to the surface before they have the time to fully mature. Frantic overproduction
causes constant flaking.
The exact link between slowing down emotionally and the skin's slowing down
is not clear medically, but this connection helped each of these people make dramatic
improvements. Slow down, see what monster catches up with you, then reevaluate if
you and your skin really need to keep running. What are you so frightened of? What
support will you need from the inside and the outside to hold your ground and face
the monster? Be sure and ask these questions as you do the other diagnostic and
treatment exercises.
clv
For the basic description and conventional treatment of each disease, I have used Fitzpatrick,
"Fundamentals of Dermatologic Diagnosis," and Arndt, Manual of Dermatologic Therapeutics. For an older but
comprehensive and thoughtful summary of the psychological side of any skin problem, try to find a copy of
Obermeyer, Psychocutaneous Medicine.
clvi
See Updike, "Personal History," for an incisive account of lifelong wrestling with psoriasis.
clvii Stanker, "The Effect of Psoriasis on the Sufferer."
clviii R.D. Braughman and R. Sobel, "Psoriasis: a Measure of Severity," Archives of Dermatology 101 (1970):
390-393.
clix
I.H.Ginsburg and B.G. Link, "Feelings of Stigmatization in Patients with Psoriasis," Journal of the
American Academy of Dermatology 20,1 (1989).
clx
Seville, "Psoriasis and Stress."
clxi
M.A. Gupta, "A Psychocutaneous Profile of Psoriasis Patients who are Stress Reactors," General
Hospital Psychiatry 11-3 (1989).
clxii Frankel and Misch, "Hypnosis in a Case of Long-Standing Psoriasis"; Kline, "Psoriasis and
Hypnotherapy"; Kohli, "Psoriasis: A Physiopathologic Adaptive Reaction"; and S.A. Winchell and R.A. Watts,
"Relaxation Therapies in the Treatment of Psoriasis and Possible Pathophysiologic Mechanisms," Journal of the
American Academy of Dermatology 18-1-1(1988).
clxiii Coles, "Group Treatment in the Skin Department."
clxiv Dermatology Perspectives 5-6 (1989): 6-7.
clxv
S.A. Winchell and R.A. Watts in a reply to the editor, published in the Journal of the American Academy
of Dermatology 19-3 (1988): 573-574.
clxvi J.D. Bernhard, et al., "Effectiveness of Relaxation and Visualization Techniques as an Adjunct to
Phototherapy and Photochemotherapy of Psoriasis," Journal of the American Academy of Dermatology 19-3
(1988):·572-573.
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19. Warts and Herpes:
A Tale of Two Sexually Transmitted Diseases
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19 Warts and Herpes:
A Tale of Two Sexually Transmitted
Diseases
We are in the midst of a worldwide epidemic of sexually transmitted diseases. At
least two of its major diseases are helped by psychological techniques: twenty-six to
thirty-one million Americans have genital herpes; forty to fifty million Americans
have venereal warts.
We must carefully distinguish between having the virus and having the
symptoms. The both creepy and reassuring reality is that we all swim in a sea of
viruses not only outside us but within us. If you have ever had chicken pox,
mononucleosis, or other such diseases, the virus is now in your body. Usually its
presence has no impact. Although recent figures are lower, at one time as many as 90
percent of Americans had the herpes virus for cold sores in their bodies. Perhaps
two-thirds of the people who have the possibility of genital herpes have had one or
several outbreaks but do not have subsequent symptoms.
Warts are caused by forty or fifty variants of the human papilloma virus (HPV).
While its story is not as clear as herpes, a vast percentage of the world population has
had a wart at some time. A British study found that 16.2 percent of schoolchildren
had active warts (it is not clear how many had the virus in their bodies but not
active).clxvii As many as 30 percent of American women may have the virus for
venereal warts within their bodies.
Here enters the immune system. Its job is to maintain law and order. When it is
functioning well, all of these microscopic predators are kept in their place. It puts an
end to herpes recurrences and often produces the spontaneous remission of warts.
The emerging field of psychoneuroimmunology studies the impact of psychological
factors on the immune system's ability to function effectively.clxviii
Preventing transmission and knowing what to say to sexual partners require
both specific information and personal judgment. The guidelines are being updated
as new research comes in, so consult your healthcare provider. The key to avoiding
transmission is having the partner avoid contact with affected skin when the virus is
present. Condoms are effective if they cover the affected area, and nonoxynol-9
spermicides also kill the virus.
