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Podcast Host 1
Foreign.
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Allison Trask
Welcome to the JAPA Podcast where we explore how PAs contribute to healthcare and the practice of medicine. Today we are going to discuss a recently published JAPA review on psychodermatology. Before we get started, don't forget that listeners can earn CME after listening to the podcast. To receive your CME credit and access your certificate, you just listen to the podcast, then complete the post test and evaluation in AAPA's Learning Central. At CME AAPA access to a dermatology provider is limited. According to the NCCPA, about 4.4% of all board certified PAs practice in dermatology. The Journal of the American Academy of Dermatologists estimates that there are only four dermatologists per every 100,000Americans. Today we are joined by JAPA author who is going to empower us all to bridge that gap. Welcome Allison trask, a dermatology PA from Vermont and Society of Dermatology PA's Diplomat Fellow. Allison, welcome. We would like to get to know more about you. Can you tell us a little bit more about your journey to becoming a dermatology PA and about your experience in completing the SDPA Diplomat Fellowship program? Yeah, for sure. So I graduated from PE School in 2005, long time ago and my undergraduate was in neuroscience and psychology. So I've always had this love for bridging things. And I started off in Community Health in Denver, Colorado and found really quickly that there was both a lack of dermatology care for my patients, you know, very much underserved and needing, you know, not being able to get them into dermatology care as well as just finding for myself that a lot of these patients who were under a lot of stress and had a lot of psychosocial determinants were unfairly burdened with dermatologic disorders. And so I, you know, became more and more fascinated by this and, and over the years wanted more, wanted to dive into dermatology more. And so in 2018 I decided to go ahead and dive in fully and switched over to dermatology completely. I actually enrolled in the SDPA program before I even got a dermatology job. I just knew I really wanted to pursue this and, and figure it out. And so I, I, I did. It took a couple two years to complete and then I moved back to Community Health. I really wanted to kind of bring it all back together and I found like this space where I, you know, couldn't quite practice dermatology full time, but I couldn't quite get it all integrated and so I decided to actually go a Step further and get a doctorate in psychiatry and kind of put it all together. And at that point is when I really fully was able to kind of bring everything full circle. So yeah, that's my, that's my path. Kind of windy.
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Podcast Host 1
We've often seen that whenever we talk to all the authors on here, the different paths that are taken and it's always interesting at how, how you get to where you are. And we, we always enjoy hearing those stories. Honestly, like your, this article that we're going to discuss was so interesting to me. The article was exploring the intersection of mind and scan, A comprehensive review of psychodermatology. And it described the relationship between psychological factors and skin conditions. So I just want to know what was the inspiration specifically behind this article.
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Allison Trask
Well, you know, kind of giving you the background of my entire professional life there. But you know, basically I, I wanted to know for myself what is the current state of, you know, treatment? What is the, what is the best evidence based treatment for these conditions? And this is where my passion lied. And I just, you figured why, why not put it all down on paper and share it with others? That was really the, the impetus. But of course that I was also doing the doctoral program and, and they gave me a lot of tools to be able to put this together professionally. And so yeah, it all came together.
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Podcast Host 1
Yeah, no, it's great. So in the article you describe the three categories of psychodermatologic disorders. There's the psychophysiologic, primary psychiatric and secondary psychiatric. How should our listeners think through these different categories? And what are some examples of each of the categories?
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Allison Trask
Yeah, so my, my, I guess second passion is, is teaching. And sometimes, you know, we, I think kind of do a disservice making things too pedantic. But in this case like, you know, we, we like to group things as humans, we like to group things. It helps us to understand things. And really this is just, you know, one way to kind of put it all together. Recognizing that these are all bi directional, that mental health and physical health are in skill. Skin as and stress all interact together and that you could just as easily like all of these diseases I think can be put into some of the same categories. So I think a good practice. But, but also, you know, I don't like getting too caught up in the categories. But yeah, I mean the primary psychiatric disorders are primarily mental health disorders. Right? They're, they're the things that's, the primary disorder is, is mental health. So that's like your delusions of parasitosis and your skin Picking disorders and your know, somatization disorders etc, and then disorders that are, you know, the, the skin disease is actually the, the primary and the, the psychiatric component is secondary. Those are secondary psychiatric disorders. It's just as it sounds, right. And so many things can go in there. Right? I, I feel like this list could go on and on, but, you know, often we think about acne and psoriasis and eczema, but so many skin disorders cause psychiatric distress. So again, that, that list can go on. And when you talk about stress and, and anything systemic stress, I always tell patients, like, stress is rarely the cause, but it makes everything worse. And so, yeah, psycho, psychophysiologic disorders are, you know, basically anything that stress makes worse, which is just about everything. So certainly there are disorders that I think we can all identify that present very prominently in people who have like, acute stress responses. Think about hives as like a primary example of that.
