Re: what causes random itching when no specific illness or iritation is present

This may lend some insight into this field of itching. Itching follows the
same nerva tracts a acute and chronic Pain. I hope this helps in your
research of the topic. Thanks for your question and please feel free to
contact me again if I may be of further assistance.


Treatment of Atopic Dermatitis:
A Comparison of Psychological and Dermatological Approaches to Relapse
Prevention
Anke Ehlers
Department of Psychiatry University of Oxford
Ulrich Stangier
Department of Psychology University of Frankfurt
Uwe Gieler
Department of Dermatology University of Marburg

ABSTRACT

A randomized controlled trial compared the effectiveness of 4 group 
treatments for atopic dermatitis, a chronic skin disorder characterized by
severe itching and eczema: dermatological educational program (DE),
autogenic training as a form of relaxation therapy (AT),
cognitive-behavioral treatment (BT), and the combined DE and BT treatments
(DEBT). BT comprised relaxation, self-control of scratching, and stress
management. Group treatments were also compared with standard medical care
(SMC). Assessments at 1-year follow-up showed that the psychological
treatments (AT, BT, and DEBT) led to significantly larger improvement in
skin condition than intensive (DE) or standard (SMC) dermatological
treatment, accompanied by significant reductions in topical steroids used.
The results corroborate preliminary reports that psychological 
interventions
are useful adjuncts to dermatological treatment in atopic dermatitis.

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The research described in this article was conducted at the Departments of
Psychology and Dermatology, University of Marburg, Germany.
We are grateful to the Bundesministerium f¸r Forschung und Technologie 
(German Minister of Research and Technology, Grant No. 0701630/3) for
funding the study.
Anke Ehlers is a Wellcome Principal Research Fellow.
We thank Kurt Hahlweg, University of Braunschweig, for training the
therapist in behavior therapy. We are very grateful to Ute Kˆhler, Johannes
Br‰uer, and Gudrun Freiling for running the groups and for their help in
patient recruitment and scheduling. We also thank Birgit Kˆhnlein and Isaac
Effendy for their dermatological assessments and Anna Pauls for data entry.
Correspondence may be addressed to Anke Ehlers, Department of Psychiatry,
University of Oxford, Warneford Hospital, Oxford, Great Britain, OX3 7JK.
Electronic mail may be sent to ehlers@vax.ox.ac.uk
Received: May 26, 1994
Revised: November 21, 1994
Accepted: November 30, 1994


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Atopic dermatitis ([AD] also called atopic eczema or neurodermatitis) is a
skin disorder characterized by severe itching and inflammation (eczema). 
Its
course is chronic or chronically relapsing. AD is among the most common 
skin
disorders. A national census of dermatological diseases in the United 
States
published in 1977 found that the disorder affects between 0.7% and 2.4% of
the population. There is a trend for further increases in prevalence (for a
review, see Schmied & Saurat, 1991 ).

The etiology of AD remains unknown (for reviews, see Faulstich & 
Williamson,
1985 ; Ruzicka, Ring, & Przybilla, 1991 ). Although there is strong 
evidence
for genetic factors, a growing body of evidence indicates a multifactorial
etiology that includes psychological factors (for a review, see Schultz
Larsen, 1991 ). These include life events (e.g., Brown, 1972 ), daily
hassles ( Schubert, 1989 ), and stressful communication with significant
others ( Ehlers, Osen, Wenninger, & Gieler, 1994 ). The hypothesis that
psychological factors play a major role in AD has a long history. Alexander
(1950) mentioned AD among the classic psychosomatic disorders, and AD is 
one
of the most frequently cited skin disorders with a suspected psychosomatic
factor ( Faulstich & Williamson, 1985 ; Whitlock, 1976 ).

The interest in psychological aspects of AD has also raised the question of
whether psychological interventions are effective in treating AD. Early
reports suggested that supportive group therapy may have beneficial effects
( Klein, 1949 ; Shoemaker, Guy, & McLaughlin, 1955 ). More recently, two
rationales have led clinicans and researchers to design psychological
interventions for AD. First, there is general agreement that exacerbations
of the disorder are related to the presence of stressors ( Brown, 1972 ;
Schubert, 1989 ; Whittkower & Russell, 1953 ). On the basis of these
observations, one could expect that relaxation training has beneficial
effects on skin condition, because it reduces the patients' stress levels.
Second, a vicious circle between itching and scratching exists in AD. The
itch is often so distressing that patients scratch themselves until they
bleed. Scratching maintains the skin lesions and, whereas it stops itching
in the short term, it also leads to a decreased itch threshold once the 
skin
starts to heal (for reviews, see Faulstich & Williamson, 1985 ; Koblenzer,
1987 ; Whitlock, 1976 ). On the basis of these observations, one would
assume that interventions designed to prevent scratching and to increase 
the
patients' coping with the distressing itch would be helpful in treating AD.

Indeed, case studies have indicated that relaxation (with or without
imagery) or biofeedback-assisted relaxation lead to improvement in skin
condition ( Gray & Lawlis, 1982 ; Haynes, Wilson, Gaff, & Britton, 1979 ;
K‰mmerer, 1987 ; Manuso, 1977 ; Schubert, 1989 ). Other case reports point
to the efficacy of hypnotic techniques, especially self-hypnosis ( Horan,
1950 ; Mirvish, 1978 ; Twerski & Naar, 1974 ).

The most commonly used intervention aimed at the reduction of scratching is
the habit reversal training originally developed by Azrin and Nunn (1973) .
Rosenbaum and Ayllon (1981) successfully used this technique to control
scratching in four patients. Habit reversal training involves
self-monitoring for early signs and situational cues of scratching and
practicing competing responses involving the hands, such as pressing the
hands firmly on the itching area or clenching the fists. Scratching 
remained
reduced at the 6-month follow-up. Similarly positive long-term results of
habit reversal combined with self-reinforcement were found in a patient
treated by Watson, Tharp, and Krisberg (1972) . Operant techniques have 
also
in some cases studies shown to be helpful in the reduction of scratching
behavior ( Allen & Harris, 1966 ; Dobes, 1977 ; Walton, 1960 ).

