A reappraisal of the role of 'mindbody' factors in chronic urticaria.

Chronic spontaneous urticaria (CSU) is a very common skin condition that causes considerable suffering and is often poorly responsive to drug treatment regimens. Most clinicians accept that multiple factors play a role in the aetiology of CSU, but there is a widespread reluctance to accept a significant role for 'mindbody' factors, despite a large number of clinical reports and studies over many decades suggesting their relevance. This reluctance has multiple origins. A primary influence is the flawed dualistic model of mind and body relatedness underpinning much of modern medical care. In this view, if a pathophysiological mechanism can be discerned, then 'mind' factors can be largely ignored. Recent evidence demonstrating intimate structural and functional relations between peripheral nerves and mast cells, and local skin secretion of mast cell-influencing neuropeptides by nerves, provides an argument for discarding old 'organic' and dualistic conceptualisations of CSU. A sound, integrative, multifactorial approach requires a unitive 'mindbody' model in which physical and subjective dimensions of personhood are seen as coexisting and equally deserving of exploration and management. Another influence is the tendency for 'psychosomatic' research studies in CSU to focus on patient experience using broad group-based diagnostic categories, such as anxiety and depressive disorders, and generic measures of stress. Two case examples are given, illustrating that CSU arises in relation to highly individual and relevant 'stories', which would not usually be picked up by these generic measures. It is suggested that an appropriate 'mindbody' management programme leading to good clinical outcomes for CSU is dependent on clinicians discerning unique patient 'stories'. Finally, a lack of formal studies comparing drug and 'mindbody' treatment outcomes will continue to negatively influence the adoption of 'mindbody' approaches in CSU. There is an urgent need for properly structured comparative studies, and the essential elements of a suitable 'mindbody' approach appropriate to such research are briefly outlined.