Most people with acne understand that being “stressed out” can make breakouts worse and that being under chronic stress can make breakouts more frequent. This is all quite true—emotions, including those that arise when you’re under a lot of stress, can have a major effect on acne. What’s going on inside your mind has a notable effect on what happens to your outer body. I outlined the various direct and indirect effects stress has on acne in the in-depth section.

Getting stress and emotional pain under control can help your skin. But ending the emotional pain is a worthy goal by itself. The pain and suffering have ruined many lives. Being happy and OK in your own skin, I believe, is more important than ‘fixing’ your skin.

I’m going to make a controversial argument in this chapter. I’m going to argue that acne and the emotional pain you feel are separate. That most people with acne just want to feel happy and live normal lives. They want to end the control acne has over their lives. That their solution to ending the emotional pain, fixing acne, may seem rational, but is exactly the wrong thing to do. That to stop the emotional pain, they have to address it directly. And in doing so, they will also help their skin.

If what I just said sounds completely backward to you, I ask you to hear me out. Give me 20 minutes to make the case. You paid good money for this course, so please hear me out.

I can’t say it enough: no one is perfect. The image we see in the mirror is seldom reflective of what the rest of the world sees when they look at us. We see every tiny flaw amplified to exponential proportions, as though our physical “shortcomings” are under the scrutiny of the world’s most powerful magnifying glass. Others might look at us and see a lovely smile, a kindly demeanor, a unique sense of style, etc. We look at ourselves, and we see acne, and we feel awful about it, which in turn causes stress, which in turn makes the acne worse—on and on in a cycle of negativity.

The truth is, our acne isn’t the enemy. Our reactions to our acne, however, can be our ultimate psychological downfall. We obsess on this one aspect of our physical appearance, keeping ourselves from fully enjoying our lives.

Psychologists call this attentional bias. Wikipedia describes it like this:

Attentional bias is the tendency of our perception to be affected by our recurring thoughts. For example, people who frequently think about the clothes they wear pay more attention to the clothes of others.

Attentional bias is the result of the filtering process that’s constantly going on in your head. The environment you are in has millions of cues, but the vast majority of these go unnoticed by you, lest you become overwhelmed with information of little salience. The filtering process that decides what is important (or salient) determines how you perceive the situation you are in.

Here’s a quick example and an opportunity to experience this process in action. Think of a color, any color at all. Hold that color in your mind and slowly look around. Notice how your eyes immediately focus on that color. Your eyes jump to everywhere you see that color. Now pick a different color and do it again. Notice the difference? The second time around, your eyes homed in on the second color. Same situation, same environment—but you picked up different things, all based on what your subconscious determined to be important.

The most important things that determine what information gets filtered out and what gets in include:

• Your beliefs about yourself (For example, “I’m ugly”, “I’m popular”, “I’m intelligent”).
• Your beliefs about the world in general (For example, “It’s a dog eat dog world out there”, “People are basically fair”).
• What’s important for you at the moment, or things that occupy your mind – ever wonder why is it that when you are thinking of buying a particular car, you suddenly see them everywhere?

It has been shown scientifically that people with acne pay more attention to pimples than people without acne. In 2013, Korean researchers conducted a study where they asked participants to look at images of 10 different people. There were 4 different images for each of the 10 people: happy expression, neutral expression, happy with acne, and neutral with acne. The participants were asked to rate the attractiveness of each image, and while they were looking at the images, researchers used eye-tracking to measure which parts of the image they paid attention. The results showed that:

• The participants with acne rated images with acne as less attractive than the participants without acne. Put in other words, if you have acne, you are likely to think acne makes you uglier than those without acne think.
• The participants with acne spent much more time looking at the pimples in the pictures than the participants without acne. In other words, if you have acne, you are more likely to see it in others than those without acne.

This filtering and selective attention happen because humans have a strong need for consistency between our internal beliefs and the external world. We need this because when things are inconsistent, we find it difficult to predict and control the future. We feel out of control.