A common rule for genital herpes was to avoid intercourse or other contact with
the affected skin from the start of the prodrome (tingling, muscle aches, or other
indications of a coming recurrence) until two days after the healing of sores. This has
been complicated by a growing awareness of the role of asymptomatic transmission
– that is, transmission with no visible sores. It is not clear how common this is. One
study concluded that it is quite rareclxix yet another called it the major source of
transmission.clxx The danger of asymptomatic transmission appears to diminish
sharply after the first six months. The clear message is that there is no clear message.
Venereal warts present similar ambiguities. Warts seem to differ in their
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incubation periods (how long after exposure you see them) and the presence of virus
after apparent clearing. One rule of thumb is to consider the virus as possibly
transmissible for six months after possible exposure and for the same time period
after visible symptoms have gone away.
Let's first cover some of the common nonsolutions to these ambiguities:
Official or unofficial self-imposed celibacy: Avoid all encounters,
flee when sex is on the horizon, or just don't ever find anyone
who turns you on.
Limit yourself to a series of casual sexual partners, telling yourself
that they don't need to know.
Only get involved with people whom you don't care about being
rejected by.
Find someone who is comfortable with the problem and stay with
him or her, even if you know the relationship is going
nowhere.
Whom do you tell, what, when, and how? What information do you owe to a new
lover? Does using a condom change things? What if your herpes or warts are not on
the scene this week, this month, this year, this decade? These intensely personal
questions cannot be answered by formula or appeal to authority. Only you can make
the decision.
What I do offer as a guideline is one of the oldest approaches to moral dilemmas:
"Do unto others as you would have them do unto you." Imagine that your positions
were reversed; that your sexual partner was the one weighing what to say and do.
Consider each of the options with them in your shoes and then act accordingly.
The Herpes Resource Center (see Appendix IV for the center's address)
newsletter, The helper (Summer 1987), suggests ways to make telling a partner
easier:
Try and develop a positive, self-accepting attitude toward the
problem. (You can't ask someone to accept something you
haven't accepted yourself.)
See the affirmative side of sharing this information. Remember, you
are clearly exhibiting trust in a new (or prospective) partner.
That is the first step toward intimacy.
Be well-informed. The ability to answer your partner's questions
thoroughly goes a long way toward building mutual
confidence.
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Use outside information sources. They can reinforce information
and offset fear and anxiety.
Try to avoid predicting or presuming a partner's reaction. To
assume that he or she will necessarily be upset can be a self-
fulfilling prophecy.
Another good rule of thumb is to pick a low-key, neutral, nonsexual time and
place to raise the issue.
Both herpes and warts introduce extra complications in pregnancy. Neither of
the most useful drugs, acyclovir for herpes or podophyllum for warts, are approved
for pregnant women. Extra precautions are important to protect the baby from the
virus. The suspected link between herpes and cervical cancer has not been
supported. The links between genital and anal cancers and warts appear to be more
substantial.
All forms of warts and herpes raise the question of transmission from one part
of your body to another (autoinoculation). This is fairly hard to do, so while it is
important to exercise good hygiene, don't drive yourself crazy about it. Ocular herpes
does exist and is the most common infectious cause of blindness, but it is rare and
virtually never is transmitted from oral or genital recurrences. Precautions – don't
touch your eyes after touching active sores; don't put contact lenses in your mouth if
you have a cold sore – are worth observing anyway.
Increasing evidence suggests that any condition that produces breaks in the skin
of the genitals can increase vulnerability to any other sexually transmitted diseases,
including AIDS. Because herpes is a fast-spreading disease involving the genitals and
is recurrent, its psychological impact can be devastating. In a survey conducted by
the Herpes Resource Center, 84 percent of people with herpes reported depression,
and 42 percent deep depression; 25 percent said they had self-destructive feelings;
35 percent reported diminished sexual drive and 10 percent withdrew totally from
sexual involvements; and 70 percent reported a sense of isolation. Work
performance suffered for 40 percent.clxxi
Such turmoil may markedly turn the course of the disease for the worse.
Depression and other emotional upsets may impair the immune system that
otherwise keeps the virus in check.
Anxiety about recurrences may trigger what is feared – a phenomenon I call
"avalanching." When a Time cover story about herpes appeared, it aroused shame,
anger, and anxiety in people with the disease – and a number of my patients suffered
recurrences as a result.
Knowing that emotional turmoil triggers recurrences, people will unjustly
torment themselves for feeling tormented. Similarly, people need to identify and
reverse agglomeration, blaming the disease for everything wrong with their lives,
including sexual problems, depression, and social withdrawal, that they may have
needed help with even before they got herpes.
