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What is Chronic Blushing?

For most of us, blushing when we’re embarrassed or anxious is a common occurrence.  But for those who suffer from a stronger type of blushing, or blush more easily, also known as pathological blushing, this abnormal facial reddening can become physically and psychologically tormenting.

Blushing is abnormal if it occurs as a response to minor psychological signs or for no apparent reason, if it causes the person to suffer, and if it interferes with his or her usual level of performance and/or social interactions.

Turning red in certain situations is not only appropriate, but expected.  This is normal blushing.

Blushing is generally trivialized and nearly always assumed to be a normal experience when, in fact, that experience can actually become a symptom. 

People who suffer from Pathological Blushing seek help not because of normal, occasional facial reddening, which we know is a natural part of life, but because they blush excessively and at socially inappropriate times.  They turn bright red when they least expect it:  when running into an acquaintance on the street, talking on the telephone, or even in front of family members.  Blushing is better tolerated when it seems socially appropriate, such as when people receive public recognition or have Happy Birthday sung to them.  It is turning red for no apparent reason that causes such distress.  Blushers may fear that others believe they are hiding a misdeed (e.g., blushing when they are teased about something they have ostensibly done in private), or they may worry about seeming to lose their composure in non threatening situations, thus being considered shy, awkward, or, in today’s jargon, a loser.

-Text above is directly from When Blushing Hurts by Dr. Enrique Jadresic

For Those Who Don't Understand Chronic Blushing 'continued'

In order to understand better, contemplate this:

Think of all the cues that normal blushing in someone sends to their audience, of one or many, when embarassment is clearly not the cause: "They must be..."

- Shy
- Nervous
- Lacking confidence
- Lying
- Hiding something
- etc.

Next think of yourself going through an entire day sending the wrong message dozens of times in every conceiveable situation. Would you feel frustrated, maybe defeated, exhausted and possibly even suicidal? To be misunderstood at such a basic human level may be hard for people to grasp.

It is possible many have overcome the effects of this condition but everyone who has it has had entirely different experiences. Many have been shown grace while others have been tormented or just mildly teased. We have to be careful not to group everyone with this condition as experiencing the same level of severity (Frequency of episodes, age in which the condition manifested itself). While there can be different triggers for each individual experiencing this condition, there are similar triggers that almost all experience. Emotions such as anger, surprise, laughter, frustration are ones that almost always trigger a blush due to the heightened sympathetic nervous system. However, it is as unique to every individual who is dealing with the condition.

Most of the stories shared have said their life has not reached the potential it could have. Nearly all who suffer with this condition expressed similar feelings: shame, lack of happiness, monetary impact, and general fulfillment in life.

A good take away would be to extend grace and to not draw conclusions about people with frequent blushing episodes. Be compassionate by all means and if you are in a position to impact whether someone promotes within your organization, remember that their blushing may not represent their inward emotions. Things are not always as they appear.

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The development and impact of this condition as we understand it, from the stories shared by others:

Typically, at around puberty, but sometimes later, the symptoms of an overactive sympathetic nervous system begin to become apparent.  However, the sufferer is not aware until someone else points it out to them.  “Why are you so red?”, “Look at how red your face is.” Or “Look at _____, she is embarrassed”.  Of course, the sufferer is very confused as they have no idea why this has happened as they are not embarrassed.

The episodes continue to happen as the physiological aspects of the overactive sympathetic nervous system continue to be triggered by a range of emotions; laughter, anger, surprise etc. (emotions that do not illicit a blush in most people).  Additionally, extreme physical activity, significant change in temperature such as coming in from the cold, or alcohol and spicy foods can also cause blushing.

Because of the response from others; teasing, simply pointing it out innocently, and in some cases purposely embarrassing the sufferer in front of others can lead to anxiety. Now the sufferer is likely to blush more as there is a psychological element that is beginning to develop.  The frequency of events throughout the day increases. This is why nearly all sufferer’s state they wish people would stop pointing it out.

