Patients With Erythrophobia (Fear of Blushing) Show Abnormal Autonomic Regulation in Mental Stress Conditions
Laederach-Hofmann, Kurt MD, FMH, APPM; Mussgay, Lutz PhD; Büchel, Bruno MD; Widler, Peter MD, FMH, and; Rüddel, Heinz MD, PhD
From the Psychosomatics and Psychosocial Medicine (K.L-H., B.B., P.W.), Psychiatric Out-Patient Department, University of Berne, Switzerland, and the Center for Psychobiological and Psychosomatic Research (L.M., H.R.), University of Trier, Psychosomatic Hospital St-Franziska-Stift, Bad Kreuznach, Germany.
Address reprint requests to: K. Laederach-Hofmann, University of Berne, Psychiatric Out-Patient Department, CH-3010 Berne-Inselspital, Switzerland. Email: firstname.lastname@example.org
Received for publication December 8, 2000; revision received April 30, 2001.
Objective: The objective of this study was to analyze the autonomic functions of patients with erythrophobia.
Methods: Forty patients with a diagnosis of erythrophobia (female/male ratio 18/22) without any other organic lesions and 20 healthy volunteers (female/male ratio 10/10) were assessed. Clinical evaluation was performed using a modified version of semistructured interviews. Autonomic testing was performed by means of spectral analysis of heart rate and continuous blood pressure by sparse discrete Fourier transformation at rest and under mental stress.
Results: There were no significant difference between the two samples in age, sex distribution, BMI, resting systolic, or diastolic blood pressure, nor was there a difference in autonomic baseline functioning between the 40 patients with erythrophobia and the control subjects. On the other hand, patients with erythrophobia consistently showed higher pulse rates (88 ± 20 vs. 78 ± 9 bpm, p < .05), higher total heart rate power values (8.40 ± 0.63 vs. 8.07 ± 1.02 p < .05), higher midfrequency spectral values (7.38 ± 0.66 vs. 7.02 ± 1.18, p < .01), higher high-frequency spectral values (6.89 ± 0.86 vs. 6.48 ± 1.44, p < .05), and lower baroreceptor sensitivity (8.62 ± 8.16 vs. 11.65 ± 4.42, p < .005) than the healthy subjects. ANOVA showed a significant group interaction (p < .0001) between the samples.
Conclusions: This study provides evidence for abnormal autonomic functioning in patients with erythrophobia when under mental stress.
BMI = body mass index;, DSM-IV =Diagnostic and Statistical Manual of Mental Diseases, fourth edition;, ICD-10= International Classification of Diseases, tenth edition;, LF/HF ratio = low frequency/high frequency ratio;, R-R interval = beat-to-beat interval in the electrocardiogram.
Erythrophobia (or facial blushing) is an interesting clinical and psychological phenomenon and is a psychosomatic disorder. It has been associated with embarrassment in both men and women when the symptom overrides normal ranges of socially accepted emotional expression. Especially in adulthood, fear of blushing seems to be quite common, whereas with growing age symptoms often disappear or lessen (1). Blushing can become a stubborn and incapacitating symptom that often severely restricts the patient’s social life.
Introduced as a separate diagnostic entity at the turn of the last century, today’s diagnostic manuals of psychiatric disorders only make a slight distinction between erythrophobia and phobia (2, 3). Depending on the particular case, possible DSM-IV categories for this syndrome might include social phobia, anxiety disorder due to a general medical condition, anxiety disorder not otherwise specified, or possibly agoraphobia without a history of panic disorder or specific phobia (other type). Based on the number and type of social situations feared, DSM-IV distinguishes between the generalized and nongeneralized (specific or distinct) subtype, which also overlap with the presence and absence of the Axis II diagnosis of avoidant personality disorder. Various research groups (4–7) have investigated the distinguishing features of these subtypes.
Although some authors consider erythrophobia or fear of blushing as a subtype of social phobia (8), Ogawa and Bouderlique (9) offer a psychodynamic approach. They subclassify an “anthropophobia” disorder, including autodysmorphophobia (fear of subjectively abnormal shape of body parts, eg, overly large nose), scopophobia (fear of showing parts of body, eg, arms or feet), erythrophobia (fear of blushing when in contact with others), and olfactory reference syndrome (a syndrome including the pathological fear of dispersing abnormal odors). Stein et al. (10) suggested classifying the olfactory reference syndrome as an obsessive-compulsive disorder. It remains unclear whether erythrophobia might also be a form of an obsessive-compulsive disorder as Pohlen postulated some yeas ago (11).
