Psychotherapy In Skin Diseases





The place of mental influence in the treatment of skin diseases will

be best realized from the role that we know the mind plays in the

production of various skin manifestations. There is a whole series of

skin affections which depend to a considerable extent on mental

conditions, worries, anxieties, shocks, frights and the like, and a

number of skin affections that have been labeled hysterical which

occur in nervous persons, due to over-attention to self and their

conditions. It has been well said that it is possible to make the feet

warm by thinking about them. Certainly attention to any part of the

skin surface causes a tingling and hyperemia may follow. Blushing is

an illustration of mental influence on the skin, and anything that

would tend to make this endure for some time would give rise to

erythematous conditions. We know the creepy, uncomfortable, hot

feelings that come over us in times of suppressed excitement when we

are waiting for something to happen; and, on the other hand, there is

a pallor and tremor that accompanies fright or fear, which points to

mental influences over the vasomotor system in the skin.





Urticarias.--Certain skin diseases, especially those allied to the

urticaria group, are prone to occur in connection with excitement and

worry. In the chapter on Neurotic Intestinal Affections attention is

called to the fact that many patients who suffer from intestinal

idiosyncrasies and have excessive reactions to special kinds of food,

as cheese, strawberries, or the like, sometimes also suffer from skin

lesions and intestinal disturbance through worry or excitement. While

preparing for examinations or undergoing some physical trial or

suffering from worry or anxiety such persons may have urticaria or

even wheals on the skin. There may be some dietary disturbance to

account for them, but they would not occur, or at least would not be

so serious and annoying, but for the disturbed mental condition. Under

these circumstances dermatographia is a common manifestation. It used

to be considered a symptom of many physical conditions, but will occur

in almost any nervous person during the course of an examination by a

strange physician or when some important medical decision is pending.





Eczema.--Not only these passing conditions of the skin, however, but

more lasting affections have been connected with mental disturbance.

Probably every skin specialist has noted in a number of his cases that

a first attack of eczema came after a period of worry or excitement,

or sometimes followed directly on a fright. When relief from the

condition has been brought about by treatment, relapses occur

during periods of business worry or family anxiety or mental stresses

of one kind or another. Cabinet crises in England are found to be

likely to be followed by the recurrence of eczematous conditions in

older members of the Cabinet or by first attacks in some of those

whose skin has been irritated by some internal condition. Unless

business worries can be removed or family anxieties allayed the cure

of eczema becomes a difficult matter. Men or women who worry about

their eczematous condition apparently prolong it. This is particularly

true if they have little to do and are likely to be much occupied with

themselves and their condition.





Herpes.--Herpetic conditions resemble urticaria in their response to

mental conditions. Herpes preputialis and herpes progenitalis occur

particularly in people who worry over the possibility of some

infection of the genitals. The lesions are likely to be indolent until

the state of mind with regard to them is relieved by reassurance as to

their comparatively innocuous character. Even herpes zoster is prone

to come on after a period of worry and anxiety. It is due to

infection, but the infection becomes more possible after a lowering of

resistive vitality in the nervous system. This is particularly true as

regards herpes facialis. It has been noted again and again that facial

neuralgia is most likely to occur after fright, deep emotion, or

prolonged anxiety. Treatment of these cases will only be successful if

the mental state is set right. This is particularly true with regard

to Bell's palsy. Patients who worry much about it and who fear that it

may have lasting results are likely to prolong its course and to put

off complete cure for a good while.





Vasomotor Disturbance.--There is a series of skin affections connected

directly with the vasomotor system of the skin which are largely under

the influence of emotional or mental factors. These represent

particularly the milder forms of Raynaud's disease and the parallel

forms of Weir Mitchell's disease. In the one case there is a spasm of

the arterioles causing what the French call "dead fingers," and in the

other paralysis of the vasomotor system with venous congestion in the

parts. They are seen particularly in persons of highly nervous

organization and especially after periods of emotional strain or

stress. There is a series of affections related to these,

characterized by numbness, paresthesiae, going to sleep of the fingers

or members, tingling, and even milder forms of itchiness--sometimes

dignified as pruritus--which are largely due to mental factors. Some

physical condition will need to be corrected, but they will only

disappear if the mind is set at rest and if the patient is kept from

occupying his attention much with them. Concentration of attention

will make them chronic.





Scurvy.--Scurvy is not usually thought of as a skin disease, though it

has many local manifestations on the skin and mucous membrane. It is a

deep nutritional disturbance of such nature that it would seem the

mind could have but little influence over it. When scurvy was common,

however, it was often noticed that any change of attitude of mind in

affected persons brought amelioration or deterioration of condition.