Some studies have used combinations of relaxation techniques, habit
reversal, and other techniques. The case reports by B‰r and Kuypers (1973)
and Ratcliff and Stein (1968) used relaxation, punishment for scratching,
and self-instructions. In more recent publications, there is a trend to
combine relaxation, imagery, habit reversal, and cognitive and behavioral
techniques designed to help patients deal with stressful life situations.
The combined treatment was successfully used in 10 cases treated by Cole,
Roth, and Sachs (1988) , in 5 cases treated by Kaschel, Miltner, 
Egenrieder,
Lischka, and Niederberger (1990) , in 3 cases treated by Horne, White, and
Varigos (1989) , and in 15 cases treated by Niebel (1990) .

Whereas these results are encouraging, several problems limited their
conclusiveness: First, with the exception of a few studies that used
single-case experimental designs, control conditions were largely missing 
so
that it cannot be ruled out that the observed effects were due to natural
fluctuations in severity or other factors such climate (AD shows seasonal
variations in severity). Second, whereas some studies report long-term
follow-up of their cases (e.g., up to 3 years in Horne et al., 1989 ), all
studies are based on very few cases so that the proportion of patients for 
whom psychological intervention is effective is unknown. Third, some of the
earlier studies were performed before international diagnostic standards
were published for AD ( Hanifin & Rajka, 1980 ). It is therefore possible
that these patients would not meet current diagnostic criteria for AD (this
particularly applies to the studies of B‰r & Kuypers, 1973 ; Dobes, 1977 ;
Ratcliff & Stein, 1968 ; Rosenbaum & Ayllon, 1981 ; and Walton, 1960 ).

In addition, to date, very few studies of AD have addressed the question of
whether psychological interventions have therapeutic benefits beyond those
of standard medical treatment. Melin, Frederiksen, Noren, and Swebelius
(1986) compared seven patients who received a combination of a self-control
program designed to reduce scratching behavior including habit-reversal
techniques and treatment with topical steroids with nine patients who
received steroids alone. The combined treatment was superior in several
measures of skin condition, itch, and scratching. Noren and Melin (1989)
replicated these results for children. Melin et al. (1986) found that
reduction of scratching was highly correlated with improvement in skin
condition in the habit reversal group. Horne, Borge, and Varigos (1992)
compared the efficacy of habit reversal training ( n = 15), self-monitoring 
with self-reinforcement and external reinforcement for reduction in
scratching ( n = 15), and standard medical treatment (waiting list, n = 
10).
Some of the assessments of severity showed greater improvement for habit
reversal than for the standard medical treatment.

Kellner (1975) reviewed an ambituous Russian study by Zhukov in which 166
patients with "various forms of neurodermatitis" (p. 1025) and 270 patients
with eczema were either assigned to 17 sessions of hypnosis, or standard
treatment (including sulfur baths). Although Zhukov reported substantially
better improvement in the hypnosis group, Kellner pointed out that these
results are not conclusive, because it remained unclear whether the 
hypnosis
and control groups were comparable, what other treatments they received, 
and
how assignments to the groups were done. A study by Brown and Bettley 
(1972)
randomly assigned 72 patients with eczema to combined psychiatric and
dermatological treatment or dermatological treatment only. Psychiatric
treatment included a combination of psychotherapy and medication for the
majority of patients. Masked dermatological assessments at 18 months did 
not
show significant differences between the groups. However, for patients with
overt emotional disturbances the additional psychiatric treatment doubled 
the rate of eczema-clear patients at follow-up. According to questionnaire
assessments, only a subgroup of 18% of patients with atopic dermatitis are
psychologically disabled ( Gieler, Ehlers, Hˆhler, & Burkhard, 1990 ).

In the most comprehensive controlled study to date, Niebel ( Niebel, 1991 ;
Niebel & Welzel, 1992 ) compared the effectiveness of psychological
interventions to an information control group. All groups received standard
medical care in addition to group sessions. The information control
condition ( n = 9; 3 sessions) was designed to increase compliance with 
skin
care. Patients received three sessions of detailed information about the
physiology of the skin, the multifactorial etiology of AD, and appropriate
dermatological treatment and skin care. The other groups received
psychological treatment of various complexities in addition to the
information. A relaxation group ( n = 16; five sessions plus two booster
sessions) received progressive muscle relaxation training. Another group ( 
n
= 16) was instructed in self-control of scratching in addition to the
relaxation training (six sessions plus two booster session). The combined
treatment group ( n = 14) received nine sesssions and two booster sessions
of information, relaxation training, self-control of scratching, and 
training in stress-management and assertiveness, as well as problem-solving
training to deal with relapses. Detailed dermatological assessments,
self-monitoring of scratching and skin care, and assessments of
self-reported distress and psychological symptoms were taken. The
preassessment-postassessment (pre-post) comparison showed significant
improvement across treatment conditions during the 3-month treatment 
period.
Although overall ANOVAs failed to show significant interactions between the
group variable and effects of treatment for most variables, within-group
analyses indicated that the psychological treatments led to significant
improvements in skin condition, scratching frequency, and self-report
measures, whereas the information control group improved significantly only
in very few measures. The most consistent treatment effects and usually the
largest effect sizes were found for the combined treatment group. A 1-year
follow-up of the psychological treatment groups showed that treatment gains
were maintained.