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Podcast Host 2
Yes, indeed, Allison. And talking about stress, let's expand on the relationship between stress and the skin. A lot of people tend to forget how stress can also have big effects on your skin. So we all learn that the skin is a barrier to the threat of external pathogens. You mentioned that in your article. But we often forget that the skin also shares the same embryonic origin as a nervous system. The immune and neuroendocrine systems also interact with the skin. How does stress itself impact the skin?
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Allison Trask
Yeah, you know, it's helpful to reframe the skin. You know, a lot of times we think of the skin as this static thing. It's just a covering, Right. It's just, it's just protecting us from the outside. And really it's actually this living, permeable membrane that's, you know, it's very much like the gut. So, you know, a lot of times we can kind of appreciate the complexity of the gut. The skin is just a continuation of that. Right. And when we start to realize that this skin is this living, permeable membrane rather than something static, it makes a lot more sense. You know, it has, it's innervated, it has a nervous system. You know, it is a very much primary immune organ, you know, in that it's. It the first thing that oftentimes that we encounter when we encounter the external world. And so it is very much a dynamic organ, you know, that is responsible for, you know, barrier management as well as immune system and nervous system, et cetera. And that stress really impacts how our bodies are homeostasis. Right. So, you know, cortisol and catecholamines all affect our barrier function, so they reduce lipid synthesis. So when we are stressed, cortisol rises, lipid synthesis declines, and our skin actually dries out, so it cannot perform its barrier function. So you can imagine how that might affect somebody with eczema. Stress increases, certainly chronic stress, especially, especially pro inflammatory signaling and dysregulation, which is directly impacting things like psoriasis, eczema, urticaria, et cetera. So yeah, there's so many. I, I could, I feel like I could go. This is like my favorite part of talking about psychodermatology is all of the, you know, the how. How everything actually interacts and how it actually does this. Right. It's. It seems obvious to me that it does. But then how. And these are the ways. Right. It's really interesting.
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Podcast Host 2
Thank you for this reminder of all the other factors that affects the skin. How does this interaction between psychiatry and dermatology? Let's say I'm in a South Florida, in a state where most dermatology practice focus on the aesthetic part of it. So you tend to forget about diseases and how many other ways skin can be affected, how to treat some skin conditions. I can tell you it's not easy to find what we call the true clinical dermatology, especially where I am from. So I like that this reminder and this class in dermatology that you're just giving us right now.
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Allison Trask
Oh, good.
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Podcast Host 2
Yeah, I can say people tend to forget that dermatology is a whole specialty. It's diseases. It's not just Botox and fillers. So when, when you think about dermatology, in my world where I am, it's Botox and fillers. Okay.
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Allison Trask
I've been seeing, I trained with a Mohs surgeon and so I did, you know, almost entirely, entirely medical dermatology. But even as an PA student, I went to Emory in Atlanta and went to Grady for my dermatology rotation. And I'll tell you, there was, it was not about, you know, there was no cosmetic dermatology there. It was all. It was very, you know, it was very formative for me. And of course now in Vermont, you know, the, the, yeah, the access to cosmetic dermatology is very low. Fortunately, the access to medical dermatology is much better.
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Podcast Host 2
But that's good. Yeah, I did my rotation in clinical dermatology as well as a pa and I was fortunate, but I chose that and most surgery and all that. So I agree with you. So upon seeing this podcast title, many of us likely leapt to thinking about body focused, repetitive behaviors referred as bfrb, like skin pricking, hair pulling, nail picking, nail biting. What are some triggers for these behaviors and are there any treatment options?
