Psyhoterapy and Allergy
‘I get ill if I do a long coach journey - six or seven hours say. I usually feel sick by the end of the journey, and have a headache. The funny thing is, if I’m walking along
the street and I happen to see a coach of the kind that I do long trips on, I feel a bit sick then too, just for a short while. It seems crazy, but I get ill just from seeing
the coach.’
What Jake is observing is the powerful effect of the mind on the body, in the reaction known as conditioning. Some people are more susceptible to it than others, but no one is
completely immune.
The Russian scientist Ivan Petrovich Pavlov first demonstrated conditioning in 1889, with his famous dog-and-dinner-bell experiment. Pavlov rang a bell every time he fed the
dog, and eventually the dog would salivate each time it heard the bell, whether dinner was being served or not. Its stomach would also begin to secrete acid, in anticipation of
the meal, simply on hearing the bell.
Modern-day experiments have shown that conditioning works with immune reactions too. For example, rats can be conditioned by repeatedly giving them an immunosuppressive drug and
always adding saccharin to their drinking water on the day the drug is given. Subsequently, just the taste of saccharin in the water is enough to- suppress their immune
responses.
This surprising discovery is partially explained by the finding that there are nerves running to the lymph nodes – key areas where the immune responses are coordinated. In other
words, the immune system and the nervous system, once thought of as completely separate domains, are in conversation with each other. In fact this is a three-way discussion,
because the hormones are also involved. The study of these complex interactions,
which we are only just beginning to understand, is known as psychoneuroimmunology.
Even before Pavlov carried out his classic experiment, Dr John MacKenzie of Baltimore had discovered that an artificial rose, in the vase on his desk, would bring on an attack
of rhinitis and asthma in one of his patients who believed that she was allergic to roses. (In fact such an allergy is unlikely –see box on p. 127. It is usually the strong
scent that triggers symptoms, the allergy being to something else, often grass pollen, which is in the air when roses flower.)
Much more recently, something similar happened – this time unintentionally – when a boy with severe hayfever and pollen asthma was undergoing hypnosis aimed at helping him
relax. Part of the hypnotist’s standard technique was to describe an idyllic scene in an alpine meadow, and ask the subject to imagine being there. For this boy, it worked all
too well – the thought of the grass pollen in the meadow brought on a severe asthma attack. The hypnotist, with great presence of mind, asked him to imagine a helicopter
suddenly appearing in the sky and rescuing him from the meadow – and the asthma attack subsided. How allergies affect the mind
In studying the psychological aspects of allergy, researchers have discovered that some patients frequently have thoughts that catastrophise the situation. In the case of atopic
eczema, these thoughts might go along the lines of ‘this terrible itching will never end’ or ‘none of the treatment really makes much difference’.
Such thoughts may be just below the surface of the conscious mind most of the time, and it is only by developing the ability to notice what is going on internally that the
allergy sufferer can become aware of them.
Researchers have also found that, when negative thoughts such as these arise, eczema sufferers are far more likely to scratch their skin and so make the eczema worse. Thus the
thought becomes a reality – a self-fulfilling prophecy.
The tendency to catastrophise difficult situations is something that most people develop (or acquire from others) at a very young age, and it may take some effort to even become
aware of this mental habit, let alone change it. Yet it is possible to start thinking about illness, and about life in general, in a different way – for example, as a difficult
challenge but one that can usually be overcome.
Allergies are in no sense unique. Any long-term disease that causes intense discomfort, makes life unpredictable or limits your activities, is bound to have profound effects on
the personality. However strong a person you are, it affects your life, and influences you in a very deep way – shaping you as a thinking and feeling individual. This is
especially true if illness begins at an early age, becoming part of your formative interactions with your parents (see box on p. 233) or marking you out as different from other
children.
This shaping can have both positive and negative aspects, and it is important to recognise that there is a choice about which aspect you emphasise. It is never too late to try
to change the emphasis. Counselling or psychotherapy (see p. 225) may help with this, especially if the counter-productive attitudes to the illness are deeply rooted in family
experiences.
The role of the mind in asthma
The diagnosis of intrinsic asthma has long since been abandoned. This diagnosis, which was commonplace in the 1950s and 1960s, technically meant ‘asthma with no external cause’.
But the widespread assumption was that the cause was psychological. As older asthmatics will tell you, this made their lives particularly miserable, because they were held
responsible for their disease. Families were often ashamed of having an asthmatic child.
The injustice of this sweeping assumption is clear today. Modern research shows that an external stimulus which initiated the asthma, such as an allergen, can usually be found.