In summary, previous research on psychological treatment of AD has 
indicated
that relaxation training, habit reversal training, and their combination
with stress-management training may be a useful adjunct to standard 
medicaltreatment and may help prevent relapse. However, more controlled 
outcome
studies are needed that assess the efficacy of these psychological 
treatment
programs. It is especially interesting to note that although relaxation
seems to be one of the most commonly used treatment components, controlled
studies of its efficacy are, with the exception of Niebel's study ( Niebel,
1991 ), lacking. For our controlled trial, we therefore decided to include 
a
group of patients who were treated with relaxation training without habit
reversal training. The cognitive-behavioral treatment program tested in our
controlled trial combined the components used in most current studies of 
AD.
These include relaxation with imagery, self-control training of scratching
including habit reversal and cognitive techniques, and stress management. A
major focus of our stress management training was on interpersonal
stressors. The rationale lies in clinical observations and questionnaire
studies that suggest that one of the major sources of stress for AD 
patients
lies in negative interactions with significant others ( Gil et al., 1987 ;
Koblenzer, 1988 ; Spitz, 1965, pp. 122-126 ) and our study using a
standardized and reliable interactional coding system ( Ehlers et al.,
1994 ) that found that patients and their significant others showed a more
negative verbal and nonverbal communication than control dyads when 
discussing a mutual problem.

Although treatment with topical steroids is the standard treatment for AD 
in
dermatological practice, it is conceivable that it does not represent the
optimal dermatological care. Positive effects of educational programs on
compliance and treatment outcome have been demonstrated in other disorders
such as diabetes ( Mazzuca, Moormann, & Wheeler, 1986 ). It is, therefore,
conceivable that the effectiveness of dermatological treatments could be
further enhanced by educating the patients about factors influencing the
disorder and by training them in the appropriate skin care for different
skin conditions (e.g., dry skin, inflamed skin). This could lead to the
patients' enhanced self-control over the course of the disorder (e.g.,
avoiding risk factors, faster improvement by appropriate skin care).
Therefore, in our controlled trial of treatments of AD, we included a group
of patients treated with a dermatological educational program designed to
model such optimal dermatological care, as well as a group receiving the
combined dermatological and behavioral treatment program.

The controlled trial presented in this article thus included four groups:
dermatological educational program (DE), cognitive-behavioral treatment
program (BT), combined dermatological and behavioral program (DEBT), and
autogenic training as a form of relaxation therapy (AT). We expected that
the best outcome at 1-year follow-up would be found for the combined 
program
(DEBT), because this program addressed most of the factors currently known
to influence the course of AD. All groups were compared in their
effectiveness with that of standard medical care (SMC).

Method
Overview of Design
Patients were randomly assigned to the group treatments (DE, AT, BT, and
DEBT). Each treatment program consisted of 12 weekly group sessions of 1.5
to 2 hrs. Between 5 and 7 patients participated in the groups. Detailed
treatment manuals and handouts for patients summarizing the most important
aspects covered in each session are found in Stangier, Gieler, and Ehlers
(in press) . To evaluate whether the group treatments were more effective
than SMC, an additional group of patients who received SMC was recruited.
Patients participating in the group treatments also received regular SMC as
needed. Patients of the SMC group were drawn from the same outpatient 
clinic. An a priori decision was made not to include SMC patients in the
random assignment. The reason for this was that, in other studies comparing
SMC with novel additional treatment options, very high dropout rates in the
SMC group after random assignment or refusal of random allocation were
observed (Hahlweg, personal communication, November 1987; Holle, 1990 ).
This effect compromises the interpretation of group differences in that a
nonrepresentative sample for SMC is retained. Because clinical observations
show that AD patients actively seek additional treatments, there was a 
great
risk that this problem would apply to the present study if random 
assignment
to SMC was performed. Interviews with patients confirmed this impression. 
It
was assumed that a better adherence to SMC would be obtained if patients 
did
not perceive this treatment as "lack of new additional treatment." The low
dropout rates in the SMC group (discussed later) confirm this assumption.

Because AD shows seasonal variations in severity (usually the skin 
condition
is worst in the fall and winter), special attention was paid to matching 
the
different treatments to the seasons. New groups of the four group treatment
conditions were started always in the same week (beginning of January,
mid-April, or end of September). The distribution of beginning of treatment 
for patients in the SMC condition was matched. Because of the seasonal
variations, the most important assessment of outcome was taken 12 months
after the beginning of treatment. For a more complete evaluation, we also
present data taken at the end of the 12-week treatment period.

Patients
Patients with AD were recruited from the outpatient clinic of the 
Department
of Dermatology, Marburg University, Marburg, Germany. Patients were
diagnosed by trained dermatologists. They had to meet the diagnostic
criteria for AD as specified by Hanifin and Rajka (1980) ; that is, they 
had
to have at least three of four core symptoms (pruritus, typical morphology
and distribution, chronic or chronically relapsing dermatitis, personal or
family history of atopic disorders) and at least 3 of 23 additional 
symptoms
(e.g., xerosis, elevated serum immunoglobulin E [IgE], tendency toward
cutaneous infections, recurrent conjunctivitis, white dermographism). A
minimum history of the disorder of 1 year was required. Furthermore,
patients had to be between 17 and 55 years of age (actual range, 17 to 52).
Exclusion criteria for participation in the study were other acute or
chronic illnesses (including asthma bronchiale) or psychiatric disorders 
requiring treatment. Furthermore, we excluded patients who were currently
receiving psychotherapy for AD. A total of 217 patients with the probable
diagnosis AD were screened over the course of 2 years. Of these patients,
124 met the study criteria and were willing to be randomly assigned to one
of four group treatment conditions to be described. After random 
assignment,
patients received an initial individual session in which the content of the
treatment program was described in detail and further assessments were
taken. At this stage, 11 patients (8.9%) decided not to participate. These
patients were evenly distributed across treatment conditions. Thus, 113
patients started group treatment.

An additional group of patients was recruited who met the same criteria as
the group treatment patients and were comparable with them in severity of
the skin lesions. These patients received SMC. Patients were asked to
participate in regular sessions with a dermatologist and comprehensive
assessments over the course of 1 year. Twenty-five patients who met intake
criteria were recruited, of which 1 (4%) decided not to participate after
the initial session in which the nature of the program was explained in
detail.