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Allison Trask
Yeah, so this is the one I think, you know, it's so common, right. I think I had in my article. 80% of people have some sort of body focused repetitive behavior. So most people kind of like appreciate or what this means. Of course it only becomes pathologic in a much smaller portion proportion of people, but it's still very common. Something like 15% of people have like an actual rises to the level of pathology. So that's, that's a lot currently. It's basically, it's classed as an obsessive compulsive disorder. Interestingly, it kind of acts more like an addiction. There's a lot of reinforcement that happens for people who pick. There's. And I think that that's often sort of missed. It's. It's forgotten that when you or not just pick. Right. Any. Any body focus. Repetitive behavior. I guess skin. I'm biased towards skin picking because it's so common. But. And often why people come see me specifically. But, but often, you know, these, these behaviors are triggered by feelings of anxiety, of boredom, of tension. Things that you often. And there's some pleasure, there's some sort of release of that tension when they engage in these behaviors. And I think recognizing, you know, what people get out of it, even though it causes a lot of distress. I mean, a lot of times people leave scars on their body and they're not happy about doing it. They don't want to be doing it. But there is, you know, there's a part of the behavior that is reinforcing. And I think if we don't address that piece of it, then you're going to miss. You're going to miss the boat. So certainly there are treatments for that compulsive aspect of repetitive behaviors. I think it's important to recognize. I have plenty of patients who also have adhd. They're on stimulants. And you know, that can increase these kind of compulsive behaviors as well as OCD and treating those with, you know, SSRIs. Often higher doses of SSRIs can be really, really helpful for them. You know, I think it's important to bring in that component, that behavioral component and use behavioral treatments as well. I think when, when, when we just try and use medications. Whether, you know, NAC is really popular, of course for repetitive behaviors and again for that compulsive p. Can be helpful that, that just like mindless unconscious, compulsive picking that can be really helpful in patients who have maybe some mild dementia. You know, their family members are like, what can I do? But a lot of times we have to integrate behavioral treatments as well. You know, I think habit reversal therapy is one of the most studied and has a lot of evidence behind it. It's actually really a very simple thing to put into practice if you. If. If you are interested in trying to integrate some behavioral treatments into practice. So I think it can be, you know, modified to regular clinic practice pretty easily as well.
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Podcast Host 2
Great. We now know that acne vulgaris is an example of repsychophysiologic disorder, meaning that it is a skin condition that is reactive to stress and emotional states. However, it can also cause psychological distress. What is. And I can see that in teenagers. How can that be? So what is your approach when you see patients who have psychological distress as a result of their skin condition?
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Allison Trask
And that's everyone. So. So I think, you know, this is probably a little bit more intuitive for most people. It's. It's kind of our bread and butter in. In primary care. Right. You know, being able to use motivational, interviewing and reflective statements, showing empathy, asking questions about people's lives. I think it's maybe a little bit harder in dermatology. A lot of times they're quicker visits, and maybe there isn't that sort of relational component as much. And I think sometimes people are afraid that it's going to take a lot of time if they confront the emotional aspect of people's disorders, when I think it's actually the opposite. I think, you know, when you acknowledge that somebody is suffering that a lot of times it diffuses things that can otherwise just kind of spiral out of control. So really, I think, you know, just being, you know, acknowledging that people are human and that, you know, you can imagine. I actually will share personally. After I wrote this article, I came down with alopecia areata. I understand, you know, how distressing it can be to go through something, you know, that affects you very physically and very publicly. It's one thing to have high blood pressure. Nobody can see it. It's another thing to have acne on your face. And we know that people treat people with acne differently. They don't necessarily get the job or they think that they're, you know, going to be less capable. There's studies that, you know, show these outcomes. So it's. It's a, you know, it's real and it's hard. And I think just acknowledging that and Validating that for people can go a long way.
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Podcast Host 1
Thank you for that. Yeah, I. I'm sitting here, I'm thinking about all the, like, all the questions that I have for you and just how the. How the. I guess the way that dermatology as I know it, I mean, from an emergency medicine PA that's. I have a limited knowledge of dermatology. Right. But I also think about, like, just in general practice, how many dermatologists, dermatology providers, are really incorporating the. The psychodermatology aspect into their practice? I'd be curious to kind of really find that out as far as. Is that a common practice, or is it really something that is kind of avoided by a lot of practitioners? Because I think that can sometimes be a really difficult conversation. But, you know, I don't know that if you. If you know all that information or not, but I just think it would be a really good question.
