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The Schema Therapy Bulletin

The Official Publication of the International Society of Schema Therapy

Announcement: Inspire 2016 International Society of Schema Therapy Conference Vienna, Austria 

The ISST board is very pleased to announce the 2016 Conference “What is it With Modes” to be held in Vienna, Austria on June 30 - July 2 2016 at the Messe Wien Exhibition & Congress Center.

The conference will be the focal point of  of schema therapy practice and research and will host a number of key note speakers from around the world. 

Details and registration details will be available soon: INSPIRE 2016

Schema Therapy in Dermatology

Dr Alexandra Mizara, BA(Hons), MSc, CPsychol, DPsych, UK

Skin disease is common, affecting approximately one quarter to one third of the UK population and represents the most frequent reason for people to consult their general practitioner1. Despite their prevalence, the majority of dermatological conditions are often considered as ‘cosmetic’ or ‘non-life-threatening’ by the general public and the profound psychosocial impact that skin disease may exert on those affected is not often recognized.2 The role of psychological (di)stress in the onset, exacerbation and perpetuation of symptoms in skin diseases such as psoriasis, atopic eczema, acne, vitiligo, alopecia is now well established.

The experience of the adult dermatology patient varies a lot. Some individuals may be relatively unaffected by widespread disease, while others can be devastated by a relatively small lesion.3 People with skin conditions often report having difficulties with their interpersonal relationships such as forming or maintaining intimate relationships due to fear of rejection. Social situations are also frequently perceived and cited as problematic. Having a skin condition adversely affects quality of life. Avoidance of activities where skin is revealed such as using the gym, holidaying in climates where minimal clothing is required or other leisure activities is common. Frequent hospital visits and time consuming medical treatments have also been identified as key concerns for dermatology patients.4

As well as affecting psychological and social functioning, there is significant psychiatric morbidity associated with skin disease. It is well established that anxiety and/or depression affects at least 30% of dermatology patients and when untreated impacts adversely on the outcome of standard dermatological therapies.5 Skin conditions such as psoriasis, atopic eczema, alopecia areata, acne and chronic idiopathic urticaria are frequently associated with major psychiatric disorders and there is strong stress-related neuroimmunomodulation that may affect the course of the disease. Some of the most common psychiatric disorders present in these clinical populations are: major depression, obsessive-compulsive disorder, social anxiety, body dysmorphic disorder, eating disorders and personality disorders such as borderline, narcissism and histrionic.

Exploration of the psychological and social factors that make a person more emotionally vulnerable and contribute to poor adaptive coping with relation to skin conditions has led to increasing research in  the area of psychodermatology. The presence of charactereological profiles among people with skin conditions has been supported by a few well controlled research studies which found that certain dermatology patients exhibit higher levels of alexithymia, neuroticism and difficulty in managing anger and hostility.5 For example, Picardi and colleagues (2005) suggested that alexithymia is  often observed in people with psoriasis and might increase susceptibility to exacerbations of diffuse plaque psoriasis, possibly through impaired emotional regulation.7

The role of maladaptive schemas in our understanding of dermatology patients is relatively novel. In a pivotal study, the presence of maladaptive schemas and their links to psychological distress in patients with psoriasis and atopic eczema were examined. Findings suggested that Early Maladaptive Schemas (EMS) are associated with psychological distress in patients with psoriasis and atopic eczema. Six predominant EMS were identified: emotional deprivation, social isolation, defectiveness ⁄shame, failure, vulnerability to harm and subjugation. Two EMS predicted psychological distress: vulnerability to harm and defectiveness⁄shame predicted anxiety and vulnerability to harm and social isolation predicted depression.8 A recent study, investigating the presence of EMS and parenting experiences among individuals with early and late onset atopic dermatitis, demonstrated that people with atopic dermatitis present with a certain pattern of early parenting experiences and a schematic profile that differed them from  the control group. The pattern of early parenting experiences was linked to the development of the schematic profile.