Treatments DE
The goal of this treatment program was to inform patients about factors
influencing the disorder and to train them in appropriate skin care. Groups
were run by a dermatologist and a nurse with a background in occupational
therapy. Each session covered a different topic relevant to AD:
AD-definition, etiology, genetic factors; itching-triggers, external
treatment, medication; treatment with different external ointments 
depending
on skin condition; treatment with topical steroids, tar, and antibiotics;
allergies; light and climate; washing, skin care, clothes, cosmetics;
nutrition and diet; vocation and leisure; alternative therapies;
psychological influences on the skin.

At the beginning of each session, the dermatologist presented the relevant
information to the group and provided handouts. A group discussion in the
format of theme-centered interaction followed, in which the participants
were encouraged to share their personal experience. The dermatologist
structured and summarized the group discussions and provided corrective
information if necessary. Finally, it was discussed how each patient could
apply the new information to his or her illness. The nurse met individually 
with participants before or after the group sessions to give individualized
instructions in skin care. The goal of these instructions was to increase
compliance with skin care and to teach the patient to tailor skin care to
skin condition. The last session was dedicated to the discussion of 
problems
that patients had incurred when applying the new information.

AT
The relaxation training followed the basic stage of AT described by Luthe
and Schultz (1969) but was specifically adapted and modified for AD. Groups
were run by a clinical psychologist. During AT, patients learn to relax by
focusing on specific parts of their body and autosuggestion. New
autosuggestive "formulas" are introduced each session in a stepwise 
fashion:
"I am calm and relaxed," "arms and legs heavy, pleasantly heavy" (muscular
relaxation), "heart beats calmly" (stabilization of heart function),
"breathing calm and steady" (regulation of breathing), "solar plexus 
streams
warmly" (regulation of visceral organs), "head free and clear" or "forehead
pleasantly cool" (regulation of blood flow in the head), and invididual
formulas of positive intentions (e.g., "not smoking makes me free," "I 
learn
easily"). The standard version of AT also includes an autosuggestion "hands 
and arms warm" (vascular dilation), which was not used in this patient
population because the increased blood flow and warming can induce itch. We
added the autosuggestion "skin calm and pleasantly cool" and individually
chosen autosuggestions aimed at controlling scratching (e.g., "I do not 
need
to scratch," or "my skin stays intact") and at coping with itching (e.g.,
"the itch dissolves," "with every breath the itching gets weaker and
weaker," "my skin is protected by soft, cool silk," "a cold wind makes my
skin numb"). Such specific autosuggestions for skin disorder patients were
already proposed by Luthe and Schulz (1969, pp. 157-159 ). AT has 
previously
been found to be useful in the treatment of AD by K‰mmerer (1987) and Cole
et al. (1988) . A recent review by Linden (1994) covering various disorders
found that the effect sizes achieved with AT are equivalent to those of
muscular relaxation. Patients received handouts at the end of each session
and were instructed to practice relaxation twice daily.

BT
The cognitive-behavioral treatment program had two goals: First, it was
aimed at a reduction in scratching frequency and intensity by self-control
techniques and to increase patients' ability to cope with itching. The 
second goal was to decrease the patients' overall stress levels by
cognitive-behavioral therapy and relaxation training. Groups were run by 
two
clinical psychologists (one male, one female). The relaxation training
followed ÷st's (1987) applied relaxation training, in which patients learn
to relax in increasingly shorter periods of time. Patients were instructed
to practice relaxation twice daily, once with and at least once without an
audiotape provided by the therapist. As in many of the studies reported
earlier (e.g., Gray & Lawlis, 1982 ; Horne et al., 1989 ; Twerski & Naar,
1974 ), the relaxation training included imagery techniques. After patients
had learned to relax, they received guided imagery exercises, in which they
imagined scenes when they had felt very relaxed or had felt cooling
sensations on their skin (e.g., walking at the sea with a light breeze), 
and
further imagery exercises in which patients reinterpreted and modified
itching sensations in their imagination. Similar techniques are used in the
treatment of patients suffering from pain ( Flor, Fydrich, & Turk, 1992 ).

In the self-control program of scratching behavior, the vicious circle of
itching and scratching was explained. Patients kept diaries of their
scratching and itching. The diaries were used to identify early signs of
itching and scratching and situations in which scratching was likely to
occur. Furthermore, diaries were used to increase the patients' awareness 
of
"automatic" scratching (i.e., scratching that occurs without preceding
itching as a generalized response to tension). Diaries were reviewed during
each session, and each patient entered the average scratching frequency on
his or her chart. Patients discussed and practiced coping skills for
itching: These included habit-reversal techniques, relaxation, positive
self-instructions, distraction techniques, and "covering" itching with 
other
strong sensations (e.g., applying ice to itchy skin). Therapists and
patients also discussed the role of catastrophizing cognitions (e.g., "the
itching will never end," "all the treatment is in vain") in increasing the
probability of scratching. Finally, therapists encouraged patients to 
reward
themselves for not scratching and discussed with them appropriate rewards.

BT included a training in problem solving for everyday problems.
Furthermore, part of each treatment session was designed to increase the
patients' interpersonal skills. Role plays were run in which patients
practiced answering (friendly and unfriendly) questions about the skin
disorder assertively. Other sessions included a training in communication 
skills (direct expression of positive feelings, making positive requests,
expressing negative feelings, problem solving). This part of the training
was modeled on the assertiveness training groups described by Liberman,
King, DeRisi, and McCann (1975) and on the behavioral family therapy 
program
described by Falloon, Boyd, and McGill (1984) . At the beginning of a
training module, the therapists role played examples for nonappropriate
(e.g., nonassertive, negative) and appropriate interactions. The group then
discussed which aspects of the behavior defined positive interactions. This
was followed by patients' role plays. Patients received handouts and
homework assignments for the three components of the program (self-control
of scratching, relaxation, and skills training).

DEBT
This treatment program combined the contents of the DE and BT programs.
Group discussions were shortened so that each treatment session did not 
last
longer than 2 hr. The dermatological part of the session was run by the 
same
therapists as in the DE group, and the cognitive-behavioral part was run by
the same therapists as in the BT group.

