Your skin: sensing & responding to the world around you

Author: Dr Ted A Grossbart

Date: Oct 2010

It's easy to think of the skin as a mere wrapping to protect the sensitive organs inside the body, but to understand its problems, you must realize that the skin is itself an organ, just like the heart, lungs, and liver. It is the body's largest organ, in fact, and perhaps its most sensitive.

The outermost layer of skin, the epidermis, is constantly renewing itself with cells that move upward from the tough dermis, which largely consists of connective tissue. Beneath the dermis, subcutaneous tissue stores fat to provide energy and insulation.

Like other organs, the skin plays its part in the complex biological orchestra of life processes. Its sweat glands relieve the body of salt, water, and waste products. With energy from the sun, it converts a cholesterol-like chemical to bone-building vitamin D. Recent research suggests that the skin plays an unsuspected role in activating immune system cells that protect the body from disease.

What makes the skin unique among organs is its exposed position up against the outside world. Other body organs can function only in a controlled, protected environment where the temperature never varies far from 98.6 degrees Fahrenheit. The skin maintains this environment, and to do so, it must be able to take on temperatures ranging from dry desert heat to bitter cold. It must be exquisitely sensitive to its surroundings: when the outside temperature rises, blood flow through the skin must increase and sweat glands must secrete liquid whose evaporation will keep the inner temperature from also rising; when the temperature dips, vessels must constrict to conserve body heat.

To sense and respond to the outside world, the skin is richly supplied with nerve endings that link it intimately with the body's control center, the brain. Messages from sensors on the skin tell the brain that the temperature has dropped or something sharp is in contact with the hand; messages from the brain immediately take steps to conserve heat or pull the arm back for protection.

Thanks to its close connections with the nervous system, the skin is acutely sensitive to emotional events as well. It turns pale and clammy when we experience fear (the "cold sweat" of anxiety), it blushes when we're embarrassed, and it glows when we're happy. Anger, depression, and elation cause subtle and measurable changes to the skin.

Mind and body, sickness and health

Actually, all body organs respond to emotion, directly or indirectly, and this interconnection of mind and body may be the most important rediscovery (Hippocrates knew it; like many truths, it was often ignored for centuries) of modern medicine. Even conservative physicians now recognize that emotionally stressful events can lay the body open to various diseases, from infection to heart attack. Modern healers prescribe relaxation exercises for high blood pressure and use hypnosis to quell pain that resists the strongest drugs. To prevent heart disease, we're advised to delete not only cholesterol from our diets but hostility and over-competitiveness from our behavior.

Medical research has linked troubled minds and troubled bodies. In one study, husbands of women who died of breast cancer showed a marked depression of immune defenses during the period of grief that followed their loss. Accumulating evidence links personality type with vulnerability to heart disease and cancer. Another study found that when people visited faith healers, antibody levels rose in their bloodstream. Your emotions, thoughts, and beliefs can make you sick or well.

Given the skin's intimate bonds with the nervous system, the role of the mind in skin disease should be small surprise; all the more so when you consider that psychologically as well as physically the skin is your boundary with the world outside, at which every act of love, hate, work, and play takes place. You touch the world and the world touches you through your skin; it is here that you experience pleasure and pain. The skin is at once your most public organ, the face you show all the world, and your supremely private territory: baring and caressing the skin is the very image of intimacy.

When something goes wrong with the skin--hives, eczema, warts, or whatever--my experience as a psychologist has taught me to keep the skin's double life, as emotional and physical organ, in mind; to remember that emotional difficulties can cause some skin diseases; and that even when the cause is clearly physical (such as from heredity, infection, or chemical irritation), it may trigger attacks or make them more severe.

Let me explain. "Emotional difficulties" doesn't mean "feelings." No matter how painful, feelings themselves cause us less trouble than our efforts to protect ourselves from them. When we don't experience the pain of difficult events,when we don't feel our feelings,we are much more prone to develop physical symptoms, including skin disorders.

Remember the Law of Conservation of Matter and Energy from high school physics? Matter and energy can't be destroyed but can only change form. Burning can turn wood into light and heat and pounds of fat can turn into energy we expend while running. Our minds and bodies are governed by what I call the Law of Conservation of Emotional Energy. We can push away the anger we're afraid will get out of control, the sexual urges we've been taught are bad, the emptiness and longing for love that parents withheld, but we can't destroy them. The feelings find their own way out to the surface, often through the skin.

