{Correspondence}

ABSTRACT

Considering that the skin is our border with the world, allowing us to make contact and exchanges with the environment, could skin alterations be seen as expressions of our yearning for the other or our need for "affective exchanges"? The authors report an observation of the clinical and emotional evolution of a baby with atopic dermatitis who took part in the support group of atopic dermatitis during nine moths. The results showed changes in the child's behavior: he could play freely, developed more concrete social interactions, decreased aggressiveness and irritability, presented a better interaction with his mother, as well as showed a considerable improvement in the status of the dermatological disease. The authors conclude that the covering reached by the interdisciplinary approach provided by the group enables an early intervention in the mother-baby relation, which could be considered as a mother-child mental health preventive strategy, avoiding future pathologies.

Keywords: Atopic dermatitis, psychodermatology, group therapy

RESUMEN

La piel es nuestra frontera con el mundo, realizando cambios y contacto con el entorno. Así, ¿no sería ella capaz de señalar, a través de sus alteraciones, nuestro anhelo por el otro, la necesidad de "cambios afectivos"? Los autores presentan la observación de la evolución clínica y emocional de un niño de 2 años de edad, portadora de dermatitis atópica, participante del Grupo de Apoyo a la Dermatitis Atópica, con su formación innovadora interdisciplinaria, durante 9 meses de acompañamiento del niño en el grupo. Como resultados, se evidenciaron cambios en el comportamiento del niño frente al libre jugar, una interacción social más concreta, con la disminución de la irritabilidad y agresividad y, principalmente, mayor y mejor vinculación entre la dupla madre-niño, así como una acentuada mejora en el cuadro dermatológico. Se concluye que la abarcadura, proporcionada por la atención interdisciplinaria, posibilita una intervención precoz en la relación madre-niño, pudiendo considerarse como una estrategia de prevención en salud mental materno-infantil, evitando posibles patologías futuras.

Palabras clave: Dermatitis atópica, psicodermagología, grupoterapia.

INTRODUCTION

"We all tend to somatize every time internal or external circumstances overpass our usual psychological ways of resistance." (Joyce McDougall¹)

Anguish is considered the main origin of all of our symptoms. The major issue is: what symptom would better represent an attempt of curing oneself? Each individual can internally create a way of presenting such an attempt: some may develop neuroses, others deliriums or even psychosomatic diseases¹.

Atopic dermatitis (AD) is a kind of dermatosis typically found among children. The major symptom is itching, which may vary in intensity. The disease presents a chronic course; intensity, and discomfort of symptoms cause serious implications in the life of patients and their families².

The incidence of such atopy has been increasing over the last decades, specially in industrialized countries, maybe due to external factors, which foster lesions severity and consequently bring some difficulties to adaptation to school, social and family life^2-5.

The opinion of dermatologists concerning the presence of a psychic component in the atopic dermatitis has a history of different opinions, from considering a psychosomatic mechanism as the major factor in the disease up to avoiding the psychological component as a factor related to this multifaceted syndrome⁶.

Psychiatric understanding of the psychosomatic diseases is very complex, objectively they can be seen as a difficulty in symbolizing and verbalizing feelings¹.

Within the complex field of psychosomatic manifestations, attachment shows to be in the origin of such diseases. Bowlby⁷ highlighted the importance of the bond between infants and mothers, who must satisfy the child's biological needs. Frustrating such necessities may cause evident pathologies, which will later be identified in the analytical processes of adult individuals. The present study highlights that the first relationships help to establish a way of functioning, the Internal Functional Model. Children with a safe model of attachment in their history are more likely to develop positive expectations towards the world, believing their needs can be satisfied; those with a not so safe model may develop less positive expectations towards the world.

Among the manifestations that take place in the development of the bond between mother and child, the need for caring and touching is the most evident one. The importance of the skin contact is very well demonstrated in the work by René Spitz, who compared two groups of babies⁸. The authors concluded that the child needs to be stimulated in order to have a normal development and that deprivation of physical contact for a prolonged time may even cause death. The author named such a type of privation of "affective deprivation" and suggests that the most efficient way of fulfilling this need is by providing physical contact⁸.

Another important issue, concerning specifically to pregnancy, is raised by Cramer⁹. He claims that the mother-to-be builds an idealized image of her baby, which she calls "imaginary baby", as well as she has in her mind images of other babies, which are different from the real one she does not know yet. However, this author emphasizes that when the infant does not correspond to the mother's expectations due to some kind of disease, she can be so disappointed that she can not respond to the child's necessities, thus damaging the development of the initial bond - the attachment⁹.

As to the therapeutic approaches currently followed, many of them have been tried, which can be associated or not to the conventional treatments. Psychoanalytical, behavioral-cognitive and educational and group therapy approaches have been proposed, but none is considered definitive.

This article reports a case of a child that attends a group for atopic dermatitis support and research (GADA) at Hospital de Clínicas de Porto Alegre, southern Brazil.