SMC
The SMC control group received cortisone treatment, if necessary, general
medical advice, and general instructions in skin care. Treatment sessions
were held as often as necessary during the first 12 weeks of treatment.
During follow-up, patients saw the dermatologist once every 3 months to
discuss their skin condition and appropriate treatment.

Assessments Medical Outcome Measures Severity of skin lesions.
Independent dermatologists who were not informed of the treatment condition
assessed the patients' skin condition. Two aspects of severity were
assessed. First, the dermatologist marked in a body schema the areas of the
skin that were affected. The body schema contained a grid of a total of
1,044 squares for the front and back. The number of squares of affected 
skin
was calculated and then transformed into the percentage of the maximum
number to yield a score of area of body surface affected by the skin
lesions. Second, the dermatologist rated the severity of the skin lesions 
in
terms of erythema, excoriations, and dryness on three rating scales from 0
 none ) to 3 ( severe ). The sum of these three ratings was calculated and
then transformed into the percentage of the highest possible score (9). 
Interrater reliability for this score was .84 ( n = 11). To yield an 
overall
measure of severity, we averaged the two percentage scores for body surface
and skin lesions. The measure of severity used in this study is similar to
an index recently developed by the European Task Force on Atopic Dermatitis
(1993) . Related indices have also been proposed by Bahmer (1992) , van
Neste (1992) , Rajka and Langeland (1990) , and Costa, Rilliet, Nicolet, 
and
Savrat (1989) .

Topical steroids.
The independent dermatologist who was was not informed of the treatment
conditions assessed which medication patients had used externally during 
the
year preceding treatment and during the 1-year follow-up. The names of the
medications, and the number and size of prescriptions were recorded. From
these records, the amount of of topical steroids used per year (in grammes)
was calculated. For statistical analyses, data were square-root 
transformed.
Agreement of the amount of topical steroids assessed by the independent
dermatologist with prescriptions recorded in clinic charts was determined
for 27 patients. Agreement was found for 85% of the cases. Discrepancies 
had
two major reasons: The amount of topical steroids assessed by the 
independent dermatologist exceeded the amount calculated from clinic charts
if the patient had received prescriptions from another dermatologist. It 
was
lower in cases when patients had received the prescription but had not
actually used the topical steroids.

Measures of Itching and Scratching Ratings of itching and scratching.
The independent masked dermatologist interviewed patients about the 
severity
of their itching and scratching during the previous 2 weeks and rated them
on scales ranging from 0( none ) to 10 ( very severe ). Dermatologist's
ratings showed small but significant correlations with diary assessments of
severity of itching ( r = .30, p < .005, n = 95) and scratching ( r = .37, 
p
< .001, n = 95).

Diary measures.
Patients kept a diary of all instances when they felt itching or scratched
during the 2 weeks pretreatment, 2 weeks posttreatment, and 2 weeks at the
1-year follow-up. Scratching was defined as a manipulation of the skin with
the fingernails or objects that caused the skin to redden. Patients wrote
down the time they felt itching or had scratched themselves and rated the 
intensity of itching and intensity of scratching on scales ranging from 0
 no itching/skin not red ) to 10 ( unbearable itching/bloody skin ). The
diaries were analyzed by counting the number of incidents entered in the
diary (frequency) and averaging the intensity ratings per day. These 
numbers
were then averaged over the 14 days of assessment. Thus, four dependent
variables were obtained: average frequency of scratching per day, average
intensity of scratching per day, average frequency of itching per day, and
average intensity of itching per day.

Itch-related cognitions.
A questionnaire developed by Ehlers, Stangier, Dohn, and Gieler (1993)
assessed the patients' cognitions concerning itching. Patients are
instructed to rate how frequently each of 20 cognitions occurs when he or
she experiences itching, on a scale ranging from 0 ( never ) to 4
( always ). The questionnaire comprises two scales of 10 items: The scale
"Catastrophizing/Helplessness" consists of items indicating negative
statements about the possibility to cope with itching (e.g., "the itching
will never stop," "I will again scratch until I bleed"). This scale has an
internal consistency of between Cronbach's a = .89 ( n = 138) and .90 ( n = 
60). It correlates highly with itch-related distress ( r = .62, n = 143) 
and
moderately with intensity of itching ( r = .39, p < .001, n = 93) and
scratching ( r = .35, p = .001, n = 93) as assessed by diary. The scale
"Coping" comprises items indicating coping strategies (e.g., "I have to
distract myself," "I should keep my hands busy"). This scale has an 
internal
consistency of Cronbach a between .78 ( n = 60) and .83 ( n = 138) and
correlates with itch-related distress ( r = .20, p < .05, n = 143).

Measures of Illness-Related Distress Questionnaire assessment of AD-related
distress.
Patients filled in the Marburg Atopic Dermatitis Questionnaire developed by
Stangier, Gieler, and Ehlers (1993) . For the present analysis, only the
scale "AD-related distress (Krankheitsgef¸hl)" is of interest. The scale
comprised 17 items designed to measure distress including poor self-image
and quality of life caused by the skin disorder (e.g., "my appearance
worries me," "I avoid situations because of my skin disorder," "I feel
desperate because of my skin disorder," "the itching drains me," "I need a
lot of energy to resist scratching"). The internal consistency in 114 AD
patients was Cronbach's a = .93.

Global disability rating.
Patients were asked by the independent masked dermatologist to rate how
disabled they were by the disorder on a 5-point scale with the categories
not at all (0), little (1), moderately (2), much (3), and very much (4). 
The
global disability rating showed a moderate correlation with the
questionnaire assessment of AD-related distress ( r = .47, p < .001, n =
140).

Measures of General Psychological Adjustment Anxiety.
Patients filled in the Trait version of the State-Trait Anxiety Inventory
(STAI; German version; Laux, Glanzmann, Schaffner, & Spielberger, 1981 ).
Anxiety was assessed because heightened anxiety levels in AD patients have
been observed in a number of studies (e.g., Garrie, Garrie, & Mote, 1974 ;
Horne, White, & Varigos, 1989 ).