Your skin, in fact, leads an emotional life of its own filled with the feelings you've avoided to protect yourself against pain. Your skin feels for you: it cries and rages; it remembers events so painful you've swept them under the rug of consciousness; it punishes you for real or imagined sins. Your skin can't talk in words but its emotional language may consist of warts or an "angry rash" of eczema or an outbreak of shingles or psoriasis.

How does emotional turmoil cause, trigger, or heighten symptoms? Researchers are actively exploring this mystery; a key discovery seems to be the body's ability to turn intensely experienced ideas and fantasies into physical realities. (If you imagine someone is breaking into your apartment, your body will go into high alert, even panic, just as if the threat were real.)

In a classic experiment, Japanese physicians Ikemi and Nakagawa hypnotized volunteers and told them that a leaf applied to their skin was a toxic plant, such as poison ivy. The plant was harmless but the subjects' skin became red and irritated. The same experimenters applied the real toxic plant to other subjects' skin after telling them it was innocuous. The expected biological reaction did not take place.

A wide range of skin symptoms have been produced and relieved experimentally with the focused mental power of concentration and suggestion. As early as 1928, Heilig and Hoff of the University of Vienna used hypnosis to alleviate outbreaks of oral herpes (cold sores). In an experiment, they could also trigger outbreaks in these patients by reminding them, under hypnosis, of the painful events that had triggered them originally (such as a death in the family) and of the itching and tingling that usually comes just before the sore appears.

Kaneko and Takaishi of the Osaka University Medical School used a similar procedure with hives. Fourteen of the twenty-seven patients they treated made complete or near-complete recoveries; only five reported no benefit. They too could bring the symptoms back with hypnosis, either by suggesting skin irritation directly or by bringing to mind situations that aroused anger.

No, I am not the first to relieve skin problems with psychological therapies. Some two dozen scientific reports, including several large-scale studies, describe successfully treating warts this way. In recent years, more and more researchers have applied these techniques to a wider variety of symptoms. For example, the British physicians Brown and Bettley found that many eczema patients improved markedly when psychotherapy was added to their regular medical care.

What can this book do for you

Rather than dividing illness into "emotional" or "psychosomatic" and "physical," I think of emotions as a factor in all skin problems. Emotional difficulties may be the sole cause of few symptoms but they play a role, major or minor, in the flare-ups of many, perhaps most. Emotional factors sometimes cause, and frequently can reduce or intensify, itching and pain even when the physical disease itself remains unchanged. All skin problems have emotional impact, regardless of cause.

How important is the emotional factor in your illness? The more of these questions you answer yes, the more significant the factor.

Ask yourself

Do your symptoms get worse--or better--with emotional turmoil?

Is your condition more stubborn, severe, or recurrent than your doctor expects?

Are usually effective treatments not working for you?

Do most treatments work but not for long?

Is each disappearing symptom quickly replaced with another?

Do your symptoms get better or worse in a very erratic, seemingly nonsensical way?

Do you see striking ups and downs in your symptoms with changes in your social environment: vacations, hospitalizations, business trips, or the comings of family members or bosses?

Do people find you strikingly stoic, unruffled, or computer like in the face of stressful life events?

Is your level of distress and concern about the problem strikingly high or conspicuously absent?

Is your skin worse in the morning, suggesting that you rub or scratch unintentionally at night?

Do you have trouble following your health care provider's instructions?

Do you do things you know will hurt your skin, such as squeezing pimples or overexposing yourself to sunlight?

Do you feel excessively dependent on your dermatologist or excessively angry with him or her? (Even if the faults are real, are you overreacting?)

Does it seem that others notice improvements in your skin before you do? Is it hard for you to acknowledge when your skin has improved?

The more of these questions you answered positively, the more likely a candidate you are for the Skin Deep program, but even if most or all of these questions don't apply to you, this psychological approach will offer three important kinds of help:

Exercises to help you focus on the hidden role of your emotions in the disease itself. Are they causing, triggering, or heightening outbreaks? You'll learn to know yourself and use this knowledge to make your skin better.

Techniques to reduce itching, scratching, burning, and pain,regardless of their source.

A systematic method to reduce the emotional impact of your illness so you can cope better and suffer less while your skin improves.

Small changes, big effects

A persistent illness reflects a stalemate between the forces of health and disease. That's why symptoms don't get progressively worse but never get entirely better. Such forces are complex: the cause of your eczema, for example, may be 50 percent hereditary susceptibility, 40 percent environmental irritation, and 10 percent emotional factor. Although the impact of the latter is relatively slight, improvement here can tip the balance in favor of health, promoting remission. It's like the way a drooping house plant comes vibrantly back to life when moved just a few feet into the light or away from the radiator.