The findings in these studies are suggestive that Schema Therapy may be relevant to the treatment of distress in people with skin conditions. Schema Therapy’s (ST)10 effectiveness in addressing complex and chronic presentations, longstanding difficulties in maintaining and achieving satisfying relationships and above all it’s compassionate and humane approach sits well with this population. In particular, schema-focused therapy has been successfully used with individuals with psoriasis, atopic eczema, acne, rosacea and urticaria pigmentosa. 

Cognitive, behavioural and experiential interventions are employed to achieve the following treatment goals: 

- to understand that the skin condition does not dictate life (choices) rather the maladaptive schemas do.

- to heal  maladaptive schemas and meet core emotional needs

- to improve relational patterns e.g. problems in personal, social lives and daily functioning. 

- to change avoidant coping, either behavioural or emotional and learn healthier ways of coping with the skin condition and other life events. 

A lot of emphasis is placed on experiential work and the therapeutic relationship as a means of behavioural and emotional change as affect has a key role in psychoneuroimmulogical nature of these skin conditions. The sessions are individually designed to meet the needs of the patient and no rigid protocol is followed but rather a framework of ST combing flexibility with standardisation is used.

Schema Therapy appears to be effective in achieving substantial change and improving adjustment in people with skin conditions. Our initial outcomes support the relevance of schema therapy for dermatology patients. Addressing maladaptive schemas in dermatology patients enables people to find more adaptive ways of coping and relating to others, and consequently less susceptible to psychological distress. Further controlled, interventional trials are needed to confirm findings in real life clinical practice and to further characterize the role of schema-focused interventions in people with skin conditions.

Referenced Articles: 

1. Williams, H.C. (1997). Dermatology. In Health Care Needs Assessment, 


2. Papadopoulos, L. (2005). Psychological therapies for dermatological   problems. In C.     

     Walker & L. Papadopoulos (Eds.), Psychodermatology: The psychological impact of skin  

      disorders. (pp. 101-115). Cambridge, UK: Cambridge University. 

3. Walker, C. (2005b). Psychodermatology in context. In C. Walker & L. Papadopoulos (Eds.), Psychodermatology: The psychological impact of skin disorders. (131-144). Cambridge, UK: Cambridge University.

4. Jowett, S., & Ryan, T. (1985). Skin disease and handicap: An analysis of the impact of skin conditions. Social Science and Medicine, 20, 425-429.

5. Picard, A., Abeni, D.,Renzi, C., Braga, M., Melchi, C.F., & Paaquini, P. (2003). Treatment outcome and incidence of psychiatric disorders in dermatologic out-patients. Journal of European Academy of Dermatology and Venereology, 17, 155-159.

6. Gupta, M.A. (2005). Psychiatric morbidity in dermatological disorders. In C. Walker & L. Papadopoulos (Eds.), Psychodermatology: The psychological impact of skin disorders. (29-43). Cambridge, UK: Cambridge University. 

7. Picardi, A., Mazzotti, E., Gaetano, P., Cattaruzza, M.D., Baliva, G., Melchi, Biondi, M., & Pasquini, P. (2005). Stress, social support, emotional regulation and exacerbation  of diffuse plaque psoriasis. Psychosomatics, 46 (6), 556-564.  

8. Mizara, A., Papadopoulos L., McBride SR.. (2012). Core beliefs and psychological distress in patients with psoriasis and atopic eczema attending secondary care: the role of schemas in chronic skin disease. British Journal of  Dermatology, 166(5), 986-93.

9. Kalaki, E. (2014). Effects of Parenting Experiences and Early Maladaptive Schemas on Adjustment to Atopic Dermatitis. Unpublished doctoral thesis.  London: London Metropolitan University.

10. Young, J., Klosko, J., & Weishaar, M.E. (2003). Schema therapy: A practitioner’s guide

      New York: Guilford.

Why Schema Therapy?

Schema therapy has been extensively researched to effectively treat a wide variety of typically treatment resistant conditions, including Borderline Personality Disorder and Narcissistic Personality Disorder. Read our summary of the latest research comparing the dramatic results of schema therapy compared to other standard models of psychotherapy.

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