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Psyche and the skin: anxiety PSYCHE AND THE SKIN: ANXIETY
Anxiety is a feeling similar to fear. It is the appropriate emotional response to the perception of a danger. The danger may be external, such as an alarming situation or a natural catastrophe; or it may be internal, such as when an individual is in a conflict situation, either real or imagined, with his own conscience and moral standards of behaviour.
Internal dangers are the principal source of human anxiety. Often the patient is unaware of what he is afraid. He may assign his anxiety to his wife, his boss, or a nuclear threat, but these are conscious rationalizations for the most part. The real conflict is usually hidden from the patient, and concerns the self-imposed, unconscious inhibition of instinctual impulses which are regarded as unacceptable. His real fear may lie in the possibility of his carrying out his primitive instinctual drives, particularly those related to sexuality and aggression. The failure of an instinct to find an appropriate outlet may result in its inappropriate discharge, causing tension to be built up to the point where some means of relief must be found. This may result in peptic ulceration, hypertension, migraines, or a skin disorder.
The body, however, conforms to a general biological principle, that of homeostasis. This means that there are automatic regulatory mechanisms which keep the internal environment constant and relatively uninfluenced by sudden external environ-mental shifts. Similarly, in the mind, internal or external dangers are 'buffered', the defence being a neurotic reaction. This of course entails a price in discomfort, as does the defensive reaction of a fever (high pulse rate etc) in serious infections. These defence reactions take place spontaneously and automatically. As far as we are concerned the psychosomatic defence reaction to various anxieties is manifested by dysfunction in the skin.
The person with an unsightly skin disease has, however, a special cross to bear because of the irrational and often cruel attitudes of society towards skin abnormalities. We may be sure that repugnance and disgust, in most cases so out of proportion to the medical significance of the skin disorder, is a defensive social response growing out of unconscious fears connected with unhealthy skin. The best example of social irrationality of this kind is that associated with the disease leprosy. Affected persons, though not appreciably contagious or ill, are banished to live in leprosariums, supposedly to render others safe but fundamentally because humans are driven to excesses combating their unconscious fear of skin disease. It would seem, then, that mankind regards the skin as the psychological symbol of spiritual and moral purity. A blot upon it, therefore, may be unconsciously interpreted as a sign of moral impurity. Skin lesions are typically and irrationally regarded as 'dirty and highly contagious'.
One must, however, beware of blaming all skin disorders on conflicts within the psyche. The flare-up of a skin disorder following an emotional upset is not proof that it is therefore a psychologically-caused (psychogenic) disorder. It is well known that exacerbations of many skin disorders occur under stress, diseases which may well have a real organic basis. For example, psoriasis, acne, or leprosy, which are by no means without their deep organic basis, may all be aggravated by anxieties or stress. On the other hand, the failure to identify an intense stress prior to the onset of symptoms by no means excludes the possibility that the disorder is psychocutaneous. In fact this pattern occurs more often than is realized. Prolonged tension without the benefit of a clear cause, will sooner or later become symptomatic. Patience and skill are necessary to detect the underlying anxiety in some individuals whose typical defence is a superficial serene equanimity. On occasions the skin lesion so successfully defends against the anxiety that the patient is actually unaware of the anxious feelings. Without time and psychological sensitivity, the doctor may fail to realize that emotional illness can be concealed behind such facades. The complete 'poker face' more often than not is evidence of repression of anxieties rather than psychic peace.
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