Most will never speak of their condition to anyone, including loved ones and doctors as they are ashamed.  They think that they are the only one dealing with this and do not know that there is a physiological element to their condition.  This results in their confusion and inability to understand why they are dealing with this. By this time, erythrophobia (fear of blushing) has likely developed followed by Social Anxiety Disorder (SAD) making it more difficult for the chronic blushing sufferer to treat.  Often withdrawal from friends, family and social situations begins and accelerates.  
Some may resort to the internet to find answers, but answers are hard to find as each site does not comprehensively cover the subject.  People may then bring it up to a doctor, but that doctor may diagnose it as only an anxiety condition or misdiagnose it entirely.  Ultimately this can become discouraging and many give up hope or resign themselves to living with this condition while changing their behaviors in order to cope.

The goal for any chronic/pathological blusher should be to seek treatment before the condition becomes life-consuming.  It appears that the longer a person goes without understanding and treating the condition, the more difficult it can be to treat the condition due to the psychological impacts.  We have heard from people who state that their blushing improved with age.  This leads one to believe that acceptance and ones perceptions of life and its battles may help reduce the anxiety reaction that this condition causes.

Conditions Linked to an Overactive Sympathetic Nervous System

Raynaud's disease is a rare disorder of the blood vessels, usually in the fingers and toes. People with this disorder have attacks that cause the blood vessels to narrow. When this happens, blood can't get to the surface of the skin and the affected areas turn white and blue. When the blood flow returns, the skin turns red and throbs or tingles. In severe cases, loss of blood flow can cause sores or tissue death. Cold weather and stress can trigger attacks. Often the cause of Raynaud's is not known. People in colder climates are more likely to develop Raynaud's than people in warmer areas.

Hyperhidrosis is a hereditary condition caused by an overactive sympathetic nervous system affecting an estimated 7.8 million Americans. Symptoms include excessive sweating of the hands, armpits, face, head or feet. It is associated with Raynaud's Disease (cold hands that often change colors because of hypersensitivity to temperature change) and facial blushing.

Chronic Blushing and Shame

Shame is a common feeling shared by chronic blushing sufferers. This was the most difficult for us to understand as we began compiling information from sufferers. It wasn’t until we read that victims of crime often feel shame due to feeling that they should have been able to control or prevent the crime perpetrated upon them. Now we could understand, as most chronic blushing sufferers think they are the only one dealing with this condition and that they should be able to control it. Unfortunately, the physiological aspect of having an overactive sympathetic nervous system cannot just be controlled.

No chronic blusher should feel shame due to their condition. It is the genetic card you were given, not something you have control over. You did not create this condition. Do not allow others to make you feel ashamed and do not impose shame upon yourself. Do not allow the ignorance of others to harm you. Shame can quickly destroy the human spirit. This is extremely important. To treat this condition you must recognize that it is nothing you are doing or have control over. All you can control is how you treat the condition and how you manage it.

Q & A with Dr. Jadresic

These questions were asked in no particular order, for more information please read When Blushing Hurts, available at Amazon or Barnes & Noble.

1) How prevalent is chronic or pathological blushing?

No studies aiming at finding the prevalence of pathological blushing (PB) have been carried out. No estimates are available. Therefore, the precise frequency of PB remains unknown. However, indirect estimations suggest that between 5 and 7% of the general population suffers from this disorder.

2) At what age is it typically diagnosed?

Blushing necessitates the prior development of a social self, it emerges at about the same time as a sense of public self. It is, no doubt, more common in the young. An interesting study of 100 chronic blushers revealed that they first recalled blushing at an average of 12.6, that is, near puberty. This coincides with our clinical experience. Now, those who develop pathological blushing do so some time later in life, but they are also young, many times in their twenties.

Most cases are not diagnosed because persons with pathological blushing do not usually seek help, mainly because of ignorance or embarassment. Those who do seek help are typically diagnosed in their 20’s or 30’s. But I’ve seen patients seeking help for their pathological blushing in their 70´s.

3) Can it come on suddenly?

