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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. --------------------------------------------------------------------------- - ---- 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 email@example.com Received: May 26, 1994 Revised: November 21, 1994 Accepted: November 30, 1994 --------------------------------------------------------------------------- - ---- 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. References Alexander, F. (1950). Psychosomatic medicine. (New York: Norton) Allen, K. E. & Harris, F. R. (1966). Elimination of a child's excessive scratching by training the mother in reinforcement procedures.( Behaviour Research and Therapy, 4, 79-84.) Azrin, N. H. & Nunn, R. G. (1973). Habit reversal: A method of eliminating nervous habits and tics.( Behaviour Research and Therapy, 11, 619-628.) Bahmer, F. (1992). ADASI score: Atopic dermatitis area and severityndex.( Acta Dermato-Venerologica, 176, 32-33.) B‰r, L. H. & Kuypers, B. R. M. (1973). Behavior therapy in dermatological practice.( British Journal of Dermatology, 88, 591-598.) Bennun, I., Hahlweg, K., Schindler, L. & Langlotz, M. (1986). Therapist's and client's perception in behavior therapy: The development and cross-cultural analysis of an assessment instrument.( British Journal of Clinical Psychology, 25, 275-285.) Brown, D. G. (1972). Stress as a precipitant factor of eczema.( Journal of Psychosomatic Research, 16, 321-327.) Brown, D. G. & Bettley, F. R. (1972). Psychiatric treatment of eczema: A controlled trial.( British Medical Journal, 26, 729-734.) Cole, W. C., Roth, H. L. & Sachs, L. B. (1988). Group psychotherapy as an aid in the medical treatment of eczema.( Journal of the American Academy of Dermatology, 18, 286-291.) Costa, C., Rilliet, A., Nicolet, M. & Savrat, J. H. (1989). Scoring atopic dermatitis: The simpler the better.( Acta Dermato-Venerologica, 69, 41-45.) Dobes, R. W. (1977). Amelioration of psychosomatic dermatosis by reinforced inhibition of scratching.( Journal of Behavior Therapy and Experimental Psychiatry, 8, 399-343.) Ehlers, A., Osen, A., Wenninger, K. & Gieler, U. (1994). Atopic dermatitis and stress: The possible role of negative communication with significant others.( International Journal of Behavioral Medicine, 1, 107-121.) Ehlers, A., Stangier, U., Dohn, D. & Gieler, U. (1993). Kognitive Faktoren beim Juckreiz: Entwicklung und Validierung eines Fragebogens [Cognitive factors in itching: Development and validation of a uestionnaire].( Verhaltenstherapie, 3, 112-119.) European Task Force on Atopic Dermatitis. (1993). Severity scoring of atopic dermatitis: The SCORAD index.( Dermatology, 186, 23-31.) Falloon, I. R. H., Boyd, J. L. & McGill, C. W. (1984). Family care of schizophrenia. (New York: Guilford Press) Faulstich, M. E. & Williamson, D. A. (1985). An overview of atopic dermatitis: Toward a bio-behavioural integration.( Journal of Psychosomatic Research, 29, 647-654.) Flor, H., Behle, D. & Birbaumer, N. (1993). Assessment of pain-related cognitions in chronic pain patients.( Behaviour Research and Therapy, 31, 63-67.) Flor, H., Fydrich, T. & Turk, D. (1992). Efficacy of multidisciplinary pain treatment centers: A meta-analytic review.( Pain, 49, 221-230.) Garrie, E. V., Garrie, S. A. & Mote, T. (1974). Anxiety and atopic dermatitis.( Journal of Consulting and Clinical Psychology, 42, 742.) Gieler, U., Ehlers, A., Hˆhler, T. & Burkard, G. (1990). Die psychosoziale Situation der Patienten mit endogenem Ekzem [The psychosocial situation of patients with atopic dermatitis].( Der Hautarzt, 41, 416-423.) Gil, K. M., Keefe, F. J., Sampson, H. A., McCaskill, C. C., Rodin, J. & Crisson, J. E. (1987). The relationship of stress and family environment to atopic dermatitis symptoms in children.( Journal of Psychosomatic Research, 31, 673-684.) Gray, S. G. & Lawlis, G. F. (1982). A case study of pruritic eczema treated by relaxation and mental imagery.( Psychological Reports, 51, 627-633.) Hanifin, J. M. & Rajka, G. (1980). Diagnostic features of atopic dermatitis.