describes the unity of mental, neurological, hormonal, and immunological
functions, addressing the impact of cognitive images of the mind
(whatever its elusive definition) on the central nervous, endocrine,
and immune systems. It encompasses biofeedback and voluntary controls,
impacts on physiology of thought and belief, past/present stress,
placebos, social relationships, and "energy medicine."
This column highlights clinical applications of cogent studies from
these arenas of holistic medicine in the new millennium.
Skin Disease: Eczema, Psoriasis
Atopic Eczema and Laughter
Atopic eczema patients often complain of sleep disturbance, and
blood levels of melatonin in eczema patients are low vs. healthy
subjects. Laughter increases NK cell activity in blood and free
radical-scavenging capacity in saliva in healthy subjects. In a
study of 48 infants age five to six months with atopic eczema (AE)
and allergy to latex and house dust mites, 24 of the nursing mothers
of these infants had AE, while another 24 mothers were healthy without
atopic eczema. In crossover fashion, the mothers viewed both an
87-min humorous DVD featuring Charlie Chaplin and an 87-min non-humorous
weather information DVD at 8 PM. Melatonin in breast milk was then
checked sequentially in samples from 10 and 12 PM and 2, 4, and
6 AM. Laughter from viewing the humorous DVD increased levels of
breast-milk melatonin in mothers with AE (p<.01) and healthy
mothers (p<.05) with no changes after viewing non-humorous information.
Allergic skin responses to latex and dust mites of infants were
reduced by feeding with breast milk after laughter of mothers with
AE (p<.01) or of healthy mothers (p<.05).
Kimata H. Laughter elevates the levels of breast-milk melatonin.
J Psychosom Res. 2007; 62:699.
COMMENT: Laughter increased levels
of breast-milk melatonin in mothers with or without atopic eczema,
and feeding infants milk with higher levels of melatonin significantly
reduced their allergic skin responses. We probably greatly underestimate
both the mind-brain effect on atopic dermatitis and the effect of
humor and laughter on a variety of physiological and pathological
functions. In this sense, humor is a serious business.
Acne Vulgaris, Biofeedback,
In 30 patients with acne vulgaris, those randomly assigned to undergo
an intervention involving continued medical treatment plus 12 biofeedback
and imagery sessions over six weeks experienced significantly greater
gains vs. a medical treatment-only group and vs. a monitoring-only
control group (p<.01). Those continuing home practice maintained
their gains, whereas those who discontinued regressed.
Hughes H, et al. Treatment of acne vulgaris by biofeedback relaxation
and cognitive imagery. J Psychosom Res.
COMMENT: Imagery is particularly successful
in dermatological conditions, probably because the skin is so visible.
Vivid imagery of internal organs is more difficult for those who
have not studied anatomy. And the vividness of imagery is correlated
with outcomes (Achterberg J, Lawlis GF. Bridges
of the Bodymind. Champaign, IL: I.P.A.T;1990). Imagery is
usually inserted into relaxation processes, which shift the basic
brain rhythm to a lower frequency (i.e., from the beta range of
13-31 Hz to the alpha range of 8-13 Hz). Images presented to the
mind-brain in this altered state of consciousness are much more
effective. Staying in the alpha frequency has also been demonstrated
to reduce catecholamine synthesis, in turn reducing the generation
of free radicals. Since many of these dermatological conditions
involve inflammation and free-radical excesses, the mechanism of
successful action may be partially explained.
Atopic Dermatitis and
Eighteen adults with resistant atopic dermatitis, mean age 33, were
treated with three hypnotherapy sessions with significant improvement
lasting through more than two years of follow-up. Nineteen out of
20 (19/20) children with severe treatment-resistant atopic dermatitis,
aged two to 15, had immediate improvement, with ten maintaining
marked improvement in itching and scratching; nine, in sleep disturbance;
and seven, improvement in mood at 18 months of follow-up. Elements
in the protocol included relaxation; stress management (problem-solving
techniques); direct suggestion of non-scratching behavior; direct
suggestion of skin comfort and coolness; ego strengthening; post-hypnotic
suggestions of relaxation, skin coolness and ease of self-hypnosis;
and instruction in self-hypnosis. For children, these elements were
placed on a "magic music" tape to be played at home. At
two years, patients’ assessments included improvement in itching
(p<.05), scratching (p<.05), sleep disturbance (p<.01),
and tension (p<.01); at 16 weeks, mean decrease in use of topical
steroids was 60%.
