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D-UPPSATSER FRN PEDAGOGISKA INSTITUTIONEN
Box 2109, 750 02 Uppsala
Cognitive Behaviour Therapy A Therapy for Atopic Eczema?
A quasi-experimental, longitudinal study of changes in symptoms
of atopic eczema in children
av
Eva Nordstrand
D-uppsats nr 2010:1 Handledare: Lennart Wikander
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Cognitive Behaviour Therapy A Therapy for Atopic Eczema?
A quasi-experimental, longitudinal study of changes in symptoms
of atopic eczema in children
Abstract
The Gelsenkirchen Programme in Germany treats children suffering
from atopic eczema
by applying recognized methods of behavioural therapy, an
approach commonly used
within psychotherapy to treat chronic psychosomatic diseases.
The therapy is derived from
a theoretical model suggesting that a perceived traumatic
incident resulting in distress may,
under certain conditions through interaction between the brain,
emotions and the immune
system (Opioid-Peptide hypothesis), lead to an erroneous
innervation of the skin which
alters the behaviour of the immune system such that when the
stress response triggers
stress hormones to be released, the immune system recruits
eosinophil granulocytes and T-
helper cells to the skin. Through their toxic character
eosinophil granulocytes damage the
skin. An additional posttraumatic consequence is a more reactive
stress response triggering
the release of stress hormones which in turn leads to a higher
stress-hormone baseline.
Stress is also assumed to reinforce the disease. The objective
of the therapy is to lower the
reactivity of the stress response thereby diminishing the
stress-hormone baseline thus
normalizing the erroneous innervation. Hence, use of topical
corticosteroids is refrained
from. The therapy is focused on trauma processing, parental
behavioural modification, a
change in family lifestyle and food conversion. The programme is
initiated by parental
training enabling parents to apply the programme at home.
The objectives of this study were to assess the degree of
parental compliance with the
programme modules as well as parental perception of changes in
the childs behavioural
and somatic symptoms of atopic eczema, and lastly to assess
whether a relationship
between the degree of programme compliance and changes in
symptoms could be
established. The approach was to convey a holistic,
cross-disciplinary view of atopic
eczema reflecting physiological, psychological and educational
aspects by providing: A
briefing on the conventional view of atopic eczema, an overview
of the theoretical model
and therapy subject to the study, an analysis of the theoretical
model and prevalence
factors using triangulation as well as presenting the outcome of
an empirical study of the
Gelsenkirchen Programme.
The empirical study was longitudinal applying a
quasi-experimental approach with two
points of measurements, six and twelve months after commencing
the programme. The
data was collected through questionnaires with mainly predefined
answers. The
respondents were adult participants of the programme. The data
was captured at the
Childrens Hospital in Gelsenkirchen - Buer, Germany between
autumn 2002 and spring
2004. Behavioural and somatic symptoms were assessed for parents
and children and
cross-tabulated with recommended use of programme modules such
as daily structure and
medication. The data was statistically analysed using PASW
Statistics (former SPSS)
version 18. For children in both groups, two response patterns
emerged: 1. Modules
recommended for daily use displayed the majority of responses
for Improved symptoms
in combination with Regular use. 2: Modules recommended for
acute health conditions
only showed the opposite pattern, the majority of the responses
indicated that the module
was Not at all used in combination with Improved symptoms. The
trend was
unambiguous across both groups. Concluding, the outcome
suggested a relationship
between degree of compliance and change in symptoms. Hence, the
objectives of the study
were met and the outcome supported the hypothesis stipulated by
the Gelsenkirchen
Programme.
Key words: behavioural therapy, atopic eczema, stress,
eosinophil granulocytes,
behavioural modification, trauma, lifestyle
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Cognitive Behaviour Therapy A Therapy for Atopic Eczema?
A quasi-experimental, longitudinal study of changes in symptoms
of atopic eczema in children
Page 1
Table of Content
Abstract
......................................................................................................................................
2
Table of
Content.........................................................................................................................
1
1.0 Introduction and Purpose
...............................................................................................
2
1.1 Disposition
.................................................................................................................
4
2.0 Approach
........................................................................................................................
6
3.0 Atopic Eczema A Briefing
..........................................................................................
7
3.1
Symptoms...................................................................................................................
7
3.2 Atopic Eczema and Causes
........................................................................................
8
3.3 Conventional
Therapies..............................................................................................
8
4.0 The Gelsenkirchen
Programme....................................................................................
10
4.1 Theoretical Model
....................................................................................................
10
4.2
Therapy.....................................................................................................................
22
5.0 Analysis of the Theoretical Model
...............................................................................
27
6.0 Analysis of Prevalence Factors
....................................................................................
46
6.1 Factors Increasing the Risk of Acquiring Atopic Eczema
....................................... 47
6.2 Factors Maintaining Atopic Eczema
........................................................................
56
7.0 Empirical Study of the Gelsenkirchen
Programme......................................................
62
7.1 Method
.....................................................................................................................
62
7.2
Variables...................................................................................................................
64
7.3 Other Factors Potentially Affecting Symptoms
....................................................... 67
8.0 Results
..........................................................................................................................
68
9.0 Conclusions and
Discussion.........................................................................................
85
10.0
Reflections....................................................................................................................
89
References
................................................................................................................................
93
Appendix A: The Questionnaire
................................................................................................
1
Appendix B: List of Literature
...................................................................................................
1
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Cognitive Behaviour Therapy A Therapy for Atopic Eczema?
A quasi-experimental, longitudinal study of changes in symptoms
of atopic eczema in children
Page 2
1.0 Introduction and Purpose
Atopic eczema is considered a hereditary, chronic disease.
Typical symptoms are areas of
inflammatory skin and intense itching. Other symptoms may be
broken, wet and swollen skin.
Skin infections as a result of the eczema are common. In some
children, the eczema may
cover minor areas of the body. In other cases most of the body
and face may be impacted. The
conventional therapy is focused on reducing symptoms through
medication. On ceased
medication, symptoms tend to reappear at times more sever than
before the therapy. As a
consequence, the patient is subject to long term medical
treatment which in cases over time
permanently impacts the skin in a negative manner with little
prospect of healing. Living with
this disease can have severe long-term impacts on the quality of
life.
There is a growing concern that the disease is becoming
increasingly common in the Western
World. According to Stockholms lns landstings online guide:
between 15 20% of all children acquire atopic eczema in Sweden.
(Vrdguiden, (2009)
Reviewing statistics of the Nattional Health System in England
(NHS Choices, 2009) and
Germany (Langer, Stresskrankheit Neurodermitis (III)) similar
numbers are referred to. In
developing countries the disease is less common or not
prevalent.
In current research, genetic heritage is considered a
precondition for acquiring the atopic
eczema. The factor(s) causing the disease are unknown however a
trend in current research is
to study factors in the environment such as food, the use of
antibiotics and inoculation as well
as lifestyle. Stress is known to impact the symptoms negatively
but it is not understood how.
Spontaneous healing exists but the contributing factors are
unknown. Hence, it is not possible
to provide any prospect of healing or give advice on how to
promote healing.
80-90% of the children lose their eczema before adulthood
(Vrdguiden, 2009)
After years of conventional treatment, Prof. Dr. med. Ernst
August Stemmann and team at the
Childrens Hospital in Gelsenkirchen - Buer in Germany, began
researching factors that could
possibly trigger the disease to develop. Based on the fact that
spontaneous healing exists it is,
according to Stemmann, logical to assume that atopic eczema can
be cured. Hence the
disease, contrary to common view cannot be chronic, and for the
same reason can genetic
heritage not be a satisfactory explanation for why the disease
is acquired. If atopic eczema
were hereditary, spontaneous healing would not exist then genes
do not change in the lifetime
of a human being.
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Cognitive Behaviour Therapy A Therapy for Atopic Eczema?
A quasi-experimental, longitudinal study of changes in symptoms
of atopic eczema in children
Page 3
Based on these conclusions, the factors involved in spontaneous
healing and the development
of the disease were studied with an interdisciplinary approach
spanning across physiology and
psychology. Building on research, a model was defined explaining
the factors causing atopic
eczema and those maintaining the disease once acquired. Based on
that model the
Gelsenkirchen Programme was formed with the intention to help
heal children with atopic
eczema.
