Peter Norén talks to DrB
Habit reversal and atopic eczema: An interview with Peter Norén MD
Peter Norén MD qualified in Medicine at Uppsala University Hospital, Sweden, in 1976 and as a Specialist in Dermatology in 1983. He has been in private practice in Uppsala since 1984, when he founded the Laser Clinic in Uppsala. His expertise has frequently taken him abroad as a teacher and a trainer. Based on his original research, he wrote "Atopic Skin Disease - A Manual for Practitioners", with Drs Christopher Bridgett and Richard Staughton. He has presented his work on the successful treatment of atopic eczema at meetings in Norway, UK, The Netherlands, Russia, and Germany.
DrB: Back in the 1980s, what was it that led to the idea that habit reversal could be used in the treatment of atopic eczema?
PN: Here at the University Hospital we were with one particular patient who had been referred with generalized atopic eczema. She complained of itch, and scratching, and the Professor of Dermatology remarked: "We should really bring you in and sedate you for a month". Everybody laughed - the Professor had a reputation for joking.
DrB: Was he suggesting this would reduce the itch?
PN: Then we did not see the difference between scratching due to itch and scratching as a habit. That came later. But he said: "If your scratching could be stopped for long enough, your skin would heal", and that got me thinking - I had always had an interest in peoples' behaviour. Suddenly I realized how important scratching was.
DrB: His suggestion was not a serious one - people were not being admitted and sedated?
PN: No, we did not do that: with children at night, physical restraint was sometimes used to deal with scratching - that was sometimes done. And the link between scratching and neurodermatitis, and lichenification, was already understood...
DrB: The Professor was suggesting chemical restraint, rather than physical restraint, and you began to think instead of a psychological intervention. That would be more humane, more reasonable. What else was happening in the 1980's, in the treatment of eczema?
PN: Well, otherwise we had by then stronger, more effective topical steroids - stronger than hydrocortisone - so we could now treat inflammation of the skin much more effectively and quickly, and just as in a boxing match, we could use a forceful intervention early on, with winning results - this was good for acute eczema: but it did not deal with habitual scratching, and chronic eczema.
DrB: So, this was how your interest in finding a treatment for scratching - and chronic eczema - began?
PN: Yes. I contacted a psychologist who was working with people who wanted to stop smoking, and asked him if he had any ideas about scratching - I understood that psychologists help with peoples' behaviour. He put me in touch with Lennart Melin, another psychologist...
DrB: And it was Lennart who told you about habit reversal ?
PN: Correct: a technique for changing behaviour in just a few days, being successfully used to treat various nervous habits, such as nail biting. Lennart involved two psychology students, and together we carried out the first pilot study using the habit reversal. They used it in its full form: there were several points to cover with each patient. One of the most important was to help each patient become aware of their behaviour. Next, to ask them to describe the behaviour in detail. They were encouraged also to discover any early warning signs of habitual scratching, and to describe situations where they especially found themselves scratching. Finally, the negative consequences of the behaviour were discussed, and only then did we go on to give instruction in habit reversal. This involved being taught a simple isometric muscular exercise, as a new, substitute behaviour. First it was demonstrated by the psychologist, then conducted by the patient - this training took place in the clinic - the assessment and training took some time to complete, perhaps an hour, or and hour and a half. But we found was that this very simple process definitely changed their behaviour - the treated patients scratched much less.
DrB: Was this the first time habit reversal had been used in Dermatology?
PN: Yes, I think so. It was then that we realized that while some scratching was a habit, some was due to itch. Could we add something to help the patient deal with itch? By talking with patients I found that some of them did have ways of safely dealing with itch - for example, pressing a fingernail into the itching skin. I also found a study demonstrating how artificially-induced itch could be modified by pressing a needle into the itching area. I saw then this was a valuable way of modifying itch too, without the risk of physical damage to the skin. Anything involving movement of the skin risked causing lichenification, as i chronic eczema.
DrB: In what way would you say the introduction of habit reversal was "a turning point"?
PN: There could now be a change of attitude, from being satisfied with getting a patient somewhat better, but without complete remission or healing.... by adding habit reversal to the new steroids now meant a complete remission could be the treatment goal... a new, more positive expectation was possible.
DrB: In the 1990's, and since, has the treatment of atopic eczema therefore generally improved?
PN: Unfortunately in Sweden colleagues have found this new approach interesting, but it seems as soon as you mention psychology, and behaviour modification, they are put off. People think it is a treatment for psychologists, and not dermatologists, to provide. They also think it must take too long for a dermatologist to use. I did suggest that spending time would save time....
DrB: Saving time in the long run is certainly clear from our clinical experience in London. What else can we do?
PN: I would like dermatologists to understand that the method is more common sense than psychology, and you do not have to do all the things that a psychologist might do in order to get good results. The key points do not take a long time. Of course the method does not suit all dermatologists, but they could arrange someone else to do it for them. A nurse, for example - as long as the dermatologist understands the importance of the treatment for the patient, and has a positive attitude. Yes, just as in Holland, Germany and in the UK, the way forward in Sweden is perhaps to involve our dermatology nurses.
DrB: Tell me a little about the current research you are doing in Sweden.
PN: We are now repeating the 1980s work, but we are isolating the habit reversal component in the treatment group - every one else is getting the same attention, time and so on. We are also focussing on each patient doing a daily assessment of progress, as it is important later on for the patient to understand how to promptly treat acute relapses. And we are carrying out the current research in three different centers, partly to recruit sufficient numbers of patients, and partly to demonstrate that the approach can be successfully carried out at other clinics, not only in my clinic.
DrB: Well, good luck with that! Before we finish, can you comment on the part self-help plays in this treatment approach for atopic eczema?
PN: Of course - habit reversal is definitely to be understood also as a self-help intervention: it is so simple and easy to understand - it does not need a big book, that would put people off. What is required is a short explanation, in a brief manual perhaps, and then a little self-discipline, and a consistent approach, to get the good results.
DrB: And now of course there is this website too...
PN: Yes, absolutely - its important that the internet can now make it possible for people everywhere to know how to treat atopic eczema successfully, and what we realized thirty years ago, and also what was demonstrated more than fifty years ago - that chronic eczema is directly caused by mechanical friction on the skin. The successful treatment of atopic eczema requires these old observations to be taken into account.
DrB: Thank you Peter.