Mind-Body Medicine: Title and subTitle BreakPractical Applications in Dermatology

Have you ever wondered how your thoughts affect your health? Did you know that you can improve your health by changing the way you think and respond to events in your life? This article covers the basics of several different techniques in mind-body medicine. Additionally, 2 pathways are presented that represent the ways thoughts can affect health. Metaphors are used to help explain certain principles and treatments.

It is extremely important for all physicians to have an understanding of the basic principles of mind-body interactions because it has been shown that there are direct connections between the central nervous system and the immune system.¹ These connections include

compartmentalized innervation with noradrenergic sympathetic fibers of primary and secondary lymphoid organs, neuropeptide and neurotransmitter receptors on immune cells and cytokine production by activated immune cells that can influence brain function.¹

Additionally, it has been found that Langerhans cells have neuropeptide receptors and also express neurotrophic factors, suggesting that there is bidirectional communication between the two.² Therefore, it is reasonable to conclude that the immune system may be influenced by thoughts and other functions of the brain. If this is so, then we can also conclude that most of the common dermatologic problems such as adult acne, rosacea, eczema, psoriasis, and other nonspecific inflammatory disorders may be directly influenced by the patient's thoughts and emotions. While most dermatologic problems are multifactorial in origin, in this article we only discuss the causative role of thoughts and emotions in the development of disease. In some patients, this may be the primary causative component, while in others it may be a tertiary or minor component. In all cases, however, knowledge of mind-body interactions and mind-body interventions can be useful in improving a patient's dermatologic condition and, in most cases, their quality of life.

To begin, construct a picture in your mind that sees every human being as consisting of 3 distinct bodies: physical, mental, and emotional. The 3 are intimately connected and changes in one will produce changes in the others. Each body vibrates at a different energetic frequency, therefore any changes in these bodies will occur at its specified rate. For example, the mind operates at the highest frequency. Throughout the day, the mind creates many thoughts and most people will quickly jump from one thought to the next and back again without much difficulty. The emotional body operates at a lower vibrational rate than the mind, and changes of state in the emotional body occur at a slower rate than in the mental body. A good example of the ease with which shifts occur in the emotional body is a child. If the child is happily playing and something occurs that upsets the child, he/she will freely express displeasure, usually by crying. A few moments later, tears are replaced by a smile. Whereas, the physical body operates at the lowest vibrational rate and changes in the physical body occur at a much slower rate than changes in the other two. To understand this concept better, consider the reaction of a person who sees a car heading straight for him/her and almost gets hit by it. The first reaction probably is the thought, "Oh no!" Fear quickly follows the recognition of danger, which releases hormones, including adrenaline, and the person moves out of the way. Once the event is over, the person may think, "I am OK" and the fear may slowly be replaced by feelings of gratitude. Finally, slowest of all, the physical body begins to return to a relaxed parasympathetic state.

Normally, all 3 bodies respond to and easily return to baseline following changes from external stimuli. Pathologic manifestation occurs when there is a problem with the ease in which the mental body returns to baseline. For a pathway that may explain how negative thoughts can lead to pathologic changes in the physical body see Figure 1. A negative thought form can be metaphorically thought of as a "demon" who has taken up residence in a person's consciousness. It constantly makes itself known and whenever the person acknowledges it and feeds into it, the demon grows stronger. For many people, this thought eventually grows so strong that they may develop the belief that it is true and unchangeable. As thought forms become beliefs, emotions become frozen in a negative state, and the body enters a chronic sympathetic state often termed stress. As a result, the normal homeostatic mechanisms fail and disease appears. The type of disease that manifests is dependent on the degrees of change in the body and the genetic predisposition of the individual.

Negative thoughts are one of the more prevalent contributors to stress. Stress is the result of a person's response to external stimuli and not the events themselves. From the viewpoint of traditional Chinese medicine, when stress is internalized, the flow of vital life energy throughout all 3 bodies is impeded.³ This vital life energy is called chi in Chinese, ki in Japanese, and prana in Sanskrit (India). To better understand the effects of stress on a person's chi, imagine that a healthy person is like a deep river, flowing smoothly on its course. A person on the shore throwing rocks of all different sizes into the river represents stressful events. As the number of rocks increases, the river's flow becomes more turbulent. This corresponds to turbulence in the flow of chi and the appearance of physical problems. Therefore, treatment plans must include a method of preventing the accumulation of more stress and, moreover, a plan for removing the stress that is already in place.