The theoretical model illustrates how the quality of a childs
home environment affects
emotions and long term stress, influences that under certain
conditions through a set of
psychological and physiological phenomena will trigger atopic
eczema to develop. The term
environment in this model refers to the quality of the mother
and child relationship, the
ability of mother and child to bond, as well as the family
lifestyle. In essence, the model
suggests an intriguing relationship between emotions and organic
damage that offers a
meaning to the term psychosomatic.
The model assumes that the disease will heal autonomously
provided a trauma is overcome,
and certain changes in parental behaviour combined with a change
in family-lifestyle are
undertaken. Behavioural therapy is the method applied where
behavioural and lifestyle
changes are key components. Having seen the positive change in
the symptoms of a few
children participating in the Gelsenkirchen Programme motivated
me to perform an
assessment of its impact on the disease with the objective to
establish whether behavioural
therapy has an impact on the symptoms of atopic eczema. Although
this study spans across
multiple disciplines, the study pursues an educational
perspective of child rearing in the home
environment. In particular, the study focuses on whether changes
in parental behaviour and
lifestyle may contribute to promote child health with regards to
healing atopic eczema. This is
an intriguing thought and it is my hope that this study
contributes to intensified research
regarding behavioural change in parents and lifestyle change as
a means to promote childrens
health or even prevent stress related diseases.
To fully assess the outcome of this study and why changes in
parental behaviour and lifestyle
lead to healing, the study first provides a brief overview on
atopic eczema and current
conventional treatments. The briefing is followed by a condensed
version of the theoretical
model. In short, physiological and psychological phenomena
driving the disease based on the
main theoretical assumptions of the model. The theoretical
review forms the background to a
summary of the therapy, of how behavioural and lifestyle changes
contribute to healing atopic
eczema. Subsequently, a theoretical analysis relates relevant
theoretical assumptions of other
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Cognitive Behaviour Therapy A Therapy for Atopic Eczema?
A quasi-experimental, longitudinal study of changes in symptoms
of atopic eczema in children
Page 4
authors to those of the Gelsenkirchen Programme aiming to seek
support for the theoretical
model.
The data collection for this study is based on questionnaire
input from caregivers regarding
the extent to which the recommended changes in behaviour and
lifestyle are complied with in
the home environment as well as an assessment of the childs
somatic and behavioural
symptoms. The parental responses enable an assessment of the
outcome of the Gelsenkirchen
Programme. The assessment encompasses:
an assessment of change in symptoms over time
an assessment of the degree of parental compliance with the
programme
an assessment as to whether a relationship can be established
between variation in
symptoms and degree of programme compliance
1.1 Disposition
Introduction and Purpose
The issue subject to this study with background information is
described here as well as the
scope and its purpose.
Atopic Eczema A Briefing
The briefing provides a brief overview of atopic eczema
illustrating the symptoms, current
views on reasons for acquiring atopic eczema, trends in research
and conventional treatments.
The overview illustrates the controversy between the
Gelsenkirchen Programme that is
subject to this study and conventional treatments.
Approach
The overall approach to the issue subject to study and meeting
the objectives of the study are
described here.
The Gelsenkirchen Programme
The theoretical model and therapy are illustrated here forming
the background to the analysis
of the theoretical model and the prevalence factors as well as
the empirical study of the
Gelsenkirchen Programme.
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Cognitive Behaviour Therapy A Therapy for Atopic Eczema?
A quasi-experimental, longitudinal study of changes in symptoms
of atopic eczema in children
Page 5
Analysis of the Theoretical Model
The theoretical model is analysed with the intention to assess
the plausibility of the
assumptions as defined by the hypothesis and to seek theoretical
support for the hypothesis.
Analysis of Prevalence Factors
The theoretical model of the Gelsenkirchen Programme encompasses
multiple assumptions in
addition to those stipulated by the hypothesis. This section
provides an analysis of such
factors based on relevant studies with the intention to seek
empirical and theoretical support
for them.
Survey of the Gelsenkirchen Programme
The survey of the Gelsenkirchen Programme is presented here.
Results
This chapter presents the results and trends in response
patterns by commenting and
illustrating cross-tabulations relevant to the purpose of the
study.
Conclusions and Discussion
Response patterns relevant to the objectives of the study are
analysed and conclusions drawn
leading into a discussion on the results.
Personal reflections round off the study.
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Cognitive Behaviour Therapy A Therapy for Atopic Eczema?
A quasi-experimental, longitudinal study of changes in symptoms
of atopic eczema in children
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2.0 Approach
The overall approach to this study was to present data across
multiple disciplines from
different angles with the intention to convey a holistic view of
atopic eczema. The
presentation is initiated with a briefing on atopic eczema
according to the conventional view
followed by a review of the theoretical model and therapy of the
Gelsenkirchen Programme.
By means of triangulation additional perspectives of the
Gelsenkirchen Programme were
obtained through three different analyses undertaken to seek
support for the hypothesis
underlying the Gelsenkirchen Programme.
Firstly as presented in Chapter 4, the theoretical model of the
programme was analysed
referencing research material by other authors. In doing so, key
assumptions of the model
were compared with views from other authors on the subject. To
ensure transparency of the
analysis, the views from other authors were kept in their
original form as empirical data and
the result of the comparison summarized. Secondly as illustrated
in Chapter 5, prevalence
factors assumed to increase the risk of acquiring and
reactivating atopic eczema were
compared with findings from other studies and the outcome of the
analysis was commented.
The compared texts were kept in their original form as empirical
data to ensure transparency
of the analysis. Lastly as described in Chapter 6, the data
resulting from an empirical study of
the Gelsenkirchen Programme were analysed assessing parental
compliance with
recommended use of the programme modules and perceived changes
in the symptoms.
The three analyses are based on different types of empirical
data that require different
approaches in reviewing them. Selecting material for the
analyses on the theoretical model
and the prevalence factors other literature than that referenced
by the Gelsenkirchen
Programme in Appendix B was intentionally leveraged
complementing the analyses already
performed by the Gelsenkirchen Programme.
My contribution to the textual analyses was to identify, compare
and summarize per
assumption relevant arguments from other authors delivering
support to the hypothesis of the
Gelsenkirchen Programme. Because the subjects are so
specialized, keeping the empirical
data reviewed in the analyses is also a means of mitigating the
risk of misinterpreting and
erroneously presenting supporting arguments. To balance this
rather factual presentation of
arguments, a more personal interpretation is provided in the
conclusions, discussion and
reflections closing the study.
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Cognitive Behaviour Therapy A Therapy for Atopic Eczema?
A quasi-experimental, longitudinal study of changes in symptoms
of atopic eczema in children
Page 7
3.0 Atopic Eczema A Briefing
The purpose of this briefing is firstly, to illustrate medical,
psychological and social
implications that this disease has on daily life for the
sufferer and the impacted family and
secondly, to illustrate the conventional therapies to enable a
better understanding of how the
behavioural therapy subject to review in this study differs from
conventional treatments.
3.1 Symptoms
The symptoms of atopic eczema are areas of dry, red, broken and
swollen skin at times
combined with an intense itch. The symptoms vary in intensity
and spread where only knees
and elbows are impacted to main parts of the body and face.
During a flare-up, the skin may
be hot and weeping. Broken skin tends to become infected with
bacteria. Scratching can
disrupt sleep and make the skin bleed. In children, this can
lead to sleepless nights and
difficulty concentrating at school. Broken skin may lead to
secondary infections which are
unpleasant and in severe cases may be difficult to treat. Eye
complications of atopic eczema
include conjunctival irritation, and less commonly,
conjunctivitis and cataracts. People with
severe eczema often find that it has a significant impact on
their daily lives. According to the
Great Britain National Health System online guide to health
care:
Pre-school children with atopic eczema are more likely to have
behavioural problems than
children who do not have the condition. They are also more
likely to be more dependent on
their parents compared with children who do not have the
condition. School children may
experience teasing or bullying if they have atopic eczema. (NHS
Choices, 2009)
Children with atopic eczema often have sleep-related problems. A
lack of sleep may affect
childrens mood and behaviour. It may also make it more difficult
for them to concentrate at
school, which may impact their performance at school. During an
eczema flare, the child may
also need to take time away from school. This may in turn affect
its ability to keep up with
school work. (NHS Choices, 2009)
The Great Britain National Health System online guide to health
care further illustrates:
Atopic eczema can affect the self-confidence of both adults and
children. Children may find
it particularly difficult to deal with their condition, which
may result in them having a poor
self-image. (NHS Choices, 2009)
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Cognitive Behaviour Therapy A Therapy for Atopic Eczema?