Yes, but it does so infrequently. What clinicians usually see is that in some persons blushing turns pathological after repeated embarrassing experiences and this takes some time to develop. These experiences are, of course, heightened by the awareness that blushing is uncontrollable but also by knowing that consciousness of blushing can induce or intensify it.

4) Is it actually a problem of the blushing or, rather, the fear of blushing?

In the past, several researchers had suggested that people who complain about blushing have a distorted view concerning their blush but do not show actual physiological blushing problems. In other words, the view was that the main problem was in the blusher’s mind, in the way the blusher thought about the blush. The belief was that fear of blushing was the essence of the condition.

recent research has shown that patients who complain about blushing blush more and/or have a heightened general arousability in social situations than those who do not complain about blushing. And this is detected by independent raters. Thus, the need to differentiate normal from pathological blushing becomes evident, something that the medical community has not yet acknowledged. Clearly, we do not all blush the same, to the same extent and severity. Next, it should be borne in mind that when blushing becomes pathological, that is, more severe or frequent, fear of blushing is found almost invariably (this fear is called erythrophobia). In addition, it is known that a substantial proportion (90% in our study, 60% in another study) of people seeking treatment for blushing meet diagnostic criteria for social anxiety disorder (SAD).

5) Is this a physical problem, a psychological problem, or both?

There is still controversy around this issue. Some authors still believe that the main problem of those who complain about their blush is that by nature they are more inclined to focus on their thoughts and bodily reactions, or that they are overly concerned about blushing itself and the possibility of it. Hence, the main problem would be a psychological one. The primary alteration being at the level of thoughts. Others authors argue that PB is primarily a biological problem, related to the autonomic nervous system, with repeated, more frequent, intense, and embarrassing blushing experiences coming first and psychological suffering and limitations to engage in social life following as a consequence.

My view is closer to the second hypothesis. This does not mean that I disregard psychological aspects. On the contrary, underneath a primarily biological phenomena one always finds a person with its own singularity, attributes, peculiarities and vulnerabilities which favour, or protect against, the disorder; and also are crucial in determining the meaning the patient gives to the ailment.

6) As a former sufferer, can you describe how this can interfere with daily life?

PB is a psychologically very consuming condition, it’s exhausting. Since it’s visible and uncontrollable and frequent, you are always on the alert. You dread blushing or the possibility of it happening. Of course anybody can blush if he/she is embarrassed but pathological blushers on many occassions blush for reasons that have nothing to do with embarrassment: seeing someone you know, running into someone you know unexpectedly, when called on in class. Blushers may become red even when they are in a group of people they are comfortable with, when they are alone speaking on the phone.

I remember blushing whenever I unexpectedly met patients or students (I am a university professor). It was not because of embarrassment but the immediate facial reddening made me feel very embarrassed in front of my patients or students. I recall a lady resident of psychiatry once saying to me: “there you go up the cherry tree again, Doctor”. Some may even blush because the attention is being focused on whoever is beside them. I call that a “solidarity-type” of blushing. I remember a woman patient who was in a supermarket with her husband and ran into an ordinary male fellow from work who she barely knew. Inmediately she turned red. Well, this triggered a very complicated, but unnecesary, marriage conflict because her husband thought she had had an affair with that man.

Pathological blushers want to engage in social situations but they dread becoming red and they start avoiding situations in which they might blush. This affects their chances of meeting opposite sex potential partners, they may avoid marriage or simply any social encounters. I recall a patient who did not want to have chidren because, knowing that the proneness to blush aggregates in families, she did not want her chidren to bear the suffering she had to live with. I have treated patients who, during college, avoided giving talks in front of others because of fear of blushing. I remember one who never gave a dissertation in university. Since he was good at written exams, he assumed in advance that he would get the lowest califications when required to dissertate. With his good qualifications in written exams he managed to compensate and get his professional degree.

