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Psychocutaneous disorders


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A comprehensive presentation about Psychocutaneous disorders taken from Rook's textbook of dermatology, along with tables and pictures. Useful for dermatologists and other healthcare professionals.

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Psychocutaneous disorders

  1. 1. By: DR. SAIMA IDREES PGR Dermatology
  2. 2. INTRODUCTION  Psychodermatology encompasses disease that involves the complex interaction between the brain, cutaneous nerves, cutaneous immune system and the skin.
  3. 3. Skin–psyche interactions May be any of the following: 1. Primarily cutaneous disorders that can be influenced by psychological factors, e.g. psoriasis 2. Primary psychiatric disease presenting to dermatology HCPs, e.g. Delusional infestation, body dysmorphic disorders 3. Psychiatric illness developing as a result of skin disease, e.g. depression, anxiety or both. 4. Co-morbidity of skin disease with another psychiatric disorder, e.g. alcoholism
  4. 4. Stigma  Term describes situation of an individual who is disqualified from full social acceptance.  Commonest dermatological situations where stigma is encountered may be:- Physical deformities:- I. Congenital naevae ,e.g. port-wine stain II. Acquired deformities from developmental disorders, e.g. tuberous sclerosis III. Widespread inflammatory skin diseases IV. Surgical or post-traumatic deformities
  5. 5.  Psychiatric disease and learning disabilities  Race and religion  Behavioural and social factors: Alcoholism and substance misuse, imprisonment Interventions in dermatological stigmata are concentrated on firstly the reduction in visibility and secondly the psychological based approaches to forestall stigmatization
  6. 6. Classification A. Delusional beliefs : i. Delusional infestation ii. Olfactory delusion iii. Morgellons syndrome
  7. 7. B. Obsessive and compulsive disorders: i. Body dysmorphic disorder ii. Lichen simplex chronicus and nodular prurigo iii. Skin picking disorder iv. Acne excoriee v. Trichotillomania/trichotillosis vi. Onychotillomania and onychophagia vii. Health anxieties(dirt, infection and wart phobias, mole and cancer phobias)
  8. 8. C. Eating disorders: i. Anorexia nervosa ii. Bulimia nervosa D. Psychogenic itch: i. Psychogenic pruritus
  9. 9. E. Factitious skin disease: i. Dermatitis artefacta ii. Dermatitis simulata iii. Dermatological pathomimicry iv. Dermatitis passivata v. Malingering vi. Pseudologia fantastica and munchausen syndrome vii. Fabricated and induced illness
  10. 10. F. Deliberate self-harm: i. With suicidal ideation ii. Without suicidal intent G. Others: i. Cutaneous disease and alcohol misuse ii. Depression in dermatological patient iii. suicide
  11. 11. Delusional Beliefs
  12. 12. Delusional infestation  (ekbom disease, delusional parasitosis, parasitophobia, monosymtomatic delusional hypochondriasis)  It is an uncommon but very disabling condition where the patient is convinced that he or she is infested with a mite, parasite, bacteria, worm, insect, virus or animate material. Epidemiology • Incidence • Age • Sex • Ethnicity Associated diseases:
  13. 13.  Itching  Biting  Burning or  Crawling sensations on the skin that may be localized or generalized.  These sensations may be intermittent, or more often, persistent and disabling. Clinical Features
  14. 14. Investigations  Skin Biopsy  MRI Brain Specimen sign
  15. 15. Management
  16. 16. Olfactory delusions (Bromidrosiphobia,Cacosmia, Phantosmia) The association of an “intrinsic” smell hallucination and a “contrite” reaction in the absence of a history of preceding depression’ (though anxiety and depression may be a consequence of ORS)  More common in young male adults (male : female 4.5 : 1), and occurs in all ethnic groups. Associated diseases include:  Depression.  Obsessive–compulsive disorders.  Body dysmorphic disease.  Dementia.  Temporal lobe epilepsy.
  17. 17. Differential diagnosis  A genuine body odour  Trimethylaminuria  Temporal lobe epilepsy  Other organic brain disease: Dementia, Parkinson disease, Brain tumour.