A quasi-experimental, longitudinal study of changes in symptoms
of atopic eczema in children
Page 8
If the child is severely lacking in confidence, it may affect
their ability to develop their social
skills. (NHS Choices, 2009)
3.2 Atopic Eczema and Causes
Atopic eczema is considered hereditary and is associated with
food allergies, allergic rhinitis,
and asthma. In the Stockholm County Health Care Systems online
guide the dry and itchy
skin is explained as follows, authors translation:
The skins horned layer contains less of a fat called ceramides.
This results in the skin having
difficulty keeping moist and therefore dries up more easily. As
the skin barrier is damaged it
feels dry and itchy. This leads to inflammations and scratching.
It is therefore important to
provide the skin with fat and moist by creaming it regularly,
often several times a day.
(Vrdguiden, 2009)
Potential causes being researched:
an imbalance in the interaction between certain cells of the
immune system.
the hygiene hypothesis which suggests that atopic eczema could
be a result of the
western world life style with a too clean home environment which
leads to the immune
system not being sufficiently stimulated. (Vrdguiden, 2009)
Another possible cause being discussed is lifestyle. A large
number of factors can be
considered life-style-related. There has been research on
organically versus conventionally
grown foods. For instance, Flistrup concludes in her study
(Authors translation):
We found no relationship between consumption of ecologically or
biodynamically grown
foods and allergic diseases or sensitisation. (Flistrup, 2005,
p. 246)
3.3 Conventional Therapies
The focus of conventional treatments is to control and manage
symptoms in various ways to
limit the discomfort of the sufferer. A brief overview of
treatments most commonly applied in
conventional health care is provided below. The intention of
this overview is not to give a full
listing of treatments, there are others not listed here, but
to:
convey a sense of the exposure to medicine that this disease
brings with it and its
impact on daily life
illustrate the difference between conventional treatments and
the therapy subject to
this study.
The Stockholm County Health Care online guide (Vrdguiden, 2009)
recommends the
following treatments. Authors translation:
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Cognitive Behaviour Therapy A Therapy for Atopic Eczema?
A quasi-experimental, longitudinal study of changes in symptoms
of atopic eczema in children
Page 9
Daily creaming of emollients
Creams with a mild antibacterial effect such as propylene
glycol
Creams containing urea although they can cause a burning
sensation if the skin is dry
and broken. Hence they are mostly not suited for young
children.
Baths with potassium permanganate which colour the skin blue
Antibiotics for infections
Topical corticosteroids (a stress hormone) for treating
eczema.
Immune modulators are used where topical corticosteroids have no
effect on eczema.
Additional treatments recommended by the Great Britain National
Health System online
guide to health care (NHS Choices, 2009):
Antihistamines cause sleepiness enabling sleep.
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Cognitive Behaviour Therapy A Therapy for Atopic Eczema?
A quasi-experimental, longitudinal study of changes in symptoms
of atopic eczema in children
Page 10
4.0 The Gelsenkirchen Programme
4.1 Theoretical Model
Below follows a highly condensed description of the theoretical
model behind the therapy.
Text by referenced authors has been used extensively in its
original form as a means of
empirical data. Authors translation:
The common textbook definition of atopic eczema refers to the
chronic, itching,
inflammatory skin, the scratching as well as the interval-like
course of the disease.
Considering aspects beyond the somatic, such as the individual
strategies for coping with
stress, the stability of the autonomic nervous system1
, the subjectively perceived life events as
well as the interaction between the family members in a typical
everyday context leads to a
different, more complex definition of atopic eczema.
Many children have difficulty falling asleep or sleeping through
the night
The children show a strong open or subtle controlling behaviour
(for instance clinging)
The sufferer often reacts to everyday stress with increased
stress and a skin reaction
Parents and even grand parents attempt to gain control over the
disease with various
methods
The disease becomes a central theme in the family
That stress plays a role in the life of the sufferer and his/her
family at least as a consequence of
the changes to the skin but also from the attempts to gain
control over the eczema is obvious.
The quality of life is decreased, aspects of life related to
health, such as relaxation, piece of
mind, ability to enjoy, bodily fitness, self-efficacy,
performance fall behind in priority
replaced by exhaustion, helplessness and guilt. Regardless of
theoretical concepts concerning
the aetiology (science that deals with the causes or origin of
disease according to
MedicineNet.com, 2009) of atopic eczema, the worsening condition
of the skin, a continuous
decline of autonomy in the sufferer as well as a dissolution of
the family alliance. If these
systematic aspects are ignored in the therapy a shift of
symptoms may be the result. As part of
the disease typical individual stress reactions can be
identified as physiological and hormonal
reactions that differ from healthy people. In healthy people the
production of stress hormones
lead to a standardised, unspecific immune reaction where the
immune cells are neutralised in
1
The autonomic nervous system (ANS) is a regulatory branch of the
central nervous system that helps people
adapt to changes in their environment. It adjusts or modifies
some functions in response to stress. The ANS helps
regulate, blood vessels' size and blood pressure, the heart's
electrical activity and ability to contract , the
bronchium's (BRON'ke-um) diameter (and thus air flow) in the
lungs. The ANS also regulates the movement and
work of the stomach, intestine and salivary glands, the
secretion of insulin and the urinary and sexual functions.
The ANS acts through a balance of its two components, the
sympathetic nervous system and parasympathetic
nervous system (The American Heart Association, 2009)
http://MedicineNet.com
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Cognitive Behaviour Therapy A Therapy for Atopic Eczema?
A quasi-experimental, longitudinal study of changes in symptoms
of atopic eczema in children
Page 11
its repositories. In the sufferer, the immune cells erroneously
migrate to the skin during stress
and cause eczema in form of an unspecific inflammation. The
itching begins only a few
minutes after the stress hormone level has declined, in the
post-stress phase, the inflammation
appears 6 72 hours later. (Langer Stresskrankheit Neurodermitis
III )
The Gelsenkirchen Programme suggests that genetic predisposition
alone does not explain
how atopic eczema is acquired. Instead, according to the
Gelsenkirchen Programme, the
disease is acquired as a result of uncontrollable stress
(distress). If a person, regardless of age,
perceives a situation as life-threatening, a fight or flight
stress reaction is triggered. If the
person perceives him- or herself as incapable of fight or flight
(becomes paralysed with fear),
uncontrollable stress is the result. Under certain conditions,
uncontrollable stress will result in
inflammatory cells and T helper cells migrating to the skin
where an unspecific inflammation
is triggered. Atopic eczema is develop and reinforced during
stress however the symptoms
appear post stress when stress hormone level in blood and tissue
sinks. This phenomenon will
be elaborated on in the following section where the hypothesis
and its key assumptions are
illustrated.
Hypothesis
Based on a number of assumptions provided below, the hypothesis
describes how atopic
eczema develops according to the Gelsenkirchen Model. Authors
translation:
The fact separation (during fearful separation) alters the
function of the postcentral
gyrus in the cerebrum. If the event separation is permanently
stored in the hippocampus,
an erroneous innervation of certain skin areas or even all of
the skin is created by the
postcentral gyrus and the skin in this area or the entire skin
becomes specifically
oversensitive.
The feeling fear (during separation) is stored in the amygdala.
Fear generates stress and
thus eosinophil granulocytes, T helper cells migrate from the
blood to the disturbed,
erroneously innervated area of the skin and provoke an
unspecific inflammation.
(Stemmann & Stemmann, 2002, p. 289)
If a human being is not in the position to adjust or cope with a
sudden or permanent change
in his/her material or psychosocial pressures with an
appropriate reaction or behavioural
modification, uncontrollable stress will be the result.