There are many different techniques in mind-body medicine for achieving these goals. Figure 2 illustrates a pathway for reversing the disease process and creating health. In dermatology, disease usually falls into several major categories such as acquired inflammatory dermatoses, congenital dermatoses, and noninflammatory dermatoses/tumors. Based on observations in the office, stress appears to be one of the most prevalent components in the cause and severity of most inflammatory skin conditions. Through the use of mind-body techniques for the reduction of stress, most inflammatory dermatologic conditions can be helped to some extent. Acquired inflammatory dermatoses are the most amenable to mind-body techniques because their life cycle is one that waxes and wanes. Other dermatologic problems can also improve, to some degree, with mind-body techniques. In all cases, however, the quality of life of the patient can be greatly improved with mind-body techniques.

We divide mind-body techniques into 2 major categories: techniques practiced by the patient and techniques used by the practitioner with the patient. The first category includes meditation, affirmations, journal writing, prayer, exercise, reading spiritual books, and biofeedback. The second category includes hypnosis and Neurolinguistic Programming (NLP, explained later). The techniques listed above that are practiced by the patient represent the categories of the mind-body techniques that are easy to do and readily available. There are many classes and books available that list a myriad of other techniques and spiritual practices.

Meditation is the practice of bringing one's total focus into the present moment. The first reports in American literature of the physical effects of meditation were made by Herbert Benson, MD, a cardiologist at Harvard Medical School, Boston, Mass. Benson observed that after 20 minutes of meditation participants' heart rate, breathing rate, blood pressure, oxygen consumption, carbon dioxide production, and serum lactic acid levels all decreased, while skin resistance increased and blood flow was altered. He called this phenomenon the "relaxation effect."⁴ Similar physiological responses have been found to occur with other techniques such as hypnosis, progressive muscular relaxation, and autogenic training.⁵

One of the simplest forms of meditation involves sitting comfortably and focusing on the breath. For most Westerners, this means sitting in a chair with the feet flat on the floor and the hands in the lap. A word or phrase is then repeated over and over for a specified length of time. This word or phrase is called a mantra. Most people will find that their mind will wander at times and they will begin thinking of different things. It is important that, when one becomes aware of the wandering, he/she lets go of the superfluous thoughts and returns to following the breath and repeating the mantra. A meditator must be willing to let go of extraneous thoughts, without judgment, and return to his/her point of focus.⁶ Since focus is the key to meditation, it can take many forms—sitting quietly, painting, playing an instrument, participating in a sport, or working out at the gym. During any of these activities, the person's mind becomes clear of everything but what he/she is doing at that specific moment. The goal of meditation is to bring one's full awareness into the present moment and simply be. When this occurs, not only can a person induce relaxation but he/she also can begin to bring the benefits of meditation into all aspects of his/her life.⁷

Affirmations are statements made in the present tense, containing only positive statements, and expressed in the first-person singular. The use of affirmations provides a simple and effective vehicle to access the "thought-healing pathway" as illustrated in Figure 2. Many of our dermatology patients look at themselves in the mirror and have decided that their problem is so awful that they are embarrassed to go out in public. Some of these patients may even have a minor skin problem, yet they refuse to believe that the problem is minor or that it is safe to be seen in public. These beliefs started out as repetitive negative thoughts (Figure 1). The use of affirmations occupies the consciousness with positive thoughts, leaving no room for negative thoughts. By repetitively using affirmations, the patient is unable to subvocalize the 2 opposing thoughts at the same time. With time, the patient's neurologic pathways shift and the positive thoughts can predominate. For example, a patient who has spider veins states that she is disfigured and cannot wear shorts. One possible affirmation for her to say may be, "I am beautiful in every way." It is not important for her to believe what she is saying; the belief comes later. The important thing is for her to say the positive words. Our advice to our patients is to use the affirmation every morning and also whenever they become aware of the presence of the negative thoughts. The repeated use of affirmations provides a powerful tool for eliminating negative self-talk, which is a major contributor to stress and turmoil in people's lives.⁸

