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
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
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
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.
1. Do your symptoms get worse--or better--with emotional turmoil?
2. Is your condition more stubborn, severe, or recurrent than your doctor
3. Are usually effective treatments not working for you?
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
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 find you strikingly stoic, unruffled, or computer like in the face
of stressful life events?
9. Is your level of distress and concern about the problem strikingly high or
10. Is your skin worse in the morning, suggesting that you rub or scratch
unintentionally at night?
11. Do you have trouble following your health care 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 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.
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
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
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
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
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
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.
Return to Book page