Uncontrollable stress leads to stress
related diseases. (a.a., p. 33)
Atopic eczema is a stress related disease mainly supported via
the vegetative nervous system,
the adrenal glands, stress and emotions (via cytokines),
maintained through reinforcement
such as attention (a.a., p. 302 )
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Cognitive Behaviour Therapy A Therapy for Atopic Eczema?
A quasi-experimental, longitudinal study of changes in symptoms
of atopic eczema in children
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Assumption 1: Emotions Impact the Immune System
The Gelsenkirchen Programme states that emotions, when causing
uncontrollable stress,
result in diseases. Stemmann argues that the immune system of
sufferers of atopic eczema
behaves differently than in healthy people. Studies (5)2
show that eosinophil granulocytes
have been found in the inflammatory tissue. In healthy people,
this is not the case. The
Gelsenkirchen Programme assumes that all emotions communicate
with and influence the
immune system such that the eosinophil granulocytes erroneously
migrate to the skin during
stress. Referring to the hypothesis, it states that the emotion
fear of separation causes
immune cells to misbehave causing an inflammation in the healthy
skin. Authors
translation:
Studies have shown that eosinophil granulocytes leave the blood
stream during fear (26)
(a.a., p. 289)
The phenomenon of eosinophil granulocytes migrating to the skin
is referred to as an
erroneous innervation of the skin which is illustrated below.
The model assumes that the
emotion fear of separation alters the immune reaction according
to the Opioid-Peptide-
Hypothesis. Authors translation:
All emotions have consequences for the immune system and impact
health negatively if
emotions are suppressed (so called blocked peptide flow) or
excessively expressed
(disproportionate stress). (a.a., p. 283)
Brain and immune system communicate on cell level with each
other (16, 17, 18). (Ibid.)
The Opioid-Peptide-Hypothesis explains how the immune reaction
is altered by emotions.
(19) (Ibid.).
It has been proven in experiments that by stimulating the
interbrain, the location of emotions,
a functional disruption or even damage of an organ can be
provoked. The animals can even
die. Functional changes and organ damages do not occur when
parts of the interbrain or the
pituitary gland are damaged (Experiment according to Hume, (21)
Now stress can no longer
occur. (a.a., p. 287)
Every piece of information that the brain receives via its
senses or generates itself contains
emotional as well as factual information. (Ibid.)
2
Numbers in parenthesis refer to literature in Appendix B.
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Cognitive Behaviour Therapy A Therapy for Atopic Eczema?
A quasi-experimental, longitudinal study of changes in symptoms
of atopic eczema in children
Page 13
Feeling and thinking can hardly exist isolated from one another.
A perceived feeling
(emotional information) is always more or less also a thought
process (factual information)
and vice versa. (22, 23) (Ibid.)
Assumption 2: Fear of Separation
Referring to studies, the Gelsenkirchen Programme suggests that
children with atopic eczema
have perceived separation as life-threatening. Children
associate mothers attention with
survival. Babies are completely dependent on their mothers to
survive. The fear of being
separated from its mother is a natural reaction. Keeping mothers
attention is a babys primary
concern during its first year. If during a separation, the child
perceives fear and feels
incapable of rescuing itself (fight of flight) this may under
certain conditions lead to
uncontrollable stress and as a result the baby may acquire
atopic eczema. Critical situations
that may trigger atopic eczema are described below. Authors
translation:
Separating the newborn baby from its mother after birth, for
example due to a caesarean or
because the baby is in need of intensive care.
Ceased breast feeding
Birth of a sibling. The main caregiver is absent for a longer
period of time.
Starting day care or school, moving away from home
Death of a care giver
Separation from the best friend or loved ones
Main care giver recommences work while the baby is still very
young, longer absence of
main care giver
Parental separation
A traumatic separation can also be perceived through:
Moving homes, environmental change
Feeling of betrayal, loss of faith or guiding principles
Loss of a loved animal
Loss of an object. (a.a., p. 290)
Once the atopic eczema has been acquired the sufferer does not
only react with stress to
separations. Other factors may provoke a stress reaction as
well. (a.a., p. 65)
Assumption 3: Eosinophil Granulocytes
Stemmann and Stemmann (2002) refer to studies showing that the
immune system of people
diagnosed with atopic eczema behaves differently from healthy
people. These studies show
that in healthy people during stress eosinophil granulocytes and
T helper cells migrate from
the blood stream to the wound to initiate self-healing through
an unspecific inflammation. For
sufferers of atopic eczema however, the eosinophil granulocytes
and T helper cells migrate to
the healthy, undamaged skin during stress causing an
inflammation that becomes visible once
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the immune cells withdraw, when stress has declined and the
relaxing phase has begun.
Authors translation:
That cells are recruited from the blood stream to the
inflammatory tissue during stress and
infiltrate the inflammatory tissue is experimentally proven (5)
(a.a., p. 278).
A substance was applied behind their ears of animals that
triggered a mild, local
inflammation. Thereafter, half of the animals were exposed to
stress, the other half was not.
Again, a substance causing an inflammation was applied behind
the ears. The inflammatory
symptoms were much more pronounced among the animals that were
exposed to stress and
significantly more cells prevailed in their skin. (9)
(Ibid.)
They (the eosinophil granulocytes-authors comment) damage the
skin through the major
basic protein (MBP), the eosinophil cationic protein (ECP), a
neurotoxin (EDN) and a
peroxydase (EPO). Not always can eosinophil granulocytes be
found in the changed tissue.
However the Major Basic Protein (MBP) can be found, an
indication that eosinophil
granulocytes have been present (during stress). (10)
(Ibid.).
Studies showed that eosinophil granulocytes left the blood
stream during fear. (26) (a.a., p.
289).
The phenomenon causing immune cells to migrate to the skin is
referred to as Erroneous
Innervation. This is a key phenomenon to how atopic eczema is
acquired and is described
below.
Assumption 4: Emotions Cause Organ Damage - Erroneous
Innervation
In layman terminology, erroneous innervation is a phenomenon
where strong emotions
experienced during uncontrollable stress alter the way in which
the brain, more specifically
the postcentral gyrus, manages the behaviour of the immune
system to cause damage to an
otherwise healthy organ. In the case of atopic eczema, this
emotion is fear of separation. The
reason why the emotion fear of separation results in an
erroneous innervation of the skin in
form of eczema is explained by a functional relationship between
the brain and the skin.
Stemmann and Stemmann describe this phenomenon as follows.
Authors translation:
In healthy people the immune system reacts as follows in
response to an injury: If the skin is
injured, a local and a central reaction are triggered. The local
reaction: Blood and immune
cells from surrounding tissue migrate to the wound. Central
reaction: Through the wound, a
disturbed area emerges which is recognised by the postcentral
gyrus through the sensory
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nerves and converted into pressure, pain, itch. The pain of the
wound triggers stress and as a
result eosinophil granulocytes and T helper cells migrate from
the blood stream to the
damaged tissue. The eosinophil granulocytes increase blood
circulation and permeability of
the blood vessels in the wound such that blood and immune cells
migrating from the blood
stream to the wound, recruited by T helper cells, may
infiltrate, produce protection against
foreign substance and begin repairing. (a.a., p. 285)
In persons with atopic eczema, the above described process could
be reversed because the
sensory function of the skin is altered. Hence, the postcentral
gyrus must be involved in the
disease.
Primary: Change in postcentral gyrus
Secondary: Through erroneous innervation of the corresponding
healthy skin area a disturbed
skin area emerges
Tertiary: During stress the inflammatory cells migrate from the
blood stream to the healthy
skin area that is erroneously monitored by the post central
gyrus. (a.a., p. 286)
Authors translation:
The outer skin layer (epidermis) and a certain area of the
postcentral gyrus originate from the
same ectoderm and stand in close functional context with each
other. (a.a., p. 284)
Since most people experience separations in their lives the
question arises: When does a
separation result in a disease and when not? Brain research can
deliver an answer.
How information is processed by the brain.
The fear during separation is divided in two pieces of
information:
Separation (fact),
Fear (emotion) and stress is triggered.