Among asthmatic children, an allergic cause exists in 80-90% of cases. Even where no specific stimulus can be found, there is still a clear-cut state of inflammation in the
airways. No one with any knowledge of asthma would now claim that it is an entirely psychosomatic disease, nor even that it is predominantly psychosomatic.
Nevertheless, once asthma has begun, the mind may play an important role in bringing on attacks, or making them worse, as many asthmatics know from their own experience. This is
entirely understandable when you think how closely breathing is tied up with our emotional lives – fear, sadness, excitement and anger all alter the usual breathing pattern in
different ways, and any of these reactions may trigger an asthma attack.
The interactions between the mind and the airways are complex in the extreme, and vary from one person to another. Anxiety and tension can make asthma a great deal worse for
some people, while others only suffer an asthma attack when the stress is over. A few people actually have less trouble with their asthma when under stress and, oddly enough,
this is the reaction that is easiest to explain. Stress activates the sympathetic nervous system (see box on p.235), which produces adrenaline, and the adrenaline opens up the
airways.
For stress to make asthma worse, as it frequently does, there must be some other reaction going on which overrides the effect of the adrenaline. Doctors don’t know exactly what
this is, but asthmatics who get worse when stressed could be hyperventilating (see p. 226) just a little – not enough for it to be obvious, but enough to make their airway
muscles contract.
Breathing through the mouth, rather than the nose, can also occur under intense stress, and this is bad for the airways because the air they receive tends to be drier, dustier
and possibly colder, for not having passed through the nose first. This raw air may irritate the sensitive airway linings of an asthmatic, and so make the airway muscles
tighten. Small local nerves, that run directly from the airway linings to the airway muscles, could cause this reaction.
Scientific tests, carried out in a laboratory, back up these casual observations. For example, many people who are allergic to grass pollen will suffer an asthma attack if the
experimenter says they are inhaling grass pollen through a mouthpiece – even though they are actually inhaling fresh air.
It can work the other way as well. Telling the same asthmatics that they are now inhaling a reliever drug will stop the attack, even though they are still breathing the same air
as before. This is the basis of placebo effect, the benefit that tends to occur with any treatment, even a dummy pill, as long as patients believe that the treatment will work.
Note that it is not necessarily the immune system producing all these reactions. There are also direct effects of the mind on the skin, in atopic eczema, on the airway muscles,
in the case of asthma, and on the nose, in rhinitis. Some of these are due to the autonomic nervous system (see box on p. 235) while others are much less well understood.
The findings described above should be reassuring for anyone who has noticed that their allergy or asthma symptoms are sometimes affected by their thoughts and feelings. There
is no need to feel bad about this, and it certainly doesn’t mean that your allergies are ‘all in the mind’. Conditioning, and other psychological responses, are an entirely
natural reaction to a very real illness.
However, if you suspect that psychological reactions are making a big contribution to your symptoms, you could try to address the problem directly. Hypnotherapy (see p. 223) can
be particularly useful in this regard, because those who are most susceptible to conditioning are also very responsive to hypnotic suggestion – which can counteract the
conditioning messages. Hypnotherapy can also help those asthmatics who
become psychologically dependent on their inhalers – something that happens quite often, especially in people with severe asthma. In the words of one asthmatic ‘If I found that
I’d left my Ventolin at home, that would sometimes start me off wheezing straight away. I was so afraid of being without it.’ Of course, it is important to carry your reliever
inhaler with you at all times, but this kind of excessive psychological dependence is distinctly unhealthy. At worst, it can lead you to over-use your reliever inhaler, which
can increase your risk of a life-threatening asthma attack (see pp. 153-4).
Sometimes the psychological effects involved in allergies and asthma are far more complex and deep-rooted than this, not just a matter of simple conditioning. It is not uncommon
for asthma attacks, in particular, to be provoked by family tensions and anxieties, or by suppressed memories from childhood. This can occur even though the asthma also has a
clear-cut physical cause, such as an allergy to house-dust mite. Some people find that their asthma always gets worse when they are in a certain place, with a certain person, or
in a particular situation. These problems are usually helped by psychotherapy (see p. 225).
While hypnotherapy and psychological treatments can sometimes be valuable, it is vital to remember that the mental factors in allergic reactions are always operating in
combination with purely physical responses – such as the triggering of mast cells by allergens (see box on p.12). Using psychological treatments alone is as much of a mistake as
ignoring the mental and emotional dimension of ill-health completely. The two aspects of treatment – physical and psychological – should always go hand in hand. Be very wary of
alternative therapists who overemphasise the psychological aspects (see p. 209).