Not everyone with herpes reacts the same way, of course: like any disease, it
affects you most strongly where you're most vulnerable ― your emotional Achilles
heel. The disease gets tangled up with unresolved issues that have lain beneath the
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surface since childhood, creating a double dose of turmoil.
It is vital to ask yourself what the symptom is doing for you as well as to you. I
can cite many instances where recurrences played the role of sexual policeman,
inflicted self-punishment, or resolved conflicts. A twenty-eight-year-old artist wanted
to become a father, for example, but suffered a recurrence whenever his wife was
fertile: clearly, the virus was acting on behalf of his doubts about parenthood. A
twenty-six-year-old computer executive who harbored deep fears of intimacy
endured recurrences whenever he met a woman who threatened to engage his
affections by exciting him both sexually and emotionally. A religious forty-two-year-
old advertising executive found herself drifting into an affair with a married man; she
felt tom between passion and principle, until her herpes resolved her dilemma.
Venereal warts also often play the role of sexual policeman. They orchestrated
one patient's ambivalence between his wife and girlfriend: whenever he was ready to
return home, warts on his penis flared up and made his wife reluctant to take him
back. With the hypnotic suggestion that he handle the situation directly, the warts
vanished within three weeks. A twenty-seven-year-old insurance adjuster suffered
from anal warts and a fear of anal intercourse. Once he accepted the fact that he was
in control – no one would subject him to anal rape so the warts were unnecessary –
they vanished in two sessions.clxxii
Our understanding of psychological treatment of genital herpes and venereal
warts has been helped by research on the nonsexually transmitted versions going
back to the 1920s. The viruses' responsiveness had been staked out well before the
sexually transmitted versions ever reached epidemic proportion.
Biological factors help determine why some people never have herpes
recurrences or warts while others have them ceaselessly. Different variants of the
virus seem to be more prone to create symptoms and to be better adapted to thriving
in one or another body part. For many people, emotional factors are critical in
determining the frequency and severity of recurrences.
In 1928, two Viennese physicians didn't stop with using hypnosis to alleviate
oral herpes symptoms. They also demonstrated that hypnotic suggestions could
experimentally trigger recurrences.clxxiii
More reports appeared sporadically for the next fifty years. Then in 1981 at the
University of Bologna, Arone Di Bertolino used hypnosis for nine patients who
suffered genital herpes recurrences weekly or bimonthly. One and a half months after
treatment, six had no recurrences, three only one or two.
Early successful treatments of nonvenereal warts also date back to Europe in
the late twenties. The best controlled experimental demonstration of hypnotic
treatment of nonvenereal warts was done here in Boston in 1973.clxxiv After five
weekly hypnotic sessions, 53 percent of patients were wart-free. The untreated
control group was unchanged.
A later study tried to pin down the "active ingredients" and predictive factors in
hypnotic wart treatment. As well as confirming the effectiveness of hypnotic and self-
hypnotic treatment, the study found that the ability to form specific images vividly
was more important than general measures of hypnotic ability. Interestingly, people
with more warts got better results. clxxv I have found common warts to be the most
responsive of all the problems that people bring. They often arise at times of
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developmental challenges, transitions, or blocks. Quite often people become able not
only to make their warts disappear but simultaneously to get their lives back into
gear.
Nonsexual warts are probably the best researched and accepted application of
the techniques in all of dermatology, so it is puzzling that almost nothing is being
done to apply this to people with venereal warts. The two clinical reports that have
been published are very promising.clxxvi I have had good results with the few people
who have come in, but there is some block in the minds of both physicians and
patients.
Most people are looking for their warts or herpes to go away first, but real gains
can be made on other levels, too. I think of genital herpes as three diseases: medical
herpes, an infection caused by a virus; psychological herpes, the emotional impact of
the disease; and media herpes, the burden of being a central player in a modern
morality play, complete with the wages of sin, lepers and whores, and scarlet letters.
A graphic demonstration of the pain of media and psychological herpes versus
medical herpes was provided by a woman in my group who had been infected some
years earlier. She had always dismissed the misdiagnosed outbreaks as a
nondescript, vague annoyance, but from the moment her herpes was correctly
diagnosed, she was plunged into turmoil and anguish.
Most people with venereal warts have to grapple mainly with the medical and
psychological versions, but especially in the era of AIDS, any sexually transmitted
condition can come with the extra baggage of fear and shame.
