2. INTRODUCTION
Psychodermatology or psychocutaneous medicine
encompasses disorders prevailing on the boundary
between psychiatry and dermatology.
Approximately 30-40% patients seeking treatment for skin
disorders have an underlying psychiatric or a psychological
problem that either causes or exacerbates a skin
complaint.
3. Skin–psyche interactions:- An essential component of
dermatological illness is relationship that somatic dermatology
has to psychological status of sufferer at time.
The influence that these psychological, psychosocial and
sometimes psychiatric factors play can be conveniently assessed
as:
1.
2.
3.
4.
Multifactorial dermatological disorders which can be
substantially influenced by psychological factors, e.g. psoriasis
Dermatological disorders as a result of psychiatric illness, e.g.
factitious dermatoses, body dysmorphic disorder
Psychiatric illness developing as a result of skin disease, e.g.
depression, adjustment disorder
Co-morbidity with another psychiatric disorder, e.g. alcoholism
4. Stigma
Term describes situation of an individual who is
disqualified from full social acceptance.
Commonest dermatological situations where stigma is
encountered may be:1. Physical deformities:Congenital naevae, e.g. port-wine stain
II. Acquired deformities from developmental disorders,
e.g. tuberose sclerosis
III. Widespread inflammatory skin disease.
IV. Surgical or post-traumatic deformities
I.
5. Implications of inferred character deficiencies:-
2.
I.
II.
III.
IV.
V.
VI.
VII.
Psychiatric disorder, i.e. their views on the skin disease are
disqualified because they also have a psychiatric diagnosis
Learning disability, i.e. they have limited emotional
capacity to respond to their dermatosis, e.g. Down’s
syndrome
Persistent treatment non–compliance, i.e. an assumption
of a fickleness of character, e.g. depressive illness
Alcoholism and drug addiction, e.g. the cutaneous signs of
substance abuse are a labelling of character weakness
Unemployment
Imprisonment
HIV status
6. 3. Stigma of: Race, e.g. implications of vitiligo for marriage
Religion, e.g. allowing the naked body to be seen by a
stranger
7. Classification
A. Psychiatric disorders without significant
dermatological disease:Delusional syndromes:-
1.
i.
ii.
iii.
iv.
v.
Parasitosis
Smell
Impregnation and contamination
Folie à deux
Other hypochondriasis, e.g. so-called Morgellons
8. B. Disorders of awareness of the body:1.
Phobias and obsessive compulsive disorders:i.
ii.
iii.
iv.
v.
vi.
vii.
Disorders of body image:- body dysmorphic disorder (BDD)
(synonyms dysmorphophobia, dermatological non-disease)
Disturbance of body size and eating:- e.g. anorexia nervosa,
bulimia
Phobias:- mole phobia, venereophobia, wart phobia,
erythrophobia, electrophobia and steroid phobia
Obsessive–compulsive behaviours:- hand washing, hair plucking
Atypical pain disorders:- glossodynia, vulvodynia and scrotodynia,
anodynia
Pruritis sine materia
Other dermatologic hypochondriases:- botoxophilia, tanorexia
9. Mental disorders and
dermatological disorders:-
B.
Classical psychosomatic
disorders:-Dermatoses in
which emotional
precipitating or
perpetuating factors may
be important:-
1.
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
Vesicular eczema of palms
and soles
AD
Seborrhoeic dermatitis
Psoriasis
Some cases of localized or
generalized pruritus
AA
Aphthosis
Flushing reactions and
rosacea
Hyperhidrosis
Urticarias.
2.
Dermatoses primarily
factitious in origin:Dermatitis factitia
Artefact by proxy
Witchcraft syndrome
Dermatological
pathomimicry
v.
Dermatitis simulata
vi. Malingering
vii. Compensation neurosis
viii. Münchausen’s syndrome
ix. Fabricated and induced
illness (Münchausen’s
syndrome by proxy)
x.
Deliberate self-cutting
xi. Self-mutilation
i.
ii.
iii.
iv.
10. 3.
Dermatoses in association with
harmful habits and compulsions:i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
xi.
Lichen simplex
Neurotic excoriations
Prurigo nodularis
Acne excoriée
Hair plucking
Trichotillomania
Trichophagia
Nail destruction
Onychotillomania
Lip-licking cheilitis
Knuckle biting
The psychogenic purpura
syndromes
4
i.
ii.
iii.
iv.
5.
6.
Autoerythrocyte sensitization
(Gardner–Diamond syndrome)
Autosensitivity to DNA
Psychogenic purpura
(idiopathic)
Stigmata
Disorders of neglect of selfcare (synonym Diogenes
syndrome)
Drug-dependence syndromes
i.
ii.
Alcohol-related syndromes
Substance abuse
11. 7.