Stewart A, et al. Hypnotherapy as a treatment for atopic dermatitis
in adults and children. Br J Dermatol.
1995 May; 132(5):778-83.
COMMENT: The use of suggestion in various
forms in children usually meets with great success. Those under
the age of ten or eleven have not yet been convinced to be skeptical
and jaded about their potential and life in general. In using biofeedback
and suggestion with children over the years, I never met with anything
but resounding successes. Suggestion is a powerful element in the
treatment of warts (see below). I do not understand why its use,
especially with children, is so limited.
Atopic Dermatitis and
Atopic dermatitis (AD) is a chronically relapsing inflammatory skin
disease with symptoms including eczematous skin lesions and severe
pruritus. Thirty-six AD patients and 37 nonatopic controls were
exposed to laboratory stressors including a spontaneous speech and
mental arithmetic tasks in front of an audience (the Trier Social
Stress Test, TSST). Leukocyte subsets were significantly elevated
ten minutes after the TSST (all p<0.001) with no intergroup differences.
Eosinophils, however, were significantly elevated only in atopic
dermatitis patients (p<0.01). AD patients, but not controls,
showed increased IgE levels (p<0.05) 24 hours later. Exposure
to the TSST resulted in elevation of IFN-g (p<0.001) and attenuation
of IL-4 (p<0.001) with no significant intergroup differences
Buske-Kirschbaum A, et al. Stress-induced immunomodulation is altered
in patients with atopic dermatitis. J Neuroimmunol.
COMMENT: Stress may be associated with
atopy-relevant immune changes in atopic dermatitis, explaining the
common observation of stress-induced aggravation of symptoms. It
is very common for a variety of inflammatory skin conditions to
flare when stress is added to the mix. Relaxation processes and
meditation are one answer for the management of the downstream effects
Warts and Hypnosis
Subjects with warts on their hands and/or feet were randomly assigned
to a hypnotic suggestion, topical salicylic acid, placebo, or no-treatment
control condition. Subjects in the three treated groups developed
equivalent expectations of treatment success. Nevertheless, at the
six-week follow-up interval, only the hypnotic subjects had lost
significantly more warts than the no-treatment controls.
Spanos NP, et al. Effects of hypnotic, placebo, and salicylic acid
treatments on wart regression. Psychosom
Med. 1990; 52:109-14.
COMMENT: One theory about warts is
that they are caused by viruses. In any event, the immune system
appears to play a role in their rejection. From the success of nutritional
treatments, including topical garlic (Dehghani F et al.,
Int J Dermatol. 2005; 44:612) and oral zinc (Al-Gurairi FT
et al., Br J Dermatol. 2002; 146:423),
we infer that the immune system, when strengthened, does a better
job with the viruses involved. Precisely how the immune system is
strengthened by imagery and hypnosis remains murky, but the empirical
evidence from several different disciplines is highly persuasive.
Skin Testing and Hypnosis
Four PPD-positive subjects were retested after hypnosis sessions
in which it was suggested that they "not react." Three
had completely negative PPD reactions; the fourth had a trace response
nonetheless read as negative.
Black S, et al. Inhibition of
Mantoux reaction by direct suggestion under hypnosis. Br
Med J. 1963 Jun 22; 1(5346):1649-52.
We think of tuberculosis skin-testing as a certain process on which
serious therapy decisions are based. We never check out either the
belief systems of the patients involved or the suggestions they
may be consciously or unconsciously giving themselves.
Dermal Reactions and
In a study of tuberculin skin testing, a suggestion was made under
hypnosis in a healthy volunteer to increase the post-hypnotic reaction
in one arm and decrease it in the other; significant differences
in erythematous area and palpable induration were apparent (p<.01).
Laser doppler measurements showed a 19% difference in erythema and
a 44% difference in dermal infiltrate thickness.
Zacheriae R, et al. Modulation of type I immediate and type IV delayed
immunoreactivity using direct suggestion and guided imagery during
hypnosis. Allergy. 1989 Nov; 44(8):537-42.
