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The door that Freud reopened

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Parable: The door that Freud reopened
Mauricio Goihman-Yahr MD PhD
Dermatology Online Journal 16 (7): 17

In antiquity physicians had a deep respect for the unconscious, the subconscious, and the supernatural. Sleep and dreams (incubations) were important parts of the healing and diagnostic processes in the Temples of Asklepios. Daniel predicted future events and diseases after interpreting dreams of others or falling in a state of unconsciousness and dreaming himself. Galen diagnosed the cause of signs and symptoms in a prominent individual after feeling the latter’s pulse when the patient had just seen the woman that he loved but felt that he could not get.

The Scientific era was at first opposed to all that. Man was a machine and only anatomical changes, be they acquired or congenital, could explain disease. Freud reopened the door that led to the psyche. This is true even if his actual interpretations and his dogmatism are now questioned. Man is much more than a machine, even more than a computer. Man can transform life events into damage. Initial pathology at one site or emotional pathology can be deviated to other organs. The skin is not only an external frontier of the being but also a window into it and from it to the outside.

A practice of dermatology based solely on inspection, diagnosis, and stereotyped, yet legally unobjectionable, treatments (be they medical or procedural) may suffice for some cases. It may be helpful in many others, but it is only the skeleton of the true scope of our branch of medicine.

A patient should sit in front of the physician, questions should be asked, and the tone of voice and the body language should be appreciated. Personal and familial history should be investigated. Life events should be noted and ought to be checked again and again at each visit. The temporal relationship of skin lesions and life happenings should be appreciated. This advice may sound rather trite, but it is, nonetheless, true.

The current situation in Venezuela, where I live, is fraught with danger and uncertainty. There is violence all around in the streets, on television, and in the newspapers. Graffiti is splashed on the walls and snarling dogs roam the streets. I have seen the sudden, explosive onset of generalized pruritus, acrodermatitis of Hallopeau, macular amyloidosis, genital herpes, psoriasis, and rosacea. Obsessive preoccupations about the appearance of skin, nails and hair have become increasingly prevalent. These observations have whetted my awareness; I inquire about the feelings of the patients towards their new or exacerbated conditions.

My questions are simple. Can any dermatologist judge all underlying factors by seeing a patient for five or ten minutes? Can a dermatologist treat these conditions just by prescribing a cream or jabbing the patient with some intra-lesional steroids? No, but do not argue that dermatology is not psychiatry or social work, or that there are too many patients to allow for the time that would be needed. Dermatology is medicine and medicine is about the human condition.

It may well be that more dermatologists are required. It may well be that many patients now treated by dermatologists should not be treated by them but by general practitioners, or, perhaps, should not be treated at all. It may well be that dermatology in particular, and medical practice in general, should be encouraged to go back to basics. Try to find out why the patient is really in your office. Interview these patients and develop a rapport instead of delegating this task to physician extenders and impersonal forms. Patients and physicians should feel and behave as partners and not adversaries.

© 2010 Dermatology Online Journal