Frequently Asked Questions

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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.

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 sometime 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 embarrassment. 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. 

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. 

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.

Now, recent research has shown that patients who complain about blushing blush more and/or have a heightened general arouseability 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). 

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 favor or protect against, the disorder; and also are crucial in determining the meaning the patient gives to the ailment. 

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 occasions 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. Immediately she turned red. Well, this triggered a very complicated, but unnecessary, 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 children because, knowing that the proneness to blush aggregates in families, she did not want her children 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 qualifications 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 their 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 color of the skin so one is able to hide the blush. Some of my patients have told me that they used to sunbathe avoiding sun protectors (“if I am already red I won’t become red in front of others”), increasing the risk of skin cancer. 

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. 

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. 

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 embarrassed 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. 

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. 

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. 

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

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. 

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.