In terms of work perspectives, blushers have disadvantages because they avoid visibility, promotions or activities where they are exposed. I could give many testimonies of patients whose job opportunities and annual income were less than their potential would suggest, limiting ther families’ economic growth and well-being. Loneliness is often a companion to blushers. PB is a condition you don´t share with anyone, not even with your loved ones. Many of my patients tell me I am the first human being they have shared their ailment with. I think having wrote the book about my own experience, and those of some of my patients, with blushing has encouraged others to seek help or at least share their disorder with others.

Depressive symptoms and depression and are common in patients with PB. More research needs to be done in this area. Not to mention the fact that blushers try many camouflage techniques in an attempt to hide their propensity to blush. These include using make-up, growing a beard or sunbathing for hours in order to change the colour of the skin so one is able to hide the blush. Some of my patients have told me that they used to sunbathe avoiding sunprotectors (“if I am already red I won’t become red in front of others”), increasing the risk of skin cancer.

7) I understand that it’s a problem with the sympathetic nervous system, correct?

Yes, that´s correct. Several lines of evidence clearly suggest that pathological blushers have a more sensitive autonomic nervous system (ANS) than non-pathological blushers. As previously stated, they blush more, and have a heightened general arousability (as indicated, for example, by higher heart rates), in social situations. This is consistent with the notion that blushing is mainly caused by cervical sympathetic outflow. In addition, pharmacological inhibition of the ANS, by adrenergic blocking agents, such as propanolol, has an effect in terms of reducing blushing. In turn, preliminary findings suggest that hypersensitivity to niacin may differentiate pathological blushers from non-pathological blushers. Besides, other recent studies indicate that genetic factors are important. Thus, studies of the serotonin transporter (5-HTT) genetic variants indicate that carriers of the S allele have higher blushing propensity. Not to mention that the efficacy of certain types of of drug, called SSRIs (selective serotonin reuptake inhibitors), in decreasing blushing strengthens the hypothesis that a serotonergic dysfunction may be responsible for psychophysiological arousal, including blushing.

8) Are most sufferers diagnosed correctly?

Strictly speaking, we don´t know because no studies aimed at this have been conducted. But, of course, the clinical evidence of the few physicians who devote themselves to assisting blushers show that most pathological blushing patients are not diagnosed at all. For many blushers, the condition can be so embarrassing that they avoid a discussion of their problem with a health care profesional. In turn, some blushers have told me that they have had the wish to buy my book “When blushing hurts” (iUniverse, 2008) but they have lacked the courage, due to embarrasment, to ask for it in bookshops. In this sense, the Internet as an information resource has grown dramatically over the years and has provided patients a valid, although not always reliable, alternative. Obviously, a considerable number of blushers are diagnosed as having a SAD and that’s OK (SAD includes blushing as one of its symptoms), as long as the health professional concedes due importance to the blushing experience. A change is necessary in medicine. Physicians ought to conceptualize blushing as a phenomena which is not necessarily a normal experience as it is nearly always assumed to be the case. Blushing can become a symptom, thus in some cases it turns into a pathology and treatment should be considered if that’s the wish of the patient.

9) It sounds as though you believe ETS is the solution to the problem. From my understanding, the surgery clips a nerve in the chest connected with blushing or with excessive sweating. Is that correct?

I don’t believe in the solution, not at all. I believe in scientific thinking, I follow the rationale of science and I like to help patients who, in a way, have been left aside by medicine, the reason being that patients were (and still are) too embarassed to seek help. First I wrote the book because I felt there was a need to put the blushing issue in the public agenda (though the book is also aimed at informing health professionals). Next, I have published the results of a study that took us several years to conduct because I wanted to draw the attention of doctors to treatment options for these patients. I believe psychological treatments should always be offered to the patient. For example, exposure, cognitive therapy, social skills training, applied relaxation, and task concentration training. Likewise, pharmacological treatment should be considered. As I state in my book, health professionals should ensure that surgery is used only as a last resort. Now, caution and prudence should not be understood as witholding treatment if clinical evidence suggests that benefits due to ETS outweigh the risks. Provided nonsurgical methods fail and there is still an indication for treatment, ETS may effectively treat facial blushing. I am not a surgeon but, to put it simple, the operation, called endoscopic thoracic sympathectomy (ETS), involves cutting or clamping part of the sympathetic nerve, the nerve that causes sweating and blushing when stimulated. It runs from the belly button to the neck, but the easiest way to reach it is by making incisions beneath the armpit.