Under the skin
To see a baby with severe eczema is heart-breaking for any parent – tormented by something it cannot understand, the child often experiences touch, not as a comforting and
pleasurable contact, but as a further irritation. According to some psychologists who have studied eczema in depth, suffering from severely itchy skin in the early years of life
may create long-lasting psychological problems. They believe that the discomfort associated with the skin, and especially with being touched, interferes with normal processes of
relating to the world and developing loving relationships with others. That is why it is so important to get the skin symptoms under control, with the proper use of steroid
creams, skin care, dietary changes if appropriate, and an anti-scratching programme (see p. 47).
Psychological symptoms from sensitivity reactions
‘People thought that because the hospital couldn’t find anything wrong with me, and because I wasn’t terminally ill, there was nothing wrong with me at all. No one could
understand how I was feeling, or even believed me. My friends and family lost patience with me. I overheard one member of my family saying they thought I was just
attention-seeking. This hurt me so much. I hated being ill all the time. I wanted to go out and enjoy myself and do the things I’d always done, but I couldn’t because I felt so
bad.’
Josey, who is now 27, was ill in this way for seven years, and her symptoms were so incapacitating that she had to give up work and abandon any sort of social life. Now, as she
puts it, ‘I have my life back again.’
The cause of her symptoms – dizziness, confusion, panic attacks, depression, shortness of breath, and a conviction that she was dying – turned out to be a sensitivity to
caffeine which was inducing hyperventilation (see p. 226). Giving up tea, coffee
and cola drinks restored her to normality very promptly, and she has not relapsed since, except on one occasion, when she unwittingly took a headache remedy that contained
caffeine.
What is clear from Josey’s story is how much the disbelief of those around her added to her problems. She felt trapped by her symptoms, which she could not overcome, while
everyone around her assumed that the whole problem was in her head, and that she could ’snap out of it’ if she chose to.
The suffering of patients like Josey could easily be avoided if more GPs knew how to recognise hyperventilation. This is one of those conditions that is well described in the
medical literature, but does not always get onto the curriculum in medical schools. As a result, many hyperventilating patients go through a lot of expensive and time-wasting
investigations, and may not get a proper diagnosis even then. This is especially sad when hyperventilation is so easy to diagnose and treat (see p. 228).
While the symptoms of hyperventilation are easy to spot, once you know what to look for, this is certainly not true of all
The autonomic nervous system
The autonomic nervous system is a kind of ‘auto-pilot’ – a set of controls that generally keeps you well adjusted to your external circumstances without you having to think
consciously about the situation at all.
The autonomic nervous system controls all the involuntary muscles – those in the heart, around the digestive system, and around the airways. It also controls the state of the
blood vessels, including those in the skin. The autonomic nervous system does its work by issuing two different sets of signals – one set that gears the body up for action and
one set that calms the body down.
Two completely separate nerve networks, the sympathetic nervous system and the parasympathetic nervous system, issue these different signals. The target organs – the airways,
heart, skin, and so on – all receive input from both networks.
The ‘get active’ signals are issued by the sympathetic nervous system, which comes into play at times of stress, excitement, fear or anger. When you can hear your heart pounding
or feel your pulse race, that is your sympathetic nervous system at work. It also makes your nasal passages and airways open up, because extra oxygen is needed for intense
physical activity, and it tightens the muscles around the blood vessels, which raises your blood pressure.
‘Chill out’ messages are delivered by the parasympathetic nervous system. This network comes on-stream when you know you can afford to relax. It slows down the heart, lowers the
blood pressure, encourages the digestive system to do its work, and makes the airways grow narrower because less air is needed when you are less active.
Adrenaline (epinephrine) is the messenger substance released by the sympathetic nervous system. Its action in tightening the muscles around the blood vessels allows adrenaline
to be employed as a drug, which saves the lives of people affected by anaphylaxis (see p. 150). During anaphylaxis, there is a massive fall in blood pressure produced by
histamine (see box on p. 12), but an injection of adrenaline can reverse this.
Both adrenaline and its derivatives, the beta-2 relievers such as Ventolin (see p. 152), also help in asthma attacks. They do this by making the muscles around the airways
relax.
The messenger substance of the parasympathetic nervous system is acetylcholine. Drugs which oppose its action – the
anti-cholinergics – can also help relieve an asthma attack (see p. 156) by blocking the airway-narrowing action of the parasympathetic.