( Acta Dermatologica Venerologica, 92, 44-47.) Hautzinger, M. (1988). Die CES-D-Skala.(Ein Depressionsmeþ instrument f¸r Untersuchungen in der Allgemeinbevˆlkerung [The CES-D scale: A measure of depression for studies of the general community]. Diagnostica, 34, 167- 173.) Hawton, K., Salkovskis, P. M., Kirk, J. & Clark, D. M. (1989). Cognitive behaviour therapy for psychiatric problems. (Oxford, Great Britain: Oxford University Press) Haynes, S. N., Wilson, C. C., Gaff, P. & Britton, B. (1979). Biofeedback treatment of atopic dermatitis.(Controlled case studies of eight cases. Biofeedback and Self-Regulation, 4, 195-209.) Holle, R. (1990). Methodische Probleme bei der Planung randomisierter Therapiestudien im Bereich der Psychosomatik [Methodological problems in designing randomized treatment trials in psychosomatic medicine].(In Projekttr‰ger Forschung f¸r die Gesundheit (Ed.), Klinische Studien in der Psychiatrie [Clinical studies in psychiatry] (pp. 18-27). Bremerhaven, Germany: Verlag f¸r neue Wissenschaft.) Horan, J. S. (1950). Management of neurodermatitis by hypnotic uggestion.( British Journal of Medical Hypnotism, 2, 43-49.) Horne, D. J. L., Borge, A. & Varigos, G. (1992). Self-monitoring and habit reversal in the treatment of atopic eczema .(Unpublished manuscript) Horne, D. J. L., White, A. E. & Varigos, G. A. (1989). A preliminary study of psychological therapy in the management of atopic eczema.( British Journal of Medical Psychology, 62, 241-248.) K‰mmerer, W. (1987). Die psychosomatische Erg‰nzungstherapie der Neurodermitis atopica-Autogenes Training und weitere Ma b nahmen [The psychosomatic adjunct treatment of atopic dermatitis-autogenic training and other measures].( Allergologie, 10, 536-541.) Kaschel, R., Miltner, W., Egenrieder, H., Lischka, G. & Niederberger, U. (1990). Eine Pilotstudie mit f¸nf kontrollierten Einzelf‰llen bei atopischer Dermatitis [A pilot study of five controlled cases of atopic ermatitis].( Verhaltensmedizin und Verhaltensmodifikation, 11, 5-23.) Kellner, R. (1975). Psychotherapy in psychosomatic disorders: A survey of controlled studies.( Archives of General Psychiatry, 32, 1021-1028.) Klein, H. S. (1949). Psychogenic factors in dermatitis and their treatment by group therapy.( British Journal of Medical Psychology, 22, 32-45.) Koblenzer, C. (1987). Psychocutaneous skin disease. (Orlando, FL: Grune & Stratton) Koblenzer, C. (1988). Stress and the skin: Significance of emotional factors in dermatology.( Stress Medicine, 4, 21-26.) Laux, L., Glanzmann, P., Schaffner, P. & Spielberger, C. D. (1981). Das State-Trait-Angstinventar [The State-Trait-Anxiety Inventory]. (Weinheim, Germany: Beltz) Liberman, R. P., King, L. W., DeRisi, W. J. & McCann, M. (1975). Personal effectiveness. (Champaign, IL: Research Press) Linden, W. (1994). Autogenic training: A narrative and quantitative review of clinical outcome.( Biofeedback and Self-Regulation, 19, 227-264.) Luthe, W. & Schultz, J. H. (1969). Autogenic therapy. (Medical applications (Vol. 2). New York, NY: Grune & Stratton) Manuso, J. (1977). The use of biofeedback-assisted hand warming training in the treatment of eczematous dermatitis of the hands: A case study.( Journal of Behavior Therapy and Experimental Psychiatry, 8, 445-446.) Mazzuca, S., Moormann, N. & Wheeler, S. (1986). The Diabetes Education Study: A controlled trial of the effects of patient education.( Diabetes Care, 9, 1-16.) Melin, L., Frederiksen, T., Noren, P. & Swebelius, C. B. (1986). Behavioral treatment of scratching in patients with atopic dermatitis.( British Journal of Dermatology, 115, 467-474.) Mirvish, I. (1978). Hypnotherapy for the child with chronic eczema: A case study.( South African Medical Journal, 54, 410-412.) Niebel, G. (1990). Verhaltensmedizinisches Gruppentraining f¸r Patienten mit Atopischer Dermatitis in Erg‰nzung zur dermatologischen Behandlung [Behavioral medicine group training in addition to dermatological treatment].