Jorge C. Ulnik1 and M. Dennis Linder2
1Department of Psychiatry and Mental Health, Buenos Aires University, Buenos Aires, Argentina and 2Section of Biostatistics, University of Oslo, Oslo, Norway
Dermatological symptoms are explained in medicine in biological terms. Nevertheless, exploring the life history of dermatological patients can lead to seductive, but non-rigorous scientific interpretations that are of associative, or even symbolic nature. Moreover, associations of physical signs and life events, suggest we consider our patients as subjects pervaded by the will to communicate not only through language, but also through their body and all its functions and malfunctions. Interpreting symptoms and eventually finding a meaning to the disease should not imply a causative attribution, because the very meaning of cause and effect is probably beyond our grasp. Hence, aware of our limits, we should know whether we wish to treat the disease as a whole, considering that the observer (the doctor, the patient or the medicine as a theoretical corpus) is not only an observer from outside, but also part of the disease that will be treated or described. Key words: interpretation; dermatological symptoms; psychoanalysis; symbolization; somatization.
Accepted Mar 29, 2016; Epub ahead of print Jun 9, 2016
Acta Derm Venereol 2016; Suppl 217: 22–24.
Priv. Doz. Mag. Dr Dennis Linder, Section of Biostatistics, University of Oslo, NO-0317, Oslo, Norway. E-mail: email@example.com
Dermatological symptoms are explained in medicine in terms of a change in the interplay of skin and blood cells, cytokines, neuropeptides, etc. in a previously homeostatic stage. The loss of homeostasis is thought as being caused by external stimuli like infections, UV radiations, or neurogenic inflammation produced by stress as co-source of inflammatory skin diseases.
Exploring the life history of dermatological patients leads more often than expected to seductive, but non-rigorous scientific interpretations of the aetiology of skin lesions, and these interpretations are often of associative, or even a symbolic nature. So, skin lesions can be seen as an overload of signals (for example psoriasis turning up in a genetically predisposed patient in a stress situation); but may also present as the unlikely result of associations of physical signs and life events, as if the skin (or “something behind it”) were a “thinking entity” capable of symbolizing and elaborating concepts, thus producing symptoms as a function of language, thought, and mental abstractions.
We should therefore explore the life history of patients and feel free to develop our own creative and subjective thoughts as a consequence of their narratives.
Since we are used to the logics “post hoc, ergo propter hoc” (B happens after A, so A is the cause of B) we risk running into this usual psychogenic interpretation when we develop our thoughts.
We are thus bound to end up suggesting that life events, attributed meanings, fantasies and emotions are aetiologies of the disease. This is too restrictive, but we can achieve both aims: we can perform our physical examination, acknowledge somatic semiology and offer biochemical therapies, but can also consider our patients as subjects pervaded by the will to communicate not only through language, but also through their whole body and all its functions and malfunctions.
This multidimensional procedure is legitimate as diseases can be considered in terms of a higher entity, seen according to the discipline by which it is approached (classical biological medicine, psychoanalysis, biopsychosocial approach etc.). This entity has its own nature and the symptoms it produces will vary according to the theory through which it is modelled. Thus the single models are only projections of the complex entity and the complete nature cannot be grasped fully, it is only projected on the screen by different lamps from different angles.
Sometimes there are lesions that appear after a loved person’s death or a separation, or the patient’s name is unconsciously connected with the symptoms or the lesions: colour, shape, etc. Patient may talk about their disease using words that reflect their emotional status: a wound that does not heal, a stain that marks a significant body part, a drawing that clearly reflects an histological characteristic of the disease, etc.
These associations can also occur in therapy, as for exampole those therapeutic processes that include some meaningful objects, according to what Levi-Strauss called “savage thinking” (1). For example, native indigenous from Costa Rica call “naked Indian” a tree that continuously sheds its cortex to protect itself from some insects that try to grow on it. Its scientific name is Bursera Simaruba. This tree could evoke a scaly skin disease. The indigenous use it to treat skin disorders, and it is reported to work!
The psychoanalyst Joyce Mc Dougall describes her own case (2). When she was a child, she developed urticaria each time she visited her grandmother in New Zealand. Although her family thought that it was an allergy to the milk from the Jersey cows, she became aware that she had allergy every time she faced her family environment, dominated by her grandmother, who had been imposing her will on everybody. When she separated from the grandmother’s influence, the urticaria disappeared. This example suggests that a person could be “allergic” to another person, even when the allergens are not present.
There are many cases with close connections between diseases and life histories, but what about evidence?
Maybe some issues are not easily demonstrable, but we can build a theoretical fundament and progress in our knowledge of clinical facts. For example, biosemiotics is a discipline that could be a background from which we can say that there are symptoms working as a function of language, thought, mental abstractions or different levels of signs (3).
However, meanings do not always manifest themselves in the same way. Sometimes the quantitative factor is essential, and the level of stress or the strength of emotions does not allow the significant to play its role. Thus, inspired by Charles Peirce’s semiotics (4), we can state 3 different forms of somatization: The index somatizations (they occur as a consequence of stimuli that are above a threshold), is a reaction to a high and unspecific stress; The iconic somatizations (they imitate the stimuli) may be influenced by the mirror neurons; The symbolic somatizations (they symbolize an idea, a feeling or a complex scene, imply a high range process, complex imitation, and an unconscious intention of the subject to communicate.
According to Steven Connor, “It is generally easy to agree with specialists in psychosomatic dermatology that, as the most important expressive organ of the body, the skin is a sensitive marker of different mental and physical states. ”What is less easy to accept, or even perhaps to understand, is the claim that the skin allows the more or less direct picturing of those mental states, as images or allegories” (5). The author mentions a woman with an eczema lesion in the same place where her mother had the tattoo of a concentration camp.