Mental disorders due to
dermatological treatment
i.
ii.
8.
Cortisone psychosis
Interferon depression
iii.
Lithium-induced psoriasis
Tranquillizer
hyperpigmentation
Anti-depressant hyperhidrosis
Dual non-associated disease,
dermatological and
psychiatric
i.
ii.
disorders
Skin cancer in patients with
major psychosis
Dermatological patients with
psychic symptoms not
amounting to a disorder:i.
ii.
iii.
Dermatological disorders due
to psychopharmacological
treatment:i.
ii.
9.
C.
D.
‘Troublesome patients’
Dysthymic responses to illness
Cosmetology associated
worries
Group and mass population
reactions:i.
ii.
Sick building syndrome
Epidemic hysteria
12. Delusions of parasitosis:- unshakeable conviction that
his or her skin is infested by parasites.
Causes: Neurological: Cerebrovascular disease,
Dementia and
neurodegenerative diseases,
Parkinson’s disease,
Huntingdon’s disease, CNS
tumours, Head injury,
Encephalitis, Meningitis,
Multiple sclerosis, Learning
disability,
Cardiovascular disorders: Arrhythmias, Heart failure,
Coronary artery bypass
Renal disease:- CRF, Dialysis
Liver disease:- Hepatitis
Endocrine disease: Diabetes mellitus,
Hyperthyroidism,
Hypothyroidism,
Panhypopituitarism,
Hypoparathyroidism,
Acromgaly,
Nutritional disorders:
Pellagra ,Folate deficiency,
Vitamin B12 deficiency,
Anorexia nervosa
14. Monosymptomatic hypochondriacal
psychosis.
Middle aged/elderly females .
Visual and tactile hallucinations of
parasites crawling, burrowing, and
biting all over their body.
Excoriations are usual
and, sometimes, extensively
produced in an attempt to extricate
organism.
15. Management
Patients with anxiety, social isolation or depression:-
psychotherapy, or antidepressants such as doxepin,
citalopram or venlafaxine.
Pimozide:- initial dose 2 mg, is increased weekly by 2
to a maximum of 12 mg daily.
Sulpiride:- 200–400 mg/day
Amisulpride:Respiridone:-1–8 mg/day
Olanzapine in small doses
16. Bromidrosiphobia:- A/K Delusions of smell
M:F= 4-5: 1
Most patients complain that smell comes from groin or
sometimes armpit.
Other beliefs:- Flatus, halitosis
Organic syndromes:-cerebral
tumours, epilepsy, alcoholism and substance abuse
T/t:- Psychotherapy, antidepressants and
antipsychotics.
18. Disorder of Body Image
BODY DYSMORPHIC DISORDER –
A patient is preoccupied and distressed with an imagined
defect in appearance or an excessive concern over a trivial
defect.
BDD is defined in DSM-IV and classified as a somatoform
disorder.
There is an underlying co-morbid mental disorder
including mood disorders such as depression, OCD, social
phobia, and/or avoidant personality disorder.
Most patients are females in their 30's.
These patients are rich in symptoms, while poor in signs of
organic skin disease.
19. Complaints related to mainly face, breast, hair, nose, and
stomach, while men presented with concern related to
hair, nose, ear, genitals, and body build.
Distress, poor self esteem, and impairment in
social, occupational, and domestic functioning.
Repetitive compulsive behavior to hide their
imaginary/trivial defect.
BDD patients are doctor shoppers, they repeatedly
undergo procedures to find solution for their flaws and
majority are dissatisfied with results and consultation.
Suicidal ideation and suicide attempts are common in BDD
patients.
20. Treatment: SSRIs:- 50% of patients may respond completely or
partially .
clomipramine
fluoxetine 50 mg/day and fluvoxamine260 mg/day for 2-
4 months
Venlafaxine 37.5 mg/day for 1 year
Cognitive behavioural therapy
21. Anorexia nervosa and bulimia
Definitions:- Anorexia
nervosa must satisfy the
criteria for:1.
2.
3.
An inability to maintain
the normal or minimum
weight for age and height
coupled with an intense
fear of gaining weight; the
BMI is less than 17.5 kg/m2
A distorted perception of
weight, size and body
configuration- essential
features
Amenorrhoea
Bulimia nervosa is defined
by the following:
1.
2.
3.
4.
Recurrent and compulsive
overeating episodes (binge
eating)
Recurrent and inappropriate
compensatory behaviour in
order to avoid gaining weight;
these include induced
vomiting and abuse of
diuretics and laxatives
Binge eating and weight
reduction behaviours
occurring at least twice per
week for 3 months
Self-esteem affected by weight
and body configuration.
22.
23. Harmful cutaneous habits
Lichen simplex and neurodermatitis:-Lichenification
describes characteristic pattern of response of predisposed
skin to repeated rubbing.