Many of the patients suffering from erythrophobia report having undergone an odyssey of therapies, measures, and interventions, including behavioral and medical treatment, in an effort to conquer the disease which itself may end in social avoidance behavior and isolation (12–14). Some of the patients suffer from concurrent cardiovascular symptoms such as palpitations, sweating, or headache, all of which may lead to the suspicion of concomitant autonomic arousal. Some findings suggest that chronic blushing can have major psychiatric sequelae such as depression, social anxiety disorder, or social phobia (15–19).
Despite a reasonable body of literature in classification issues, surprisingly, literature is scarce concerning relevant clinical and pathophysiological investigations. Similarly, epidemiological studies using newer classification systems and respective prevalence data are lacking today. So we have to rely on existing data which, however, might not entirely suffice for precise criteria used nowadays (1). Most of the research conducted to date is based on a psychoanalytical approach (8, 9, 20–22). In one study the Rorschach test was administered to erythrophobic subjects (23). A thorough search of medical literature only revealed case reports on erythrophobia (24–26) or reports on the following intervention strategies: behavioral therapy (27–31), pharmacological intervention (32, 33), or different surgical approaches mainly consisting of endoscopic thoracic sympathectomy (34–38).
In addition, blushing must be distinguished from flushing (39, 40). Drummond and Lance (41) observed that stimulating gustatory impulses has an effect on the autonomic nervous system in patients with unilateral lesions of the sympathetic nerves (as a result of a variety of disorders). Interestingly, the denervated side showed flushing, inasmuch as the intact facial part showed both sweating and flushing. Obviously, the cervical sympathetic outflow is involved in thermoregulatory and emotionally elicited facial sweating, flushing, and blushing—which results in the pathophysiological explanation for the success of surgical interventions. This hypothesis was developed based on studies conducted by Mellander et al. (42) and Buck and Park (43). The former research group stimulated the respective regions by transmural nerve stimulation and norepinephrine. They concluded that beta-adrenergic neuroeffector mechanisms of the facial veins might be involved in emotional blushing. The latter investigators found parallels to fight-flight reactions. The investigations of local mechanisms enabled medicine to treat these patients with beta-blocking agents (eg, (44) and Discussion section).
However, the question as to whether and to what extent autonomic dysfunction of the cardiovascular system might be involved in erythrophobia or social phobia has not been clarified to date. Although autonomic dysfunction has been studied in a variety of diseases (eg, coronary heart disease (45, 46), diabetes mellitus (47), as well as in psychiatric disorders such as panic disorder (12, 14, 48), somatization disorder (49, 50), and anxiety or antisocial behavior (51)) it has hitherto merely been the subject of speculation in erythrophobia (52). Panic disorder has been revealed as one of the psychiatric disorders with important psychosomatic health risks (48, 53, 54) similar to depression (55) or somatic diseases as diabetes mellitus (47). The pathophysiology of these disorders involved in early death seems to involve autonomic nervous system dysregulation (56). There is, however, a paucity of empirical data about patients with erythrophobia despite the fact that dysfunction of the autonomic nervous system could have similar sequelae as in panic or anxiety disorders. Hofmann et al. (5) showed psychophysiological differences between social phobia subtypes during a social stress task. They compared three groups of patients: 23 patients with social phobia; 9 patients who were not afflicted with avoidant personality disorder, and 14 who were, and compared them with 22 normal subjects who were assigned the task of giving a talk in public. Differences in heart rates were discernible between the three groups. The patients with social phobia without avoidant personality disorder had the highest rates. Inasmuch as no significant differences were noted in baseline values, there were significant differences between the groups’ heart rates when preparing and giving the talk (task by group). Our study seeks to clarify whether patients suffering from erythrophobia display abnormalities in autonomic functioning. In addition, differences in reactivity in response to a mental stress condition are included to complete the picture.
PATIENTS AND METHODS
All patients participated in the study because of intractable and persistent symptoms of erythrophobia. Patients suffered from erythrophobia for a period of 4 to 22 years (mean, 11 years) and reported having tried two to seven different therapeutic approaches without any durable success. Because there is no sufficient description of this disorder or a definition in either of the two psychiatric classification systems [DSM-IV (3) and ICD-10 (2)], we included patients with the following symptoms:
* blushing of face or/and neck in any situation alone or in company (with or without subjective perception of distress), and
* distress when even thinking about the individual key situations, and
* consequently alteration in social contacts (number, time spent) due to facial reddening or
* increasing avoidance of situations eliciting the respective reaction (so called “phobic development”) or
* problems in social, personal, or vocational performance due to blushing or
* feelings of shame, guilt, or no such feelings associated with blushing.
