530 Proc. roy. Soc. Med. Volume 68 August 1975 Dr D G Brown (St Mary's Hospital, London W9) and Dr R S Kalucy (St George's Hospital, London SWJ7)
Correlation of Neurophysiological and Personality Data in Sleep Scratching One of us has studied patterns of scratching in a consecutive series of eczema patients (Brown 1967). A sizeable proportion of the patients scratched particularly at night. These 14 compared with the remaining 20 did not differ in extent and activity of the eczema. The sex ratio was identical and average ages were very similar but differences in scratching patterns could be related to the way these individuals coped psychosocially with their emotional drives and conflicts. For example, the night scratchers were less often sexually satisfied and active (31 % compared with 50 %). Though usually admitting to psychological symptoms such as anxiety and depression when these were carefully enquired after, they tended not to complain of them spontaneously. Somatization of emotions was indicated by a preferential reporting of psychophysiological rather than psychological symptoms. Their avoidance of ambiguity, ambivalence and conflict was suggested by their significantly higher score on a questionnaire test of intolerance of ambiguity (Brengelmann 1960), significant at the 5 % level. Thus night scratchers may be in a state of high drive or tension which is partially coped with by day-time activities and perpetuated by external frustration and neurotic conflicts which are dealt with by defences such as denial. These defences could be expected to be less effective in sleep, and scratching could then become a discharge manifestation. One would predict that night scratchers remain tense even in sleep. How this interacts with dreaming, another
20 possible outlet for drives that do not find adequate outlet in the waking state, seemed worthy of investigation. We examined a few patients with prominent night scratching in terms of clinical presentation, patterns of itching and scratching, personality tests, neurophysiology and dreams. We report in detail here only on the Sleep Laboratory findings and comment briefly on how we have attempted to understand them in relation to the other data. Description ofPatients Studied Through liaison with the dermatologists at St George's Hospital we were referred cases in whom enquiry indicated that night scratching was a marked feature. Details of the 4 cases studied are given in Table 1 and their response to the itch questionnaire in Table 2. Tests on the Eysenck Personality Inventory (Eysenck & Eysenck 1964) and Foulds' Hostility and Direction of Hostility Questionnaire (Caine et al. 1967) showed that they tended to be introverted neurotics with a high level of aggression directed mainly inwards on to themselves. Thus M G was a perfectionistic, narcissistic man, successful in his work but with a disastrous marriage. His marital problems preceded his prurigo. They began with his wife's inability to conceive, and her difficulties in giving him the sensual adoration he craved for. His reaction was to withdraw resentfully from her and drive her to desperation (and a depressive breakdown). At interview he talked freely, but with a curious blandness and lack of distress. He rationalized and denied a lot, and seemed out of touch with the aggressive and particularly the sadomasochistic aspects of himself and his behaviour. A Latin by birth, he came to England to work in the hotel trade. At the same time he seemed to adopt an exaggeratedly defensive persona a sort of caricature Englishman which gratified several emotional needs, as well as helping him in his work. For example, he described how good he feels when he suffers and absorbs the violence of awkward customers. Though near to exploding at times, he steels his shaking limbs. His skin flushes and sweats, and often subsequently itches severely. -
Table I
-
Details of the 4 cases studied Case MG XL EH GR
Sex Male Female Female Male
Age 41 53
46 31
Duration Dermatological diagnosis (years) Nodularprurigo 11 Eczema Acne excoriee Atopic eczema
37 19 26
Table 2 Patients' response to the 'itch questionnaire' Itch worse when worked up and on edge Itch worse when angry Itch worse when worried Itch worse when relaxed Itch very bad when undressing Itch worse in bed than in day Itch prevents sleep Itch wakes up from sleep Find have scratched in sleep
MG Yes
Yes
Yes Yes Yes ? Sometimes Often
GR Yes
IL
EH
Yes
Yes
Yes Yes
Yes Yes Often
Yes
Sometimes Often
Someumes Often
Sometimes Often Often
-
21
Section of Dermatology
531
Sleep Laboratory Studies Patients were asked to come in to the Sleep Laboratory at 9 p.m. and were introduced to the procedure. The first night was for adaptation. On three subsequent nights recordings were taken throughout the night with leads recording EEG activity, EMG activity in orbital and submental muscles and, by means of leads attached to the forearms, scratching. Fig 1 shows sample records with a bout of scratching occurring during rapid eye movement (REM) ('dream') sleep. On the final night dream studies were performed. These required continuous observation of the EEG by the research workers, and the waking of the patient when episodes of REM were established. This normally leads to the elicitation of dreams. Our technique was that recommended by Breger et al. (1971) and all dreams were tape-recorded. One of the 4 declined to come in for the dream elicitation night.
