cognitive behaviour therapy –a therapy for atopic …332116/fulltext01.pdf · cognitive behaviour...

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



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



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



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.



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



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.



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.



Page 6

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.



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)



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:



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.



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



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 )



Page 12

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.



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



Page 14

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



Page 15

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)


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.



Page 16

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.)



Page 17

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)



Page 18

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:



Page 19

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



Page 20

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.



Page 21

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


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



Page 22

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.


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.



Page 23

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



Page 24

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



Page 25

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



Page 26

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.



Page 27

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



Page 28

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



Page 29

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)



Page 30

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



Page 31

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

cognitive behaviour therapy –a therapy for atopic …332116/fulltext01.pdf · cognitive behaviour...

Documents