Journal writing is the next, most simple technique to use for self-help. As with affirmations, writing in a journal requires no classes and the only skills needed are reading and writing. Patients are instructed to set aside the same time each day for their journal writing. At the start of a session, it is important to sit quietly for a few moments and take some breaths to become centered. The next step is to write whatever comes to mind, without stopping to think about what is being written. The final step is to read over the entry. Writing in a journal helps unlock the unconsciousness and bring repressed emotions and thoughts up into consciousness. It also creates a new perspective for the patient to approach his/her challenges. Studies of college students and executives have shown that immune function can be improved through the use of a journal. In addition, when the test subjects stopped writing in their journals, their immune function returned to the prestudy baseline after about 6 months.⁹ The following comments were made by 2 patients regarding their journal writing experience. "Whenever I write in my journal, I feel like the problems I was having are now in my book and no longer in my body." "I feel lighter . . . like a load has been lifted from me."

Dossey in his book Healing Words¹⁰ defines prayer as communication with the Absolute (this is the name he chose to represent God). In this book, he states that there are more than 300 experiments using prayer involving living organisms, from microbes to humans, and that about half of the studies show that prayer can cause a statistically significant change in the test subjects. The studies he quotes in his book show that all types of prayer are equally effective, including prayers that specify an outcome vs nonspecific types of prayer such as, "Thy will be done." The studies showed differences in an individual's ability to evoke a positive effect from prayer. In essence some people were better "prayers" than others. It appears that the more effective prayers were more able to alter their state of consciousness and enter a more meditative or prayerfulness state than those who were less effective prayers. It is helpful to suggest to patients that prayer be approached like a meditation, in which the object of the meditation is the prayer itself. With this approach the prayer experience can be intensified. Most studies on prayer have been performed with microscopic organisms like bacteria and fungi.¹¹ One of the most profound studies of prayer and health was reported by cardiologist Byrd.¹² In his study, a computer assigned the 393 patients admitted to the coronary care unit to either a group that was prayed for by outside prayer groups or to a control group. This study was done according to a strict double-blind protocol.

The results of this study showed that the prayed-for patients differed significantly from the control group in the following areas:

While the results seem difficult to believe, the study was well designed. If the focus of the study were a medication, then it might be heralded as a new miracle drug. This study had some flaws, which Dossey discusses in Healing Words.¹⁰ The flaws, however, are overshadowed by the positive implications, if even part of the study's results are true.

Biofeedback is a technique that uses machinery to measure autonomic functions such as heart rate or muscle tension. The patient uses various imagery exercises and learns how to consciously alter these autonomic functions. In the rheumatology literature, the use of biofeedback has been shown to be beneficial in the treatment of Raynaud disease and phenomenon. In this study, patients were taught biofeedback first as a relaxation technique and then as a method of increasing the skin temperature in their fingers. All patients in the study were able to elevate their baseline fingertip temperature. The results suggested that biofeedback is useful in the treatment of Raynaud disease and phenomenon, and that "further studies were required to completely evaluate the efficacy and clinical significance of biofeedback."⁹

The essential goal of both hypnosis and NLP (Richard Bandler & Associates Seminars GroupInternational, Hopatcong, NJ) is to help a patient access resources that he/she has available in his/her subconscious and use them to change his/her behavior. Milton Erickson is considered to be the father of modern hypnosis and was a firm believer that everyone is born possessing all the resources needed to create new behaviors. The problem is that most people have set up conscious and unconscious blocks that thwart their healing process. Erickson used hypnosis to help his patients bypass these blocks and overcome their problems. Richard Bandler and John Grinder studied the works of Erickson and other therapists who had the reputation of being miracle workers when it came to curing patients with behavioral disorders. They found that Erickson and other therapists used certain language patterns when working with their patients. Bandler and Grinder developed specific language models based on their study that achieved success for various mental conditions. In the 1970s, they began to teach these models in conjunction with hypnosis and called their new technology Neurolinguistic Programming.^{11 ,13}

Neurolinguistic Programming is a process-oriented science as opposed to the content-oriented science of traditional psychotherapy. This means that an NLP practitioner only needs to know the type of problem that the patient is having and what the patient desires as the outcome of the session. The actual details of the situation and the patient's history is unimportant to make therapeutic changes. One of us (M.R.B.), for instance, had a patient who became very stressed at work and her acne flare up corresponded with the start of a new job. During the session, he helped the patient create a relaxed state and associate this relaxed state with events that previously triggered her stress. The specific details of what caused her stress at work were not important to help her overcome and feel better about the situation.