Depression.
Patients completed the Center for Epidemiological Studies Depression Scale
(CES-D; [German version] Hautzinger, 1988 ). This scale was chosen because
it was developed to measure depression in the general population and 
because we did not assume that our patients would show clinical levels of
depression.

Results
Dropouts
Patients who received less than 10 of the 12 treatment sessions were
considered dropouts. During treatment, 1 patient in DE group, 5 in the AT
group, 1 in the BT, 2 in the DEBT, and 2 in the SMC group dropped out. The
groups did not differ significantly in dropout rates, ? 2 4, N = 137 = 4.5 
.
Posttreatment assessments are based on 96% of patients receiving DE, and
83%, 97%, 93%, and 92% of the AT, BT, DEBT, and SMC groups, respectively.
The groups did not differ in terms of sex distribution (percent female in
each group = DE: 60%, AT: 72%, BT: 57%, DEBT: 62%, SMC: 68%), ? 2 4, N = 
126
= 1.65, ns ; age (mean ages in years = DE: 24.6, AT: 25.0, BT: 25.4, DEBT:
25.4, SMC: 22.3), F (4, 125) = 0.92, ns ; duration of the disorder (mean
duration in years: DE = 15.3, AT = 11.1, BT = 15.7, DEBT = 15.2, SMC =
13.8), F (4, 120) = 0.82, ns ; education, ? 2 8, N = 111 11.24, ns : or
serverity of skin lesions (see Table 1 ), F (4, 125) = 0.78, ns .

During the 1-year follow-up, six additional patients dropped out: two from
DE, one from AT, two from BT, and one from SMC. One-year follow-up data 
were
thus available for 88% of patients receiving DE and 80%, 90%, 93%, and 88%
of the AT, BT, DEBT, and SMC groups, respectively.

Treatment Credibility and Expectancies
At the end of the first treatment session, patients completed two rating
scales assessing treatment credibility and expectancies, as well as a
questionnaire designed to measure patients' evaluation of their therapists
 Bennun, Hahlweg, Schindler, & Langlotz, 1986 ). Patients rated how logical
it appeared to them that the treatment program was effective for patients
with AD on a scale ranging from 0 ( not at all ) to 10 ( very logical ) and
how confident they were that the treatment would improve their skin
condition on a scale ranging from 0 ( not at all to 10 ( very confident ).
No group differences were observed: logical: M s = 6.7, 6.1, 6.2, and 6.7
for DE, AT, BT, and DEBT, respectively), F (3, 91) = 0.75; confident: M s =
5.2, 5.5, 5.7, and 5.9, for DE, AT, BT, and DEBT, respectively, F (3, 91) =
0.46. For none of the scales assessing patients' evaluations of the
therapists were significant differences observed: For DE, AT, BT, and DEBT, 
respectively, positive regard means were 3.5, 3.4, 3.6, and 3.4, F (3, 93) 
=
1.92; experience and competency means were 3.1, 3.3, 3.3, and 3.4, F (3, 
93)
= 2.33, p < .10; and direct guidance means were 3.1, 3.1, 3.3, and 3.3, F
(3, 93) = 1.52.

One-Year Follow-Up
The results of treatment outcome at 1-year follow-up for the four group
treatment programs (DE, AT, BT, and DEBT) and SMC are summarized in Table 1
. Furthermore, the results for repeated measures analyses of variance
(ANOVAs) that compared the efficacy of the group treatments are presented.
In case of a trend for significant baseline differences, the results are
based on analyses of covariance (ANCOVAs) using baseline scores as the
covariate. For all measures except for cognitions expressing coping with
itching and depression, time effects indicated improvement in the group
treatment conditions. These time effects were qualified by interactions of
Group * Time for severity of skin lesions, amount of topical steroids, and
diary assessments of frequency of scratching and itching (discussed later).
Table 1 also summarizes which of the group treatment conditions led to
greater improvement than SMC.

Medical Outcome Measures Severity of skin lesions.
A significant Group * Time interaction indicated that the groups differed 
in
their improvement of skin lesions: AT, F (1, 44) = 7.38, p < .01; BT, F (1,
47) = 4.33, p < .05; and DEBT, F (1, 47) = 3.42, p = .07, tended to be more
effective than DE. The psychological group treatments, but not DE, were 
more
effective than SMC: AT, F (1, 42) = 11.87, p = .001; BT, F (1, 45) = 7.59, 
p
< .01; and DEBT, F (1, 45) = 6.02, p < .05.

Topical steroids.
A trend for a significant Group * Time interaction was observed. Further
analyses showed a larger reduction in the amount of topical steroids used 
in
the DEBT group compared with DE, F (1, 44) = 5.11, p < .05. For AT and BT,
there were only trends in the same direction (AT, p = .11; BT, p = .10).
Only the DEBT group showed significantly larger reductions than SMC, F (1,
41) = 4.24, p < .05.

Measures of Itching and Scratching Ratings of itching and scratching.
All treatment conditions, including SMC, showed similar improvement on the
ratings of scratching and itching as assessed by the independent 
dermatologist by interviewing patients.

Diary measures.
Table 1 presents the results for 6 DS, 5 AT, 12 BT, and 15 DEBT patients
with complete (i.e., entries for 2 weeks) baseline and follow-up data,
respectively. Compliance for the diary assessment was better in the BT and
DEBT groups than in the AT and DS groups, ? 2 3, N = 98 = 10.15, p < .05 .
We still decided to report the available data because they might reveal
important trends. In none of the groups, patients who completed the diaries
differed from those who did not complete them in terms of severity of skin
lesions, dermatologist asjysessments of scratching and itching, or
subjective disability. ANCOVAs showed that the groups differed in the
reduction of frequency of itching and scratching from baseline to follow-
up.
Further ANCOVAs revealed that patients in the DEBT group showed larger
reductions in scratching frequency than DE patients, F (1, 18) = 13.09, p <
.005, and AT patients, F (1, 17) = 8.40, p = .01. The same results were
found for frequency of itching: DEBT vs. DE, F (1, 18) = 9.32, p < .01; 
DEBT
vs. AT, F (1, 17) = 5.93, p < .05. In addition, BT patients tended to 
report
larger reductions in frequency of itching than DE patients, F (1, 15) =
3.53, p = .08. Analyses were repeated taking all patients into account who
had at least 1 week of complete data for baseline and follow-up 
assessments.
For this analysis, no difference in compliance was found (11 DE, 10 AT, 24
BT, and 22 DEBT), ? 2 3, N = 98 = 3.45, ns. Similar trends for group
differences were observed.