Scurvy develops with special virulence during discouragement; it gets

better with the dawn of hope. It has been known to be much improved by

the prospect of a naval engagement when all the sick men wanted to get

into the fighting. The famous case of the Siege of Breda in 1625 is

often quoted. The city was about to capitulate because so many of the

soldiers were suffering from the disease. The Prince of Orange,

however, sent word that a new and powerful remedy had been discovered

that was sure to cure the affection, and that he had secured some of

it and it would not be long before they would all be well. What he

sent was a remedy that had been used with indifferent success for

scurvy when taken in large doses. He could send only enough to give a

few drops to each patient. This small dose was wonder-working in its

effect and proved to have the healing virtue of a gallon of the

liquor. Most of the patients got better and surrender was put off.





Warts.--A striking evidence of the influence of the mind upon the skin

is given by what we know of warts. All sorts of charms have been not

alone suggested for them but found to work in certain cases. Lord

Bacon in his "Natural History" tells the story of the charming away of

warts and exemplifies it by his own experience. When he was about

sixteen a number of warts--at least 100--came out upon his hands. One

of these had been there from childhood. The manner of their cure he

details as follows:



The English Ambassador's lady, who was a woman far from

superstition, told me one day she would help me away with my warts;

whereupon she got a piece of lard with the skin on, and rubbed the

warts all over with the fat side; and amongst the rest that wart

which I had from my childhood. Then she nailed the piece of lard,

with the fat towards the sun, upon a post of her chamber window,

which was to the south. The success was that within five weeks'

space all the warts went away, and that wart which I had so long

endured for company. But at the rest I did not marvel, because they

came in a short time, and might go away in a short time again; but

the going away of that which had stayed so long doth yet stick with

me.



Lucian, the Greek satirist, tells that warts were cured by magic in

his time. Carpenter in his "Human Physiology," page 984, says: "The

charming away of warts by spells of the most vulgar kind belonged to

those cases which are real facts, however they may be explained." Dr.

Hack Tuke in his "Influence of the Mind Upon the Body" says: "In

visiting a county asylum some years ago my attention was directed to

several of the patients who were pestered with warts and I solemnly

charmed them away within a specified period. I had quite forgotten the

circumstance until on revisiting the institution a few months

afterwards I found that my practice had been followed by the desired

effect and that I was regarded as a real benefactor." This feature of

the method of removing warts, setting a date before which they shall

disappear, is noted in most of the successful charms. Dr. Tuke tells

of a case in which a gentleman on shaking hands with a young lady

noticed that she had many warts. He asked her how many she had; she

replied about a dozen, she thought. "Count them, will you," said the

caller; and taking out a piece of paper he solemnly took down her

counting, remarking: "You will not be troubled with your warts after

next Sunday." Now it is fact that by the day named the warts had

disappeared and did not return.





Neurotic Pigmentation.--Pigmentation occurs very commonly as the

result of neurotic conditions. Dr. Champneys, in his article on

"Pigmentation of the Face and Other Parts, Especially in Women," in

St. Bartholomew's Hospital Reports, Volume XV, has illustrated this

very thoroughly. The pigmentations of women during the phases of

genital life, menstruation, pregnancy, the menopause and the fact that

eunuchs are usually fair and fat, while deep pigmentation in the white

race is usually associated with sexual irritability, all make

interesting studies in this subject. From comparative anatomy

and physiology the influence of the nervous system over pigmentation

has been very well illustrated. Bruecke in 1851 established the

influence of the nerves on the color of the chameleon and of the frog,

and there have been many confirmations of his work. Pouchet, in 1876,

in the Journal de l'Anatomie et de Physiologie proved that fish

gained the power of changing color by practice and lost it by disuse.

The influence in most cases, animal and human, which produces

pigmentation is exerted by the nervous system through the vascular

supply. The duskiness that sometimes comes with emotion, the pallor

that accompanies strong mental disturbance, as well as the blushing

states, show that the vasomotor system can be influenced in every

part. Pigmentation often seems only a consequence of local continuance

of such disturbance. Many of the feminine patients in whom even deep

discolorations around the eyes occur in connection with menstruation

are typical neurotic individuals. It is worry in combination with the

physical disturbance that produces the pigmentation. There are some

cases on record where emotional states have caused loss of pigment in

the negro or other colored races, or in the hair, as when, in

well-substantiated cases, people's hair has become white in a single

night. In every case of pigmentary disturbance, then, the individual

must be carefully studied and as far as possible all emotional

disturbance must be eliminated. Without this other treatment usually

fails.