The factual information is stored in the hippocampus. The
emotional information is stored in
the amygdala. The information is forwarded to the prefrontal
cortex where the context
between factual event (separation) and emotion (fear) is
evaluated. The evaluation translates
into action, function. If the fear of separation is considered
harmless by the prefrontal cortex
(I have everything under control!) then the prefrontal cortex
blocks the action:
The fact, the separation has been dealt with and is not an
issue
Fear is not necessary and the stress reaction is stopped. The
impacted stays healthy.
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If however, the prefrontal cortex loses control over the event
of separating, then atopic eczema
will develop according to the following mechanisms: Separation
turns into an unsolvable
problem, alters the brain function, calls for an erroneous
innervation of the skin.
Fear becomes unmanageable which results in uncontrollable stress
which leads to immune
cells migrating to the erroneously innervated area of the skin
causing an inflammation.
With declining stress, itching is triggered. The logically
thinking brain is blocked so that
conscious, logical, voluntary influence of what is happening no
longer is possible.
Symptoms, itching and inflammation develop first when emotions
and stress decline, or have
declined, in other words, a process that occurs during the
consecutive three days after the
event. If an infant acquire atopic eczema, the cause can be
found during the past three days
because an infant cannot hold stress and emotion long term. In
adults stress as a result of
separation can last several weeks until a resolution diminishes
stress and then symptoms
appear. (Stemmann, pp. 1- 2)
Information, when its intensity increases above a certain level,
in other words provokes
uncontrollable stress, leads with no exception to the same
bodily reaction in every human
being. (Stemmann & Stemmann, 2002, p. 288)
Everyone becomes paralysed by fright when the fright provokes
uncontrollable stress and the
brain alters the muscle tone. (Ibid.)
This principle is transferred to atopic eczema. Events with a
typical content were searched
for shortly preceding the first appearance of atopic eczema.
There are newborns that acquire atopic eczema on their first or
second day after birth.
What have these babies experienced and perceived? Without
exception these children
(mostly for instance through a caesarean) have been separated
from their mothers. They
must have felt fear from separation.
Infants that had to be separated from their mothers often
acquire atopic eczema. (24)
(Ibid.)
In the lives of people suffering from atopic eczema there are
more often stories of
separations (25) (Ibid.)
Objection: Separations are part of life and yet not everyone
acquires atopic eczema.
Answer: Atopic eczema apparently only develops when feeling
powerless, unable to act -
fears for life and as a result uncontrollable stress is
provoked. A person is highly
agitated but a stress regulation does not occur. A change in the
postcentral gyrus
occurs that leads to an erroneous innervation and function of
the healthy skin
(disruption of the senses and specific hyperreactivity of the
skin). The
determining factor is the individual shock as perceived by the
impacted. The
type and degree of the trauma is subordinate to the individual
perception.
(Ibid.)
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Factors Increasing the Risk of Acquiring Atopic Eczema
Lifestyle
As mentioned above, according to Stemmann, infants can under
certain circumstances
experience uncontrollable stress through separation from their
mothers as they are completely
dependant on their mother for survival. Stemmanns view is
reiterated below. The description
is intentionally left in its original form as is serves as input
to the description of the theoretical
model.
If contact persons change frequently it requires a great amount
of adjustment by the baby, an
ability that should not be taken for granted in every newborn
and infant. The consequences are
uncontrollable stress and disease. (How important the contact to
a caregiver is and what good
it does may be confirmed by any adult who has spent time in a
hospital being dependant on
constantly changing staff for care. Readjusting to unknown
people requires strength and the
ability to change). The life of newborns and infants has changed
drastically in the Western
World. 20 30 years ago, the predominant view was that the first
year the baby needs
quietness and security. The baby was barely exposed to new
stimuli or changing
environments. The life of an infant was mainly spent either at
home or outdoors in the
carriage. In todays mobile society, the life of a baby has
changed dramatically. The common
view among young parents is: As long as the baby is with its
parents, it does not harm the
baby. This statement was made unknowingly of the development and
functions of the immune
system and many babies pay for it with their health, then since
then, babies take part in almost
all parental activities (in good faith of its parents),
activities that a baby can hardly survive
without stress and becoming ill. Such activities are:
Long car drives
Flying to foreign destinations
Frequent visits to, in the eyes of the baby, foreign people in
unknown environments
Participation in parties, seminars, shows, expositions and so
on, sometimes until late
at night.
Such an irregular life means an utmost emotional strain to a
baby as infants react to every
change with stress even in their sleep. In addition, babies are
exposed to frequent situations
where separation occurs: from the known home environment, from
the known neighbourhood,
from loved ones.
That the risk of a baby living with such a stress generating
lifestyle may perceive a situation as
life-threatening compared to in the past has risen enormously.
This explains why atopic
eczema, particularly among babies, shows an increase in the
Western World and will continue
increasing unless the manner in which society views and
interacts with babies changes. (a.a.,
pp. 52-53)
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Chronic overload increases the risk of acquiring atopic eczema.
For example: A child had just
started day care and is struggling with the change. Its
Grandfather dies and all of a sudden the
child has acquired atopic eczema. Getting accustomed to day care
and coping with
Grandfather passing away war more than it could handle. (a.a.,
p. 42).
A child who experiences being paralysed by fear does not always
acquire atopic eczema. Whether he
or she does, depends on its previous experiences and
capabilities of dealing with strong emotions.
Factors Maintaining Atopic Eczema
Autonomous Reactivation
Once the disease has been acquired, the immune system maintains
atopic eczema
autonomously. Authors translation:
In the wild, animals survive acute diseases without medication.
They increase their bodily
defence in that they generate stress and thereby overcome the
disease (unspecific self-healing).
The inflammatory skin sends a signal to the interbrain that
triggers a stress reaction as a means
of self-healing. Stress is generated in waves with the purpose
to increase the immune reaction.
In spite thereof, self-healing cannot occur as eosinophil
granulocytes and T helper cells
erroneously migrate to the skin during stress and thereby
reactivate the eczema anew. (a.a., p.
296)
The peaks and drops or waves of stress hormones also influence
the emotions and the
behaviour of the sufferer. The behaviour swings between
unprovoked strong emotional
expression (mainly at home) or extremely withdrawn (away from
home) versus recovery. The
waves of stress hormones being generated by the immune system in
turn have an impact on
the disease such that emotions are excessively expressed or
suppressed which in turn generate
stress.
Reinforcing the Disease
A traumatic experience that has not been overcome shapes the
behaviour of a human being.
(a.a., p. 290)
Children who have perceived a separation as traumatic develop
behaviours aimed at avoiding
situations potentially resulting in separation from the mother,
such as:
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Extreme controlling: Behaviours aimed at obtaining and
maintaining mothers attention
seeking confirmation of being loved, securing survival. Such
behaviour can range from
extreme clinging to the mother, continuously following the
mother around the house,
holding on to her leg, pulling mothers clothes and screaming
until picked up and
screaming in panic.
Social insecurity
Poor self-esteem
These behaviours are assumed to be:
conditioned with the purpose of avoiding potential separation
from the mother and
emotional stress
reinforced behaviours
a result of the somatic symptoms
triggered by unavoidable situations perceived as
life-threatening (Ibid.)
The Gelsenkirchen Model refers to studies showing that the
overall daily stress-hormone
baseline among children with atopic eczema and their mothers is
increased. Clinging and
controlling behaviours cause stress in the parent as well as the
child involved. A behavioural
dynamic generating stress develops according to the following
pattern: The child is afraid of
losing mothers attention (attention here means conveying
positive empathic affection), clings
to obtain attention, to avoid stress. Mothers response behaviour
may vary. Some mothers
may be worried about the child screaming so intensely and give
attention to the child.
Attention reinforces the childs controlling behaviour and
confirms that there is a reason for
fear. Others may feel irritated as a result of being clinged on
and feeling controlled and hence
ignore the childs request for attention by turning away, or
looking at the child in an irritated
manner, or avoiding eye-to-eye contact with the child, or
speaking to the child in a raised
voice, reactions that the child perceive as rejection. Rejection
triggers stress which reactivates
the disease. Eosinophil granulocytes and T helper cells migrate
to the skin resulting in an
eczema flare-up. At which stage or in which situation the mother
rejects the child depends on
her concern for the childs anxiety, the intensity and frequency
of the childs behaviours as
well as the parents tolerance, or ability to cope with such
controlling behaviours, in other
words how easily the mother feels stressed by these behaviours.
