Bernard Lerer. M.B.. Ch.B.
Hyperhidrosis: A review of its psychological aspects Most human beings are all too often uncomfortably aware of the association between sweating and the emotions. Many people experience profuse sweating unrelated to heat, which has variously been labeled essential. emotional. congenital idiopathic. or local hyperhidrosis. While extensive research has been done concerning its physiologic basis. surprisingly little research has been done on its psychological aspects. This type of hyperhidrosis tends to become aggravated under conditions of mental stress-thus the assumption of an emotional component in its pathogenesis. Besides the obvious emotional stress the condition itself imposes and the considerable social and professional limitations associated with it. sufferers have long been noted to be "unusually nervous in nature."1 Excessive sweating may also accompany diagnosed emotional illness such as anxiety neurosis, but most often it is
seen as an entity in its own right. Although these factors indicate a close link between essential hyperhidrosis and the emotions. they do not clarify the nature of the relationship. Hyperhidrosis has long been regarded as having a psychosomatic component,2 but references to it in standard psychiatric texts are, in general. scanty. Engels and Wittkower S regard the disorder as "an anxiety phenomenon mediated by the autonomic nervous system." While the existence of disordered function of the sympathetic nervous system producing sudomotor over-activity is well documented, little has been done to clear up the role of the psychological component in the disorder's pathogenesis. Emotional sweat response
K uno,! in his classic monograph, explains the features of sweating caused by mental stress and various sensory stimuli that can be differentiated from sweating in response
Dr. Lerer is associated with the department of psychiatry at Hadassah University Hospital. Jerusalem. Reprint requests to Dr. Lerer. Hadassah Univer. sity Hospital. Kiryat Hadassah Jerusalem. Israel.
to heat. Mental sweating occurs predominantly on the palms and soles and in the axillae,'·5 but also on the forehead. s Alien and associates' have. however. shown that such sweating may appear equally over the whole body surface. They conclude that no evidence indicates that the sweat glands of the hands and feet behave differently than do the sweat glands of the rest of the body in response to mental factors. Mental sweating may be elicited by mental arithmetic. emotional stress such as fear and resentment. and ischemic pain. I . 5.s Its features differ markedly from those of thermal sweating in absence of a latent period for onset. immediate attainment of secretion rate proportional to the intensity of the stimulation. and cessation on removal of the stimulus.· Thermal sweating is under the control of the heat-regulating center of the hypothalamus. whereas the centers for mental sweating are uncertain. 9 Mental sweating may be explained teleologically as a manifestation of the fightflight response. It facilitates adherence of the skin to an object
about to be grasped and occurs at the exact sites of contact. IO • 11
Essential hyperhidrosis The sweating that occurs in essential hyperhidrosis is identical in its distribution and most other characteristics to that induced in normal subjects by mental stress. IO A markedly increased responsiveness of sweat production to stressful stimuli may. however. be demonstrated. 12 The condition may thus be viewed as a quantitative exaggeration of the normal emotional sweat response. Physiologic stimuli such as emotional excitement. fear. resentment. pain. sensations of physical discomfort. and mental effort produce in such individuals copious sweat output. whereas in normal individuals the quantity of sweat may be minimal in response to the same stimuli. No abnormalities of the thermoregulatory mechanism of the thermal sweat response have been shown to exist.
Clinical features Hyperhidrosis of the type described afflicts young people. who usually come to the physician before the age of 20. Although excessive sweating may have appeared during early childhood or puberty. it most commonly appears during adolescence. a period troubling enough in itself. Few cases are seen after the age of 25. The incidence is markedly high among
Japanese people. according to Cloward 13-20 times greater than in other Oriental or in Caucasian races. The family history is often positive. although no genetic basis for the condition has. as yet. been shown. The hyperhidrosis is symmetrical in nature. affecting the palms. soles. and often axillae as well. Axillary hyperhidrosis may also occur as a separate entity. The disorder. unlike thermogenic hyperhidrosis. is not related to heat. although some patients report that warm weather aggravates it. The relationship to mental stress of all types is striking. Two subtypes of the disorder have been described: a continuous type that is worse in warm weather. and a phasic type that is more directly precipitated by emotional stress. 14
These manifestations may be regarded as complications of the condition. The condition itself may be associated with an intrinsic. deep-seated emotional disorder in a relatively large percentage of cases. Little has been done to investigate the nature of this disorder or to ascertain whether psychological factors play a role in the pathogenesis of essential hyperhidrosis. No clear personality traits have been shown to be associated with hyperhidrosis. Bar and K uypers U characterize patients with this condition as "afraid and not able to express their emotions." They speak of the "sudophobia" that may develop and the vicious circle thus begun. On psychological examination such patients are. in their experience. "hypersensitive. restless. tense. or frightened people." Dosuzkovl 6 re-
.. The emotional suffering associated with essential hyperhidrosis can be intense. Persons suffering from it may be incapacitated. ... "
Psychological aspects The emotional suffering associated with essential hyperhidrosis can be intense. Persons suffering from it may be severely incapacitated in their work opportunities and social contacts. Acute embarrassment may lead to social withdrawal. depressive reactions. and even suicidal ideas. Secondary skin complications may aggravate the associated emotional difficulties. Some patients report concomitant anxiety symptoms such as tachycardia. tremors. and diarrhea during periods of excessive sweating.