COMMENT: We consistently and constantly
underestimate the power of the mind to influence what we believe
to be isolated body effects. Humans are not minds and bodies but
integrated holistic beings. Individual hypnosis case histories have
demonstrated that pupil size can be reduced in one eye and simultaneously
increased in the other eye. We are surely only beginning to understand
the enormity of the power of the mind and brain to influence health
and the Mind
It is only recently that Western physicians are rediscovering the
link between thought and health. The spectrum of causative factors
in inflammatory dermatoses are often multifactorial. Stress and
negative thoughts are major factors in dermatological conditions.
This review article begins with some basic information on the ways
that thoughts affect health. Practical methods of intervention,
including meditation, journal writing, affirmations, prayer, biofeedback,
and hypnosis, are presented. In the same journal issue, another
review points out that skin does more than present one's "face"
to the world; it plays a vital role in the maintenance of physical
and mental health.
As our most ancient interface, skin retains the ability to respond
to both endogenous and exogenous stimuli, sensing and integrating
environmental cues while transmitting intrinsic conditions to the
outside world. As such, it has long been a target for the application
of both medical and nonmedical therapies of healthy and diseased
states. Our understanding of how the skin and topical therapies
affect health is in its infancy. Conversely, we know little of how
our internal systems affect our skin. By exploring an elaborate
web of neuro-immuno-cutaneous-endocrine (NICE) phenomena, we seek
to shed light on the generally acknowledged, but inadequately defined,
relationship between mental and physical health. We use skin as
our window, noting some of the biological mediators linking nervous,
immune, cutaneous, and endocrine functions. It is likely that these
mediators are important in homeostasis and that they affect several
dermatological and psychiatric conditions.
Bilkis MR, Mark KA. Mind-body medicine. Practical applications in
dermatology. Arch Dermatol. 1998;
O'Sullivan RL, et al. The neuro-immuno-cutaneous-endocrine network:
relationship of mind and skin. Arch Dermatol.1998;
COMMENT: I could have not stated it
Herpes Labialis and
Forty-nine freshmen nursing students reported recurrences of herpes
labialis for a year and completed a battery of four psychological
tests. Sixteen out of 49 (16/49) had recurrences in a year. Significant
correlations with aspects of the psychological tests resulted (from
NS to p<.05 to p<.01). One-third to one-half of all recurrences
could be predicted from combinations of sociometric and psychological
Katcher AH, et al. Prediction of the incidence of recurrent herpes
labialis and systemic illness from psychological measurements. J
Dent Res. 1973; 52:49-58.
COMMENT: This and similar studies repeatedly
show that psychological characteristics demonstrating how an individual
will handle the physical and psychosocial stresses of life will
predict the frequency with which they will succumb to outbreaks
of herpetic skin reactions.
Herpes and Stress
In 49 first-year medical students, those falling in the above-median
scores on the obsessive-compulsive, depression, anxiety, hostility,
and symptom index scales of the Brief Symptom Inventory experienced
high stress scores and excessive rises in herpes antibody titers
on the day prior to exams (p<.0001) vs. those in the below-median
group. High loneliness was positively correlated with higher EA
(early antigen) and VCA antibody titers.
Glaser R, et al. Stress, loneliness, and changes in herpesvirus
latency. J Behav Med. 1985; 8:249
COMMENT: Yes, we do have to treat the
herpetic outbreaks. Better we should help the patient evoke the
preventive strategies to prevent the outbreak in the first place.
Hives and Expectation
In this case report, a subject known to be prone to the development
of hives was tested by striking the forearm with a small paddle,
leading to the immediate development of a reactive hyperemia and
development of an urticarial reaction. Some time later, when the
reaction had dissipated, a sham blow was delivered to the arm (the
paddle was stopped a quarter-inch short of the skin), resulting
in the same change in reactive hyperemia and hive formation in spite
of the fact that the skin had not actually been struck.
Graham DT. The pathogenesis of hives: Experimental study of life
situations, emotions and cutaneous vascular reactions. Proc
Ass Res Nerv Ment Dis. 1950; 29:987-89.
COMMENT: This ancient case report from
one of the great contributors to the psychosomatic literature from
the medical residents of Harold Wolff at Cornell contributes volumes
to what we must understand about the power of expectation. The hive
formation in this hives-prone patient from a sham or simulated blow
was equivalent to that from the real blow. Many of our patients
live with powerful untoward reactions to psychological blows they
believe will happen to them.