Two examples of typical
controlling behaviours in children with atopic eczema are
illustrated below:
Example 1: Scratching and the Immune System
Scratching until bleeding triggers an immune reaction where
stress hormones are released
reducing the itch. With the stress reaction, eosinophil
granulocytes and T helper cells are
released into the blood stream and migrate to the skin due to
the erroneous innervation
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causing an inflammation which results in itching. Scratching and
itching becomes a vicious
circle.
Itching does not cause a subcortical activation and hence stress
is not triggered. Pain
resulting from scratching activates the thalamic areas (38)
(a.a., p. 301)
Pain generates stress and the stress hormone release neutralises
itching. (Ibid.)
As a result of a traumatic separation, the child tries various
behaviours aimed at obtaining and
maintaining mothers attention and keeping her near. Scratching
may turn into a controlling
behaviour when it results in mothers attention. If scratching
yields attention it reinforces
scratching. Depending on how often the mother invests time in
preventing the child from
scratching and on how tolerant the mother is this can become
quite stressful to the mother
resulting in irritation and rejection. The child fears
separation from its mother, a stress
reaction is triggered; eosinophil granulocytes and T helper
cells are released into the blood
stream and migrate to the skin causing an inflammation which
results in itching. As the stress-
hormone baseline declines, itching is according to the
Gelsenkirchen Programme no longer
triggered.
Example 2: Sleep and the Immune System
The sleeping pattern of children with atopic eczema is usually
disturbed. Studies have shown
that these children sleep only a few hours at a time and the
sleep is very shallow. According to
the Gelsenkirchen Model, sleep is perceived by the child as a
separation from the mother
which generates stress. As a consequence, the child constantly
seeks confirmation in various
ways throughout the night that mother is near. The child is not
fully relaxed during sleep
hence the sleep is shallow. The deep sleep required for
regeneration can under these
circumstances not be reached. To get to the deep sleep stage,
full relaxation and several hours
of undisturbed sleep are the prerequisites.
As described above regarding scratching, during stress hormone
release, the itch disappears
and the eczema pale. In the evenings and at night, fewer stress
hormones are released as a
prerequisite for rest and regeneration. Relaxation is the reason
why the eczema appears more
strongly and itching is more severe whereas as the stress
hormones are increasingly released
the symptoms will be less predominant. Itching results in
scratching. If scratching continues
until pain occurs, stress hormones are released and itching
disappears. With the stress,
eosinophil granulocytes and T helper cells are directed to the
skin and itching begins - a
vicious circle.
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Mothers understandably want to help the child out of its misery
by giving the child attention
in various ways, by scratching, by giving medication, creaming,
carrying, soothing, or taking
it to the parents bed. Through these nightly activities mother
and child become exhausted and
stressed. As a result, the mother may at some point begin to
reject the child not realising that
the response at night of giving attention to the child is a
reinforcement of a controlling
behaviour. Every time the child is being given attention as a
response to screaming, the
controlling behaviour is reinforced.
Receiving affection and confirmation of being secure is
necessary for a child. However,
controlling behaviours have a devastating influence on the
relationship between mother and
child therefore, this dynamic must be interrupted. The childs
need for confirmation must be
met in a different setting, not as a response to a controlling
behaviour but as a daily scheduled
routine that is predictable to the child. Controlling behaviours
must not be responded to with
attention but with a controlled withdrawal of attention as
opposed to rejection. This will be
described more in the section on therapy below.
Loss of Autonomy
Authors translation:
The ill child loses its autonomy through a trauma from a
perceived life-threatening separation
that is not overcome or emotionally processed and the chronic
disease makes it dependant
which lowers its self-esteem. (a.a., p. 299)
The caregiver may even reinforce the loss of autonomy and
self-esteem in expressing how
powerless he/she feels in being confronted with the disease and
provide assistance and
support to the child above and beyond what is required. The
feeling of losing ones autonomy
influences the immune system thus making the child more prone to
become ill.
Lifestyle
Just like the Western lifestyle increases the risk of babies
acquiring atopic eczema that
lifestyle also maintains the disease once it has been acquired
through factors triggering stress,
such as: frequent separations, frequent changes of environments
and human interfaces. These
factors require constant readjustment which generates stress
particularly in babies as they lack
strategies for dealing with changes. A flood of impressions
demands attention and processing
and preoccupies the mind which prevents relaxing. A view
sometimes expressed by parents is
that babies need to get used to change as this is how our
society works. Exposing babies to
frequent change seems to be an intended process of
socialization, preparing babies for a
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lifestyle of frequent change. However, babies learn what they
are ready for according to a
programme that cannot be altered or accelerated by external
influences. Exposing a baby to
circumstances that it is not able to cope with will generate
stress rather than teaching them
strategies for coping with change.
4.2 Therapy
To provide an all encompassing illustration of the therapy is
not possible within the scope of
this study. Below follows a brief summary of the therapy that
represents information deemed
relevant to enhance the readers understanding of the subject in
order to assess the outcome of
the study. Relevant information was provided by:
Stemmann, E. A. and Stemmann, S., Selbstheilung (Spontanheilung)
der
Neurodermitis Das Gelsenkirchener Behandlungsverfahren 2002.
Parental seminars given by Lion, K. A. and Langer, D.3
Referenced text is frequently used in its original form as
empirical data. Based on the
assumptions illustrated above, an approach to therapy was
developed by Stemmann with the
objective to reduce the stress-hormone baseline. Behavioural
therapy constitutes the core of
the therapy. The method applied by the Gelsenkirchen Programme
is a parent and offspring
training programme initiated by a three-week stay at the clinic
and continued at home.
Regular medication and creaming are part of the conventional
therapy. The objective of the
Gelsenkirchen Programme however, is to reduce the stress-hormone
baseline. Since topical
corticosteroids are stress hormones and these are believed to
reinforce atopic eczema they are
refrained from. Instead, other treatments not containing topical
corticosteroids are used to
treat the eczema in acute conditions but not as a regular
treatment.
The focus of the therapy is not to avoid short-term,
instantaneous peaks of stress hormone
release but to enable self-healing by reaching a lower
stress-hormone baseline long-term.
Authors translation:
Self-healing is accomplished by reversing the effects of the
factors maintaining the disease:
Stress is reduced. Coping with stress is practised. Emotions are
not suppressed but
appropriately lived through. Reinforcements are removed from
strengthening the disease and
instead consciously applied to promote health (a.a., pp.
302-303).
3
The thesis was reviewed by Langer.
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Atopic eczema is treated from a psychosomatic view according to
a multifactor model. By
applying methods of systematic desensitization, flooding of
stimuli and reversed conditioning
to increase tolerance to stress clear improvements are achieved.
Every-day situations of the
clinic are used for this purpose (situations of separation,
medical checkups, meals, parent-
child interactions). In parallel, the caregiver participates in
methods of cognitive restructuring,
stimuli confrontation in-sensu and in-vivo (for example:
separation training, sleep training,
dealing with difficult situation such as scratching) to modify
the copying behaviour of the
caregiver. In addition, psychological support is provided where
methods of relaxing (autogenic
relaxation, progressive muscle relaxation) as well as
self-management methods
(Meichenbaum) complement the programme. The family takes part in
the programme to lose
feelings of guilt and improve compliance. Short term substances
that may impact the sufferer
negatively, for instance allergenic foods, are avoided through a
diet conversion. (Langer
Stresskrankheit (III) Neurodermitis)
A lower stress-hormone baseline is accomplished through multiple
areas of training where
conveying affection and consistency to the child are the guiding
principles of the programme.
Overcome the trauma (fear of separation): The child is given the
opportunity to learn
through constant repetition throughout the stay that the
perceived life-threatening situation
that according to the model triggered the disease is not
life-threatening. Separation is
practised with a consistently repeated positive outcome -mother
returns- under supervision of
experienced staff until the situation no longer is perceived as
threatening and no longer
triggers a stress reaction with the child. This training is a
prerequisite to successful
behavioural modification.