ports on the psychoanalysis of a patient in whom excessive sweating first appeared at the age of 27. He labels the condition idrosophobia and sees it as a special form of pregenital conversion. He notes that his is the only discussion of the problem in the psychoanalytic literature other than references to it in association with other emotional disturbances.
Treatment The unsatisfactory results achieved in the management of
essential hyperhidrosis are indicated by the multiplicity of treatments that have been tried. Topical applications are ineffective. and systemic atropinelike drugs and ganglion blockers at best have only a temporarily suppressive effect. Troublesome side effects further limit their efficacy. Sympathectomy (upper thoracic ganglionectomy) causes anhidrosis and provides symptomatic relief. but has disadvantages apart from the complications of the operation. Sweating may return after some years. either from regeneration of sympathetic fibers or from fibers that do not pass through the sympathetic ganglia. l? Palms and soles may become excessively dry. and severe compensatory hyperhidrosis may occur in other parts of the body.14 Symptomatic relief may be obtained in axillary hyperhidrosis by excision of the axillary vault. Hyperhidrotic patients should ideally be assessed by a psychiatrist before being sent for surgery. The use of psychological techniques to treat a condition whose link with the emotions is ostensibly so great has been surprisingly limited. Dosuzkov'sl6 report is the only one dealing specifically with the use of psychoanalytic techniques. Hypnosis is suggested by Grant. 16 . who reports the successful treatment of a single case of axillary hyperhidrosis. Psychotherapy of a supportive nature is. of course. indicated in those cases where emotional symptoms are prominent but obviously secondary to the basic disorder. The psychotherapy may be combined with appropriate psychotropic medi-
cation. When a more deepseated emotional disorder exists. psychotherapeutic intervention may be tried as the primary therapy. and in such cases surgery is probably best not done. Bar and Kuypers l5 state that patients with hyperhidrosis may be given sedatives and psychotherapeutic treatment when their fears are not too deeply repressed to impede motivation. When excessive sweating is an adjunct to clearly defined mental illness. appropriate psychiatric treatment is. of course. indicated. Behaviorally oriented techniques are advocated by
.. Psychotherapy ofa supportive nature is. of course, indicated in those cases where emotional symptoms are prominent but obviously secondary to the basic disorder. The psychotherapy may be combined with appropriate psychotropic medication...
some authors.u.19.2o Bar and Kuypers l5 quote a single case successfully treated by assertiveness training and systematic desensitization. Emotional sweating is spontaneous and relatively temperature independent, and should theoretically be amenable to the techniques of instrumental conditioning. It is interesting to note in this context the case quoted by Dunbar 2 of a patient who was able at will to produce sweating in different areas of his body. K uypers and Cotton 19 report successful reduction of the rate
of palmar sweating in normal subjects with such techniques. They are uncertain as to whether the type of conditioning involved was cognitive. autonomic. or a mixture. The experiment raises interesting possibilities as to the use of·a similar technique in the management of essential hyperhidrosis. The same authors subsequently report the reduction of palmar sweating in four hyperhidrotic subjects with instrumental conditioning. 20
Conclusions For the psychiatrist. essential hyperhidrosis remains an open question. Empirical observation has established a definite link between the condition and emotional disorder. for hyperhidrotic patients tend to manifest psychopathology. the scope and extent of which may exceed that expected from the condition itself. Controlled psychodiagnostic assessment of hyperhidrotic subjects may provide some answers to these questions. Then it may be possible to evolve therapeutic techniques. whether dynamic or behavioral. that may obviate the need for serious surgery. at present the only effective treatment that is available. # REFERENCES I. Kuno Y: Human Perspiration. Springfield. III. Charles C Thomas. 1956. pp 104. 142.351. 2. Dunbar HF: Emotions and Bodily Changes. New York. Columbia University Press. 1935. p 403. 3. Engels WD. Wittkower ED: Allergic and skin disorders. in Freedman AM. Kaplan HI (eds): Comprehensice Texthook of Psychiatry. Baltimore. Williams and Wilkins. 1967. p 1095. 4. Kuno Y. Ikeuchi K: On perspiration from the palm of the hand
