THE VITAL FUNCTIONS
The skin covers the entire body with a protective surface; it is the largest and the most exposed bodily organ. The skin performs numerous vital functions: it regulates the body's temperature and serves the sensory functions of reacting to touch, heat, and cold.
The human skin is quite sensitive to external influences, such as heat and cold, pressure, and blows. Physical harm to the human body often starts with the skin, and most accidents begin with damage to this protective cover. Small wonder that the skin is also sensitive to harmful influences coming from within the organism, both physical and mental (Medausky, 1980).
The weight of the skin of an average-sized adult is between 6 and 7% pounds, and it has a surface area measuring approximately 2 square yards. The thickness of skin can vary from %2 of an inch to Vs of an inch. The composition of the skin includes numerous glands, nerves, skin cells (which are specialized), hair and hair follicles, and blood vessels (Katch & Katch, 1980).
ANATOMY AND PHYSIOLOGY
The skin is composed of three layers: the epidermis, the dermis, andthe subdermis. The epidermis is the outer portion of the skin, which normallycontains no blood vessels or nerves. The dead cells that are sloughedoff are contained in the outer layer of the epidermis, called the cornifiedlayer, or the stratum corneum. The epidermis is generally tough because itcontains keratin, a hornlike material. The lighter layer, below the cornifiedlayer, is called the stratum lucidum.
The skin that is visible on the surface of the body is made up mostly ofdead cells. This surface skin is renewed slowly, as the dead cells are con-stantly being cast off, and smoother, healthier skin remains. Healthy skinhas many pores, which are the openings of glands. The sebaceous glandssecrete an oily fluid that causes the skin to appear either waxy or greasy.Hair, which is found nearly all over the body, grows from follicles, whichare pits within the skin.
Just below the epidermis, which includes the cornified layer, the stratumlucidum, and the stratum mucosum, is the dermis. Hair follicles and asystem of blood vessels are found throughout the dermis, along with theelastic fibers that are responsible for the elasticity of the skin. Nerves andnerve endings are found in the dermis, allowing sensations to be experienced.These nerve endings are responsible for keeping the skin out ofdanger by modifying conditions in emergencies such as cold or heat. Thenerve endings alert the body to external dangers. The nerve endings fortouch sensation exist in greater number than those for cold and heat. Thedermis extends into the epidermis; therefore, the two layers interweave.The third layer of the skin, called the subdermis, is located below thedermis. This layer is made up of fatty tissues that have the ability toinsulate (Clark & Cumley, 1973).
Melanin, a brown to black pigment, influences the color of the skin.The production of melanin is caused by a sequence of biochemical reactions.This series begins with the oxidation of tyrosine and is catalyzed bytyrosinase. Tyrosine is an amino acid and tyrosinase is an enzyme. Heriditaryfactors determine how much melanin is produced. However, melanincan be present in greater amounts than normal, may be missing entirely, ormay be distributed unevenly. When there is a small amount of melanin inthe skin, the skin has a pink color. When the skin appears yellowish, thismay be due to the presence of the pigment carotene. This pigment is oftenfound in many vegetables and is related to vitamin A. When there is anexcessive consumption of foods with vitamin A, the skin may becomeabnormally yellow. This condition is known as carotenemia. Other unnaturalcauses can create discoloration of the skin. Jaundice causes the skinto appear more yellow as the result of internal organs that are afflicted withsome form of disease. Skin changes with age, irritation, or excessive exposureto sunlight or wind.
SKIN AND PSYCHOSOMATICS
The skin, being the protective surface of the body, is exposed to numerousharmful influences, and the nerve endings in the skin are recipientsof a great vaiiety of antigens. The skin is highly sensitive to pain,which can be elicited by physical and psychological factors. Most skindiseases are not lethal, but they are usually quite painful and may seriouslyaffect the physical and mental functioning of an individual (Medansky,1980).
Psychological factors and especially emotions exert considerable influenceson the skin. Blushing is usually an expression of shame, and itchingis a sign of impatience. The body surface is also the somatic locus ofexhibitionism. Reflex changes in the skin, such as pallor and flushing, areconstituent parts of the emotional states of rage and fear. The skin functionsas an important sensory organ and is affected by conversion symptomssuch as anesthesia and paresthesia. Clinical studies of skin manifestationsas a part of neurotic symptomatology have been conducted onneurodermatitis, eczema, angioneurotic edema, uticaria, and pruritis. Ineczema and neurodermatitis, sadomasochistic and exhibitionistic trendshave been claimed to be correlated with the skin symptoms (Alexander &Flagg, 1965; Engels, 1983, 1985; Torch & Bishop, 1981).