the first half of the night. (4) There was no tendency for patients to become more aroused in the second half of the night. (5) Eight periods of REM were examined and five yielded no dreams whatever, and denial in one patient (M G) that he was even asleep. This compares with the usual findings of 80-85 % of dreams reports following wakings in that period. One patient denied dreaming on each of four wakenings. The other 2 patients each denied dreaming on one of two wakenings, and the dreams recalled were characterized by their own passive-observer role, with painful feelings or longings epitomized by another of the dramatis personae.
Discussion Nocturnal scratching could be seen as part of a general state of arousal, this correlating with loss of deep sleep and with increased motility. It is not possible to say whether nocturnal scratching Results reflects the normal intermittent arousal state that Scratching occurred frequently in all 4 patients occurs during sleep and is associated with body throughout the night in all sleep stages, and was movement, changes in galvanic skin responses most marked in the first half of the night. Its and blood flow. It may be, for example, that such regular occurrence during REM periods is of changes stimulate the skin which is already special interest since the dreaming person is sensitive and produce scratching. Alternatively, normally in a state of extreme hypotonia. There the scratching could be autonomous of sleep but, were almost no occasions in any patient through- because it involves movement, eliminates the need out the whole period of recording (20 nights) in for movement arousal generated from a more which motility occurred independently of scratch- central focus. ing. Motility associated with scratching was more The relative absence of Stage 3 and 4 sleep may frequent throughout the night than normal be of considerable importance since this deeper motility, and there was much more movement sleep is primarily associated with bodily restorathan one would see in a normal subject. tion after the day's efforts. The relationship Sleep stages were qualitatively and quantitatively between this and the chronicity of their dermatoses different in these skin patients from the normal: is suggestive and deserves further exploration. (1) There was an abnormal delay in getting to Likewise, REM sleep and dreaming have been sleep. (2) There was very little deep sleep (Stages 3 associated with psychological restoration, psychoand 4). (3) REM sleep was relatively reduced in logical problem solving and integration of new
Fig 1 Episode ofscratching (right arm) during REMperiod (EOG)
532 Proc. roy. Soc. Med. Volume 68 August 1975
experience with old. The unusual paucity of dreaming in these patients could, therefore, be part of a general position of denial, a position which might limit their capacity to resolve psychological problems. Our observations might reflect the consequence of a cycle of organic change, itching and scratching, which maintained the high level of arousal and tension in these patients. However, in the 2 patients with nodular prurigo and acne excoriee there was little dermatological evidence of primary organic pathogenesis. But all cases showed emotional frustration and conflict in relation to dependency and contact. They were in difficult life situations and reacted to these with resentment, guilt and despair at being unable to change things, and with defences such as denial and projection. The neurophysiological findings, at least in part, could be a reflection of these stresses and the patients' arousal response to them. They represent a psychosomatic compromise solution to the conflicts. Scratching becomes the main form of motility in these night scratchers, the restorative deeper stages of sleep are rarely entered, and there is relatively little dreaming, with its opportunities for psychological drive discharge and problem solving. These might be factors leading to chronicity of these cases. Scratching might even serve the defensive function of avoiding deeper sleep and thus contact with disturbing fantasies and feelings (dreams).