Parental behavioural modification: The mother learns through
daily training to modify her
behaviour towards the child thus enabling the child to adjust
its behaviour (cease controlling
and become more autonomous). The parental behavioural
modifications in combination with
the childs behavioural response strengthen the bond between
mother and child leading to a
secure affectionate relationship. This leads to further changes
in parental behaviour and
lifestyle. The negative behavioural dynamics escalating stress
are replaced by positive
behaviours reducing stress and strengthening the bond between
mother and child. The
questionnaire used in the empirical study of the Gelsenkirchen
Programme indirectly indicates
whether the ability of mother and child to bond and separate has
strengthened. To accomplish
this, the caregiver practises, at times supervised, to apply
behavioural modifications in various
daily situations where the stress-causing dynamics are most
prevalent. In short, the mother
learns to consciously convey affection and withhold attention as
a means of reinforcement
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versus lack of reinforcement depending on the childs behaviour.
Lack of reinforcement,
withholding attention, is the response when the child practises
controlling behaviours.
Affection (confirming, reinforcing that the child is secure) is
conveyed when the child is
relaxed. Affection is conveyed through prolonged eye-to-eye
contact with the child, smiling at
the child, hugging it, etc.
Establishing a secure affectionate relationship: Reinforcement
of controlling behaviours in
the interaction between child and caregiver may weaken the
ability to bond thereby further
reinforcing the disease. The therapy therefore aims at
establishing a secure affectionate
relationship strengthening the ability of caregiver and child to
bond thereby promoting a
healthy behaviour in the interaction between caregiver and child
including the ability to
separate. For this purpose, the mother sets aside thirty minutes
per day of exclusive,
uninterrupted time playing with the child at home. This
procedure should ideally occur at the
same time every day to convey predictability as this makes the
child feel secure. This
procedure is optimally carried out in the morning to prevent
controlling behaviours to even
commence. In addition, throughout the day when the child plays
independently mother
conveys affection through body language.
Time Out: The abilities to separate and bond are closely
interrelated. To strengthen these
abilities in mother and child, time out is practised. Timeout
promotes relaxation and reduces
controlling behaviours in the child. Children less than 10 years
of age practise relaxing by
playing undisturbed with a play of choice for thirty minutes
alone on a daily basis. It should
be a purpose-free play that enables the child to be lost in
play, to reach a near meditative state
of mind. This should ideally occur at the same time every day.
Playing undisturbed enables
the child to use its imagination which enables it to relax.
Caregivers, and children above 10
years of age, practise relaxation (autogenic relaxation,
progressive relaxation or fantasy travel,
a way of meditating for children and adults) on a daily basis.
Practising relaxation techniques
enhances the caregivers capability of dealing with controlling
behaviours in a sovereign, calm
manner withholding attention without rejecting the child. Time
out also serves the purpose of
disrupting controlling behaviours and developing a more
adequate, self-confident behaviours
(I can play on my own)
Sleep training: Relaxing is a prerequisite to sleep. The
inability to sleep without the mother
being near is viewed as a controlling behaviour. Hence, sleep
training is initiated at the clinic
and continued at home. A daily structure with stages of activity
and relaxation according to
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the age of the child is a prerequisite. Supporting independence
and the ability to relax are
equally important prerequisites to promote a sound sleep.
Increase resilience: Affection and short-term stress are used as
a conscious approach to guide
the child to establish behaviours where he/she will feel secure,
by showing that being relaxed
yields the desired affection, a response much more pleasant than
the response to controlling
behaviours. Recalling that the therapy aims at reducing the
stress-hormone baseline, short-
term stress peaks resulting from withheld attention is an
inducement for the child to alter its
behaviour.
Emotional competence: Emotional competence is practised as part
of the programme. This
results in a flow of peptides and a reduction of the
stress-hormone baseline. Referring back to
the suppressed or excessively expressed emotions stating that
the child needs to develop
emotional competence. Authors translation:
Self-perception, recognising and allowing emotions, appropriate
expression of feelings,
letting emotions serve a positive purpose and the skill to cope
with feelings of others.
(Stemman & Stemmann, 2002, p. 306)
Providing a framework
When the disease has manifested itself through controlling
behaviours between caregiver and
child, the parental relationship suffers and may become
instable. This leads to increased
uncertainty in the child which through the disease attempts to
stabilize the family. This role
has additional negative consequences for the disease as it adds
stress. Therefore, the
programme provides relationship counselling with the dual aims
to move the responsibility of
the parental relationship back to the parents and to stabilize
the family alliance, either through
a strengthened partnership or through separation. Focus is on a
establishing a clear family
structure that does not add to longterm stress and frees the
child from taking on
responsibilities it is not equipped to handle.
Clear rules on expected behaviour in ritual situations are
necessary. For example: when
getting dressed, brushing teeth and eating, where conflicts
often occur. Behaviours causing
irritation and stress in the parent must be interrupted to
prevent stress to escalate.
A regular daily routine including that the child should always
sleep at home in its own bed
at scheduled hours
Meals and snacks should be consumed at home at scheduled hours
at a dedicated place
Natural, logical consequences: Predictable, logical, consistent
consequences should follow
when the framework is ignored. The child should be given the
opportunity to learn from
the consequences of its own actions thus taking responsibility
for its own actions (risk free
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environment is a prerequisite). Explaining, negotiating,
bribing, raising the voice, holding
child in a firm grip, are all actions causing stress and anxiety
preventing learning, hence
they should be avoided.
Conflict solving techniques that involve short-term stress peaks
but in the long run will
contribute to a lower stress-hormone baseline.
Being the leader: Mother takes responsibility and makes
decisions as opposed to asking
the child what is wants. This will shift the responsibility to
the mother. Children need
leaders it makes them feel secure. If children are put in the
situation of being the leader
they will react with stress.
Clear communication: Clearly communicate expectations such as I
want you to.- as
opposed to can you please.
A Change of Lifestyle
No visits by others at home for the duration of the programme
unless absolutely necessary
No visits to others for the duration of the programme
No travel for the duration of the programme
The child should not accompany parent(s) to activities.
No scheduled activities for the child for the duration of the
programme
Shopping should be organised without the childs participation as
much as possible
Car transports with the child should be avoided to the extent
possible
A regular daily routine involving spending time outdoors in the
nature
A diet conversion
The more stringent restrictions in lifestyle are maintained for
approximately six to eight
weeks. Within this timeframe, an improvement in the skin
condition and a stabilization of the
autonomic nervous system (ANS or visceral nervous system) are
often the case. From then
on, changes may be introduces incrementally according to what
the child can handle. Only the
diet is maintained throughout the full year.
The more the parent modifies his/her behaviour according to the
model, the more it enables
the child to alter its behaviour. The parent, through his/her
response in behaviour shows the
consequences of the various behaviours displayed by the child.
The decision to try a different
behaviour always lies with the child. In situations previously
categorised as dead-lock this
method provides the child with the option to alter its
behaviour. If a pleasant consequence
follows (time with parent, affection conveyed) the child may opt
to keep this behaviour.
With this model applied, according to the Gelsenkirchen
Programme, the stress-hormone
baseline will drop over time, the child will become more stress
resistant, and the distorted
stress response will be reversed to normal mode of operations.
In other words, eosinophil
granulocytes and T helper cells will no longer be directed to
the skin during stress. The
controlling behaviours will disappear over time and the child
will become more autonomous.
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5.0 Analysis of the Theoretical Model
This section provides a theoretical analysis of the assumptions
stipulated by the hypothesis
with the intention to seek theoretical support for the
hypothesis. The approach used in this
analysis was described in Chapter 1. Empirical data from other
authors was leveraged to
assess key assumptions of the Gelsenkirchen Programme. The data
was kept in its original
form to ensure transparency and risk mitigation.
Compared with conventional therapies and current trends in
research, the Gelsenkirchen
Programme appears controversial. In order to assess the
plausibility of the theoretical model,
this section reviews and analyses literature that addresses the
assumptions on which the
therapy is based.
To identify relevant literature, the following libraries, search
engine and databases have been
searched: The library at the Department of Education, the
Library at the Department of
Teaching, DISA, LIBRIS (www.ub.uu.se), Google (www.google.se).