All psychosomatic disorders serve a purpose, such as gaining affectionor escaping from responsibilities. Psychosomatic disorders require visibility,and the skin is a choice location for visibility. The need to be seenand to get attention is well served by skin diseases, and with the exceptionof clearly organic cases, most skin diseases are psychosomatic.Psychosomatic disorders are often associated with self-directedharmful behavior. Self-induced pain and accident-proneness are usually ofpsychosomatic origin. In skin diseases, scratching is of considerableetiological significance. Psychoanalytic studies imply that scratching is dueto inhibited hostile impulses, which, because of guilt feelings, are deflectedfrom their original target and are turned against oneself. Craving for physicalsigns of affection, such as being held, cuddled, stroked, and soothed,is involved in skin reactions to the feelings of guilt for being overdemanding.Scratching is used as a self-punishing defense mechanism (Alexander,1950; Musaph, 1964, 1977).
ALLERGIES
Allergies have been defined as an II overreaction" of the organism'sdefense system. Usually, the body fights antigens (the foreign invadingbodies) by producing antibodies, but in allergies, the development of antibodiesin reaction to allergens is excessive and definitely out of proportionto the threat.
Allergies represent a combination of physicochemical and psychologicaldeterminants. The invading allergens can affect the gastrointestinalsystem, the respiratory system, and the skin. Allergic disorders vary frommild to very severe, and even lethal. Well over 10% of the U.S. populationhas some allergy, and one need not exclude the possibility of there beingcertain genetic predispositions to allergies.
Most probably, the "hammer-and-anvil" scheme mentioned in Chapter15 applies to allergies. The genetic predisposition of the immune systemis the anvil, and the two hammers are the allergens and the stressors. Parental rejection is a highly relevant emotional "hammer" in asthma; frustrationsand the loss of a beloved. person are relevant "hammers" in neurodermatitis;and the emotional inconsistency of a child's parents plays therole of "hammer" in infantile eczema.
DERMATITIS
Dermatitis is an inflammation of the skin. The inflammation can be caused by either physical or psychological factors or by both. Obsessive compulsive neurotics, perfectionists, and anxiety- and guilt-ridden individuals often suffer from various skin ailments, especially dermatitis. The main symptoms of dermatitis are reddening of the skin, erythema, crusting, blisters, scaling, cracking, oozing of fluids, and intense itching. The severity of the symptoms is usually related to an emotional disorder: disturbed individuals develop facial and genital lesions; the least disturbed have blisters on their hands (Whitlock, 1976). Infantile dermatitis is most often a product of maternal rejection. The rejected child resents the rejecting mother, and the skin eruption may represent outbursts of anger and hostile feelings. Some children resent themselves for resenting the rejecting parents; they blame themselves for being the cause of maternal rejection and punish themselves for being "bad children"
Adult dermatitis is often caused by sexual conflicts, lack of self-esteem, and sexual problems.
A Case Report
A few years ago a young married woman was referred to me by a dermatologist. He had treated her unsuccessfully for two years for a recurring severe skin rash in the pubic area.
This very attractive 28-year-old woman came reluctantly to my office. She told me in a most angry and belligerent manner, that she is not a mental case, does not need any psychotherapy, and despises shrinks. I replied calmly that she was under no obligation to talk to me, but that her doctor had given up on treating her; he had told me that her problems must be psychogenic and had requested my help. The young woman decided "to give me a chance." She asked, "Should I undress to show you the mess I am in?" When I told her that no psychoanalytic or other psychotherapeutic methods require undressing, she replied sarcastically, "How can you cure it if you refuse to look at it?" I explained to her that her doctor had given me, in writing, a detailed description of the symptoms and his diagnostic evaluation.
It took a while before we discovered the truth. Four years before, the woman had married a man 10 years her senior. Her husband was anxious to have children, but she had asked him "not to rush her." Two years before, the husband had made it clear that he did not intend to wait much longer. His words had sounded like an ultimatum and the young woman went off the birth control pill. However, something strange happened. She developed a pubic skin rash with intense itching. Sexual relations had become most uncomfortable, and quite often painful. The woman offered oral, manual, and any other sexual gratification to her husband, always with apologies and excuses, but the husband was quite annoyed about her skin rash.
She went for help. The kind and competent dermatologist tried his best. He treated her for almost two years. Finally, he gave up and referred the woman to me. She did not tell him about her husband, nor did she tell me. She talked in my office about everything else except about her husband's wish to have children. She loved her husband and praised him and felt guilty for depriving him of genital sex relations.
This had been going on for a while when she had a strange dream that offered the right clues. In the dream, her belly was getting big, and her pelvic bones were shrinking. After the dream, she asked me, "Why don't you want to see me naked? How can you help me if you don't see the skin rash? I know that my lower part, the pelvic bone, is abnormally narrow. I am fat on the top and skinny at the bottom!" I explained that the dermatologist had described her skin condition, and her concern about the shape of her body offered an important clue.
She admitted her fear of pregnancy. She felt she had no chance to give birth to a child, and she feared that, in labor, either she or the infant would die. I sent her to a gynecologist-obstetrician for a thorough examination. Her fears were irrational, and the rash disappeared. Recently, I received a letter from her. She has three children.