Treatment:- antihistamines, TCA doxepin in doses as low
as 25–50 mg/day
thalidomide 50–100 mg/daily for up to 2 months
Pathological skin picking(Dermatotillomania):recurrent picking accompanied by visible tissue damage
and functional impairment.
Clinical features:-lesions are polymorphic, newer lesions
are angular excoriated erosions with a serosanguineous
crust.
24. Healing with
erythematous, white and
atrophic centrally and
commonly hypertrophic
and hyperpigmented at the
periphery
Site:-face, hair margins,
sides of neck, chin, upper
chest, shoulders, upper
arms and thighs.
Management:-supportive
psychotherapy
Cognitive behavioural
therapy
Compulsive nature of
disorder:antidepressants:-SSRI
A-B-C model of habit
disorders, that is Affect
regulation, Behavioural
regulation and Cognitive
control
Lamotrigine
25. Acute excoriations and
chronic, scarred, atrophic lesions due to
pathological picking on face, neck and
shoulders
Acne excoriee
26. Trichotillomania:-term was first used by Hallopeau in 1889
derived from the Greek thrix hair, tillein pull out and mania
madness.
Morbid craving to pull out hair.
Revised DSM-IV diagnostic criteria:a.
b.
c.
d.
e.
Recurrent pulling out of one’s own hair resulting in hair loss
An increasing sense of tension immediately before pulling out
hair or when attempting to resist behaviour
Pleasure, gratification or relief when pulling out the hair
Disturbance is not better accounted for by another mental
disorder and
Disturbance provokes clinically marked distress and/or
impairment in occupational, social or other areas of functioning.
27. C/F:-short, irregular, broken
and distorted hair.
plucking activity are
centrifugal from a single
starting point or linear, in
wave-like activity.
Trichobezoar and the
Rapunzel syndrome:-balllike aggregations of fibre-like
materials( hair) in stomach
and small intestine.
Swallowed hair is retained
within folds of gastric
mucosa.
Trichotillomania
28. Investigations: Scalp biopsy: normally hairs amongst empty hair follicles in a noninflamed dermis.
Follicular plugging with keratin debris is evident.
deep distortion and curling of hair bulb.
Barium contrast and CT scan:-gastrointestinal bezoars
Management:-cognitive behavioural therapy (CBT) is
effective alone and combined CBT and TCA or SSRIs.
Clomipramine more useful than SSRI alone.
29. Psychogenic Pruritus
Psychogenic pruritus (PP) is a poorly defined entity in
which the patient has intractable or persistant itch, not
ascribed to any physical or dermatological illness.
Pruritic episodes are unpredictable with abrupt onset and
termination, predominantly occurring at the time of
relaxation.
PP can be generalized or localized.
The commonest sites of predilection are legs, arms, back,
and genitals.
A significant number of patients have associated anxiety
and or depression.
Detailed cutaneous and systemic examination and routine
baseline investigation should be performed to rule out
cutaneous and systemic causes of pruritus before
diagnosing PP.
30.
31.
32.
33. Cutaneous phobias
Fear of contamination, e.g. dirt phobia, germ
phobia, wart phobia
2. Fear of malignancy, e.g. cancer phobia, mole phobia
3. Fear of emotional display, e.g. blushing, sweating
1.
34. Factitious skin disease
DSM-IV-TR criteria:1. Intentional feigning of physical or psychological signs
or symptoms
2. Motivation is to assume the sick role
3. External incentives for behaviour (such as economic
gain, avoiding legal responsibility, or improving
physical well-being, as in malingering) are absent.
35. Dermatitis factitia:- caused entirely by actions of fully
aware (i.e. not consciously impaired) patient on the skin,
hair, nails or mucosae.
F>m, children, from age of 8 years, pre-pubertal children
having an equal sex ratio, rising to 3 : 1 female
predominance in early teens
Etiology: psychosocial stress of a major life
neurotic and react to adverse situations in an immature,
impulsive manner.
Depression
personality disorder:-borderline or hysterical in females and
paranoid in males
36. C/F:- 2 characteristics:1. physical signs
2. fabricated story that accompanies it
patient often describes :
Sudden appearance of lesions with little or no
prodrome.
No complete description of genesis of individual skin
lesions.
37. Clinical signs: Commonest site are face (cheeks) in 50% children, Dorsa of
hands, forearms
most frequently of non-dominant limb, mostly on covered skin
lesions are polymorphic, bizarre, clearly demarcated from surrounding
normal skin and can resemble many inflammatory reactions in skin
crude, angulated, destructive processes with a tendency to a linear
configuration, Circular erosions or blisters of a uniform size, as result of
thermal, chemical or instrumental injury
Secretan’s syndrome:-Oedema of limbs from constricting bands and
hysterical dependent posture has been described.
