describes the unity of mental, neurological, hormonal and immunological
functions with its many potential applications.
PNIE addresses the impact of cognitive images of the mind (whatever
its elusive definition) on the central nervous system and consequent
interactions with endocrine and immune systems. It encompasses many
arenas, including biofeedback and voluntary controls, impacts of thought
and belief on physiology, past and present effects of stress on mental,
emotional and physical function, placebo effects, effects of social
relationships on health and disease, and impacts of "energy
medicine" on personal function and that of others. This column
highlights the impact of cogent studies from these arenas on the understanding
of holistic medicine in the new millennium.
Atopic dermatitis and stress
Atopic dermatitis is a chronically relapsing inflammatory skin disease with
eczematous skin lesions and severe pruritus as principal symptoms. The relevance
of stress in the pathology is widely accepted and the specific goal of this
study was to investigate the impact of acute psychosocial stress on atopy-relevant
immune functions in atopic dermatitis patients; 36 patients and 37 nonatopic
controls were exposed to a laboratory stressor including a free speech and
mental arithmetic tasks in front of an audience (the "Trier Social
Stress Test"). Blood samples were collected 10 minutes before and
1, 10 and 60 minutes after the stress test as well as 24 h after the experiment
at identical time points under resting non-stressed conditions. Significantly
elevated lymphocyte, monocyte, neutrophil and basophil counts 10 min after
the TSST (all p<0.001) were not different between subjects and controls.
In contrast, eosinophil counts were found to be significantly elevated only
in atopic dermatitis patients and not in controls (p<0.01). Patients but
not controls showed increased IgE levels (p<0.05) 24 h after the stress
test. Immunomodulators interferon-gamma (p<0.001) and interleukin-4 (p<0.001)
were raised and attenuated, respectively, by the stress experience in both
subjects and controls.
Buske-Kirschbaum A, Gierens A, Hollig H, Hellhammer DH. Stress-induced immunomodulation
is altered in patients with atopic dermatitis. J Neuroimmunol 2002 Aug; 129(1-2):161-7
COMMENT: These findings suggest that stress affects white blood cell, interferon-gamma
and interleukin-4 in everyone, but that there is a subset of people prone to
rapid IgE and eosinophil increases within 10 minutes of exposure. Whether stress
management training can attenuate these generic leucocyte changes and the eosinophilic
changes in atopic-prone individuals will need to be shown through more thorough
investigation. There is certainly evidence (see below) that the skin appearance
and symptoms can be significantly altered by suggestion and imaging approaches.
It would seem likely, as this study suggests, that this improvement comes about
through alteration in underlying immunological and biochemical processes.
Atopic dermatitis and relaxation techniques and autogenic affirmations
The effectiveness of four treatments for atopic dermatitis, a chronic skin
disorder characterized by severe itching and eczema, was assessed in randomized
controlled fashion. A dermatological educational program was compared to
autogenic training as a form of relaxation therapy, cognitive-behavioral
treatment (comprised of relaxation, self-control of scratching, and stress
management techniques) and combined behavioral and autogenic training treatment.
These four approaches were also compared to standard medical care. At one-year
of follow-up, autogenic training, cognitive-behavioral and combined treatments
had led to significantly greater improvement in skin condition than either
intensive educational or conventional dermatological treatment. Significant
reductions in the use of topical steroids were also recorded.
Ehlers A, Stangier U, Gieler U. Treatment of atopic dermatitis: a comparison
of psychological and dermatological approaches to relapse prevention. J Consult
Clin Psychol 1995 Aug; 63(4):624-35
COMMENT: These results corroborate preliminary reports that psychological interventions
are useful adjuncts to dermatological treatment in atopic dermatitis. If the
power of suggestion with visible images is a valid approach to fostering bodily
changes, the skin, since it is our most visible organ would be a logical starting
point. In this study, both cognitive-behavioral and autogenic-relaxation approaches
as well as the combination brought about better 1-year results than mere education
or standard conventional treatment. Participative and experiential approaches
usually achieve better results than didactic approaches usually featured in
educational programs. Practitioners can weave into the education that is a
requisite part of a holistic approach, a variety of ways to entrain patient
participation. One beginning is to help paint for patients the images of improvement. "Images
or mental pictures tend to produce the physical conditions that correspond
to them." (Assagioli R. The Act of Will. New York, Viking, 1973) and "The
human nervous system responds not only to perceived reality but also equally
to imagination." (Anderson R, unpublished, 1984)
Atopic dermatitis and hypnotherapy
Eighteen adults with resistant atopic dermatitis, mean age 33, were treated
with 3 hypnotherapy sessions with significant improvement lasting through
at least two years of followup. Nineteen of 20 children with severe treatment-resistant
atopic dermatitis, age 2-15, had immediate improvement, with 10 maintaining
marked improvement in itching and scratching, 9 in sleep disturbance and
7 improvement in mood at 18 months of followup. Elements in the protocol
included relaxation; stress management (problem solving techniques); direct
suggestion of non-scratching behavior, 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 2 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: Hypnosis can have a powerful effect in the therapeutic milieu. Suggestions
in three separate sessions encompassing non-scratching behavior, skin comfort
and coolness, and relaxation resulted in marked improvement in these patients,
even at follow-up 2 years later. The use of steroids at four months was 60%
reduced. Given the long-term hazards of steroids, even applied topically, most
would agree that decreased use would be a positive step. Even suggestions made
outside the setting of hypnosis, but made only in an induced altered state
of consciousness, such as the alpha-brain-wave state, can have a powerful effect.