Itch-related cognitions.
Patients in the AT condition, F (1, 37) = 6.01, p < .05, BT condition, F 
(1,
39) = 6.19, p < .05, and DEBT condition, F (1, 39) = 5.21, p < .05, showed
significantly larger decreases in cognitions that catastrophized itching or
expressed helplessness than SMC patients. For the factor "coping with
itching," no significant increases were observed in any of the groups.

Measures of Illness-Related Distress
All treatment conditions, including SMC, led to similar improvement on the
questionnaire of AD-related distress and the global disability rating
assessed in the dermatological interview.

Measures of General Psychological Adjustment
Only the DE group, F (1, 33) = 7.39, p < .01, and DEBT group, F (1, 39) =
6.27, p < .05, showed larger reductions in trait anxiety than SMC. None of
the treatments resulted in decreased depression scores.

Posttreatment Assessment
ANOVAs (or ANCOVAs, in the case of a trend for baseline differences)
comparing pre-, and posttreatment assessments of the DE, AT, BT, and DEBT
treatments on the outcome measures showed significant improvement on all
assessments (all p s < .005, except for p < .05 on CES-D). The only 
variable
that showed differences in treatment gains between the group treatments was
coping cognitions related to itching, F (3, 86) = 2.77, p < .05. Patients
who had received psychological treatments showed an increase in coping
cognitions, whereas DE patients did not: AT versus DE, F (1, 44) = 3.27, p 
<
.08; BT versus DE, F (1, 45) = 5.32, p < .05; DEBT versus DE, F (1, 43) =
5.24, p < .05.

All group treatments were superior to SMC in improving severity of skin
lesions: For DE, F (1, 45) = 10.0, p < .01; for AT, F (1, 45) = 15.87, p <
.001; for BT, F (1, 48) = 10.28, p < .01; and for DEBT, F (1, 46) = 15.65, 
p< .001. All group treatments were also superior to SMC in improving the
severity of AD-related distress (ANCOVAs): For DE, F (1, 39) = 11.22, p <
.01; for AT, F (1, 39) = 4.81, p < .05; for BT, F (1, 42) = 6.36, p < .05;
and for DEBT, F (1, 37) = 10.54, p < .01. The psychological and combined
treatments were significantly superior to SMC on the global disability
rating (ANCOVAs): For AT, F (1, 37) = 8.83, p < .01; for BT, F (1, 42) =
4.94, p < .05; and for DEBT, F (1, 39) = 14.30, p = .001. They were also
significantly superior on catastrophizing-helplessness cognitions related 
to
itching: For AT, F (1, 39) = 9.7, p < .01; for BT, F (1, 40) = 10.26, p <
.01; and for DEBT, F (1, 38) = 10.92, p < .01. For DE, there were trends in
this direction: For disability, F (1, 38) = 3.38, p < .08; for
catastrophizing, F (1, 41) = 4.01, p < .06. Only the BT and DEBT groups
showed greater reductions in dermatologist's assessments of severity of
itching and scratching than SMC (ANCOVAs). Results for itching were as
follows: For BT, F (1, 42) = 6.00, p < .05; for DEBT, F (1, 39) = 5.76, p <
.05. Results for scratching were as follows: For BT, F (1, 42) = 6.29, p <
.05; for DEBT, F (1, 39) = 3.23, p = .08. Furthermore, there were trends 
for
larger reductions in trait anxiety and depression in AT and DEBT, compared
with SMC ( p s < .09).

Discussion
Assessments taken 1 year after the beginning of treatment-that is, during
the same season as initial assessments-showed that AT, BT, which comprised
relaxation, self-control of scratching, and stress management with a focus
on interpersonal stress, and DEBT led to significantly larger improvement 
in
skin lesions in AD than SMC. The same result was obtained for posttreatment
assessments. Thus, the psychological treatments (AT, BT, and DEBT) led to
significant and stable additional treatment effects in skin condition 
beyond
those of SMC. These results are in line with the case studies of relaxation
training reviewed in the introduction, the controlled trials of
habit-reversal training of Melin et al. (1986) , Noren and Melin (1989) ,
and Horne et al. (1992) , and the controlled trial of relaxation,
self-control of scratching, and stress management of Niebel ( Niebel, 1991 
;
Niebel & Welzel, 1992 ).

DE led to greater improvement in skin lesions than SMC during the 3-month
treatment phase, but these additional treatment gains were not maintained
during follow-up. Furthermore, at follow-up DE patients showed less
improvement than the psychological and combined (AT, BT, and DEBT) 
treatments. This result is particularly important because the group
treatments were matched for number of sessions and were comparable in terms
of treatment expectancies and patients' evaluations of the therapists.
Whereas one could have argued that duration of contact with the therapist
and intensity of treatment might partly be responsible for differences in
efficacy between SMC and the psychological treatments, this explanation
cannot account for differences between DE and the other group treatments. 
We
can therefore conclude that the psychological treatments led to significant
additional improvement in skin condition, compared with intensive
dermatological treatment.

The reduction in the severity of skin lesions in the groups receiving
psychological treatment cannot be accounted for by greater use of topical
steroids. On the contrary, the psychological treatment groups showed both a
better skin condition and less cortisone use during the 1-year follow-up.
DEBT even led to larger reductions in the amount of topical steroids used
than SMC and DE. This pattern of results supports the conclusion that
psychological treatments are an important adjunct to the dermatological
treatment of patients with AD.

