THE STORY
BEHIND
YOUR
SKIN
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CONTACT DR.
GROSSBART
I'm available to answer your questions.
You may want help finding a local therapist with
special skills, have reached an impasse, or just
want to let me know how it's going.
In addition to my Boston practice, I work by
telephone with people around the world. Working
together, it is quite likely we can get you the relief you've been hoping for.
Ted A. Grossbart. Ph.D.
Harvard Medical School
Email:
ted@grossbart.com
Web:
http://www.grossbart.com
Phone:
(617) 536-0480
BUY THE BOOK
Want to own a copy of Skin Deep? Buy the
paperback from Health Press.
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1 Your Skin: Sensing and Responding to the
World Around You
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.i
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 supplied with nerve
endings that link it intimately with the 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 modem
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
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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.ii 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 bloodstreams.iii Your emotions, thoughts, and beliefs can make you sick – or
well.iv
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
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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.v
A wide range of skin symptoms have been produced – and relieved –
experimentally with the focused mental power of concentration and suggestion.vi 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.vii
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.viii
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.ix 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.x
WHAT THIS BOOK CAN 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:
1. Do your symptoms get worse – or better – with emotional
turmoil?
2. Is your condition more stubborn, severe, or recurrent than
your doctor expects?
3. Are usually effective treatments not working for you?
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4. Do most treatments work but not for long?
5. Is each disappearing symptom quickly replaced with another?
6. Do your symptoms get better or worse in a very erratic,
seemingly nonsensical way?
7. 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?
8. Do people fmd you strikingly stoic, unruffled, or computerlike
in the face of stressful life events?
9. Is your level of distress and concern about the problelem
strikingly high or conspicuously absent?
10. Is your skin worse in the morning, suggesting that you rub or
scratch unintentionally at night?
11. Do you have trouble following your healthcare provider’s instructions?
12. Do you do things you know will hurt your skin, such as squeezing pimples
or overexposing yourself to sunlight?
13. Do you feel excessively dependent on your dermatologist or excessively
angry with him or her? (Even if the faults are real, are you overreacting?)
14. 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:
1. 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.
2. Techniques to reduce itching, scratching, burning, and pain –
regardless of their source.
3. A systematic method to reduce the emotional impact of your
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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 houseplant 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 out break. 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, 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.xi
From Body to Mind
That your mind can make your body suffer may take some getting used to but few
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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 de-pigmentation 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.xii
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.xiii 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.xiv
Skin diseases are no more dirty, shameful, or reprehensible than pneumonia or
diabetes, of course. Were we purely rational beings, 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
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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.xv
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 bel