When something happens that goes against our existing beliefs, we get uncomfortable. This phenomenon is called cognitive dissonance. Humans go to great lengths to get rid of cognitive dissonance. One way we do this is by rationalizing, or giving excuses for doing things we know we shouldn’t do. Let’s say you want to lose some weight, but you also really need to have a donut. When faced with such a situation we tell little lies. You might say it’s not such a big deal; I’ll go to gym tomorrow to make up for it.

Another way to reduce cognitive dissonance is to put a different spin on what happened. Simply Psychology website has a good bit that shows to the lengths people go to defend beliefs they are heavily invested in:

Cognitive dissonance was first investigated by Leon Festinger, arising out of a participant observation study of a cult which believed that the earth was going to be destroyed by a flood, and what happened to its members — particularly the really committed ones who had given up their homes and jobs to work for the cult — when the flood did not happen.

While fringe members were more inclined to recognize that they had made fools of themselves and to “put it down to experience”, committed members were more likely to re-interpret the evidence to show that they were right all along (the earth was not destroyed because of the faithfulness of the cult members).

This happened again in 2011 when American evangelist Harold Camping predicted that the world will end. Many people who believed him sold all of their possessions and took out billboards and ads to warn other people about the end of the world. At least one person committed suicide and a mother tried to kill her own children to spare them the agony. When the world didn’t end, Mr. Camping offered many explanations. Such as that it was only a spiritual apocalypse and that the world had been saved because of the faith people put in God.

Another biblical group predicted that the world will end on 7.10.2015. At 8.10.2015 they published a statement saying the world is on life support and will end any day now. Religion Dispatches has a good article on other ways people explain and justify failed end-of-the-world predictions.

These are extreme examples, but they serve to show to the lengths people go to defend and rationalize their deeply held beliefs. The point being that if you believe you are ugly or flawed in some other way, you will go to great lengths to defend such beliefs and to make sure your experience of reality matches your beliefs.

This is one example of the various cognitive biases humans come hardwired with. Wikipedia explains:

Individuals create their own “subjective social reality” from their perception of the input. An individual’s construction of social reality, not the objective input, may dictate their behaviour in the social world. Thus, cognitive biases may sometimes lead to perceptual distortion, inaccurate judgment, illogical interpretation, or what is broadly called irrationality.

Let’s return to the statement I made at the beginning of this page. That acne per se is not your enemy – your reaction to acne is.

Many who suffer emotionally because of acne, believe their suffering to be an even inevitable, even rational, response to their visible skin problem.

My argument here is that what seems like a reasonable response is the result of selective attention to the perceived flaws and cognitive biases that shape your experience of reality to fit your pre-existing beliefs.

This was stated already in the 1st century by the Greek philosopher Epictetus:

Men are disturbed not by things, but by the view which they take of them. – Epictetus

To illustrate the point, I opened a few posts on the 1st page of the emotional and psychological effect of acne sub-forum at acne.org. These are just a few snippets from the posts.

Does anyone else experience a warped mental perception of their skin?

I feel the amount of over analysing, pore scanning and obsessing that I have done over the last few years has done some damage to my mental image of myself. Even when I am having a relatively good skin day, when I imagine myself and how I look – I see my skin as red, scarred and disgusting.

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You don’t realize that the first thing people see are your eyes, smile, hair, and more general characteristics. Rather, people like us assume the first thing people see are our flaws, because thats the first thing we look at anytime we see ourselves in the mirror!

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You need to stop looking in mirrors, I was over analyzing my face too but it does nothing, looking at your face isn’t going to change anything, it’s just giving you more time to pick out your flaws and dwell on them which isn’t healthy, especially mentally. When I started to avoid mirrors and reflective surfaces my self confidence and self esteem grew, because I wasn’t torturing myself and beating myself up about my appearance.

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I have this problem. I haven’t really had acne for about 10 years (a few minor break outs, but nothing serious), but I got so used to fixating on it I now see my whole body in high definition. So I see all the light scarring, blotchy complexion, razor burn, blackheads and blemishes that other people don’t notice unless they get right in your face.

My brain is also still a bit trapped in the teenage world, when your appearance is genuinely important and will usually affect how other people treat you and speak to you. I forget that adults will not necessarily treat you disrespectfully because of the way you look.

—

I can’t focus, I can’t focus, I need to focus. My director is looking at me. Is she looking at me or my messed up face, God where’s my mirror, I need to go to the toilet.