Acknowledgments: We are grateful to Miss Margot Hartmann for technical help, to Dr Kenneth Sanderson and Dr Stephen Gold for letting us report on their patients, and to Professor Arthur Crisp for his encouragement. REFERENCES Breger L, Hunter I & Lane R (1971) Effect of Stress on Dreams. International University Press, New York; p 195 Brengelmann J C (1960) Journal of Mental Science 106, 717 Brown D G (1967) Journal of Psychosomatic Research 11, 27 Caine T M, Foulds G A & Hope K (1967) Manual of the Hostility and Direction of Hostility Questionnaire (HDHQ). University of London Press, London Eysenck H J & Eysenck S B G (1964) Manual of the Eysenck Personality Inventory. University of London Press, London
The following paper was also read: Measurement of Itch and Response to Treatment Dr R H Felix (University Department of Dermatology, Royal Victoria Infirmary, Newcastle upon Tyne, NE] 4LP) REFERENCE
Felix R H & Shuster S (1975) Glaxo Symposium on Mechanisms of Topical Corticosteroid Activity. Churchill Livingstone, London (in press)
22
Cases Confluent and Reticulate Papillomatosis (Two Cases) J D Kirby MB MRCP and P F Borrie MD FRCP (Department of Dermatology, St Bartholomew's Hospital, London ECJA 7BE) Case 1 A N, man aged 19 History: For one week slightly itchy rash on chest and back. He had dieted, losing 14 lb (6.4 kg) in weight within several weeks, and overall 3 stone (19 kg). On examination: Bright red papules, each with a slightly warty surface and in places becoming confluent distributed across chest and extending to epigastrium. On his back the thoracolumbar spine was involved with a lateral spread across the scapulae (Fig 1). Wood's light examination negative. Mycology: Numerous Pityrosporon orbiculare spores on skin scrapings from the back, fewer organisms from the chest. Pityrosporon orbiculare was cultured. M.furfur was not seen. Skin biopsy: Hyperkeratosis, a corrugated epidermis with papilloma formation. CEdema of superficial dermis and an intense cellular infiltrate, composed mainly of lymphocytes. PAS stain showed round thick-walled yeasts in the corneal layer (Fig 2). Course and treatment: After several months the intensity of pigmentation faded to a muddy brown colour. The papules flattened and became slightly scaled. A reticulate pattern formed at the periphery of the rash merging into normal skin. Several treatments with 1 % selenium sulphide in Ung. Emulsif. Aquos. produced almost total clearing of the rash.
Case 2 L S, woman aged 19 History: Slight irritation and rash on either breast for one week. She had bruised her left side in a road traffic accident. For three weeks whilst under observation in hospital she refused food and drink. Rash developed during third week. On examination: Pigmented papules formed a reticulate pattern on medial aspect of either breast (Fig 3). Wood's light examination negative. Mycology: P. orbiculare and P. ovale were seen in scrapings from both breasts but not in material obtained from adjacent normal skin. P. orbiculare and P. ovale were cultured. Skin biopsy: Changes were the same as in Case 1: the cellular infiltrate was less intense. PAS stain showed round yeasts in the stratum corneum budding in some areas. Course and treatment: One week's treatment with clotrimazole cream produced some clearing of the rash.
Correlation of Neurophysiological and Personality Data in Sleep Scratching One of us has studied patterns of scratching in a consecutive series of eczema patients (Brown 1967). A sizeable proportion of the patients scratched particularly at night. These 14 compared with the remaining 20 did not differ in extent and activity of the eczema. The sex ratio was identical and average ages were very similar but differences in scratching patterns could be related to the way these individuals coped psychosocially with their emotional drives and conflicts. For example, the night scratchers were less often sexually satisfied and active (31 % compared with 50 %). Though usually admitting to psychological symptoms such as anxiety and depression when these were carefully enquired after, they tended not to complain of them spontaneously. Somatization of emotions was indicated by a preferential reporting of psychophysiological rather than psychological symptoms. Their avoidance of ambiguity, ambivalence and conflict was suggested by their significantly higher score on a questionnaire test of intolerance of ambiguity (Brengelmann 1960), significant at the 5 % level. Thus night scratchers may be in a state of high drive or tension which is partially coped with by day-time activities and perpetuated by external frustration and neurotic conflicts which are dealt with by defences such as denial. These defences could be expected to be less effective in sleep, and scratching could then become a discharge manifestation. One would predict that night scratchers remain tense even in sleep. How this interacts with dreaming, another
20 possible outlet for drives that do not find adequate outlet in the waking state, seemed worthy of investigation. We examined a few patients with prominent night scratching in terms of clinical presentation, patterns of itching and scratching, personality tests, neurophysiology and dreams. We report in detail here only on the Sleep Laboratory findings and comment briefly on how we have attempted to understand them in relation to the other data. Description ofPatients Studied Through liaison with the dermatologists at St George's Hospital we were referred cases in whom enquiry indicated that night scratching was a marked feature. Details of the 4 cases studied are given in Table 1 and their response to the itch questionnaire in Table 2. Tests on the Eysenck Personality Inventory (Eysenck & Eysenck 1964) and Foulds' Hostility and Direction of Hostility Questionnaire (Caine et al. 1967) showed that they tended to be introverted neurotics with a high level of aggression directed mainly inwards on to themselves. Thus M G was a perfectionistic, narcissistic man, successful in his work but with a disastrous marriage. His marital problems preceded his prurigo. They began with his wife's inability to conceive, and her difficulties in giving him the sensual adoration he craved for. His reaction was to withdraw resentfully from her and drive her to desperation (and a depressive breakdown). At interview he talked freely, but with a curious blandness and lack of distress. He rationalized and denied a lot, and seemed out of touch with the aggressive and particularly the sadomasochistic aspects of himself and his behaviour. A Latin by birth, he came to England to work in the hotel trade. At the same time he seemed to adopt an exaggeratedly defensive persona a sort of caricature Englishman which gratified several emotional needs, as well as helping him in his work. For example, he described how good he feels when he suffers and absorbs the violence of awkward customers. Though near to exploding at times, he steels his shaking limbs. His skin flushes and sweats, and often subsequently itches severely. -