* These items were assessed using a semistructured interview (57, 58). In addition, the above mentioned items correspond to the most important psychometric instruments designed by Leary and Meadows (59) for assessing patients with erythrophobia. All interviews were conducted by a physician who was familiar neither with the testing procedures used nor with the objectives of this study. The videotaped interviews were used to evaluate the patients’ psychological status. Four patients had signs of a developing social phobia and eight reported social contacts as the main reason for blushing. In addition, the following items were also assessed: symptoms or signs of the disease, extent of symptom (face, head, and neck), concomitant sweating etc., as well as previous treatment strategies used, former diseases or illnesses, medication, personal medical history, use of alcohol, or smoking (Table 1).
* Forty patients with erythrophobia were selected out of a sample of 62 patients. Twenty-two were excluded because of age (<18 years), presence of full-blown phobic symptoms, anxiety or obsessive-compulsive traits, medication with beta-blocking agents or tranquilizers, or major social or vocational problems associated with blushing. Furthermore, most of the participants reported having tried out numerous medical treatments including behavioral therapy. No patient had undergone surgery (thoracic sympathectomy) before testing. The 40 patients were compared with 20 age- and sex-controlled healthy subjects. Control subjects were either staff members at the hospital or members of the investigators’ families. They were healthy, normotensive subjects who were not on any medication.
* Exclusion criteria for both groups included the presence of any organic disease (besides erythrophobia for the patient group), hypertension (following the new WHO criteria (60)), peripheral or autonomic neuropathy (diagnosed clinically and neurologically), coronary heart disease, and any other psychiatric disorders. None of these control subjects suffered from erythrophobia or had a history of blushing. Nobody in either group was a heavy smoker (more than one pack of cigarettes per day) or alcohol drinker (more than 40 g of alcohol per day). If they smoked or drank alcohol moderately, they had to have discontinued doing so at least 1 day before the onset of testing.
Testing took place in the psychophysiological laboratory of the Unit for Psychosomatic and Psychosocial Medicine, Department of Endocrinology and Diabetology, University of Berne, Switzerland. All participants were informed about the nature of the recording, the tasks, and the different test phases. Subjects remained comfortably seated in a reclining chair throughout the whole session and were instructed about the testing procedures. After application and adjustment of measuring devices there was a 20-minute equilibration phase (61) and, thereafter, baseline values were recorded for a 5-minute period. The Stroop Color-Word Test was used as a mental stress test (62) because it is an effective means of decreasing interbeat intervals and increasing systolic blood pressure, plasma norepinephrine, and epinephrine concentration (63). It is, therefore, a valid mental stress test that can elicit the specific reaction pattern suggested to be of importance in patients with erythrophobia (42). Response time and error rate served as measures of performance level. In addition, all patients and control subjects were pressured to give faster and more accurate answers.
An electrocardiogram was recorded using self-adhesive electrodes attached to the right and left side of the chest just below the collar bone and below the rib cage on the left side of the body. For determination of R-peak time (2 ms accuracy), Einthoven lead II was used. Tonometric blood pressure was assessed continuously by a Colin device (Colin Inc., Takeda, Japan) with a reference pressure cuff attached to the ipsilateral arm. The tonometric device was placed on the radial artery of the left forearm that was placed on an armrest. To measure breathing activity, a strain gauge (ZAK Inc, Simbach/Inn, Germany) was positioned around the chest at the level of the xyphoid process.
Spectral analysis of heart rate variability was performed with the CARSPAN program (64). Data acquisition was done with a sampling frequency of 512 Hz. The program uses a sparse discrete Fourier transformation of the succession of cardiac events. To account for the interdependency of power values with the respective heart rate, ie, due to varying sex or age, raw values of power spectral density were divided by the mean heart rate of the respective experimental phase (64). Frequency bands were defined as follows: A low-frequency component encompassed the range of 0.02 to 0.06 Hz. The midfrequency ranged from 0.07 to 0.14 Hz. In other studies, this frequency band is often defined as low-frequency band (61, 65, 66). The high-frequency band covered fast fluctuations in the range of 0.15 to 0.40 Hz. Total power represents fluctuations of the whole spectrum from 0.02 to 0.40 Hz. For later analysis midfrequency and high-frequency bands were considered relevant. The midfrequency band reflects a mixture of sympathetic and parasympathetic tone, whereas the high-frequency band is mainly influenced by parasympathetic activity (66, 67). Correspondingly, continuous blood pressure was subjected to spectral analysis. Also, to assess the ratio between parasympathetic and sympathetic activity, the LF/HF ratio was calculated. The ratio LF/HF gives an impression of the sympathovagal balance. This ratio has been derived from reflex maneuvers of the baroreceptor function by phenylephrine or nitroglycerin test or by application of negative or positive pressure around the neck or at the lower limbs or by tilting (68). It has proved to be useful in assessing regulatory reserve and balance (67). For the respective frequency ranges, the modulus was determined on the basis of coherence values between systolic finger blood pressure amplitude and heart rate variation above 0.50. Mulder (64) was able to show that the modulus within the midfrequency band expresses the momentary increase in baroreflex sensitivity (69, 70). Several groups have confirmed the validity of noninvasively assessed baroreflex sensitivity compared with more traditional tests (67, 71) such as the phenylephrine method (69). In our sample, women were investigated for autonomic functions only in the second half of their menstrual cycle (61). Patients were informed about their test results and therapy options in a follow-up consultation after completion of test evaluation.