  18. 18. Management
  19. 19. Morgellons syndrome The phenomenon comprises: • Sensations of crawling, stinging and biting under the skin. • Sores that do not heal. • Fiber‐like filaments, granules and crystals that appear on or under the skin lesions . • Joint and muscle pain and fibromyalgia. • Debilitating fatigue. • Cognitive dysfunction, poor concentration and memory. Treatment : Pimozide, risperidone together with topical antiseptics, systemic antibiotics and (sometimes) phototherapy.
  20. 20. Obsessive and compulsive behaviour
  21. 21. Body dysmorphic disorder  It is characterized by preoccupation with a real or an imagined defect in physical appearance, or if there is a slight physical anomaly, concern is out of proportion to the anomaly.  Occurs in 1-2% of general population  The female to male ratio is 2 : 1, more in adolescents  Management: i. Treatment of skin ii. Education for patient and family iii. SSRIs iv. CBT v. Antipsychotics
  22. 22. Lichen simplex chronicus and nodular prurigo  Regular rubbing and pressure on the skin produces characteristic thickened, coarsely grained papules and nodules with hyperpigmentation.  Sites: Nape and sides of the neck, elbows, thighs, knees and ankles  Lesions may be in varying stages of evolution, from early, small, violaceous papules with surface excoriations to chronic areas that present as hyperkeratotic plaques with pigment changes, described as ’dermatological worry beads’.
  23. 23. Lichen simplex chronicus
  24. 24. Skin picking disorder (Dermatotillomania):-  Recurrent picking accompanied by visible tissue damage and functional impairment.  Clinical features:-Lesions may be quite deep extending into the dermis. Older lesions show pink or red scars, some of which may be hypertrophic. Chronic lesions may also show atrophic scars.
  25. 25. Management Lichen simplex chronicus Skin picking disorder
  26. 26. Acné excoriée  Common particularly in adolescent girls under emotional stress  It is a variant of skin picking disorder with the lesions largely confined to the face i.e. around the hairline, forehead, pre-auricular cheek and chin areas.
  27. 27. Acné excoriéeAcute excoriations and chronic, scarred, atrophic lesions due to pathological picking on face, neck and shoulders
  28. 28. Management  Topical retinoids/antibiotics  Systemic antibiotics  Habit reversal  Cognitive Behavioural Therapy and other talk therapies  Selective Serotonin Reuptake Inhibitors  Isotretinoin  Phototherapy  Other antidepressants, e.g. mirtazapine  Mood stabilizers  Lasers  Hypnosis
  29. 29. Trichotillomania/Trichotillosis  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.  Diagnostic criteria:- a. Recurrent pulling out of one’s own hair resulting in hair loss. b. An increasing sense of tension immediately before pulling out hair or when attempting to resist behaviour. c. Pleasure, gratification or relief when pulling out the hair. d. Disturbance is not better accounted for by another mental disorder. e. Disturbance provokes clinically marked distress and/or impairment in occupational, social or other areas of functioning.
  30. 30. Clinical features:  Short, irregular, broken and distorted hair.  Plucking activity are centrifugal from a single starting point or linear, in wave-like activity. Trichobezoar :  Ball-like aggregations of fibre- like materials( hair) in stomach and small intestine.  Swallowed hair is retained within folds of gastric mucosa. Rapunzel Syndrome:  A trichobezoar with a tail that extends at least to the jejunum. Trichotillomania
  31. 31. Endoscopic image of a trichobezoar extending into the pylorus
  32. 32. Rapunzel Syndrome
  33. 33. Investigations  Diagnosis is clinical  Scalp biopsy is rarely needed to distinguish trichotillosis from scarring Alopecia.  Barium contrast and CT scan:-gastrointestinal bezoars
  34. 34. Management  Habit reversal  CBT  SSRIs  Hair weaves  Hair extensions  Treatment of any iron deficiency  Treatment of keloid  Mood stabilizers (e.g. gabapentin and pregabalin)  Antipsychotics  Topiramate  Phototherapy
  35. 35. Onychotillomania and Onychophagia
  36. 36. Cutaneous phobias • Fear of contamination, e.g. dirt phobia, germ phobia, wart phobia  Fear of malignancy, e.g. cancer phobia, mole phobia
  37. 37. Eating Disorders
  38. 38. Anorexia and Bulimia nervosa  Anorexia nervosa must satisfy the criteria for:- 1. 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 2. A distorted perception of weight, size and body configuration 3. Amenorrhea  Bulimia nervosa is defined by the following: 1. Recurrent and compulsive overeating episodes (binge eating) 2. Recurrent and inappropriate compensatory behaviour in order to avoid gaining weight; these include induced vomiting and abuse of diuretics and laxatives 3. Binge eating and weight reduction behaviours occurring at least twice per week for 3 months 4. Self-esteem affected by weight and body configuration.