Pruritus.--Pruritus in the old is often a bothersome symptom. All

sorts of remedies, internal and external, are recommended for it and

successes are reported with them. Whenever there are many remedies for

a symptom complex, it usually means that the suggestive element in all

of them is large. For pruritus the influence of the patient's mind is

extremely important. Often it will be found that these old patients

are getting out scarcely at all, but are living in close confinement

in their rooms, the air of which is scarcely ever changed. I have

known even the keyholes to be stuffed and arrangements made by which

the cracks between the door and the frame were rendered impervious to

air. In these cases the most important feature of any treatment is to

secure a proper amount of air. Sir Henry Thompson, the great English

surgeon, in his advice how to grow old successfully, written when he

himself was over 80, suggested that the cells of the skin needed an

air bath every day. He advised that men should make all their toilet

arrangements for the day without any garments on. Washing, the

preparation of clothing, shaving, and whatever else was done in the

early morning was to be accomplished after the night clothes were

taken off and before other clothes were put on. He lived to be well

above eighty and was sure that this practice had been of help to him.

Stimulating rubbings, if done gently and without the production of too

much reaction, will always benefit these people.



If old people have no interest, nothing that attracts their attention,

and if they once develop pruritus their mind gets concentrated on

their cutaneous sensations and it will be impossible to relieve them

by any treatment until their minds get occupied with something else.

Anyone who wants to sit in a chair for a few minutes and think about

his cutaneous sensations will soon realize how vividly these can be

brought to mind and how annoying they can become. To sit and think of

a portion of the body is to want to scratch it before long. Scratching

produces a flow of blood to the surface that adds to the itchy

feeling. The only way to get away from it is to get the mind

occupied with something else. Of course, where circulation is weak

because of failing heart or disturbed because of arteriosclerosis,

treatment directed to these conditions should be employed, but the

influence of the mind on blushing and skin feeling must not be

forgotten.



When pruritus develops in the old in connection with phases of

arterial degeneration--its most intractable form--it is important to

remember that diversion of mind is the most important therapeutic

agent that we have. The old have few diversions. They have given up

their ordinary occupations, they are often no longer interested in

reading, friends whom they used to know have died, and they are left a

great deal to themselves. Under these circumstances anything the

matter with them brings about a concentration of attention. This is

even more true if they have been very well in earlier life and have

had practically no experience with sickness.





Hysterical Cutaneous Conditions.--There are certain cracks of the skin

with ulcerative lesions which occur in hysterical patients in the

neighborhood of the knuckles that represent a phase of unfavorable

influence of the mind. When these patients begin to worry or be

anxious they know that these skin lesions will follow. Expectancy

seems to make it certain that the lesions will come and attention adds

to their chronicity. It has been noted that "chapped hands,"

especially when accompanied by deep cracks in cold weather, are made

worse by anxiety or worry. In many neurotic patients it is impossible

to treat such conditions satisfactorily unless the patient's mind can

be put at ease. It is surprising how intractable these conditions can

be, but that is usually because all the physician's attention is

devoted to the skin instead of a considerable portion of it being

given also to the patient's mental and nervous condition.





Artefact Skin Lesions.--Of course artefact skin lesions produced by

the application of carbolic acid or nitric acid or ammonia or some

other chemical irritant, or by rubbing with pumice stone, or with the

thumb as schoolboys make what in my schooldays were called "fox

bites," are skin lesions connected with a special state of mind and so

deserve a mention here. The physician finds them under the most

unexpected circumstances at times and in patients apparently above all

suspicion of their self-infliction. They can only be prevented by

changing the patient's state of mind, though this is scarcely what is

ordinarily thought of in psychotherapy. Where skin lesions are

atypical it is well to bear in mind the possibility of this curious

condition.





The Mind in Dermatotherapy.--I have had old dermatologists assure me

that they felt that the mind influenced materially the course of many

forms of skin disease. Younger dermatologists are prone to be

localists; as they get older the treatment of the patient's general

condition is felt to be more important; after twenty years of

experience they realize the place of psychotherapy in the treatment of

their cases. What is said here is only meant to be suggestive, but

certainly sufficient data are supplied to make it quite sure that the

mind greatly influences skin conditions and must always be treated if

success, especially in chronic cases, is to be secured. I have seen

confidence in a particular physician or remedy do much for even the

most sloughing and obstinate psoriases. Eczema follows the same law.

If psychotherapy can help in the treatment of conditions that are so

often intractable, it must surely not be neglected in other cases.





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