Data Transformation and Statistical Analysis
Values were calculated for the resting and mental stress phase, respectively. Statistical analyses were performed with a PC-based SAS, and StatView package (SAS Company, Los Angeles, CA). Autonomic functions were used as raw-values of the frequency transformation (sparse discrete Fourier transformation) (CARSPAN, University of Groningen, NL) and transformed by the natural logarithm (ln)—these were used in all additional analyses. Statistical significance was set at 0.05. Descriptive statistics as well as Student’s t tests and χ2 tests were performed. For group comparisons, ANOVA was used.
There were no differences between patients and control subjects in age [32 ± 9 years (mean ± SD) for patients, and 34 ± 7 for control subjects (p = NS)], sex distribution [female/male quotient 18/22 for patients, and 10/10 for healthy subjects (p = NS)], body mass index (BMI) [22.0 ± 2.6 kg/m2 for patients, and 24.0 ± 2.9 kg/m2 for control subjects (p = NS)], alcohol intake, and smoking.
In resting conditions, systolic blood pressure did not significantly differ between groups. However, significantly shorter interbeat intervals were found in patients than in controls (p < .05) denoting a higher heart rate. No other hemodynamic or spectral differences were found between patients with erythrophobia and normal control subjects in resting conditions. However, in mental stress conditions patients with erythrophobia showed significantly shorter interbeat intervals (p < .005), and, consequently a higher heart rate (p < .05). Breathing patterns and respiration rates were not significantly different in either resting conditions or mental stress tasks between patients and normal control subjects.
ANOVA revealed that the transformed spectral values of patients with erythrophobia and control subjects in resting conditions were not significantly different. For mental stress conditions patients and normal control subjects showed different values in total power heart rate spectra (p < .05), midfrequency band (p < .005), and high-frequency band (p < .05). Baroreflex sensitivity did not, however, reach the significance level (p = .19) neither in resting nor in mental stress conditions, although a tendency to lower values was obvious in patients with erythrophobia. The quotients of low frequency to high-frequency values, reflecting the sympathetic/parasympathetic balance were 1.15 for patients with erythrophobia, and 0.94 for normal subjects (p = NS) in resting conditions, and 1.95 vs. 2.21 (p = NS) for patients and control subjects, respectively, in mental stress conditions. Interbeat intervals as a measure of acceleration of heart frequency revealed similar changes from resting to mental stress testing in patients as in healthy subjects(Table 2 and Figure 1).
The analysis of performance data revealed comparable complete response times of 1.21 ± 0.07 sec for patients and 1.19 ± 0.05 sec for the control sample (p = .82). At the same time, no differences between women and men were found and no significant difference in variance testing was discernible despite a visibly broader variance in men than in women, especially in the group of patients (Figure 2). In addition, the number of correct answers (correct answers per second) was similar in the patient (0.83 ± 0.03) and the healthy group of subjects (0.89 ± 0.03), p = .43. For all the above mentioned results, significant gender differences were not discernible.
By using ANOVA for repeated measures with experimental groups as between conditions (resting, mental stress) and frequency bands as within factors, heart rate spectral values in mental stress conditions showed a significant interaction in total, midfrequency, and high-frequency bands (all p < .001) in that patients with erythrophobia revealed a less marked reduction in heart rate variability than control subjects (Figure 3).
In conclusion, patients with erythrophobia do not seem to be able to reduce sympathetic and parasympathetic tone to comparable values as normal subjects do or up-regulate it as an effect of a more pronounced counterregulation in mental stress conditions. This finding is in line with the hypotheses of Mellander et al. (42).
