PSYCHOLOGICAL ASPECTS OF DERMATOLOGY


The characters or personalities of these three patients contained similar features, and their experiences prior to the outbreak of illness were strikingly alike. They were upright and good – living men keenly conscious of their own virtue and rectitude; the skin disease followed closely some disaster; and, in the belief that their misfortunes were utterly undeserved, they harboured an acute sense of injustice.


Mr. President, Ladies and Gentlemen,

Firstly, I wish to express my thanks and appreciation for the great honour, of which I am quite unworthy, entailed in the privilege of addressing this Congress.

My interest in the importance of psychological factors in the aetiology of skin disease was aroused initially by a conversation with Dr. J.L. Halliday in the course of which he described his findings in three consecutive cases of dermatitis. All three were men in late middle life. None had a history of dermatitis. In each the onset had been dramatic in the rapidity with which the eruption had spread over the body surface and the failure of the methods of treatment hitherto employed to bring about alleviation.

The characters or personalities of these three patients contained similar features, and their experiences prior to the outbreak of illness were strikingly alike. They were upright and good – living men keenly conscious of their own virtue and rectitude; the skin disease followed closely some disaster; and, in the belief that their misfortunes were utterly undeserved, they harboured an acute sense of injustice. Halliday approached the problem by applying the principles of aetiology now associated with his name, and later labelled the condition, “Jobs Dermatitis”.

Many of you will no doubt be familiar with these principles and their value as a guide to the student of cause and effect. They contain these questions to be answered by the diagnostician who concerns himself with aetiology.

1. What kind of person is this?

2. Why did he take ill when he did?

3. When did he take ill how he did?

4. What purpose does the illness serve?

5. What is the prevalence of the illness?

This association of ideas – Job and dermatitis – was brought back to his memory when some months later I encountered the following persons.

CASE I.

A Jewish storekeeper, aged 66, had had extensive “eczema” for three years. Almost the whole of his skin had been involved at one time or another. The onset had been sudden and the dermatitis had spread rapidly, accompanied by intolerable itching. In the first year he had consulted his family doctor and three or four dermatologists. In the past two years he had attended weekly at an outpatient department.

Life Situation.

He was living alone in a single apartment, Twenty – five years ago at the age of 41, he had married a beautiful girl aged 17, an orphan without dowry. Five months after the marriage she had given birth to a daughter – not his child. He had forgiven her and brought up the child as his own. He had lavished kindness and money on both wife and daughter.

He had been successful in business and owned two retail shops besides having an interest in a wholesale establishment. Except for a few hundred pounds, he had placed all his assets, including his business, in his wifes name. Five years ago, when he was 61, she, then aged 37, had formed an attachment with another man, is possessed her husband of his entire fortune, and sacked him from his own business, Litigation had followed and dragged on for two years. His capital has been exhausted, which prevented him from contesting the matter further. At this point his skin eruption had made its first appearance.

As he related his story, he repeatedly emphasized his goodness to his wife and the rectitude of his past life. He seemed also to link his past business and material success with his righteous way of living.

Treatment.

In the course of discussion I said to him, “You will no doubt have heard of Job?” He replied, “Doctor, I was born and brought up in Russia. I knew the book of Job almost by heart before I was 14 years old.” I said, “Then you will remember that he was the most prosperous man in the land and that he regarded his great wealth as no more than a just reward for his righteousness? And you will remember how thieves and robbers stole his flocks and herds and burned his crops, and how a whirlwind destroyed his seven sons and three daughters.

You will remember also how his soul was torn in pieces. It was beyond his comprehension how such disaster could befall a man so good as he, who believed the tall of his riches was the measure of his righteousness. You will remember what happened to him. His body itched and oozed intolerably. so has yours.”

He was greatly moved and said nothing for a few minutes. Then with tears in his eyes he informed me that I was the first person to give him some inkling into the real nature of his trouble.

Late in the evening of the day on which this interview occurred, his friend, who had sent me to him and who vouched for the truth of his story, in a state of great agitation and indignation, informed me, that an hour or so after my visit, two psychiatrists, sent by the patients wife, had called, certified him insane and removed him to a mental institution. This step was taken because of his behaviour on the previous day when he had hurled a brick through the plate glass window of one of the furrier shops formerly owned by him and where his wife was then attending to customers.

About a year later I learned that, after a flare up of the dermatitis during the weeks following my discussion with him, the skin condition had settled down and that there had been no recurrence. No medicine had been administered by me.