The first author (M.R.B) has used hypnosis and NLP for several types of problems: treatment of neurogenic skin problems, stress reduction, improvement of self-image and quality of life as a result of a skin problem, and as anesthesia for minor surgical procedures/sclerotherapy. The following are examples of treatments with the NPL techniques that the first author used with some of his patients. The explanations of the actual procedures have been simplified and, for the sake of brevity, examples of the language patterns used are not included.

Patient 1, an aspiring actress and model in her middle 20s, complained of constantly picking at her skin that created marks and scars. This problem was distressing to her. She denied any pruritus. The essence of the first author's work with his patient was to suggest that she develop new behaviors that provided the same benefit as the unwanted behavior. Moreover, it was suggested that these new behaviors be fully evaluated by her subconscious so that the negative aspects are minimized. All negative behaviors have some sort of reward for the person engaged in that behavior. If we simply "command" the person to stop the unwanted action, then they may develop an even worse behavior or resume the old one. After 1 session with her, the patient completely stopped picking at her skin. This remission lasted for about 1 year when she returned complaining that the problem was back. Once again, hypnosis was used and the condition resolved itself after 1 hypnosis session.

Patient 2, a 30-year-old white woman, complained of a scar on her left thigh. The scar was flat, brown, and 3 × 1 cm. Objectively, this was not a terrible problem. Subjectively, however, she stated that the scar was so horrible and disfiguring that she could not expose it in public. For example, she stated that if she needed to use a communal dressing room, she would either wait until it was empty or stand in a corner with her hip facing the wall before removing her pants. A common reaction to a patient with this type of problem might be to try to convince her that the scar is barely noticeable and she should stop obsessing about it. Had that been done, she would have looked for a new physician because her point of view would not have been acknowledged. Instead, it was acknowledged how awful this problem was for her and NLP techniques were used to neutralize her emotional reaction to the scar. On the follow-up visit 1 month later, she said that while she did not like having the scar, she no longer had any problems exposing it in public. In this case, the use of NLP did not improve the appearance of the problem; it did, however, greatly improve the patient's quality of life.

Patient 3 (a woman) was treated with sclerotherapy and patient 4 (a woman) was treated for multiple electrodessicated and curreted dermatosis papulosa nigra. In both cases, a hypnotic induction was done and suggestions of anesthesia were given. Patient 3 stated that there was no pain compared with the severe leg cramping she had experienced during previous sclerotherapy sessions. Patient 4 also experienced no pain while the procedure was performed. A 1.5-cm seborrheic keratosis was even electrodessicated and curreted from her cheek without any memory of it ever happening. As an aside, patient 4 has had many sessions for the treatment of her dermatosis papulosa nigra and on her all subsequent visits hypnotic anesthesia was induced in less than 1 minute.

In this article, we have offered some illustrations of how a person's health and thoughts are connected and how stress plays a role in the origin and exacerbation of health problems. The old mechanistic viewpoint of health and disease, as started by Rene Descartes, is now known to be obsolete. The connection between our thoughts and health has been well established thanks to the work of many health care practitioners, including Larry Dossey, MD, Bernie Seigal, MD, Herbert Benson, MD, Dean Ornish, MD, Jon Kabat-Zin, PhD, Joan Borysenko, MD, and others. The field of mind-body medicine is vast and offers the dermatologist an opportunity to treat his/her patients on more levels than simply prescribing medications for symptomatic relief. Our responsibility as physicians is to promote health in addition to combating disease. In almost all cases, the medications we prescribe will help alleviate the symptoms, yet they do little to induce a remission. Through the use of mind-body medicine, improved nutrition, exercise, and general improvement in lifestyle, we as physicians can play a pivotal role in teaching our patients how to be healthy.

Accepted for publication April 16, 1998.

Our special thanks to Hilary Bilkis, MS, LMT, for proofreading and editing the manuscript.

Corresponding author: Michael R. Bilkis, MD, MSC, 48 Miami Trail, Rockaway, NJ 07866.