Shifting the Script: How Inner Dialogue Influences Psoriasis Progress

Mr. Quigley:
This is On the Frontlines of Psoriasis on ReachMD. I’m Ryan Quigley, and today I’m joined by my colleague, Dr. Michael Greenberg, a dermatologist at the Illinois Dermatology Institute, to discuss how patients’ inner dialogue can affect their progress in psoriasis.

Dr. Greenberg, thanks so much for doing this. It’s great to see you.

Dr. Greenberg:
Well, thank you, Ryan. And let’s go right to Michael. Stop the doctor because we’re talking about human patients today, so let’s humanize this conversation.

Mr. Quigley:
Perfect. I love it. Well, thank you, Michael. It’s great to have you on.

To start us off, what role does a patient’s inner dialogue play in their perception and management of psoriasis, and really any dermatological condition?

Dr. Greenberg:
Let’s talk about what inner dialogue means. An inner dialogue is that conversation that we have in our head constantly from the moment we wake up to the moment we go to sleep. It’s telling us we’re either good or bad or are worthless. We all have it, whether you deny it or not. It’s that little voice that speaks to you.

There’s two inner dialogues. The one inner dialogue that says, “Hey, don’t go up on the roof because there’s no guardrail there,” that’s an okay dialogue. It’s the same one that says, “Hey, don’t start vaping. Don’t do drugs.” Listen to it. But we have another dialogue inside that always seems to be negative. So with psoriasis patients specifically, that dialogue may sound like, “I’m disgusting. I’m ugly. I’m untouchable. I’m unlovable.” These are things that play in these patients’ minds that they really don’t tell us unless we explore it with them.

Now, what do you do about this? Well, the first thing is you need to expose that, and if you’re going to do that, you need to make sure that you have some emotional contact with the patient, because you’re going to get some tears on this. So you can’t just rush into a room for four minutes and say, “Oh, hi. How’s your psoriasis? Oh, it’s not so bad? Bye,” and out of the room. You’ve got to sit down and actually connect with the patient. The question you ask is, “How do you feel?” And they’ll say, “I feel disgusting.” And that’s when you turn and say, “Ah, so that’s your inner dialogue that we all have. You’re not disgusting at all. You happen to be a lovely person,” or whatever you want to fill in there, “and you happen to have psoriasis.”

But what does that inner dialogue do? What does that unhappiness do to patients? Well, number one, it makes them give up on their treatment very often. And the thing is, this dialogue goes on day after day after day. It’s nothing that you can just solve with one visit with the patient. They have to work on it every day. And sometimes I will make them do things that may sound very silly, but they work. I’ll make them go into a bathroom, look at their psoriasis and speak into the mirror and say, “You’re beautiful. You’re fine. You’re awesome.”

Mr. Quigley:
Now, something I want to ask you from a clinician’s perspective is, when you have a patient who is not quitting treatment, and they’re continuing to progress and things seem to be going okay, but they wear a mask, and they still have some severe cases of that negative self-talk and that inner dialogue, how do you identify patients like that? And how can you help them work through that when it’s a little bit trickier to spot that they’re dealing with those inner thoughts?

Dr. Greenberg:
Well, first of all, it depends on how much psychologically this is affecting them. I mean, this approach is not therapy. So, for instance, I might suggest that certain patients see a therapist about this, about their feelings, and go deeper into this. I can’t do that in the office, and I don’t think we should be doing that as dermatologists necessarily. We can offer this type of advice.

But, for instance, I see it in some psoriasis patients—I see it more in acne patients—a severe depression that comes on people. That needs to be handled clinically by another medical professional and not by us in the office, but I think it’s important to be able to suggest that and open that doorway for patients.