THE MIRROR NEURONS AND THE SKIN
Mirror neurons are brain cells that help us to understand the actions of other people simulating in the brain the same actions through the activation of motor plans. Reproducing face’s motor movements during emotions, mirror neurons help us feel what other persons feel, through some neuronal connections with the insula and the limbic system. These cells appear to create a sort of intimacy between the Ego and the other helping us to feel the same as others.
Mirror neurons discoveries explain the close bond between perception and action. For example, they activate themselves when a person kicks a ball, sees someone else kicking a ball, sees a ball prone to be kicked or hears the word “to kick”. So, perception is very important even when it is only the word. By means of the mirror neurons, what a person perceives, prints his body via mirror neurons – Insula – Limbic system.
But, what will be printed? Where? With what ink? Could the skin be the paper?
Iacoboni (6) says that in an experiment with magnetic resonance imaging, when showing facial expressions of babies to a mother, they trigger a cascade of automatic brain answers of simulation that recreate real interactions between mother–baby.
Ramachandran (7) says that when someone is touched it is possible to empathize with the other person, activating one’s own mirror neurons as if one were touched on the same place of one’s body. “But you do not actually experience the touch. There is a feedback signal from touch and pain receptor on your skin, preventing you from consciously experiencing the touch. But if you remove the arm you dissolve the barrier between you and the other human being and when he or she is touched you literally experience the touch. The only thing that is separating you from him is the skin. Remove the skin, and you dissolve the barrier between you and the other human being (…) If a person with a phantom leg sees another person who is touched, he feels his phantom leg to be touched. But the astonishing thing is that if he feels pain in his phantom leg, he sees another person who is being caressed and he feels pain relief in his phantom leg...”.
“The Ego and the other are melted in an inextricable way through mirror neurons” (7). What should be only a simulation performed by mirror neurons turns out to be a reaction of the skin’s immune system. We could, inspired by Lévinas, see here the correlation of his assertion of the ego existing only when the “other” exists (8).
LEVELS OF SYMBOLIsATION
Arcimboldo’s paintings evoke different levels of objects. For example: Level 1: a pear, a carrot, an apple, etc.; Level 2: a face; Level 3: someone’s known face; Level 4: the summertime.
The combination of insignificant elements produces the birth of the meaning. But the combination does not wear down the creation of the meaning: if you draw away your perception you can engender a new meaning. You can combine the elements at another level. The author (or the interpreter) displacement takes part of the work’s essence. A great example is the reversible head of ”The Gardener” that becomes a bowl of vegetables when inverting the painting.
In the same way, the subject (the patient) or the doctor takes part of the disease status. But the disease is a composition (as Archimboldo’s heads are) and the lesions are their parts. At the same time, each part is also a composition, and depending on the way that you compound the different parts, the result will be one disease or another. The skin as an organ and the location of the lesions are part of a composition too. In this way, “psoriasis” is an Archimboldo’s head, and its treatment will be different if the patient’s view is one or another. Moreover, Archimboldo’s analogy and Barthes’ theory (8) teach us that the observer (the doctor, the patient or the medicine as a theoretical corpus) is not only an observer from outside, but part of the disease that will be treated or described. In the same way, the perceiver, depending on the distance and on his culture, preferences, etc. is a part of the work of art.
Thus, there is a staggering of articulations making up our complex psyche and biology. Moreover, there is a “superarticulation” that merges psyche and soma and produces a sort of “thinking entity”, as mentioned at the beginning of the article. This entity is not the final outcome or the subject itself, but the factory of meanings that works either with symbols (highest level), or signs (lowest level), and at the same time it combines the different levels with semantic short-circuits. Following these short-circuits, patient and doctor establish equivalences: sometimes, the equivalence of being and sometimes the equivalence of making.
In Connor’s opinion (5), the argument that the daughter of a Holocaust survivor images her guilt at her family’s survival by developing a patch of eczema in precisely the place where her mother had her identifying tattoo erased literalizes the idea of the mind’s power to write on the skin, or the skin’s power to change its own form. ”(….) the skin literally change its form or appearance to act out* this figures or beliefs. (…) And yet stories persist of marks forming on the skin which are not only tokens of a general excitation or suffering, such as the eczemas or erythemas affecting many people in states of anxiety, but specific visual representations or enactments of events”.
Psychoanalysis is a psychotherapeutic method as well as a research one. With these aims, the psychoanalytic process encourages free associations as well as the search of a meaning linked to the personal life history and of unconscious fantasies. Thus, it implies a way of thinking and a way of linking thoughts, words, dreams and symptoms, that psychoanalysts call “working through”. This way of thinking promotes associations and meaning related to the somatic symptoms that could be close to the deepest conflicts and wishes or imaginative in the same way as the pictures we can “see” looking at the clouds or at the mountains. So, a secondary association and meaning of a somatic symptom, discovered throughout the psychotherapeutic workout, can be part of the process as well. Nevertheless, we can conclude deeming it legitimate to interpret symptoms as symbols when the patient (and the doctor) are in need of finding a meaning for the disease. This does not (and must not) imply a causal attribution, because the meaning of cause and effect is probably beyond our grasp and the ultimate origin of things is still a mystery. Hence, aware of our limitations, we should know whether we wish to treat symptoms, causes, complications or the disease as a whole, remembering that: (i) cause is not the same as origin; (ii) symptom is not the same as the whole disease; (iii) the disease is not the person, and even less his/her family; (iv) boundaries are blurred and ever changing, the same as the skin throughout life; and (v) all these entities may change their role in the course of time.