At the writing of this second edition, some of the herpes hysteria has settled
down, but it is not entirely clear that this has translated into a lessened impact on
individuals. I frequently hear, "I know I shouldn't be feeling so upset about my
herpes; after all, it's not a big deal medically and it isn't AIDS." So now they suffer a
double dose: they're not only upset about the herpes but also because they
"shouldn't" be so upset.
Support and mutual help groups have become an established approach for
helping people with genital herpes (see Appendix IV). The Herpes Resource Center
actively supports research with direct support and congressional lobbying, it
maintains a hot line, it publishes The Helper, an excellent newsletter, and it supports
local help groups and educational conferences.
There are now similar support groups for those afflicted with venereal warts
(see Appendix IV).
LEGAL ISSUES
The legal implications of sexually transmitted diseases are developing rapidly. In
some states, it is a criminal offense to transmit a sexually transmitted disease (STD).
A growing number of people have successfully sued the person who infected them
without informing them of the possible risk. This is a very complicated matter legally,
psychologically, and sociologically. I served as an expert witness in a case that was
successfully settled out of court. While each instance needs to be examined
individually, I came away convinced that there are instances in which legal action,
although quite demanding emotionally, is ultimately therapeutic.
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Two of your reasons for hesitation may be smaller obstacles than you imagine:
the case can be "sealed," with proceedings behind closed doors, and your name not
be used. You may imagine that your mental state either before or after transmission,
could be used to make you look bad. Quite the contrary, your present turmoil may
well be part of the damages for which you should be compensated. If you were in
rough shape before transmission that also may help your case. The legal doctrine of
the "eggshell plaintiff" states clearly that damages resulting from preexisting
vulnerability deserve compensation. You were who you were at the time and that is
no excuse.
No news is all good or all bad. We've looked at possible advantages of sexually
transmitted skin problems like the "sexual policeman." These are ironic advantages:
they give us things we may feel we need but are better off without. There are also
other more straightforward advantages. Certainly few would argue that they are
actually worth the aggravation of having the problem; think of them more as a
compensation or partial payback. Here are some in the words of the people who
discovered them:
"I'd probably still be doing the bar scene if my STD hadn't brought
me up short and forced me to look at what I was running
from."
''When we couldn't have intercourse, my husband and I discovered
a whole wealth of sexual activities and subtleties that we'd
lost."
"I am now a better human being, more open, compassionate,
caring, and honest. Looking back, I used to be a real shit."
"I'm much more in touch with my body's needs than I ever was
before I got it. 'Stress control' used to be just a Yuppie cliche.
No more."
"It forced me to learn to talk honestly about sex, and that ability has
carried over to other areas."
"Getting herpes heightened my self-hatred to the point that I had to
get into psychotherapy. It changed my life."
Tuning in to the upside (without whitewashing the downside) may increase
your body's ability to handle viruses. Silver linked active coping (versus resignation
or wishful thinking) to improved outcome for people with ten or more herpes
recurrences a year.clxxvii Kemeny and associates linked depression, fewer suppressor
T cells, and more frequent herpes recurrences.clxxviii
clxvii Rulinson, "Warts: A Statistical Study"
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clxviii Locke and Colligan, The Healer Within.
clxix Ikemi and Nakagawa, "A Psychosomatic Study"
clxx
Bray, personal communication.
clxxi Herpes Resource Center of the American Social Health Association, The Helper (1981): P.O. Box 13827,
Research Triangle Park, NC 27709.
clxxii D.M. Ewin, "Condyloma Acuminata: Successful Treatment of Four Cases by Hypnosis," American
Journal of Clinical Hypnosis 17-2 (1974): 72-78, is a very important paper. These warts are far more common
than I had first realized and are also predisposed to some cancers.
clxxiii Heilig and Hoff, "Uberpsychogene"
clxxiv Surman, et al., "Hypnosis in the Treatment of Warts"
clxxv N.P. Spanos, et al., "Hypnosis, Placebo, and Suggestion in the Treatment of Warts, Psychosomatic
Medicine 50 (1988): 245-260.
clxxvi Ewin, "Condyloma Acuminata" and A.J. Straatmeyer and N.R. Rhodes,"Condyloma Acuminata: Results
of Treatment Using Hypnosis," Journal of the American Academy of Dermatology 9 (1983): 434-436.
clxxvii P.S. Silver, Journal of Psychosomatic Research 30-2 (1986).
clxxviii M. Kemeny, et al., Psychosomatic Medicine 51-195