Your beliefs, and especially your deeply held core beliefs about yourself, are the rules that guide you through life. They filter, color, and modify every experience you have. And this happens largely outside of your conscious awareness.

Your emotional life is controlled by the 8-year old you

While many of your core beliefs may appear dysfunctional to you now, we have to understand the context they formed in. Most of your core beliefs formed when you were very young.

Children are egocentric by nature. For a child, everything is about them. Parents divorced because he was a bad child. Overstressed father says something harsh because the child is bad and up to no good. Post about beliefs at Janet Greene’s website puts it well:

Your core beliefs are neither dysfunctional nor skewed. They are valid conclusions that were reached by a child, from that child’s current perception of an experience at that time. It is, however, inappropriate and often dysfunctional to filter your entire adult experience according to the life rules of an 8 year old.

For many, the bus of our emotional life is driven by an 8-year old child. Is it then any wonder that we crash and burn so often?

This selective attention to our flaws, driven by our core beliefs, results in a skewed body image, anxiety, depression, withdrawal from social activities, and overall lowers our quality of life.

To further support the role beliefs and self-image plays, consider the fact that people with mild acne often suffer just as much as those with more severe acne.

Body dysmorphic disorder and acne

This observation was made in a 2007 paper about body dysmorphic disorder (BDD) in acne patients.

Interestingly, the impact that acne has on an individual”s quality of life may have very little to do with the severity of his or her disease as measured by a physician. The patient who is covered with inflammatory pustules may report less psychosocial hardship than another individual who, although having mild acne as judged by her dermatologist, refuses to leave her home until her lesions resolve.

Bowe, W. P., Leyden, J. J., Crerand, C. E., Sarwer, D. B. & Margolis, D. J. Body dysmorphic disorder symptoms among patients with acne vulgaris. J. Am. Acad. Dermatol. 57, 222–30 (2007). https://www.ncbi.nlm.nih.gov/pubmed/17498840

Wikipedia describes BDD as “a mental disorder characterized by an obsessive preoccupation that some aspect of one’s own appearance is severely flawed and warrants exceptional measures to hide or fix it. In BDD’s delusional variant, the flaw is imagined. If the flaw is actual, its importance is severely exaggerated“.

BDD is relatively common among acne patients. A 2003 study showed that 8.8% of Turkish people with mild acne had BDD. While a 2007 study looking at people in the US found that over 30% of those with very mild to mild acne met the criteria for BDD; meaning they are preoccupied with acne and it causes at least moderate distress and social impairment. The latter study also showed that the rate of BDD was twice as high among people who were currently on or had taken Accutane before. At the time of the study, all the participants had non-existent to mild acne. The most likely explanation is that the ghosts of past acne haunted these people, making them afraid acne might come back and thus more sensitive to even mild acne. We’ll return to this point later on this page.

Signs that you may have BDD include:

• You spend a lot of time worrying about your skin.
• People often tell you your acne isn’t so bad and you shouldn’t worry about it.
• Acne causes you a lot of emotional pain and suffering.
• You’ve skipped school, work, or social events because of how your skin looks like, and you feel like your life would be so much better without acne.
• You pick your skin frequently.
• You regularly check how your skin looks like on mirrors and other reflective surfaces.
• You often seek reassurance (i.e. “Can you see my pimples?”, “Does my skin look OK?”)
• You use clothes, makeup, and other things to hide the pimples.

Again, I want to stress that everyone does these things to a certain degree. It’s okay to be concerned about your skin and to try to hide the pimples. It’s the degree that counts. And of course this has to be balanced against the severity of your acne. The more severe your acne, the less problematic these behaviors become.

When they become excessive, and you feel like acne, or trying to get over it, becomes a significant part of your life. That’s when we have a cause for concern.

Before we move on, I want to say that let’s not get too hung up on BDD, and whether you have it or not. I use it as an example in this chapter. Studies on BDD and body image issues make it painfully clear that most sufferers aren’t aware they might have a psychological/emotional problem. The vast majority just try to fix what they perceive to be their flaws. Which is exactly the opposite of what they should be doing.