We don’t often think about that. We’re very busy giving our treatments—biologics, steroids—but we need to take a look at those patients who, even though we go through this process with them, they’re still depressed or they’re still upset, and we need to acknowledge that the kind of information that I’m giving them as a clinician may not be enough. So there are professionals—psychologists, therapists, psychiatrists—the patients need to go to, but we need to make that referral. We need to suggest to a patient, “Look, I see how depressed you are. That really concerns me. I want you to see a professional on the outside because dealing with this is more important than just clearing a rash.”

Mr. Quigley:
Thank you for that, Michael.

For those just tuning in, you’re listening to On the Frontlines of Psoriasis on ReachMD. I’m Ryan Quigley, and I’m speaking with Dr. Michael Greenberg about how patients’ inner dialogue can influence their engagement in psoriasis care.

So, Michael, I do want to shift gears a little bit more. So, when you’re working with patients who are dealing with this self-dialogue and this negative self-talk, how do you normalize help-seeking for mental and emotional support? As a clinician, do you have avenues, or do you direct patients to a certain place to get help for these things? Do you kind of have that on, for lack of better phrasing, speed dial in order to get these patients connected with further help?

Dr. Greenberg:
Yes, I have certain clinicians that I will refer to. But let’s go back one step before we do that. The first step is to engage emotionally with the patient, not to stay professionally distant, and admit that you have negative self-talk too.

I do this with patients. I explain I’ve always had a weight issue my whole life, and I lost a whole bunch of weight last year, but when I look in the mirror, I don’t see the thinner guy that I am. I always see the bigger guy. And when you tell patients that you have it too, you’re inducing them more to go for help, and then I’m able to give them practitioners that are on my speed dial or talk to them about if they have their own therapists. It’s pretty amazing when you become intimate with a patient and talk about your own negative self-talk how they respond and how it yields better patient outcomes.

Mr. Quigley:
Now, Michael, when it comes to these patients who are dealing with this negative self-talk, is it encouraging to you and other dermatology specialists out there to see that mental health is kind of at the forefront right now? People are a lot more open to talking about it. Does it make your jobs easier to be able to talk about this more openly with patients now as opposed to maybe 20, 30, or 40 years ago? It feels like back then people may have had their guards up a little bit more.

Dr. Greenberg:
Absolutely, Ryan. The problem comes in, though, in so many of our practices we have a manager that says we can spend 10 minutes with a patient. That’s where the problem is because many dermatologists don’t think they can handle that type of issue within a short period of time. That’s not true. It doesn’t take more than a couple minutes to really say to a patient how you feel and that they really look okay. That’s the real issue here. Yes, you’re absolutely right—mental health has become acceptable to talk about, but we need to have the training in our residency programs, and we need to take the time in our practices to do it. That’s key.

Mr. Quigley:
Now, as we approach the end of our program, Michael, I do want to ask you, what other key takeaways would you like to share with our audience? And what words of encouragement would you like to share with anyone who may be dealing with this negative self-talk as they battle psoriasis, acne, or any other dermatological conditions?

Dr. Greenberg:
The first key takeaway is that you are not this body, this mound of skin and bones here. You’re a person. You have a body. Let’s put things in an honest perspective. And your body isn’t going to be perfect, and things are going to happen to it, but you don’t have to let that affect your life, your happiness, or your peace of mind. All you have to do is understand that we’ve got great medicines. That’s the point.

We have wonderful things to help psoriasis. I’ve seen miracles with patients. I remember my first biologic where this patient was so bent over with psoriatic arthritis and psoriasis and that we started him on biologics. I saw him back for a follow up a month later. I couldn’t believe who he was. He was walking around, and he hugged me and started crying. That was for the medicine as much as for the emotional therapy that I gave him, and that’s the key takeaway. We don’t have to be locked into an old model of medicine where we are simply a body without a mind.

Mr. Quigley:
And that is a great way to end this discussion. I want to thank my guest, Dr. Michael Greenberg, my ReachMD colleague, for joining me to discuss patients’ inner dialogue and its impact on psoriasis management. Michael, it was great having you on the program. This was a wonderful talk.