  39. 39. Cutaneous manifestations  Xerosis and pruritus.  Russell’s sign (knuckle pads from chewing the skin overlying the knuckles)  Nutritional disease: Pellagra, Dermatitis enteropathica, Anaemia and hair loss secondary to iron deficiency.  Cutaneous microvasculature: Raynaud phenomenon, Acrocyanosis and Perniosis.  Hair abnormalities: Hypertrichosis, Hair loss.
  40. 40. Psychogenic Pruritus
  41. 41. Psychogenic itch  Pruritus is a multifactorial symptom.  Misery and colleagues have proposed diagnostic criteria for psychogenic pruritus. There are three compulsory criteria: 1. Localized or generalized pruritus sine material. 2. Chronic pruritus (>6 weeks). 3. Absence of a somatic cause
  42. 42. Management First line: i. Emollients ii. Topical steroids iii. Antihistamines iv. Behaviour oriented therapy(Habit reversal treatment) Second line: 1. Tricyclics(doxepin, amitriptyline) 2. SSRIs (fluoxetine, citalopram) 3. Phototherapy, Photochemotherapy 4. Cooling creams e.g. 2%menthol Third line: 1. Mood stabilizing antidepressents(trazadone, duloxetine)
  43. 43. Factitious skin disease
  44. 44. Definition by DSM-5 A. Falsification of physical or psychological signs and symptoms, or induction of injury or disease, associated with identified deception. B. The individual presents himself or herself to others as ill, impaired or injured. C. The deceptive behaviour is evident even in the absence of obvious external rewards. D. The behaviour is not better explained by another mental disorder such as a delusional disorder or another psychotic disorder.
  45. 45. TYPES  Dermatitis artefacta  Dermatitis simulata  Dermatological pathomimicry  Dermatitis passivata  Malingering  Pseudologia fantastica and Münchausen syndrome
  46. 46. Dermatitis artefacta  Caused entirely by actions of fully aware (i.e. not consciously impaired) patient on the skin, hair, nails, scalp or mucosae.  Occurs in children from age of 8 years onwards, pre- pubertal children having an equal sex ratio, rising to 3:1 female predominance in early teens. In adults F>M.  Due to psychosocial stress of a major life event
  47. 47. Clinical features  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.
  48. 48.  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
  49. 49. Dermatitis factitia. Crude, linear, angulated and destructive factitious dermatitis straight edges and sharp angulation of lesions.
  50. 50. Non‐healing wound after surgery with characteristic central ’interference haemorrhage’. Dermatitis factitia showing the drip sign
  51. 51. Clinical variants  Factitious cheilitis.  Factitious nail disease.  Hair artefact.  Witchcraft syndrome.  Constriction artefact.  Purpura artefact.  Dermal artefact.  Postsurgical artefact.
  52. 52. Factitious cheilitis due to repeated lip sucking. Factitious nail disease
  53. 53. Glue applied to look like herpes zoster Dermatitis simulata
  54. 54. Dermatitis passivata  Young Diogenes syndrome; accretions of facial keratin and debris
  55. 55. Fabricated and induced illness  Münchausen syndrome by proxy where the illness in a child is fabricated by the parent, usually the mother The most common presentations are:  Bleeding and bruising (44%),  Central nervous system depression (19%),  Apnoea (15%),  Diarrhoea (11%),  Vomiting (10%),  Fever (10%)  Rash(9%).
  56. 56. Deliberate self‐harm
  57. 57. With suicidal ideation Without suicidal intent  Self‐mutilating behaviour is often grouped with other behaviours, such as self‐poisoning, attempted hanging or jumping from heights, as ’parasuicide’ or ’deliberate self‐harm’  It is the self‐injurious behaviour, or self‐mutilation, occurring outside the context of conscious suicidal ideation Treatment: • Selective Serotonin Reuptake Inhibitors • Dopamine antagonists • Opiate antagonists • Mood stabilizers, • β‐blockers • Analgesics
  58. 58. THANKYOU