Blush and your embarrassment becomes public; complete strangers hold you up to ridicule. The anxiety that blushing can cause leads some sufferers to become virtual recluses. Matthew Brown looks into erythrophobia, the fear of blushing.
Helen's face burns up if someone so much as looks at her. "Even my neck turns red," she says. "I even feel this when I am sitting quietly in the classroom - I blush furiously for no reason. It's really starting to depress me. It's as though I'm weird, some sort of freak. Is there anything I can do?" Helen's plea for help is one of hundreds to be found on Internet chat rooms set up for chronic blushers; she's among the thousands of people who live in constant fear of going red.
"This is causing me real pain, and soon I won't know what to do," says another message, this time anonymous. "I'm going slightly mad."
Blushing, an involuntary dilation of the blood vessels in the face or neck, is commonly associated with shyness and is generally regarded as the hallmark of embarrassment - the outward sign of someone's inner emotional turmoil and social discomfort. Everyone blushes to some degree; for some it's more common and more visible, and for a few it's a debilitating condition.
Twenty-year-old student David Curtis (not his real name) dropped out of university because of his blushing. The most frustrating thing, he says, is that it stops him going out or having girlfriends.
"I avoid doing normal things, until eventually most people get fed up asking me," he says. "With a lot of people it can lead to depression, and I have heard of people committing suicide. It leads many people into a deep despair."
David believes he has allowed himself to be "pushed around" because of his condition, and remembers skipping school to avoid being laughed at by schoolmates. "It's difficult to venture an opinion when you know you'll go red," he says. "So often you just take second best, or allow something to pass by or continue."
According to Professor Robert Edelmann, psychologist and author of Coping with Blushing, going red is a normal response to emotions such as anxiety or apprehension, anger or guilt. What distinguishes people who suffer from excessive blushing is not how red they get, but their fear of the attention and further embarrassment it might cause.
"There are two sides to blushing," he says. "There's the physical thing with the blood rushing to the surface of the skin. That's entirely normal. And there's the psychological fear, which is to do with the way people see themselves."
Blushing, he says, is a symptom of social phobia in which sufferers believe others are judging them. This fear of social evaluation has physical symptoms, such as faintness, shortness of breath, sweating, raised heartbeat - and blushing.
It is the fear of blushing - of revealing the anxiety - rather than the red face itself, that is so debilitating, and traps sufferers in a vicious circle.
"It's like any fear," says Professor Edelmann. "If you are wary about a situation, you go into it in a state of anxiety, fearing the worst, which means you're more likely to stumble over your words or do something that you think makes you look bad in other people's eyes. This then causes further blushing. It becomes a self-fulfilling prophecy."
The classic response is to avoid feared situations. Some people avoid certain kinds of jobs, or have a limited social life. For others, the condition can be so acute they even find it difficult to go out shopping. "The fear generates fear," says Professor Edelmann. "But it's difficult to avoid social contact altogether unless you're a complete hermit.
"For someone who wants to teach, for example, it makes life very difficult, because you're up there for public display every day, in front of a class of 30 sniggering children who are judging your every move."
But Professor Edelmann's own research suggests there are very few, if any, physiological differences between the skin temperature of people who perceive themselves as blushers and those who don't. In fact, he says, some blushers tend to think they've gone red even when they haven't.
"I used to ask my patients to tell me when they thought they were blushing," he says. "I remember one teacher I worked with who said immediately, 'I'm blushing now'. But I'd never seen anyone so white."
That's not to say blushing is not a real and disabling problem for many people. Professor Edelmann reckons he was contacted by some 3,000 people while doing research for his book, many of whom were obviously "virtual reclusives". In fact, an estimated 2 per cent of the population could be clinically diagnosed as chronic blushers, and another 7 to 10 per cent are prone to blushing. Also, social phobia is now considered one of the most prevalent of all anxiety disorders.
For David Curtis, the frustration caused by having to avoid certain situations eventually became too much, and he is now seeking treatment. Having tried cognitive behavioural therapy, and drugs such as beta-blockers and tranquillisers, he is now considering surgery.
The operation, called endoscopic transthoracic sympathectomy (ETS), works by clamping or dividing the overactive nerves that stimulate the tiny blood vessels in the face. The Finnish and Swedish surgeons who pioneered the technique claim it is a painless and non-invasive procedure which uses an endoscope the size of a pen to enter the chest cavity. The sympathetic nerves are then cut so they no longer cause blood to rush to the face.
The 20-minute operation, performed under a general anaesthetic, has been available in Britain since May. About 85 per cent of operations are successful, but possible side-effects include excessive sweating below the chest and in the back area. It is available on the NHS, and privately at a cost of about pound;4,000.
Surgery might seem an extreme course of action, but for some it is liberating. "Since the surgery I don't suffer from facial blushing at all anymore," a former patient reports on one surgeon's website. "It's a new and exciting experience for me. I'm not afraid of meeting people anymore."
Professor Edelmann believes the resort to surgery is proof of people's need for a quick fix. While he acknowledges that biological differences can make some people more sensitive to anxiety cues - and therefore likely to blush more easily - he believes our responses to blushing, and the social situations that cause it, are learned.
"People want an instant solution," he says. "But what really changes in people who have the surgery is their mindset; they just feel more confident."
Whereas recovery from surgery can take just 24 hours, psychological remedies take a long time and a lot of hard work. Their aim, he says, is not to eliminate blushing but to eradicate the psychological processes which make it a problem.
Psychotherapy focuses on relaxation techniques and changing the way a person thinks about him or herself, so blushing is no longer such a devastating experience. Sufferers are asked to focus on the physical aspects of the person they're interacting with and away from their own anxiety.
"It takes practice and practice and practice," says Professor Edelmann. "But confidence tends to grow over time."
Coping with Blushing by Robert Edelmann (Sheldon Press, pound;5.99). A factsheet on blushing, and what can be done about it, is available from the National Phobic Society. Tel: 0161 227 9898Email: firstname.lastname@example.org.Website: www.phobics-society.org.uk
* THE BLUSHING RESPONSE
Blushing is caused by involuntary dilation or expansion of the blood vessels beneath the skin in the face or the neck, stimulated by the sympathetic (involuntary) nervous system. Technically, it is called cutaneous or peripheral vasodilation.
Blushing is a normal part of the process of regulating body temperature, and is most obvious when we exercise. Excess heat can escape the body when the vessels near the skin fill with blood, preventing us from overheating. Similar face reddening can be caused in some people by certain drugs, such as histamine, by alcohol and, in women, by the menopause.
Fear of blushing is called erythrophobia. For erythrophobics, blushing is a conditioned automatic reflex, whichoccurs without warning in social situations. Sufferers believe others notice them blushing, and get more embarrassed, which causes further blushing. As a result, they tend to avoid certain activities and social situations.
The condition can be treated with drugs used to control anxiety, such as propranolol and other beta-blockers, or Prozac. Some websites suggest herbal remedies such as St John's wort, ginseng and sage, as well as homeopathy and acupuncture.
Psychotherapy focuses on relaxation techniques and cognitive behaviour therapy. Sufferers are taught to think positively about themselves, and to focus their thoughts away from their own anxieties on to others' behaviour and physical characteristics.