Alopecia Areata: Stress and Hypnosis
Focus on psychological aspect and hypnotic approach
Ria Willemsen and Johan Vanderlinden
Lambert Academic Publishing.
Isn’t it a complex issue, at first glance? Can it be inviting to the reader to follow authors in their search for understanding interactions between stress and the puzzling disease? How can hypnosis affect the disease? Which evidence for treatment with hypnosis? The book is the result of a doctoral thesis, a huge work of the first author, Dr Ria Willemsen, to get a doctoral degree in medical sciences. The pioneering work, offers the reader up-to-date reviews of numerous scientific studies, helpful for anyone who wants to do further research in the areas covered. You can follow the authors in their fascinating journey, being guided into the field, curious about the outcome of studies and research. The book is well structured, information organized and nicely illustrated with original drawings of Dr. Willemsen herself. Even readers who are not familiar with one of the topics get enough basic knowledge and information to understand what it is all about. And as in a detective story, with every finding new questions arises and ideas for future research, fascinating the reader and the search for truth and new discoveries.
Part 1 gives a global introduction of Alopecia areata, “a highly unpredictable, autoimmune skin disease resulting in the loss of hair on the scalp and elsewhere on the body”. (p11). Possible new concepts as ‘immune privilege’ (losing it, means the body attacks its own hair follicles) are explained in a separate box. The discovery of the “brain-hair follicle” axis (p28) and further evidence for local neuroendocrine skin axis that operates as an important “brain-skin” connection (p 48) announces the important interactions between stress, emotions, and hair/skin. “Controversy on the association between stress and AA is still going on”(p.25), despite quite a lot of studies, mostly focusing on recent stressful events. A personal research study filled the gap, showing an association between AA and early life stress. Authors take the opportunity to emphasize long term health consequences of early traumatic experiences in childhood, all dependent on “reduced ability to control HPA-axis response to psychological stress”, and surprising results that “more than 10 % of low-grade inflammation is attributable to childhood maltreatment” (p.43).
Alexithymia is “a personality trait characterized by difficulties in differentiating and describing feelings” (p 45). I was quite surprised to read a prevalence of 10%-13% among general population samples, assessing alexithymia with a TAS, Toronto Alexithymic Scale- TAS20, self-report. As it is a triggering factor for many medical and psychiatric disorders, and related to changes in sympathetic activity, immunity and brain activity, all medical doctors and specialists should be aware of alexithymia. High alexithymic scores were found in patients suffering from IBS, Myocardial infarction and severe asthma (p.48), and alexithymia is also linked to other diseases. As publications on alexithymia show relationship between dermatological diseases (alopecia areata, psoriasis, atopic dermatitis), it makes sense that dermatologists screen for alexithymia.
With AA – alexithymia and early life traumatic experiences – authors feel ready for new questions and research: to their and my surprise, in their research alexithymia scores are not associated with emotional neglect or childhood experiences. A statistically significant difference was found for the level of education: the current analysis showed statistically significant results with regard to correlation between alexithymia and level of education, a low level of education increasing risk of alexithymia.
Part two, on hypnosis and alopecia areata, you get some introduction on what hypnosis is, on brain mechanisms in hypnosis and on how “high tech revolution in brain research provided evidence for some ‘low tech’ interventions such as psychotherapy and hypnosis” (p 77) Information is clear and useful for readers who are neither familiar with hypnosis nor with applications and usefulness in medical setting. Experts in hypnosis alike, get useful up-to-date information on recent research in brain function, mechanisms of pain modulation, possible modulation of immunology by hypnosis. 2 studies reported decrease in activation in the precuneus (involved in consciousness) in hypnosis: other states with hypometabolism in this area are vegetative states, drug-induced anesthesia and sleep. A short overview opens up a window to hypnosis practice, practical applications in surgery, analgesia, different medical indications, underpinned with scientific studies – RCT, Cochrane, meta-analysis.
Despite usefulness in dermatology, “no evidence based studies for some of our common and routinely used conventional dermatological treatments” were found. At first glance one could expect less results for hypnosis in alexithymia patients, because of their lower imaginative capacity. Surprisingly a recent study by Gay, Marie-Claire (2008)could prove effectiveness of hypnotic imagery intervention on reducing alexithymia.
The first of the 3 personal research studies on hypnosis for AA, added hypnosis to conventional treatment for AA or offered hypnosis as the only treatment. Psychological wellbeing improved, with decrease of anxiety and depression, and hair growth. Filled with hope, another study was planned for treating patients with refractory AA, and daily self-hypnosis. Average quality of life improved, decrease of anxiety and depression scores was found, but without conventional treatment no influence on hair growth.
Symptom oriented suggestions created by the author, or co-created together with the clients are inspiring: sun, imagining gardening, a tree metaphor, and clients invited to identify with the tree to absorb everything they need to grow, explore ingredients that can help and healing imagery, all show ways to foster regeneration and growth. Here again, the scientific spirit remains active, looking for explanation of why some suggestions in hypnosis work: vasodilatation, change in cytokine expression by lymphocytes leading to local immunomodulation.
I can recommend the reading to students and professionals working with hypnosis in medical and psychotherapeutic settings, and to all dermatologists and seriously curious in the field of psychoneuroimmunology. For all of them, something new is to discover in this book. The extended literature review gives a very good base for further study and research in one of these areas.
As research gave evidence of the importance of early-life trauma and alexithymia, I am curious to read more about results of (hypnosis) of consequences of trauma, and alexithymia, besides the symptom oriented and ego- strengthening methods described in the book, on the outcome of AA. Perhaps this was not the aim of this study, and came along the line of research as discoveries. The demands and restrictions of delivering a scientific work perhaps set limits on some creativity and clinical work. Despite this I fully appreciate the richness and content of this concise work, and the courage and efforts of authors to deliver this work.