One of the ways in which acupuncture appears to work is by adjusting the activity of the autonomic nervous system. When
acupuncture is used to deal with the immediate symptoms of an asthma attack, this is probably how it makes the airways open up.
sensitivity reactions. Food sensitivity can occasionally cause some unexpected psychological symptoms, such as bouts of hysterical crying (see p. 80) that no conventional doctor
would ever associate with food.
Inevitably, patients with sensitivity problems such as these will initially be diagnosed as having a psychological illness rather than a physical one. It may be a very long time
before the correct diagnosis is established.
Even if the patient works out the link between eating the food and experiencing the psychological response, the doctor may well remain unconvinced. What complicates matters for
doctors is that quite a few people with genuine psychological problems would prefer to think that these have a non-psychological cause, such as a sensitivity to food. (In the
opinion of most doctors, patients of this kind are far more common than patients with psychological problems that are genuinely caused by food or chemical intolerance.) For such
patients, accepting that their problems have a psychological cause means thinking about what that cause might be – and it is often something deeply distressing which the person
would rather forget.
Unfortunately, for people who get into this situation, the phoney explanation doesn’t actually help at all, though it can provide a temporary distraction. Ignoring unpleasant
hidden memories is not the answer – the problem does not go away, it just festers. Facing up to the real underlying problem is the only way to get rid of the distress (see p.
225).
If you have psychological symptoms of any kind, bear in mind that psychological causes are by far the most likely. Such causes can include difficult life circumstances, damaging
experiences during childhood, loss of close relationships, or extremely traumatic incidents in the more recent past. Where there are longstanding problems, neurological factors
(damage to the nerves or brain) or metabolic factors (something affecting the balance of chemicals in the brain), might also play a part, or sometimes be the sole cause.
For a busy doctor, without much time to spare, it is immensely difficult to distinguish patients who really do have psychological symptoms due to food or chemical intolerance,
from patients with psychological problems that they have mistakenly attributed to an intolerance reaction.
What adds to the difficulty is that, with time, psychological causes can sometimes be grafted onto a straightforward intolerance problem. This occurs because illness of any kind
can produce some psychological problems of its own, especially if the person affected cannot lead a normal life. The psychological effects of the illness invariably get worse if
the person concerned has been treated with disbelief by doctors, family or friends – as
is frequently the case when a person has indefinite long-term symptoms that are due to food or chemical intolerance. Separating the secondary psychological reactions to the
illness (or to the scepticism of others) from the primary psychological symptoms that are genuinely produced by the intolerance reactions is far from easy.
Hyperventilation and chemical intolerance
Hyperventilation (see pp. 226-9) and chemical intolerance (see p. 84) often go hand in hand. A person who is sensitive to airborne items which they cannot avoid inhaling, such
as perfume or petrol fumes, may well feel apprehensive when they catch a whiff of these, and unconsciously alter their breathing in response. They may hyperventilate.
If they do, this can both aggravate the sensitivity symptoms, and increase their anxious feelings – because one key symptom of hyperventilation is anxiety (see p. 227). In this
way the problem begins to feed upon itself, and can spiral out of control.
Hyperventilation, pure and simple, may also masquerade as chemical intolerance. In these cases, a deep underlying anxiety probably exists in the person concerned, and one way in
which this expresses itself is as a fear of synthetic chemicals. The person’s fear triggers hyperventilation, which is the initial cause of symptoms. That is not how the person
interprets those symptoms however – because the person was anticipating a reaction to synthetic chemicals, the symptoms seem to confirm that a reaction has occurred. Again, a
vicious circle has been started which is hard to break.
Another possible scenario is that someone with a few sensitivity reactions – for example, a reaction to perfume and cigarette smoke – starts to feel concerned about other
chemical sub-
‘ and to suspect that these might also cause problems. If an anxious reaction to the presence of these substances develops into hyperventilation, symptoms will ensue from the
hyperventilation. These symptoms will appear to confirm the person’s fears about yet more sensitivity reactions. In this way, people with relatively mild chemical intolerance
can begin to believe that their chemical intolerance reactions are far more extensive and disabling than they actually are.
Where the symptoms of hyperventilation are all tangled up with symptoms due to genuine chemical intolerance, opinions tend to split. Some doctors will interpret all the symptoms
as psychological, while other doctors will attribute them all to the intolerance. Both are over-simplifying the problem, and missing a crucial ingredient – hyperventilation.