GADA meetings take place at every 15 days, at the weekends. They are split in two different moments: with and without the presence of their mothers. This group is pioneer in the way how it is composed: it counts on the presence of dermatologists, psychiatrists and medical students; it follows a combination of approaches as emotional and educational support group therapy and behavioral techniques of symptoms reduction.

CASE REPORT

A 2-year-old male patient was referred to GADA by the Dermatology Outpatient Service at HCPA. His mother, 22 years-old, and father, 23 years-old, had a casual relationship from which the baby was generated. His father left his mother in the second week of gestation, when she found shelter with her family with whom she lives until now.

The boy has atopic dermatitis and ectodermic dysplasia, presenting an ugly appearance, with several pruritic and eczematous lesions and with a fetid stench.

The patient's mother says that gestation was smooth in what concerned her physical status, however, it was very complicated emotionally. She also confessed the she always imagined that her baby would resemble her. Moreover, she had a strong desire to prove the child's paternity through a DNA testing. The baby was born through normal delivery, at term, and looked much like his father. Since he was born, he was frequently ill and required frequent medical care. At the age of 5 months he was diagnosed as having ectodermic dysplasia, which caused even more pain to his mother, as she thought she had generated an ill child. The child's neuropsychomotor development was normal, with some disorders related to repeated infections. He used to lie on the cold floor in order to find some coldness, his mother said he wanted to play with other children, but he did not manage to do so because of his shy and aggressive behavior.

Initial psychiatric assessment

The boy presented a messy appearance, with spread and infected skin lesions that had a fetid stench. He was lucid, anxious and had low tolerance to frustration. He had an increased irritability and he presented himself in an aggressive and shy behavior. It was very difficult to understand him, his voice tone was low and he did not look straight to the interlocutor, showing almost no interest in objects and games. He failed in recognizing/acknowledging his mother, was withdrawn and had a few expression of affect, with no social interaction. He had atopic dermatitis and a delay in the development of his motor abilities when compared to other children his age.

Evolution

When he arrived at GADA, he did not interact very much and remained distant from the group. In the presence of a factor that caused anxiety, he scratched himself in a self-aggressive manner and remained withdrawn from the group.

The patient ignored his personal therapist and remained in isolation. After some meetings and with the arrival of other patients in the group, the patient got closer to his therapist and partners, and attempted to make some exchanges.

The mother-child relationship called our attention in this case. She did not show to have empathy with him and did not hide her difficulty in dealing with her child. She was not able to hold him adequately or to fulfill his demands. He invested in some trials of asking help to his mother, but ended up giving up, probably because he received no response.

After 9 months attending the meetings, he presented a completely different behavior, being participative and adequate during the interaction activities. His relationship with his therapist and other patients was easier, he was developing his supportive competences.¹⁰ and recovering from the dermatologic lesions. He was beginning to recover a lost time, and in a short time he was passing through all phases of playing, as if he were confident to perform them.¹¹

DISCUSSION

In the case reported here, the proximity with the therapist worked as a support, he always requested her presence while playing. The next step was then to indirectly approach his mother. Through secondary investments, we tried to mobilize the mother to repeat some forms of handling the child, thus strengthening her maternal capacity. The mother-child relationship started to get closer when the lesions improved, she started to look attentively to her son and to touch his skin.

The main objective of this approach was to invest in the warm relationship between mother and child, showing to her that she was able to build a natural bond that could minimize her child's anguish⁷.

The clinical course of the atopic dermatitis is influenced by a series of genetic, biologic and psychological factors¹². It is this complex interaction, associated to a stressor, that originates the eczematous outburst. When the dermatologic conditions worsen, there is a reduction of the stress continence limit and, as a consequence, there is back-nourishing of lesions¹³.

The patient we followed in this paper was rejected by his mother, possibly because of a confrontation between the fantasized baby and the real one⁹. Moreover, the boy had many lesions on his skin, which prevented his mother from touching him. Panconese & Hautmann¹⁴ consider that children with atopic dermatitis are sometimes rejected by their parents because of the skin lesions: they can not touch their kids. This situation can be circular, creating a conflict between mother and child that will worsen the clinical skin and emotional conditions.

The case reported here shows a child and his request for help, simbolized by a psychosomatic manifestation in the form of atopic dermatitis. It illustrates how an intense somatic eclosion can represent a conflict that exceeds the usual tolerance capacity of a child.

A dermatologic and psychiatric approach of children with atopic dermatitis and their parents makes possible to increment the therapeutic resources, the acknowledgement and management of emotional factors involved in an attempt to understand the psychodynamics understanding of the disease.

An interdisciplinary intervention enables an early intervention in the relationship between child and mother, which can be considered a strategy of mental child and mother health prevention, avoiding possible pathologies in the future.

Longitudinal controlled studies are required, following defined methodologies, with larger groups of children in the same age, provided that we have not found in the literature other studies with similar interventions in 2-year-old children with atopic dermatitis. This would provide further conclusions.

REFERENCES

Received March 22, 2005.

Accepted July 26, 2005.

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Publication Dates

• Publication in this collection
  09 Nov 2006
• Date of issue
  Apr 2006

History

• Received
  22 Mar 2005
• Accepted
  26 July 2005