Getting over acne won’t fix the problem

I’ve often said that you can’t fix emotional issues with a knife and fork. I say this because many people with emotional-type acne ruin their lives with restrictive diets and excessive supplement programs in an effort to get over acne. I’ve heard from many individuals who have been on these diets for years.

The problem is that they are trying to solve the wrong problem. The problem is not acne. It’s the emotional pain. While at first it may seem I’m splitting hairs here, trust me when I say I’m not. And I have good science to back this up.

These people are going to extreme lengths to end the emotional pain they’ve linked to acne. The problem is that acne doesn’t cause the pain, it merely brings the pain to the surface. It’s a scapegoat. It’s much easier to say I’m ugly because I have acne than to admit I feel ugly and just don’t like myself. We can pour all that self-hatred and loathing on acne and conveniently externalize it. It’s not about me, it’s about my acne, and can’t you see how much I’m doing to get rid of it – life just isn’t fair.

All the self-hating and loathing is just beneath the surface, swept under a thin rug; you can see it easily when you start reflecting. And that’s why getting over acne won’t make much of a difference in your life. Sure, you’ll be happier for a while, but soon you’ll find a new thing to worry and obsess over.

How do I know this? Because studies show that’s what happens to most people with BDD. The journal European Psychiatry published a study in 2007 where they followed BDD patients who had had cosmetic surgery for 5 years. While this is a small study, it’s still illustrative. Here’s what the researchers wrote:

Nevertheless, at follow-up, 6 of the 7 operated BDD patients still had a BDD diagnosis. Five of them were preoccupied with a new body site vs none among the operated non-BDD patients.

Tignol, J, Biraben-Gotzamanis, L & Martin-Guehl, C. Body dysmorphic disorder and cosmetic surgery: evolution of 24 subjects with a minimal defect in appearance 5 years after their request for cosmetic surgery. European Psychiatry (2007) https://www.ncbi.nlm.nih.gov/pubmed/17900876

Most of the operated BDD patients said they were happy with the surgery and felt better about themselves – when asked shortly after the surgery. But as time passed, the old gremlins raised their ugly heads, and the people became more and more miserable.

Other studies have produced similar results, including:

• A significant proportion of BDD sufferers undergo repeated cosmetic surgery.
• In most cases BDD remains as bad as it was before the surgery, or it gets worse. Though one study showed that in 9% of the participants no longer had BDD and 21% showed some improvement one year after cosmetic surgery.
• A study that looked at 200 BDD sufferers who sought non-psychiatric treatment (surgery, medication for acne, etc.) found that there was no change in BDD in 91% of the cases.
• 83% of plastic surgeons believe people with BDD won’t be satisfied with the results of cosmetic surgery.
• Dermatologists report that patients with BDD are more likely to threaten doctors with physical harm or legal action. One BDD patient even killed his/her dermatologist.

Do you know what works for BDD? Cognitive behavior therapy (CBT) and other such psychological treatments. There’s good evidence to show psychological treatments work much better trying to fix the perceived flaws with surgery, drugs, or cosmetic procedures. To give you an example, in one study, BDD was eliminated in 82% of the people treated with group cognitive behavior therapy. This shows that getting over BDD requires fixing your thoughts – not your body.

Acne patients have one more reason to remain worried; their acne might come back. I’m not aware of any studies on this, but reading popular acne forums you get the impression that this is not uncommon among people who have managed to get their acne under control.

The point I’m belaboring here is that if you want to end the emotional pain, you have to address it directly – instead of trying to get rid of the trigger that brings it to the surface. Because, even if you manage to get rid of that trigger, chances are a new trigger will emerge to surface the same pain.

To do that, you have to look inside and find out what you really believe about yourself. Unmask the rules that define your life. It will take some time, but with some effort and patience you can replace the dysfunctional beliefs with ones that are rational and better reflect the reality.

As you do this, you unseat the 8-year old driving the bus of your emotional life. And you can stop the emotional carnage. As you do that, you not only become happier and more satisfied with yourself, but reducing stress and anxiety very likely also helps your skin and overall health. But consider those as happy side-effects. What matters is for you to feel OK in your own skin – even if it’s not perfect.