This case tended to confirm Hallidays hypothesis in respect of the first three fields of inquiry, namely, the kind of person he was, the time of onset and the mode of illness. Having experienced strongly and over a lengthy period of time an emotional constellation centered on the belief that he had been most unjustly wronged, his bodily reaction had apparently been dermatitis.

What of question 4 – What purpose does the illness serve? After a period of rumination I asked myself one day, “Why do we weep when we do?” The answer seemed to be that, when we look at something too sad to bear, tears fill the eyes with the purpose of shutting out the painful scene, thereby protecting the integrity of the central nervous system in its highest and perhaps most delicate form of functioning.

It seems reasonable enough, in the present connection, to advance the suggestion that dermatitis with its wealth of distracting unpleasant sensations could be viewed as a physiological mechanism, analogous to weeping and evolved to preserve the sanity of a mind obsessed with an intolerable load of a mixture of self – pity and anger. If this assumption is correct one would anticipate an ebb and flow on the part of the eruption as the intensity of the feelings aroused by Fates harsh blows were forgotten or recalled to memory. This in fact occurred in this case.

Finally a correlation between the emotional state discussed above and dermatitis could not be fully established unless it fulfilled the law of prevalence, that is, gave an answer to question 5. Is it possible from the study of a service of cases of dermatitis to uncover in them a more than average incidence of resentment, self – pity and anger. From my own experience of patients with the disease I believe that his is so. For example, I know of no group of patients less disturbed by the likelihood of hurting the feelings of their medical advisers.

They are foremost in suggesting to their general practitioners that they should be referred to a skin specialist, brazenly implying incomparably greater merit in such a personage. In quick succession they will consult one therapist after another, invariably being more ready to criticize than to praise his predecessor. When one dares, after history taking, to infer that the cause of the illness might lie in the patient himself, there are no patients so likely to demonstrate their high content of aggression in their being intensely allergic to the merest whisper of weakness in themselves. They do this not only by personal demeanour, often reaching rudeness, but by exhibiting an aggravation after interview.

INITIAL EXACERBATION AS RESPONSE TO

PSYCHOLOGICAL APPROACH

In the early days of my association with homoeopathy it had been put to me that the aggravation of symptoms so often encountered after the administration of medicine, amounted to proof of the material activity of the infinitely small dose in a sensitive person. Indeed, it was claimed that this reaction of initial aggravation, not only went far to substantiate the basic principles of Homoeopathy, but also showed a wise choice of drug. I saw no reason to doubt these claims until my experience with dermatitis.

It is my custom in treating a patient with chronic illness to instruct that the administration of medicine commence on the following morning. I found that many of these persons with skin disease exhibited a severe aggravation within seven or eight hours of case – taking, that is, before any medicine had been taken. During the middle nineteen forties when I was very interested in fitting dermatitis into an aetiological pattern, and so, of course, seeing many patients with this affliction, my two partners used to plead with me to lay off these dermatitis people unless I myself were on duty during the coming night!

On over a dozen occasions, after I had spent half – an – hour in elucidating he life situation prior to the onset of dermatitis in a patient, there had been an aggravation within six or seven hours of such severity that whoever of us happened to be on night duty was summoned from his bed to attend the victim. Such experiences went far to persuade one of the validity of an emotional factor in dermatitis and to enable one to define the factor.

It appeared that, in bringing back to a patients conscious mind half -forgotten wrongs, his emotions relating to past injustice were kindled afresh with a resulting exacerbation of the disease. Although these skin patients were notoriously difficult to cure, it gradually became apparent that it was remarkably easy to make them worse.

The implications of this study pointed to the existence of a physiological mechanisms. The inability to describe step by step, the processes involved, does not invalidate such a hypothesis. Correlations between sadness and weeping of embarrassment and blushing are universally accepted in the absence of complete knowledge in detail of all the mechanisms concerned.

EFFECTS OF PHYSICAL IRRITATION

Further observations seemed to provide additional confirmation of a physiological association between the emotions aroused by a feeling of injustice and reaction of the skin, and to widen the scope of application. Forms of dermatitis, hitherto attributed to physical and chemical agents, became comprehensible if one could accept the view that the skin became sensitized by an emotional state to a degree that induced intolerability to contact with a material substance previously well tolerated.

