Essential Psychiatry for the Aesthetic Practitioner

Evan A. Rieder, Richard G. Fried, Evan A. Rieder, Richard G. Fried

• Publisher: Wiley-Blackwell
• Year: 2021
• ISBN:
  9781119680062
• Edition: 1
• Topic: Medicine
• Subtopic: Dermatology

ESSENTIAL PSYCHIATRY FOR THE AESTHETIC PRACTITIONER

Aesthetic practice requires an understanding of human psychology, yet professionals across cosmetic medicine and related fields receive no formal training in identifying and managing psychological conditions. Essential Psychiatry for the Aesthetic Practitioner provides concise yet comprehensive guidance on approaching patient assessment, identifying common psychiatric diseases, and managing challenging situations in cosmetic practice. This much-needed guide brings together contributions by dermatologists, plastic surgeons, psychiatrists, psychologists, and other experts to help practitioners understand the role of psychology in cosmetic practice and improve interpersonal relations with their patients.

Assuming no previous background knowledge in psychiatry, the text provides cosmetic practitioners of all training and experience levels with clear guidance, real-world advice, and effective psychological tools to assist their practice. Through common clinical scenarios, readers learn to determine if a patient is a good candidate for a cosmetic procedure, enhance the patient experience, deal with difficult personalities in the cosmetic clinic, recognize obsessive compulsive and body dysmorphic disorders, and more.

• Describes how to use psychologically informed approaches and treatments for aesthetic patients
• Features easy-to-use psychological tools such as motivational interviewing, progressive muscle relaxation, guided imagery, and acceptance and commitment therapy
• Includes extensive references and practical tips for understanding the psychological implications of cosmetic treatments
• Covers cosmetic consultations for female, male, and transgender patients
• Discusses the history and psychology of beauty as well as the role of cosmetics and cosmeceuticals
• Emphasizes the importance of screening for common psychological comorbidities
• Addresses the impact of social media on self-image and its role in a growing crisis in beauty and appearance
• Highlights the need to develop new guidelines to treat rapidly evolving patient populations
• Explores how gender fluidity and variations in ethnicity are changing the approaches to aesthetic patients

Essential Psychiatry for the Aesthetic Practitioner is required reading for dermatologists, plastic surgeons, cosmetic doctors, dentists, nurses, and physician assistants and all other professionals working in aesthetic medicine.

Part I
The Basics

1
Stress, Skin, and Beauty: The Basic Science Base

Mary D. Sun¹ and Evan A. Rieder²

¹ Icahn School of Medicine at Mount Sinai, New York, NY, USA

² The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA

The relationship between stress and skin health has been documented since ancient times. Today, patients of aesthetic medical providers continue to cite psychological stress as a common precipitating factor of exacerbations in skin diseases such as acne, eczema, and psoriasis. This connection is invoked in scientific literature and frequently discussed in the lay media, with implications for general wellness practices as well as the provision of appropriate medical care. Despite this long history, the precise mechanisms through which stress impacts the skin are not yet well understood. However, recent advancements have illuminated multifactorial and bidirectional interactions between the brain, nervous system, microbiome, and skin, with key implications for the inflammatory and microbiological milieu. This area of investigation has the potential to significantly inform aesthetic care and should be regarded with great interest.

Basic Science Principles

Introduction

In this section, we provide an overview of the biological pathways believed to play a role in the relationship between psychosocial stress and the physical appearance of skin. Stress is defined as any set of aversive stimuli that provoke an associated response, which can be thought of as a coping mechanism in an individual [1, 2]. Clinically significant effects caused by stress are primarily due to impacts on the internal processes that maintain and restore skin homeostasis. We consider only psychosocial stress and do not include somatic forms of stress such as chronological aging, photoaging, and/or physical shear stress, unless the effects of somatic stressors are facilitated or potentiated by psychological stress. We further emphasize the role of chronic stress.

Our discussion occurs in the context of known neuroendocrine effects of stress. Stress increases levels of cortisol [3], known as the “fight‐or‐flight” hormone, which activates the hypothalamic‐pituitary‐adrenal (HPA) axis [4, 5]. For this reason, the HPA axis is also referred to as the central stress axis. Overactivation of the stress axis can have consequences across multiple levels of molecular function, affecting the sympathetic nervous system [4, 6], immune response [7, 8], cholinergic response [9], and microbiome [10–12]. There is also strong epidemiological evidence that the presence and exacerbation of many skin conditions such as acne [13], chronic itch [14], and psoriasis [15] have an emotional component. Progression of such skin diseases is often comorbid with negative outcomes in mental health and quality of life, suggesting a bidirectional relationship [16, 17]. Indeed, nearly one‐third of skin disorders are estimated to occur with or be worsened by psychiatric disorders and/or psychological distress [17]. The recent discovery of a fully functional, peripheral HPA axis in the skin [18] further clarifies this relationship and suggests impacts across the inflammatory and atopic responses, skin barrier dysfunction, vulnerability to cutaneous infection, and impairment of wound healing and melanogenesis. Additionally, emerging evidence from studies of the cutaneous microbiome suggests that stress can act through the “gut‐brain‐skin” axis to induce dysbiosis [19]. This gives us further insight into how lifestyle factors such as diet, personal care (hygiene), and sleep can mediate the effects of stress on skin health and appearance. This chapter summarizes these clinically important relationships and emphasizes areas of significant academic, clinical, and commercial impact.

The Central (Systemic) HPA Stress Axis

In times of psychological stress, the body mounts a neuroendocrine‐mediated immune response controlled by the sympathoadrenal and central nervous systems. Increased cytokine levels [20] activate the locus coeruleus–norepinephrine sympathetic adrenomedullary (LC‐NE/SAM) system, which secretes epinephrine and norepinephrine that further upregulate the immune response, as well as the HPA axis [21]. Notably, the results of these changes differ by stress duration. During acute stress, cytokine proliferation increases and lymphocytes are mobilized from the blood to the surface of the skin [22]. This creates conditions of sympathetic hypersensitivity and generates inflammation through the actions of various proinflammatory factors [7, 21].

Conversely, chronic stress actually suppresses the inflammatory response. The HPA axis negatively feeds back to the LC‐NE/SAM system, where secretion of corticotropin‐releasing hormone (CRH) and arginine vasopressin (AVP) [23] stimulates the release of anti‐inflammatory peptides from the anterior pituitary [21]. Adrenocorticotropic hormone (ACTH) is also released, causing the adrenal medulla to secrete cortisol and prolactin [21, 24]. Cortisol downregulates inflammatory cytokines and upregulates anti‐inflammatory factors [25], suppressing Th‐1 mediated cellular immunity in favor of Th‐2 mediated humoral immunity. At the same time, ACTH upregulates glucocorticoid response elements (GREs) and increases expression levels of anti‐inflammatory genes [26]. Under conditions of high glucocorticoids, prolactin attenuates the reactivity of the HPA axis by reducing input to the hypothalamus [27]. Therefore, the chronic stress response mobilizes resources within the body while mitigating potentially dangerous levels of inf...