10) Is it a risky surgery? What negative consequences can it have?

Again, I am not a surgeon but what I know is that complications are rare but have been reported. So, Horner’s síndrome is seen in less than 1% of patients undergoing ETS; pneumothorax or pleural drainage 2%; intercostal neuritis (which I personally experienced), 1 to 6%; sympathethic reinervation with reappearance of symptoms up to one year after the operation 2%; and gustatory sweating when eating certain foods 1 to 8%. Compensatory sweating (CS) is the most commonly reported side effect. The ANS is needed for the body to regulate its temperature through sweating. If you are unable to sweat from the face (which happens after ETS), the rest of the body has to compensate, leading to excessive sweating elsewhere. Well, CS is seen in almost all patients treated for PB with ETS (99% in our study). Even though this figure seems high, it should be mentioned that the majority of patients (89% in our study) say that they are satisfied with their final result and would recommend it to others.

11) How expensive is the surgery?

In Chile the overall cost is about US $ 7000 (In Santiago, where I live, the cost ranges from 4,000 to 10,000 US$). However, health insurance covers the costs and the patient has to pay about 1000 US $. In Colombia ETS is cheaper. In the United States the operation costs are much higher.

12) Brandon took drugs for his condition, but it sounded like he really didn’t like the effects. Your study found that surgery was more effective than sertraline-treated patients. Is it your view that patients who are profoundly affected should proceed directly to surgery?

My view is that at least pharmacological treatment should be tried for two to three monts, regardless of the severity of PB, before attempting surgery.

13) What, if anything, can be done to help young adults like Brandon, who suffer so much from this condition?

There is a lot to be done for patients suffering from disabling blushing. To start with, there is a need to create awareness of this condition and to provide easy access to all available information on the topic. Doctors, psychologists, and health professionals on one hand, and specialized journalists on the other, have a responsibility in this sense. In particular, there is a need to differentiate normal from PB. Next, the availability of a wide range of treatment options for PB should be emphasized. We envision an ideal situation where patients seeking help for their blushing are assisted before they go on to develop a severe SAD. So far, little has been said about psychological treatments. But I envision a situation where psychological treatments are extensively researched and those treatment modalities that turn out to be effective are made available to the public. There is some available information on this subject but we know little about it. Pharmacological treatments should also be better investigated. There is information on the treatment of SAD but there is an almost complete lack of studies on the drug treatment of PB. Likewise comparative studies of available treatments should be carried out. My study is a pioneering one since up to the present there are no other studies comparing different treatment modalities. Timely treatment of depression associated to PB , as well as timely treatment of PB, will diminish the risk of other young attempting suicide.

14) Is there anything that lay people can do when they encounter someone who is blushing to make it better and to ease the person’s anxiety?

Not drawing attention to her/his facial reddening helps a lot. On the contrary, commenting on the other person’s blushing increases self-focused attention and favors blushing. As a matter of fact, task concentration training (TCT), which is more helpful than other psychological strategies, aims at redirecting attention from bodily symptoms to a social task. We would do well to eliminate the stigma associated to blushing (“she/he is hiding something”, “she/he is embarassed”, “She/he is a loser”) so that people can do so without distress. The fact is that many people just blush because they have an extremely sensitive ANS. To develop a reliable website that provides information on blushing, therapists, health professionals (including surgical team that perform ETS) would certainly be a contribution. Obviously, relatives and friends of chronic blushers, or patients themselves, are in a good position, and at times have the necessary intrinsic motivation, to start this type of initiative. Patients themselves could run self-help groups, write their personal accounts about how they have coped with PB and participate on Internet discussion forums.

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