If you have recurrent warts, shingles, or genital herpes, for instance, you're possibly free from symptoms most of the time: the balance is toward health, with the disease-causing virus held in check by the body's immune system. An emotional upheaval causes a temporary dip in defenses, allowing the virus to come out of hiding and cause an outbreak. You develop psoriasis only if you've inherited susceptibility to the disease, but about two-thirds of the time, what triggers an attack or flare-up is the emotional factor.

You can't change your heredity or eradicate the virus that causes warts or herpes but the psychological techniques presented here can minimize stress and turmoil and maximize healthy emotions to give you leverage for major improvements. By applying them, my patients have made warts disappear, extended the period between herpes outbreaks (or ended them altogether), banished hives, and made persistent skin infections less severe.

The theory is that we succeeded in focusing the mind, via relaxation and suggestion, to effect tiny changes in blood flow, body temperature, muscle tension, and immune function that made enormous differences in the physical processes that produce skin symptoms.

Symptom relief

Pain, itching, burning, and tenderness respond particularly well to my approach. Doctors have long noted that these symptoms don't necessarily correspond to the severity of their physical causes. After an injury has healed completely, for example, the pain may persist for years; eczema may remain physically severe while its itching diminishes. I've taught my patients to use techniques such as self-hypnosis and imaging to dramatically reduce pain and itching. Like them, you can learn to harness your imagination to bring cooling, soothing relief from the symptoms that cause you the most distress. You can do this for the most physical of diseases in the same way that doctors have used hypnosis to quell the pain of cancer and childbirth.

From body to mind

That your mind can make your body suffer may take some getting used to but few people question the reverse connection: the emotional anguish that attends any long-term physical illness. It is a blow to self-esteem to feel so vulnerable, especially when a disease restricts your ability to live in a normal way and achieve normal satisfactions. You may feel a sense of shame for your weakness: you suffer from feeling your body is not under your control. You may be forced by disease into a childlike dependency; you must look to your doctor for relief, as you once looked to your parents.

Skin diseases have a special power to torment. Appearance-altering illnesses, such as acne, eczema, psoriasis, and ichthyosis, can promote extreme shame and isolation. Vitiligo, for instance, is a depigmentation of the skin, purely a cosmetic problem in most cases, causing neither itching nor pain. Yet a study of patients found 40 percent reporting depression at its appearance.

Transmissible diseases heighten a sense of personal badness or dangerousness, as genital herpes illustrates all too dramatically. In a survey of herpes sufferers, 84 percent reported depression, 70 percent a sense of isolation, and 35 percent impotence or diminished sex drive.13 None of these are physiologically related to the disease; all represent a profound emotional reaction I call psychological herpes.

The root of its special turmoil, suggests psychiatrist Ted Nadelson, is the sense of "dirtiness" (absolutely without basis in fact) that attaches to skin disease but not to ulcer or heart attack. Dirt, according to Freud, is "matter in the wrong place" (contrast drinking a glass of water with spitting into it and then drinking). Your skin is the boundary between the inside of your body and the outside world; a sore or eruption seems, in fantasy, as if these internal contents have spilled out?they are out of place and thus dirty. Because this kind of dirt cannot be washed off, it seems particularly loathsome.

From toilet training onward, we're taught to associate "clean" and "dirty" with good and bad. The saying that cleanliness is next to godliness expresses a deeply rooted belief. The dirt that appears in skin disease feels like the dirty, shameful part of ourselves, the impulses, that we've been taught to keep contained within. It seems as if we cannot control our bodies or our impulses or hide the deep parts of ourselves that others manage to keep out of sight.

Skin diseases are no more dirty, shameful, or reprehensible than pneumonia or diabetes, of course. Were we purely rational beings, any disease would seem a bodily problem to be treated and survived, no more and no less. However, none of us are such beings: our emotions are what make us human, and shame, guilt, anger, and despair are part of the heritage.

The physical toll of skin disease is bad enough and its emotional turmoil compounds the pain. If you're like many of my patients, you're adding a totally unnecessary layer of misery with self-criticism. "It's minor medically, I must be psycho to make such a big deal out of it," they say. "I don't have such a bad case but I'm so depressed. My parents always complained I was `oversensitive.' I guess they were right."