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Allison Trask
I know. I mean, you know, I know my experience. Right. I don't know the data, but I think. I think many dermatologists and dermatology PAs are attuned to the emotional aspects of dermatology just because it is. So, again, every single one of my patients comes in distressed. Unless they're coming in for a skin check with nothing on them, they're distressed by what it is that is happening. It's very. It's very in their face. So I think. I think dermatologists tend to be the type of people who are drawn to that. And. And so there. I think there's a large portion of dermatologists who are actually, you know, a little bit psychologists and psychiatrists as well. There is certainly, I know surgeons who maybe tend towards less and intermittent. Okay, here, please just go see Allison. I. She. She can help you. But I think, yeah, I think it is more common. The problem, as you said, is just getting people into care can be quite a challenge. And that was my experience as a primary care provider is my patients, you know, I couldn't get them in to see a dermatologist, and if I could, they ended up back to me the very next visit for various reasons. And, you know, I. Another area, I guess, another niche that I have is just, I guess being comfortable with patients with severe pervasive mental illness in general, being comfortable with that spectrum, which is, you know, sometimes, I think, a challenge for many providers. They. They don't understand what they're dealing with and the myriad of medications people can be taking and kind of the impact that that can have. And so sometimes it's a very Innocent thing that they, people just don't know. They're not used to working with those populations. And so I, I, I feel like I probably fill that gap for the entire state of Vermont. I hear that Dartmouth, which is one of our close kind of referral areas, catchment areas, has an integrated dermatology clinic. And I'm very excited to go check that out. But yeah, it's not common to have as much integration as I try to offer.
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Podcast Host 1
Thanks, Allison. So, you know, we only have a few more minutes and I have a couple more questions for you. So what is your key takeaway when you have a suspicion for a psychodermatologic disorder?
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Allison Trask
Well, I think emotional distress can definitely amplify symptoms and I think that is what really can kind of set us or kind of derail us. My key takeaway is just don't make the mistake of dismissing patients concerns just because they present with psychiatric complexity. And notice your own internal responses to dysregulated behavior. And just practicing calm and centered and trying to avoid spiraling with the patient. Make sure that they get the workup that they need, which might be referrals. You know, sometimes I think people forget that there are things that we can do. And so just getting people, you know, getting them the care that they need and, and listening and caring. Right,
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Podcast Host 1
Very true, very true. So what do you think is the biggest challenge in caring for patients with psychodermatologic disorders?
- [20:32]
Allison Trask
Oh boy. You know, aside from, as we said, access and time, I, you know, I'll just put a plug in for learning motivational and interviewing. It was one of the things that for me changed my practice the most and I think just can really help any provider with probably any, any level of care. But especially when you're dealing with high emotional stakes, I think motivational interviewing can be really helpful. Yeah. And just recognizing that when, because resources are so low, sometimes you have to, you know, utilize your, your apps for psychiat like either CBT apps and self guided CBT and just helping patients get the care that they need. Sometimes it's really hard. We didn't even talk about mental health care, but you know, like, yeah, it's hard to get into dermatology, it's hard to get into mental health. And yeah, getting all of these things together is really a challenge. I agree.
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Podcast Host 2
And I like that you guys use interventional, I mean motivational interviewing in that space as well. I would never think that. But I guess anytime a patient is faced with stigma or any type of bias, it works well. So that makes sense. This has been a very interesting talk. Allison, thank you for joining us. Before we wrap up, do you have any final thoughts for our listeners?
- [21:49]
Allison Trask
Oh, well, thank you, guys. It's been fun. I had a great discussion. Just, you know, the brain and the skin are in constant conversation, and when that conversation becomes dysregulated, it shows up clinically. I think we can say that about a lot of things. But this skin is, you know, it's right there. So pay attention. Yeah. Thanks, guys.
- [22:09]
Podcast Host 2
Great. Thank you. And to our listeners, don't forget, listeners can now earn CME by listening to the podcast. To receive your CME credit and access your certificate, you just listen to the podcast, then complete the post test and evaluation in AAPA's learning central@cme aapa.org and until next time, it.