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From the Townsend Letter for Doctors & Patients
May 2003

Review and Commentary
by Robert A. Anderson, MD
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Psychoneuroimmunoendocrinology 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 suggesting 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; 44(8):537-42

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 right circumstances.

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; 29:987-89.

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,, 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


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