38. Drip-sign:- corrosive liquids.
Excoriations:- nail files, sanding boards, cheese graters or wire
brushes
Punched out necrotic areas:- cigarettes, soldering irons
Dramatic dermal induration and necrosis occur from foreign
body injection of milk, oil, or grease into breasts, thighs,
abdomen and penis .
The other common presentation is chronic, non-healing infected
wounds.
A patient is unable to provide clear history of evolution of the
lesions and typically denies any role in the production of the
lesions.
39.
40.
41. Witchcraft syndrome:- Artefact dermatitis can be
provoked on an unknowing and unsuspecting victim
by proxy.
Dermatological pathomimicry:- patients may
intentionally aggravate an existing dermatosis using
explanation of its genesis given by their dermatologist
Atopic patients reintroduced allergens
44. Secondary Psychiatric Disorders
Skin problems, especially chronic skin diseases, affecting
exposed body parts because of the visibility and resultant
disfigurement lead to embarrassment, depression, anxiety,
poor self image, low self esteem, and suicidal ideation in
the patients.
Also, patients have to commonly face social isolation and
discrimination and, at times, have difficulty getting jobs.
Many patients are able to cope up with the disease while
few develop secondary psychiatric morbidity.
45. Dermatologist should look into this aspect of chronic
disfiguring dermatoses.
If the dermatologist suspects significant secondary
psychological morbidity then interrogation, counseling,
psychiatric referral should b done.
46. Management of Psychocutaneous
Patients
Most of the patients with psychocutaneous disorders
can be broadly categorized under four diagnoses:
(a) Anxiety,
(b) depression,
(c) psychosis,
(d) OCD.
The choice of a psychotropic medication is based
primarily on the nature of the underlying
psychopathology.
47. Anxiety
Therapeutic modalities for anxiety include BDZ, non-BDZ,
and CBT.
Risk of dependence on BDZ is quite high; hence, they are
indicated only for short-term treatment (2-4 weeks) for
severe and disabling symptoms and should be avoided in
milder forms.
Non-BDZ used in the treatment of anxiety are selective
SSRIs (citalopram escitalopram, paroxetine), serotoninnorepinephrine reuptake inhibitors (SNRIs) (venlafaxine
XL, duloxetine), antihistamines (hydroxyzine), betablockers (propranolol), and the antiepileptic pregabalin.
48. Depression
In mild symptoms, watchful waiting or CBT is
recommended.
Moderate symptoms can be managed with SSRI and CBT.
In cases with severe symptoms and suicidal ideation
admission, antidepressants with possibly electroconvulsive
therapy (ECT) are recommended.
49. Antipsychotics
Antipsychotics are used in the therapy of psychocutaneous
disorders such as delusions of parasitosis, dermatitis
artefacta, and monosymptomatic hypochondriasis.
The goal of the dermatologist is not to relieve the patients
of their delusion, but to help them function better with the
delusion.
50. Obsessive Compulsive Disorder
Disorders like BDD and impulse control disorder (acne
excoree, trichotillomania, onychotillomania,
neurodermatitis) are treated on the lines of OCD.
Develop insight into the etiology of their problem, they are
more amenable to see a psychiatrist and engage in nonpharmacological management (CBT).
For patients who are unwilling or unable to initiate
behavioral modification, pharmacological therapy can be
helpful.
Currently, three SSRIs-fluoxetine, paroxetine, and
sertraline-are the first-line therapy for the management of
OCD.
51. Non-Pharmacological Treatments
There is a significant psychosomatic/behavioral
component in many dermatologic conditions hence
complementary non-pharmacological
psychotherapeutic interventions
1. biofeedback
2. CBT
3. hypnosis
4. placebo
Have positive impacts on many dermatologic
disorders.
52. Biofeedback
Biofeedback is a non-invasive conditioning technique
with wide applications in the field of medicine.
Biofeedback training encompasses a wide variety of
progressive muscle-relaxing techniques, autogenic
training, imagery techniques, transcendental, and
other meditation techniques as well as other
relaxation-directed programs (i.e., breathing
techniques, self-talk, and others).
Relaxation training is primarily directed at minimizing
sympathetic reactivity and enhancing parasympathetic
function.
53. Cognitive Behavioral Therapy
CBT deals with dysfunctional thought patterns (cognitive)
or actions (behavioral) that damage the skin or interfere
with dermatologic therapy .
Hypnosis
Hypnosis is an intentional induction, deepening,
maintenance, and termination of a trance state for a
specific purpose.
Hypnotic trance can be defined as a heightened state of
focus that can be helpful in reducing unpleasant sensations
(i.e., pain, pruritus, dysesthesias), while simultaneously
inducing favorable physiologic changes.