Once the new images and ideas are incorporated, the previous state of balance
in perceptions, physiological functions and behaviors may be permanently altered.
This has advantages over conventional treatment of atopy which is usually only
symptom-directed and must be continued permanently.
Dermal reactions and hypnosis
Eight volunteers underwent skin testing for type I and type IV reactions
before and after hypnosis. Histamine skin prick testing after hypnosis
decreased flare showed significantly less erythema (p<0.02). The size of
the wheal did not change. In a second study of tuberculin skin testing, a suggestion
was made under hypnosis-directed guided imagery 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<0.01).
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;
COMMENT: These volunteers did not have a skin "disease" but participated
in this demonstration to illustrate the susceptibility of skin reactions to
hypnotic suggestion. Reactivity to skin testing in this instance was altered
by hypnosis. Other studies have shown the power of suggestion capable of objectively
and significantly altering the intensity of skin testing for inhalant allergens,
even to the point of eliminating a previously demonstrated reaction altogether.
This reminds me of the descriptor in a recent movie: "A beautiful mind." We
may be just scratching the surface of those aspects of bodily behavior and
physiological/biochemical function which could be altered by the mind in the
Psoriasis and stress
In 80 psoriatic patients, a high prevalence
of panic disorder was found; 71% of patients had a diagnosable psychiatric
disorder: 35% a personality disorder;
17.5% a mood disorder; 12.5% anxiety disorders and 6% a schizophrenic trait.
There had been a significant stressful event in 89% of cases before relapse,
but the differences did not meet statistical significance. In 68% the stressful
incident was mild. The intensity of the stress was not as important as the
assessment of the patient's adaptive and coping skills. The disease
appears to be an attempt to express a defensive somatic response to an identity
crisis, allowing patients to shift their attention to an outer world event,
protecting them against anxiety about internal disintegration.
Mizzetti M et al. Psoriasis, stress and psychiatry: psychodynamic characteristics
of stressors. Acta Derm Venereol Suppl 1994; 186:62-64
COMMENT: Embedded in this psychiatric jargon is the significant association
with psoriasis and diagnosable psychiatric disorders. And, although not statistically
significant, a stress event was related to recurrence in an overwhelming portion
of cases. It would then be important for general physicians and dematologists
to be mindful of this relationship and ask appropriate questions regarding
the nature of the stress. Only then could steps be suggested to manage the
stress event(s) to attempt to decrease the incidence of recurrence.
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 PUVA treatments.
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 Sep-Oct; 60(5):625-32
COMMENT: A brief mindfulness meditation-based stress reduction intervention
delivered by audiotape during ultraviolet light therapy appeared in this study
to increase the rate of resolution of psoriatic lesions in patients with psoriasis.
Again, meditation entrains an altered state of consciousness, in which images
of improvement can be mentioned by a therapist or heard from a recorded audiotape
voice. Can the excessively rapid hyperproliferative dermal cell division in
psoriasis be altered by a mental shift such as a meditative state? The answer
in this Kabat-Zinn research paper would appear to be yes. While much additional
research will be needed to provide a plausible mechanism with biochemical and
energetic pathways, this area of investigation holds enormous promise for many
physical ills and abnormalities. The skin just happens to be more visible.
Urticaria and beliefs
In this case report, a subject known to be prone to the development of hives
was tested by striking the forearm with a 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
toward the arm without touching 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;
COMMENT: The patient in this report was so
responsive to touching or stroking the skin he fits the description of dermographia,
in which any contacted skin
almost immediately becomes erythematous and hyperemic. Touching, however, is
not necessary to induce the hive formation. It can be induced, as this report
shows, by only the expectation or belief that the skin will be struck. In a
sense, the mind appears to participate in some way to facilitate a cellular
memory of previously being struck; the result in present time is triggered
by the assumption that a blow will be delivered. There may be very wide applicability
of this principle of expectation and belief to many other organ systems and
to many disease entities.
Robert Anderson is a retired family physician. In mid-career, his
practice took on a more holistic nature as decades passed. He has authored
five major books, Stress Power! (1978), Wellness
Medicine (1987), The
Complete Self-Care Guide to Holistic Medicine (1999) (co-author), The
Scientific Basis for Holistic Medicine, (5th edition) available from
American Health Press, firstname.lastname@example.org, and Clinician's Guide to
Holistic Medicine (McGraw Hill, 2001).
Anderson served as the founding
president of the American Board of Holistic Medicine, is a past president
of the American Holistic Medical Association, former Assistant Clinical
Professor of Family Medicine at the University of Washington, and currently
Adjunct Instructor in Family Medicine at Bastyr University.
Psychoneuroimmunoendocrinology Review and Commentary
by Robert A. Anderson, MD
614 Daniels Drive NE
East Wenatchee, Washington 98802 USA