( Verhaltensmedizin und Verhaltensmodifikation, 11, 24-44.) Niebel, G. (1991). Psychobiologische und verhaltenspsychologische Perspektiven der atopischen Dermatitis [ Psychobiological and psychobehavioral perspectives of atopic dermatitis ].(Unpublished postdoctoral thesis (Habilitationsschrift), University of Kiel, Germany) Niebel, G. & Welzel, C. (1992, July). Differential effectiveness of behavioral group trainings supporting dermatological standard treatments of adult outpatients with atopic dermatitis .(Paper presented at the Second International Congress of Behavioral Medicine, Hamburg, Germany) Noren, P. & Melin, L. (1989, July). Treatment of atopic eczema in children with a combination of hydrocortisone cream and the habit reversal technique .(Paper presented at the Second International Congress on Dermatology and Psychiatry, Leeds, Great Britain) ÷st, L. G. (1987). Applied relaxation: Description of a coping technique and review of controlled studies.( Behaviour Research and Therapy, 25, 397- 410.) Rajka, G. & Langeland, T. (1990). Grading the severity of atopic dermatitis.( Acta Dermato-Venerologica, 144, 13-14.) Ratcliff, R. G. & Stein, N. H. (1968). Treatment of neurodermatitis by behaviour therapy: A case study.( Behaviour Research and Therapy, 6, 397-399.) Rosenbaum, M. S. & Ayllon, T. (1981). The behavioral treatment of neurodermatitis through habit reversal.( Behaviour Research and Therapy, 19, 313-318.) Ruzicka, T., Ring, J. & Przybilla, B. (Eds.) (1991). Handbook of atopic eczema. (Berlin: Springer) Schmied, C. & Saurat, H. J. (1991). Epidemiology of atopic dermatitis.(In T. Ruzicka, J. Ring, & B. Przybilla (Eds.), Handbook of atopic eczema (pp. 9-14). Berlin: Springer.) Shoemaker, R. J., Guy, W. B. & McLaughlin, J. T. (1955). The usefulness of group therapy in the treatment of atopic eczema.( The Pennsylvania Medical Journal, 58, 603-609.) Schubert, H. J. (1989). Psychosoziale Faktoren bei Hauterkrankungen [Psychosocial factors in skin disorders]. (Gˆttingen, Germany: Vandenhoeck & Ruprecht) Schultz Larsen, F. (1991). Genetic aspects of atopic eczema.(In T. Ruzicka, J. Ring, & B. Przybilla (Eds.), Handbook of atopic eczema (pp. 15-26). Berlin: Springer.) Spitz, R. A. (1965). The first year of life. (New York: International Universities Press) Stangier, U., Gieler, U. & Ehlers, A. (1993). Der MarburgerNeurodermitis- Fragebogen (MNF) [The Marburg Atopic Dermatitis Questionnaire].(In U. Gieler, U. Stangier, E. Br‰hler (Eds.), Hauterkrankungenin psychologischer Sicht [ A psychological perspective of skin disorders ] (pp. 115-134). Gˆttingen, Germany: Hogrefe Press.) Stangier, U., Gieler, U. & Ehlers, A. (in press). Neurodermitis bew‰ltigen. Verhaltenstherapie, dermatologische Schulung, Autogenes Training [Coping with atopic dermatitis: Behavior therapy, dermatological education, autogenic training].(Berlin: Springer) Twerski, A. J. & Naar, R. (1974). Hypnotherapy in a case of refractory dermatitis.( American Journal of Clinical Hypnosis, 16, 202-205.) van Neste, D. (1992). Functional relevance of severity scores of atopic dermatitis.(Multi-parametric in vivo evaluation of biophysical parameters with non-invasive methods. European Journal of Dermatology, 2, 319-324.) Walton, D. (1960). The application of learning theory to the treatment of a case of neuro-dermatitis.(In H. J. Eysenck (Ed.), Behaviour therapy and the neuroses (pp. 272-274). Oxford: Pergamon Press.) Watson, D. L., Tharp, R. G. & Krisberg, J. (1972). Case study in self-modification: Suppression of inflammatory scratching while awake and asleep.( Journal of Behavior Therapy and Experimental Psychiatry, 3, 213- 215.) White, A., Horne, D. J. D. & Varigos, G. A. (1990). Psychological profile of the atopic eczema patient.( The Australian Journal of Dermatology, 31, 13-16.) Whitlock, F. A. (1976). Psychophysiological aspects of skin disease. (London: W. B. Saunders) Whittkower, E. & Russell, B. (1953). Emotional factors in skin disease. (London: Cassell) 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
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