Ichthyosis and Hypnosis
A 16-year-old boy presented with fissured, thickened, papillomatous
skin lesions, which had progressed from a mild presentation at birth
and now completely covered several areas of his body. Attempted
surgical excisions resulted in severe contractures. Hypnosis was
undertaken. At the initial session, the suggestion was made that
the lesions would clear from one arm. Within five days, a heavy
dermal layer of the left arm sloughed off, leaving soft pink skin
from the shoulder to the wrist ten days later. Histologic sections
of the sloughed skin revealed ichthyosis. There was no positive
family history. Main body parts were systematically targeted in
following hypnosis sessions resulting in 50-90% clearing of different
areas. There was no relapse at the end of one year.
Mason AA. A case of congenital ichthyosiform erythrodermia of Brocq
treated by hypnosis. BMJ. 1952 Aug
COMMENT: Hypnosis is often thought
of when all else fails. It deserves to be used much earlier in the
treatment of many conditions. It also has great utility in ancillary
treatment to augment many conventional approaches.
Psoriasis and Meditation
Thirty-seven patients with psoriasis about to undergo ultraviolet
phototherapy (UVB) or photochemotherapy (PUVA) were randomly assigned
to either a mindfulness, meditation-based, stress reduction intervention
guided by audiotaped instructions during light treatments, or to
be controls receiving light treatments alone. Psoriasis status was
assessed by direct inspection by unblinded clinic nurses; direct
inspection by physicians blinded to the patient's random assignment;
and blinded physician evaluation of photographs of psoriasis lesions.
Four sequential indicators of skin status were monitored during
the study: a First Response Point, a Turning Point, a Halfway Point,
and a Clearing Point. Subjects in the meditation tape groups reached
the Halfway Point (p=.013) and the Clearing Point (p=.033) significantly
more rapidly than those in the no-tape condition, for both UVB and
Kabat-Zinn J, et al. Influence of a mindfulness meditation-based
stress reduction intervention on rates of skin clearing in patients
with moderate to severe psoriasis undergoing phototherapy (UVB)
and photochemotherapy (PUVA). Psychosom
Med. 1998; 60:625-32.
COMMENT: John Kabat-Zinn has authored
numerous papers on the beneficial effect of mindfulness meditation
in managing pain and other conditions. Here, a brief mindfulness,
meditation-based, stress reduction intervention delivered by audiotape
during conventional ultraviolet light therapy increased the rate
of resolution of lesions in patients with psoriasis. One cannot
imagine a more efficient use of resources than the use of a "canned"
audiotape to enhance mindfulness.
A dermatomyositis patient used Transcendental Meditation and visual
imagery for 294 days, recovering against significant statistical
odds. In regression analysis between measures of arm strength, rash,
and pain and application of mind-body treatments, significant relationships
for both meditation (p = 0.02 to 0.001) and visual imagery (p=0.02
to 0.002) emerged. Stress had a significant negative impact on skin
symptoms but not arm strength. Benefits of meditation had half-lives
of 48-59 days for skin condition and no detectable decay for arm
strength. Benefits of visual imagery were more transient, with half-lives
four to 18 days. The effects of stress had half-lives of only one
to three days.
Collins MP, Dunn LF. The effects of meditation and visual imagery
on an immune system disorder: dermatomyositis. J
Altern Complement Med. 2005; 11:275.
COMMENT: Since dermatomyositis is a
humorally mediated immune microvasculopathy, the benefits of meditation
and imagery comport with a growing body of evidence showing that
these techniques influence immune system function. A few decades
from now, these integrated holistic approaches will have supplanted
many conventional therapies that are often likened to using a sledge
hammer to kill a gnat.
Robert Anderson is a retired family physician
who has authored several major books, Stress
Power!, Wellness Medicine,
Clinician's Guide to Holistic Medicine
(McGraw Hill, 2001), and The Scientific
Basis for Holistic Medicine, (6th edition 2004), available
from American Health Press, firstname.lastname@example.org.
Anderson founded the American Board of Integrative Holistic Medicine,
is a past president of the AHMA, and former Assistant Clinical Professor
of Family Medicine at the University of Washington. Dr. Anderson
teaches The Art of Primary Care at Bastyr University.
Robert Anderson, MD
614 Daniels Drive NE
East Wenatchee, WA 98802-4036 USA