Table I
-
Details of the 4 cases studied Case MG XL EH GR
Sex Male Female Female Male
Age 41 53
46 31
Duration Dermatological diagnosis (years) Nodularprurigo 11 Eczema Acne excoriee Atopic eczema
37 19 26
Table 2 Patients' response to the 'itch questionnaire' Itch worse when worked up and on edge Itch worse when angry Itch worse when worried Itch worse when relaxed Itch very bad when undressing Itch worse in bed than in day Itch prevents sleep Itch wakes up from sleep Find have scratched in sleep
MG Yes
Yes
Yes Yes Yes ? Sometimes Often
GR Yes
IL
EH
Yes
Yes
Yes Yes
Yes Yes Often
Yes
Sometimes Often
Someumes Often
Sometimes Often Often
-
21
Section of Dermatology
531
Sleep Laboratory Studies Patients were asked to come in to the Sleep Laboratory at 9 p.m. and were introduced to the procedure. The first night was for adaptation. On three subsequent nights recordings were taken throughout the night with leads recording EEG activity, EMG activity in orbital and submental muscles and, by means of leads attached to the forearms, scratching. Fig 1 shows sample records with a bout of scratching occurring during rapid eye movement (REM) ('dream') sleep. On the final night dream studies were performed. These required continuous observation of the EEG by the research workers, and the waking of the patient when episodes of REM were established. This normally leads to the elicitation of dreams. Our technique was that recommended by Breger et al. (1971) and all dreams were tape-recorded. One of the 4 declined to come in for the dream elicitation night.
the first half of the night. (4) There was no tendency for patients to become more aroused in the second half of the night. (5) Eight periods of REM were examined and five yielded no dreams whatever, and denial in one patient (M G) that he was even asleep. This compares with the usual findings of 80-85 % of dreams reports following wakings in that period. One patient denied dreaming on each of four wakenings. The other 2 patients each denied dreaming on one of two wakenings, and the dreams recalled were characterized by their own passive-observer role, with painful feelings or longings epitomized by another of the dramatis personae.
Discussion Nocturnal scratching could be seen as part of a general state of arousal, this correlating with loss of deep sleep and with increased motility. It is not possible to say whether nocturnal scratching Results reflects the normal intermittent arousal state that Scratching occurred frequently in all 4 patients occurs during sleep and is associated with body throughout the night in all sleep stages, and was movement, changes in galvanic skin responses most marked in the first half of the night. Its and blood flow. It may be, for example, that such regular occurrence during REM periods is of changes stimulate the skin which is already special interest since the dreaming person is sensitive and produce scratching. Alternatively, normally in a state of extreme hypotonia. There the scratching could be autonomous of sleep but, were almost no occasions in any patient through- because it involves movement, eliminates the need out the whole period of recording (20 nights) in for movement arousal generated from a more which motility occurred independently of scratch- central focus. ing. Motility associated with scratching was more The relative absence of Stage 3 and 4 sleep may frequent throughout the night than normal be of considerable importance since this deeper motility, and there was much more movement sleep is primarily associated with bodily restorathan one would see in a normal subject. tion after the day's efforts. The relationship Sleep stages were qualitatively and quantitatively between this and the chronicity of their dermatoses different in these skin patients from the normal: is suggestive and deserves further exploration. (1) There was an abnormal delay in getting to Likewise, REM sleep and dreaming have been sleep. (2) There was very little deep sleep (Stages 3 associated with psychological restoration, psychoand 4). (3) REM sleep was relatively reduced in logical problem solving and integration of new
Fig 1 Episode ofscratching (right arm) during REMperiod (EOG)
532 Proc. roy. Soc. Med. Volume 68 August 1975
experience with old. The unusual paucity of dreaming in these patients could, therefore, be part of a general position of denial, a position which might limit their capacity to resolve psychological problems. Our observations might reflect the consequence of a cycle of organic change, itching and scratching, which maintained the high level of arousal and tension in these patients. However, in the 2 patients with nodular prurigo and acne excoriee there was little dermatological evidence of primary organic pathogenesis. But all cases showed emotional frustration and conflict in relation to dependency and contact. They were in difficult life situations and reacted to these with resentment, guilt and despair at being unable to change things, and with defences such as denial and projection. The neurophysiological findings, at least in part, could be a reflection of these stresses and the patients' arousal response to them. They represent a psychosomatic compromise solution to the conflicts. Scratching becomes the main form of motility in these night scratchers, the restorative deeper stages of sleep are rarely entered, and there is relatively little dreaming, with its opportunities for psychological drive discharge and problem solving. These might be factors leading to chronicity of these cases. Scratching might even serve the defensive function of avoiding deeper sleep and thus contact with disturbing fantasies and feelings (dreams).