Much has been written on the multiplicity of cause, but the common man attaches blame to the most variable factor in the picture. For instance, if a motor car mounts a pavement and knocks down half – a – dozen people, the unusual behaviour of the motor car is held to be the cause of the accident, and not the presence of pedestrians on the pavements. When, on the other hand, a young child rushes out on to a busy street after his ball and is injured by a moving vehicle, cause is linked up with the sudden and unexpected action of the child.

Such a line of reasoning will often shift the responsibility for the occurrence of an illness from a material substance outside the body to processes operating within the body itself. In other words, if a hundred men working among lime all contracted dermatitis, one would unhesitatingly attach blame to irritating properties in the lime; but if only one man developed a skin lesion, the more significant relevant factor is his own highly personal exaggerated response to lime.

Many of us find that certain areas of skin, notably the back of the hands, crack and even bleed during a spell of cold frosty weather. However, it is also common experience to find that after a few mild days the skin has regained its normal texture without any treatment whatsoever. The removal of the environmental cause of the disorder is sufficient to bring about cure. It seems curious that, when a patient complains of a skin disorder, accepted as being due to a physical irritant, such as cracks behind the ears which he attributes to the metal frame of his spectacles, the eruption may fail to clear up when he ceases to wear the offending glasses, and may spread over large areas of skin. This occurred in the following case.

CASE 2.

A theatre manager, aged 40, complained of four weeks irritation, followed by cracks, behind both ears. He attributed the cutaneous lesion to his metal spectacle frames but admitted that these had been worn by him for over ten years without previous trouble.

On my advice he temporarily discarded the spectacles. Medicine and an external application were prescribed. The fissures healed but soon reappeared and now seemed resistant to these and various other remedies. Later, dermatitis appeared on the back of the neck and the face.

Life Situation: He had married twelve years ago. Before marriage his wife had been a dancing instructress. She has an extreme mother – attachment, and he said that even yet he felt that her mother meant much more to her than he did. Like most such women she was sexually frigid. Her only pregnancy, ten years ago, was terminated on account of hyperemesis – as might be expected.

He did not usually leave the theatre at night until 10.45, reaching home about 11.15. It was his custom to telephone his wife when some untoward happening made it possible for him to come home earlier. About five months before the onset of his illness he went home one night at 9.30 without making the usual telephone call. On going upstairs he found a man, unknown to him, in his wifes bedroom with her. There was no definite evidence of misconduct, but he became obsessed with doubts and suspicions.

He was an uncompromising type of man, with a limited capacity for seeing anothers point of view. He adhered to his own principles and standards, judging others by them; nor, having once formed an opinion, did he readily change his mind. Since the bedroom episode his wife and he met only at meal – times and rarely exchanged a word. He maintained a cheerful exterior to his business associates but ruminated unceasingly on his domestic crisis. Providence had been unkind to him. For many years he had endured a wife who was not in love with him and who had now, perhaps, added infidelity to her short – comings.

Progress: Although I knew this man socially I had no inkling of the above difficulties until they were disclosed in an interview above difficulties until they were disclosed in an interview about two months after the commencement of treatment. Following the disclosure he became covered in a few days with a papulovesicular eruption from head to toe. After further interviews and discussions he agreed that in all probability his skin disease was determined by his recent emotions, and that the present state of affairs should be ended, either by reconciliation with his wife or by a complete break.

He took a months leave, which he spent in his native town. After a week he reached a decision and instigated proceedings for a divorce. By the end of his months holiday he was free from dermatitis. During the next four months, pending legal hearing and judgment, he had repeated crops of boils, but this affection also vanished soon after decree was granted in his favour. He resumed wearing his spectacles and has now remained trouble – free for many years.

INDUSTRIAL DERMATITIS.

During the war years there was an increase in the incidence of so – called industrial dermatitis. The vast majority of the case occurred among munitions – workers, and the oils used in the engineering industry have been blamed for them. Yet is it extraordinary that a person should be able to work with oil for months or even years without discomfort and then should develop dermatitis, which is rarely limited to the parts of the skin which come into contact with the oil.

Moreover, if the oil was the sole aetiological factor in the production of the dermatitis, one would expect that withdrawal from the noxious agent would be rapidly followed by spontaneous cure, or at least by obvious improvement. But this never happens. On the contrary, the dermatitis, is liable to drag on for months, to spread all over the body, and to resist all medicaments.

During this period the patient becomes anxious about his earning ability, and, besides drawing his weekly compensation, often consults a solicitor with a view to obtaining a capital sum to reimburse him for the damage inflicted on his skin “because, as everyone knows, the dermatitis may return at a later date”.

G. Gladstone Robertson