Conducting autonomic tests with patients suffering from long-standing erythrophobia [mean 11 years (range 4–22)] revealed interesting insights into autonomic regulation in these patients in comparison with healthy subjects. The two samples did not show any differences in age, sex, BMI, or systolic blood pressure. In resting conditions, patients with erythrophobia showed no significant differences in heart rate spectra compared with the normal control subjects. During mental stress testing patients with erythrophobia showed significantly higher power values of total, midfrequency, and high frequency spectra of heart rate compared with control subjects indicating a significantly higher sympathetic and parasympathetic tone in patients compared with normals. However, baroreflex sensitivity was not different to normal control subjects. All the values of the patients were still within normal ranges as described by the Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology (67).
One important finding of our study with patients suffering from erythrophobia is that these patients seem to have alterations of the heart rate variability profile compared with normal control subjects. All of the patients had a significantly higher heart rate together with higher power spectral activity during mental stress than the healthy control subjects. This is consistently true for total, midfrequency, and high-frequency spectra. Higher heart rate should be associated with lower heart rate variability, visible in lower power spectral activity (66, 67, 72). This is, however, exactly the opposite in patients with erythrophobia. These patients have higher spectral activities during mental stress than normal control subjects despite a similar shortening of interbeat intervals. Patients with erythrophobia might presumably have higher parasympathetic influences (represented in higher high-frequency values) to heart rate variation than do normal volunteers (73) together with higher sympathetic activity. This is, however, only true of mental stress conditions, whereas no difference is visible between patients with erythrophobia and healthy control subjects in resting conditions. Possible mechanisms for this phenomenon may lie in altered sinus node susceptibility or a different breathing pattern of patients compared with normal control subjects. The latter can be excluded by the analysis of breathing frequency that did not reveal any significant differences despite slightly lower values in patients.
However, patients with erythrophobia are not characterized by altered baroreflex sensitivity as has been described in a proportion of somatization or panic disorder (13, 48, 50). The comparison of these findings with patients suffering from blood phobia displayed an opposite pattern. In a population of patients with mitral valve prolapse, Kochiadakis et al. found a significant deviation in autonomic nervous system tone with predominance of the sympathetic division. This predominance was more marked in symptomatic patients. In a similar setting, Hofmann et al. (5) found differences in heart rate analyses in various subgroups of patients suffering from panic disease. Another group (51) investigated spectral differences in male adolescents with anxiety or antisocial behavior and discerned a disruption of parasympathetic coherence to heart rate changes in patients with antisocial and sociophobic behavior. Parasympathetic and sympathetic activity (reflected by the midfrequency band) in patients with erythrophobia is higher than in the control group under mental stress conditions. This suggests more active parasympathetic counterregulation in patients with erythrophobia than in normal control subjects—a fact which was speculated about by Mellander et al. (42) nearly 20 years ago. Thus, our findings discerned a marked difference in the reaction pattern to mental stress; patients with erythrophobia show altered autonomic regulation as opposed to normal control subjects.
Being the first study of autonomic functioning in patients with erythrophobia compared with normal control subjects, several limitations have to be discussed. First of all, the patients investigated may represent a sub-sample of patients with a severe form of this disorder because they had a persistent history of erythrophobia and had been referred to a specialized medical unit at a University Hospital Center. In addition, the healthy volunteers recruited were either hospital staff members or related to the investigators. This might have created a certain bias in that staff members (who made up about one third of the healthy volunteers) might have been more familiar with the investigating procedure than the participating patients were. However, the same argumentation need not apply to the participating subjects who were related to the investigators because the latter were as unfamiliar with testing procedures in a clinical setting as the patients. We looked for possible differences in resting values and mental stress values of autonomic function but could not find any significant ones.
Different breathing patterns must be taken into account in possibly producing some of the differences (presumably in high-frequency bands). In our study, the values of breathing frequencies were, however, not significantly different between patients with blushing and normal control subjects.
Clinical Implications and Concluding Remarks
Erythrophobia is a frequent symptom in adolescents, which diminishes over time. Only few of the patients suffering from this disorder may seek help because they often consider it as a stigma and are often told by their family physicians that there is no cure for it. In addition, erythrophobia is generally treated as a medical banality and no serious efforts are made to treat it. Many of our patients, most of whom have suffered for years, reported a history of multiple treatment failures. Based on this first study of the autonomic nervous system in patients suffering from erythrophobia, we demonstrated the presence of an abnormal autonomic reaction to mental stress. Nevertheless, the question as to whether these findings are an epiphenomenon or rather a cause of blushing has yet to be answered. Therapy might, therefore, focus either on improving coping strategies or reversing this disease by means of medical or surgical measures.
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Autonomic testing,; fear of blushing (erythrophobia),; baroreflex sensitivity,; spectral analysis,; blood pressure,; semistructured interviews.
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