Acknowledgments: We are grateful to Miss Margot Hartmann for technical help, to Dr Kenneth Sanderson and Dr Stephen Gold for letting us report on their patients, and to Professor Arthur Crisp for his encouragement. REFERENCES Breger L, Hunter I & Lane R (1971) Effect of Stress on Dreams. International University Press, New York; p 195 Brengelmann J C (1960) Journal of Mental Science 106, 717 Brown D G (1967) Journal of Psychosomatic Research 11, 27 Caine T M, Foulds G A & Hope K (1967) Manual of the Hostility and Direction of Hostility Questionnaire (HDHQ). University of London Press, London Eysenck H J & Eysenck S B G (1964) Manual of the Eysenck Personality Inventory. University of London Press, London
The following paper was also read: Measurement of Itch and Response to Treatment Dr R H Felix (University Department of Dermatology, Royal Victoria Infirmary, Newcastle upon Tyne, NE] 4LP) REFERENCE
Felix R H & Shuster S (1975) Glaxo Symposium on Mechanisms of Topical Corticosteroid Activity. Churchill Livingstone, London (in press)
22
Cases Confluent and Reticulate Papillomatosis (Two Cases) J D Kirby MB MRCP and P F Borrie MD FRCP (Department of Dermatology, St Bartholomew's Hospital, London ECJA 7BE) Case 1 A N, man aged 19 History: For one week slightly itchy rash on chest and back. He had dieted, losing 14 lb (6.4 kg) in weight within several weeks, and overall 3 stone (19 kg). On examination: Bright red papules, each with a slightly warty surface and in places becoming confluent distributed across chest and extending to epigastrium. On his back the thoracolumbar spine was involved with a lateral spread across the scapulae (Fig 1). Wood's light examination negative. Mycology: Numerous Pityrosporon orbiculare spores on skin scrapings from the back, fewer organisms from the chest. Pityrosporon orbiculare was cultured. M.furfur was not seen. Skin biopsy: Hyperkeratosis, a corrugated epidermis with papilloma formation. CEdema of superficial dermis and an intense cellular infiltrate, composed mainly of lymphocytes. PAS stain showed round thick-walled yeasts in the corneal layer (Fig 2). Course and treatment: After several months the intensity of pigmentation faded to a muddy brown colour. The papules flattened and became slightly scaled. A reticulate pattern formed at the periphery of the rash merging into normal skin. Several treatments with 1 % selenium sulphide in Ung. Emulsif. Aquos. produced almost total clearing of the rash.
Case 2 L S, woman aged 19 History: Slight irritation and rash on either breast for one week. She had bruised her left side in a road traffic accident. For three weeks whilst under observation in hospital she refused food and drink. Rash developed during third week. On examination: Pigmented papules formed a reticulate pattern on medial aspect of either breast (Fig 3). Wood's light examination negative. Mycology: P. orbiculare and P. ovale were seen in scrapings from both breasts but not in material obtained from adjacent normal skin. P. orbiculare and P. ovale were cultured. Skin biopsy: Changes were the same as in Case 1: the cellular infiltrate was less intense. PAS stain showed round yeasts in the stratum corneum budding in some areas. Course and treatment: One week's treatment with clotrimazole cream produced some clearing of the rash.