in man. J Orient Med 9:385. 1928. 5. List CF. Peet MM: Sweat secretion in man: I. Sweat responses in normal persons. Arch Neurol Ps}'chiat 39:1228-1237.1937. 6. McGregor IA: The sweating reactions of the forehead. J Ph}'siol 116:26-34. 1952. 7. Allen JA. Armstrong JE. Roddie IC: The regional distribution of emotional sweating in man. J Physio/235:749-759. 1973. 8. Abram WP. Allen JA. Roddie IC: The effect of pain on human sweating. J Physiol235:741-747. 1973. 9. Kennard D: The nervous regulation of the sweating apparatus of the human skin and emotive sweating in thermal sweating areas. J Ph}'siol 165:457-467. 1963. 10. Sulzberger MS. Herrman F: The Clinical Significance 0/ Disturbances in the Deliver}' of Sweat. Springfield. III. Charles C Thomas. 1954. pp 226-228. II. Comaish JS: Book Review. Brit J Derm 86:308-309. 1972. 12. Allen JA. Armstrong JE. Roddie IC: Sweat responses of a hyperhidrotic subject. Brit J Derm 90:277· 281. 1974. 13. Cloward RD: Hyperhidrosis. J Neuro.wrg 30:545-55 I. 1969. 14. Champion RH: Disorders of sweat glands. in Rook A. Wilkinson DS. Ebling FJG (eds): Textbook o/Dermatology. Oxford. Blackwell Scientific Publications. 1972. pp 15171519. 15. Bar LHJ. Kuypers BRM: Behaviour therapy in dermatological practice. Brit J Derm 88:591-598. 1973. 16. Dosuzkov T: Idrosophobia: a form of pregenital conversion. Ps}'choanal Quart 44:253-265. 1975. 17. Gillespie JA: Extent and permanence of denervation produced by lumbar sympathectomy; a quantitative investigation of its effects on sudomotor activity. Brit Med J 1:79. 1961. 18. Grant G: Essential hyperhidrosis. Med J Aust 2:390. 1971. 19. Kuypers BR M. COllon DWK: Conditioning of sweating: a preliminary report. Brit J Derm 87: 154-160. 1972. 20. Cotton DWK. Kuypers BRM: Treatment of hyperhidrosis by con· ditioning. Dermatologica 146:371372. 1973.
Letters Definition disputed To the editor: I must call attention to an error of definition in the August 1977 issue of Psychosomatics. In "Perspectives in biological psychiatry Part 2: Affective disorders," one reads on the first page: "Progress in psychopharmacology has brought to attention the important role of genetic factors in primary affective disorders, i.e., conditions in which changes in mood in the direction of either mania or depression (unipolar), or in the direction of both mania and depression (bipolar), are regarded as one of the most fundamental psychopathologic features (Leonhard, 1965)." The main statement is correct; however, the definition of a unipolar affective disorder is implied to be exclusive depressive episodes (which is correct) or exclusive manic episodes (which is an error). It is confusing that the term "unipolar" refers to depressions alone. It is perhaps even more confusing that the term "bipolar" may refer not only to alternating depression and mania but also to recurrent mania in the absence of depression. In the latter case, "bipolar" has always been a bit of a misnomer; nevertheless, that is the way it is defined: "Affective disorder is defined as bipolar when mania occurs, whether depressions occur or not. Unipolar affective disorder involves depressions alone (21, 41, 56),") I. Woodruff RA. Goodwin DW. Guze SB: Psychiatric Diagnosis. New York. Oxford University Press. 1974. p 3.
Stephen M. Cox, M.D. Lexington, Ky.
Dr. Ban replies To the editor: In Leonhard's classification, I affective psychoses are subdivided into "bipolar" and "unipolar" and unipolar affective psychoses into "pure melancholia and its subgroups" and "pure mania and its SUbgroups." The term "unipolar" was introduced by Perris 2 to replace the term "monopolar" used by Leonhard. Irrespective of this, I would agree with Angse that pure mania or recurrent mania should belong to the bipolar group because of its severe loading of familial factors. I would also agree with Angst that "unipolar mania" is just a theoretical concept that has never been properly substantiated. Nevertheless, the fact remains that in Leonhard's classification, "pure mania and its SUbgroups" refer to a subgroup of "monopolar" ("unipolar") affective psychoses. I. Leonhard K: Differenzierte Diagnostik der Endogenen Psychosen. Folia Psychiat Neurol Jap 19:89-98. 1965. 2. Perris C: The heuristic value of distinction between bipolar and unipolar affective disorders. in Angst J (ed): Classification and Prediction of OU/· come of Depression. New York. Schattauer. 1974. pp 75-84. 3. Angst J: Discussion of C Perris presentation. in Angst J (ed): Classifica· tion and Prediction of Outcome of Depression. New York. Schaltauer. 1974, p 85.
Thomas A. Ban, M.D. Nashville, Tenn.
Address all correspondence to:
The Editor in Chief Wilfred Dorfman, M.D. 1921 Newkirk Avenue Brooklyn, NY 11226