I'll tell you what I tell them: If even a minor skin disease is making you feel depressed, anxious, or otherwise upset, you're just reacting normally. Spare yourself the added burden of blame for feeling what anyone else would feel in your place.

Different skin diseases carry their own brands of torment: a person with genital warts may brood about contagion but he's spared the visible stigma that bedevils the woman with acne. Severe itching is invisible to others but can become a life-consuming obsession. Here are seven emotional reactions I see most often:

1. "I'm bad. No one will love me." People with skin diseases commonly reproach themselves with terms such as "outcast," "leper," "damaged goods," "reject," "disgusting," or "pizza face." They feel defective and hopeless; the more visible or contagious the problem, the worse the feeling. "No one will want to go out with me. I'll never get married. My chances at a normal life are shot," they think.

2. "I hate the world. I hate myself." People with communicable diseases such as venereal warts and herpes often harbor rage against those who infected them: some become bitter and cynical about the opposite sex and a few even transmit the disease intentionally. People with psoriasis and ichthyosis, which are hereditary, may rage against their parents. Pain, itching, marred appearance, and disability can provoke a deep anger against the disease and the world of "normal" people. The anger sometimes turns inward. While few people are at risk of killing themselves, a far more common danger is fractional suicide. Despairing sufferers kill off little pieces of themselves: a passion is allowed to cool; a hobby is abandoned; an opportunity for pleasure or success is ignored.

3. "I'm so alone." Skin sufferers frequently withdraw from social life, casting themselves as lepers who have no place among decent folk, and the insensitive or irrational reactions of others compound the problem. It is particularly common to feel that "No one who doesn't have my disease can understand how I feel." A Swiss study of people with a range of skin disorders found their circle of friends diminished dramatically; they typically made no new friends after the disease appeared. Many people resigned from clubs and organizations when symptoms started, exchanging social activities for solitary pursuits, such as walking, stamp collecting, and reading.

4. "My life is hopeless." Powerless to change their skin symptoms for the better, many people extend a feeling of despairing impotence to all the challenges of adult life. A lengthening history of unsuccessful treatments deepens this sense of hopelessness.

5. "It's all because of my skin." Sufferers often blame their skin disease for everything that's wrong with their lives, bathing "the good old days" in a false glow. A man may believe his social isolation is caused by his eczema when actually he was withdrawn and fearful of dating long before the symptom became troublesome. Preexisting sexual problems, depression, and anxiety are easily lumped together as the fault of the illness, making it doubly difficult to relieve either skin symptoms or real-life problems.

6. "My disease means . . ." The search for meaning in misfortunes is human and healthy, but if allowed to run wild, it causes trouble. Abetted by well-meaning friends and family who suggest, "everything happens for a reason," many skin patients falsely conclude they're being punished for their sins or victimized by a malevolent fate.

7. "It's an avalanche." In any disease where emotions play a role, anxiety about recurrences or flare-ups can trigger exactly what is feared: it's a self-fulfilling prophecy. Panic about the illness can infect the whole sense of one's life, it may seem that everything is caving in at once. Less dramatically, the anxiety-disease-anxiety cycle can simply prevent symptoms from getting better.

Only the most philosophical of us can hope to ride through illness without emotional turmoil. The more you learn to understand these feelings, however, the better control you can achieve over them. Even while you're still in pain, tormented by itching, or unavoidably aware of your marred appearance, you can shed some of the self-blame, fear, and anxiety that seemed to come with the territory.

One secret is getting to know your emotional weak points. Anyone may suffer embarrassment when he or she must present a blemished face to the world, but a person whose self-esteem is low to begin with will endure a special distress. If your upbringing made you uncomfortable about your sexual needs, genital warts or herpes may provoke an extra dose of agony. Knowing why you suffer your larger-than-life torments is the first step toward cutting them down to size.

Understanding your conflicts, needs, and fears, understanding your skin's emotional life, is also the most important first step toward controlling the psychological factors that cause, trigger, or aggravate your disease. For this reason, self-diagnosis is the groundwork of my program. In the chapters to follow, you'll learn why "know yourself" is a key part of the prescription for healthier skin.

Dr Ted A Grossbart, PhD is a licensed clinical psychologist in private practice in Boston. He is a Senior Associate and Clinical Supervisor for Beth Israel Hospital's Department of Psychiatry, and an Assistant Clinical Professor of Psychology at Harvard Medical School. A Phi Beta Kappa graduate of the University of Michigan, he received his MA and PhD in clinical psychology from Boston University.

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