The literature selected
meets the following criteria:
be scientific,
provide theoretical and empirical support for the theoretical
model and the therapy
of the Gelsenkirchen Programme
illustrate and assess parental and offspring training as a form
of therapy.
Swedish as well as international works have been explored in the
process. Databases searched
are DISA, LIBRIS, the library at the Faculty of Education at
Uppsala University and Google.
Search terms used were: atopiskt eksem, atopic eczema, atopic
eczema, stand-alone and in
combination (according to language) with beteendeterapi,
beteendefrndring, behavioural
therapy, behavioural modelling, cognitive behavioural therapy,
learning, training, stress,
atopic dermatitis, Waldorf, anthroposophic lifestyle, disruptive
children.
Searches in DISA and LIBRIS on these search terms: atopic
dermatitis, atopiskt eksem,
atopic eczema yielded quite a few results however the search
results focus on aspects
irrelevant to this study and was consequently not selected. The
outcome of atopiskt eksem in
combination with beteendeterapi or beteendemodulering gave no
results. The English
equivalents were equally unrewarding. The search term disruptive
children gave some
results of which one book was selected. Visiting the home page
of the Waldorf school in
Uppsala led to one study that is referenced. The same study can
be found in LIBRIS and
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DISA using the search term Waldorf. Entering anthroposophic
lifestyle in google resulted
in some articles that are referenced.
The selected literature is mainly a result of visiting the
library at the Faculty of Education and
does not cover atopic eczema per se. Instead, some of the
assumptions underlying the
Gelsenkirchen Programme are addressed albeit applied to other
diseases and disorders. The
selected literature also addresses parental training as an
approach to therapy similar to the
Gelsenkirchen Programme, but in the context of treating
Attention Deficit Hyperactivity
Disorder (ADHD).
Literature referred to by the Gelsenkirchen Programme has
intentionally been refrained from
as the purpose of the theoretical analysis is to seek
theoretical support from other sources than
those used to form the theoretical model as this would
strengthen the models plausibility.
Below follows an analysis of the findings by different authors
according to this disposition:
Emotions
Separation
Stress
Erroneous innervation
Analysis of prevalence factors
Parental and offspring training
This study is concerned with the relationship between emotions,
stress, and organ damage
related to atopic eczema. Sue Gerhardts views as illustrated in
Why love matters 2006
serve as the single source of comparative theoretical arguments
for Emotions, Separation,
Stress and Erroneous innervation. This narrow choice of
literature was partly motivated by the
limited literature findings corresponding to the search criteria
but also by the fact that
Gerhardts arguments and the provided scientific support she
delivers often align with those
of Stemmann albeit used to explain other stress related health
phenomena. Hence, detailed
analysis was required to compare both theoretical views. Both
reasons contributed to the
approach to theoretical analysis which is a comparison of
arguments per assumption. To a
great extent, the referenced text is used in its original form
as a means of empirical data.
Sue Gerhardt, a psychoanalytic psychotherapist in a private
practice, illustrates in Why love
matters 2006, the importance of motherly affection to the
development of a babys brain and
its learned strategies for coping with emotions and stress,
strategies that stay with us as adults.
Gerhardt describes how lack of affection increases the
stress-hormone baseline in babies and
young children which impairs the brains development. According
to Gerhardt, a higher stress
baseline also impacts the immune system and the stress
sensitivity into states that under
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certain conditions lead to various more or less severe
behavioural deficiencies in adults.
Gerhardt further suggests that certain deficiencies, such as
strongly aggressive behaviour, or
disorders like depression, or diseases like cancer may well be
the result of stress arising from
an insecure mother and child affection. In short, Gerhardt
illustrates a relationship between
emotions and stress, and deficiencies, disorders and
diseases.
A report by Bo Dahlin, Ingrid Liljeroth and Agnes Nobel (2006)
comparing municipal
schools with Waldorf schools in Sweden was leveraged in the
analysis of prevalence factors.
Bo Dahlin is a professor in Educatin at Kalmar University.
Ingrid Liljeroth is associate
professor in special education at Gothenburg University. Agnes
Nobel was associate professor
in Education at Uppsala University. In addition, some articles
on anthroposophic lifestyle as
well as Sue Gerhard with Why love matters served as reference
material.
Ulf Axberg is psychologist and psychotherapist associated with
the Faculty of Psychology at
the Gothenburg University. In his research he focuses on what he
referred to as noisy
children. He has been active within child psychiatry in
Skaraborg where he worked with
children and youngsters. A report by Ulf Axberg on parental and
offspring training for
children and youngsters with ADHS was drawn upon in reviewing
the parental behavioural
training recommended by the Gelsenkirchen Programme.
Assumption 1: Emotions Impact the Immune System
Emotional Security and Stress
Gerhardt suggests a relationship between emotional security and
stress. She describes that an
insecure mother and child attachment resulting from the
caregiver not responding to the
babys calls for help or being responsive in an unpredictable
manner increases the stress
baseline in the child. The following excerpts refer to studies
supporting her views and shed
light to her views on the relationship between emotional
security and stress.
Children with secure attachments do not release high levels of
cortisol under stress, whereas
insecure children do. (Gunnar and Nelson 1994; Gunnar et al.
1996; Nachmias et al. 1996;
Essex et al. 2002 in Gerhardt, 2006, p. 72)
There is a powerful link between emotional insecurity and
cortisol dysfunction. So it is not
necessarily the nature of the stress that matters, but the
availability of others to help manage it,
as well as the inner resources of the person experiencing it.
(Gerhardt, 2006, p. 72)
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By 1 year old, children who are in secure relationships that
respond to their need and regulate
them well are unlikely to produce high levels of cortisol even
when they are upset, whereas
those in insecure relationships do. (a.a., p. 73)
The key feature of insecure attachments is a lack of confidence
in others emotional
availability and support. (Ibid.)
Referring to research by Candice Pert, a scientist who has
studied the biochemicals of
emotions, Gerhardt states that good emotional immunity comes out
of a secure affectionate
relationship between mother and child. Apparently, the quality
of the relationship between
mother and baby in the babys first year seems to make a large
difference as to the emotional
security and the behaviour of the cortisol function. Gerhardts
statement indirectly supports
the Gelsenkirchen Programme which recommends behavioural changes
in the caregiver such
that affection is conveyed in a predictable manner to establish
a secure affectionate
relationship hence reducing stress in the child. Emotions impact
the immune system via the
stress response which is described below.
The Stress Response
Like Stemmann, Gerhardt suggests that emotions influence the
behaviour of the immune
system. Gerhardt clarifies that this is done by altering the
stress response. This is further
illustrated below under the heading How Emotions Impact the
Immune System. Excerpts
from her book below illustrate her view to this effect and refer
to studies supporting the
assumption of a relationship between emotions and the behaviour
of the immune system. The
description is intentionally left in its original form as the
purpose of the description is to
illustrate Gerhardts view as empirical input to the theoretical
analysis and to the conclusions
drawn thereof.
Clearly, the stress response is one key element of our emotional
make-up. When we are
regulating our emotional states, we are also regulating our
hormone and neurotransmitter
levels. However, the ability to do this effectively is strongly
influenced by our parent figures
and their own capacity to tolerate their babys cries and demands
and their way of
responding. (a.a., p. 83)
A robust stress response is rather like a strong immune system;
in fact, as Candice Pert has
argued, they are interconnected. It provides host resistance to
the future stresses of childhood
and adult life. But like the social brain, it too is shaped by
the quality of contact between
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parents and babies. Good emotional immunity comes out of the
experience of feeling safely
held. Touched, seen and helped to recover from stress, whilst
the stress response is
undermined by separation, uncertainty, lack of contact and lack
of regulation. (Ibid.)
Above all, it seems to be vital to be able to switch off the
production of cortisol at the right
moment, without being flooded by it or having to suppress it.
(Ibid.)
Gerhardt and Stemmann both represent the view that children may
have a highly sensitive
stress-response already at birth but the suggested reasons
differ. Stemmann argues that a baby
may experience fear of separation during pregnancy, for instance
due to an amniotic fluid
analysis leading to bleedings, or due to premature contractions
or through a caesarean.
Gerhardt suggest that newborns may already be stress
sensitive