The only self-report measures that consistently showed group differences at
post- and follow-up assessments were cognitions concerning itching. 
Patients
receiving psychological treatments reported a greater reduction in 
frequency
of catastrophizing cognitions compared to SMC at both assessments. The
pattern of results observed for this self-report measure thus resembled the
results for severity of skin lesions most closely. In addition, patients
receiving psychological treatments reported larger increases in the
frequency of coping cognitions during treatment than DE patients. These
results are similar to those of Flor, Behle, and Birbaumer (1993) , who
found that psychological, but not medical, treatments led to increases in
coping cognitions in pain patients. However, the increases in itch-related
coping cognitions were not maintained during follow-up. If replicated, this
pattern of results has possible implications for the conceptualization of
cognitive-behavioral interventions. It suggests that it might be useful to
put greater emphasis in treatment on the direct modification of
catastrophizing cognitions related to itching and possibly other aspects of
the disorder similar to treatments of anxiety and depression (e.g., Hawton,
Salkovskis, Kirk, & Clark, 1989 ). Most currently used treatment programs
instead focus on increasing coping cognitions.

At posttreatment assessment, the group treatments were superior to SMC on
measures of AD-related distress and global disability. However, these
advantages were not maintained during follow-up. The lack of differences at
follow-up was due to improvement in the SMC group. This pattern of results
indicates faster improvement in self-reported disability for patients
receiving additional treatment beyond SMC.

Because the BT and DEBT programs were directly aimed at a reduction in
scratching behavior, one might have expected a greater reduction in
scratching in these groups. In line with this assumption, BT and DEBT were
superior to SMC in dermatologist's assessments of severity of itching and
scratching after treatment. In addition, although the diary data have to be
interpreted with caution because of more missing data (i.e., diaries were
filled out for less than 2 weeks) in the AT and DE groups, they indicate
some trends in the expected direction. However, group differences were only
observed in frequency, not intensity measures. Most other studies showing
decreased scratching behavior after habit-reversal training (e.g., Melin et
al., 1986 ; Niebel, 1990 ) have used frequency measures of scratching. It
would be desirable for future studies to include both measures in the 
assessment so that differential effects for frequency and intensity could 
be
assessed (see also Niebel, 1991 ). The differential compliance may also
indicate differential treatment effects in that the purpose of
self-monitoring was more obvious for patients participating in the BT and
DEBT programs.

Although none of the treatments targeted anxiety or depression directly, 
all
group treatments led to decreases in these measures. These findings are
similar to those of Niebel (1991) . Treatment effects for anxiety, but not
for depression, were maintained during the 1-year follow-up. The DE and 
DEBT
groups showed greater improvement in anxiety at 1-year assessments than 
SMC.
These data suggest that the heightened anxiety levels often observed in
patients with AD ( Garrie et al., 1974 ; Horne et al., 1989 ) can be 
reduced
with treatment. That DE and DEBT groups showed advantages over SMC on this
measure at 1-year assessments may be linked to the detailed information
about the disorder that patients received during treatment.

When interpreting group differences in the outcome variables, one has to
bear in mind that a replication of the present study is necessary before 
final conclusions can be drawn, especially if the number of variables
assessed is taken into account. For comparisons with the SMC group, one 
also
has to bear in mind that patients were not randomly assigned to this
condition because of the aforementioned considerations. Although the
procedure chosen for the present study ensured a low dropout rate for the
SMC group, and although this group was comparable with the other groups in
many crucial respects (e.g., severity of skin lesions, duration of the
disorder, patients drawn from the same clinic), one cannot completely rule
out that uncontrolled variables may have influenced the pattern of results.

Overall, the largest differential treatment effects were found for the
medical outcome variables, whereas measures involving self-reports yielded
few significant group differences at follow-up. This may partly be due to
the fact that all groups showed improvement in these measures (except for
depression at 1-year). The lack of differences may point to nonspecific
therapeutic mechanisms such as therapist's attention, self-monitoring, or
support received from other group members, and regular 3-month appointments
with a dermatologist during follow-up, which may have increased compliance.
It is also possible that self-report measures may be more susceptible to 
demand characteristics in that patients felt obliged to report at least 
some
improvement, and that some of the simple rating scales that were chosen to
model the assessments used in routine clinical practice may lack
reliability.

No significant differences between AT and the more comprehensive BT were
observed. These results indicate that relaxation is an important component
of psychological treatments of AD. Our study is the first controlled study
to establish clear treatment effects of relaxation training in AD. The
results are consistent with the positive effects of AT on other disorders
such as migraine, hypertension, or rehabilitation from myocardial 
infarction
(for a review, see Linden, 1994 ). It is unclear whether differences 
between
the psychological treatments would have been established if the BT program
had been spread over more sessions. This would have allowed more practice
for the different treatment components. Patients sometimes remarked during
the BT sessions that they would have liked to spend more time on the
different treatment components. Nevertheless, the results indicate that AT
is an effective treatment, which also has the advantage that it is
economical with respect to therapist time.

We expected that DEBT would be the most effective program. Very few 
measures
point in this direction: Only DEBT led to significantly larger reductions 
in
cortisone use than SMC. DEBT, but not AT and BT, led to larger reductions 
in
anxiety at follow-up compared to SMC. In addition, diary data showed larger
reductions in frequency of scratching and itching than AT and DE. Although
these data have to be interpreted with caution, they are plausible because
DEBT included specific strategies to reduce scratching behavior. Again, it
is possible that clearer advantages of the DEBT program could be 
established
if more time had been allowed for the different treatment components.

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Table 1.

Linda
Dr. Linda J. Weyandt MD/ CRNA
Web Sites: http://www.webspawner.com/users/anesthesiaservices/ http://www.webspawner.com/users/medlegalconsult/
WASHINGTON UNIVERSITY SCHOOL OF MEDICINE
IMGI District Manager for Texas http://www.imgi.org