Recognising and treating hyperventilation (see p. 228) can help a great deal to alleviate the illness.
The psychologisation of illness
‘From the moment Joanna was born, she was never hungry’ Sandra recalls. ‘It took all day to force an ounce of milk down, and she seemed to have terrible stomach pains. At six
months old, after countless trips to the doctor, she was admitted to hospital. The hospital doctors couldn’t work out what was wrong, and in the end they said that she was just
very independent and that she wouldn’t eat until she could feed herself. I couldn’t believe my ears – what a thing to say about a six-month-old baby!’ But as far as the doctors
were concerned, that was that.
As Joanna got older, the symptoms got worse. She developed severe constipation, opening her bowels only once every four weeks. Because her over-full bowel put so much pressure
on her bladder, she wet herself several times a day.
‘She hated school, because the other children teased her, saying she smelled. And she had such awful stomach pains that she couldn’t bend down to tie her shoelaces. When she was
six she was admitted to hospital for a second time.
‘Again they said there was nothing physically wrong with her and it was all in her head, and this time they decided that it must be because something traumatic had happened at
home. They wanted her to see a psychiatrist. It was terrible. I knew nothing like that had happened to her at home, but it was impossible to convince them.’ There was talk of
Joanna being taken away from her parents, because of suspicions about child abuse.
Two weeks before seeing the psychiatrist, something happened to change Joanna’s life. Sandra saw an item on television about a book on food allergies. She bought the book and,
remembering how fiercely Joanna had rejected milk as a baby, she hazarded a guess that milk was the problem. She immediately took all dairy products out of Joanna’s diet.
The effect was astonishing. ‘Within 12 hours her tummy ache had gone, and after six weeks she began opening her bowels almost every day. She stopped wetting herself, and was so
much happier and healthier.’ In fact, all of Joanna’s symptoms went away. and she has remained well on a milk-free diet.
Psychologisation is most frequently encountered by patients %vith medical problems that are unrecognised by conventional medicine – Joanna is a typical example of such a
patient. Occasionally, however, those with true allergies find themselves in the same situation. Take, for example, someone who has collapsed after being stung by a wasp but
gives a negative skin-test result to wasp venom. In the case of insect-sting allergy, skin-tests are supposed to give very few false negatives – so the doctor may be sceptical
about the patient’s observation of what happened. A PAST test (see p. 92) may be ordered, but sometimes this too gives a false negative.
Doctors are – not unreasonably – more inclined to believe that the patient is an unreliable witness (there was never any insect involved), or that the patient has a
psychological problem that has led to this consultation, than that both these tests gave a false-negative result. A patient in this position may need to be quite persistent to
get proper treatment. The same goes for anyone else with unusual allergic reactions that are initially labelled ‘psychological’ by their doctor. In such cases, good
communication is everything.
Good communication with your doctor
Given the intense pressure under which they work, doctors often react badly to symptoms that don’t fit into a neat diagnostic pigeonhole, or don’t respond to standard treatment.
They simply do not have the time for unravelling complex problems and there is a common tendency to ‘psychologise’ such symptoms automatically. This often does great damage to
the patients concerned, boxing them into a corner from which it is impossible to escape – the more they try to convince the doctor their symptoms are genuine, and request
further tests or treatment, the more the doctor views them as difficult, demanding patients with psychological problems. Unfortunately, it is part of the dogma about
psychosomatic illness that patients affected by it will object vehemently to such a diagnosis. So the more you insist that the symptoms are not psychological, the more this
confirms the diagnosis as far as many doctors are concerned.
The psychologisation of illness becomes a real nightmare where the patient is a child, and parents are accused of actually causing the symptoms in some way (see Joanna’s story,
left). This has happened more than once to children with unusual sensitivity reactions.
Good communication skills may stop you from sliding into this situation with your doctor. Firstly, whatever else you do, stay very very calm. Getting emotional, agitated or
angry always causes doctors to suspect a psychological cause for your symptoms.
Secondly, be very open with the doctor, and don’t conceal anything. Be clear about describing symptoms, and accurate about times, the intensity of the reaction and any other
details. Never, ever exaggerate. If you are given to describing things quite colourfully in everyday life, tone it down as much as possible for your doctor’s benefit.
Thirdly, don’t make your own diagnosis – doctors are taught to believe that patients who diagnose themselves may well be suffering from hypochondria. Present any medical
knowledge you have acquired from books or the Internet as tactfully as possible. Finally, it will probably help a lot to use the appropriate words to describe your illness when
talking with the doctor.