The document discusses various psychocutaneous disorders where there is an interaction between the mind, brain, and skin. It categorizes the disorders into psychophysiological disorders like atopic dermatitis and psoriasis that are exacerbated by stress, primary psychiatric disorders without real skin disease, secondary psychiatric disorders that develop due to skin disease, and cutaneous sensory disorders with unpleasant skin sensations but no proven dermatological cause. Treatment involves addressing any underlying psychiatric conditions through therapies like CBT, relaxation training, and medication.

1. DR PRERNA KHAR
JUNIOR RESIDENT-1

2.  Psychocutaneous medicine/psychodermatology-
interaction between mind, brain and skin.
 The brain and skin - formed from the ectoderm and
affected by the same hormones.
 Psychiatry - “internal invisible disease”
dermatology - “external visible disease”
 Significant psychiatric & psychosocial co-morbidity in
30% of dermatology patients.

3. Psychophysiological
disorders
Bonafide skin
disorders
exacerbated by
stress
Eg: Atopic
dermatitis,
psoriasis,alopecia
areata, urticaria
angioedema,acne
vulgaris
Primary psychiatric
disorders
Without real skin
disease but serious
psychopathology
& visible skin
lesions
Eg:Trichotillomania
delusional parasitosis,
psychogenic
excoriation,
onychophagia,
factitious dermatitis
Secondary
Psychiatric disorders
Develop
psychological
problems d/t skin
disease and
associated
disfigurement.
Eg: Adjustment
disorder with anxiety
and depression,
major depressive
disorder, generalized
anxiety disorder.
Cutaneous Sensory
Disorders
Unpleasant
sensation over skin
no proven skin
etiology, in whom
psychiatric
diagnosis may or
may not be evident.
Eg: Idioipathic
pruritis, body
dsymorphic
syndrome ,
pruritis ani,
glossodynia

4.  1. Characteristics of the disorder: congenital condition,
acquired disorder, associated symptoms, location of
the lesion, timing of appearance of lesion wrt age,
chronicity of illness.
 2.Individual characteristics: Personality ,body image
and self schema, skin diseases and relationships.
 3.Cultural attitudes to skin diseases: Often expressed
as stigma. “Skin faliure” leads to discomfort, shame
and isolation.

5.  Relationship B/w stress & skin disorders as mediated
b/w the endocrine, autonomic & immune system.
 Stress response - determined by the individuals
interpretation of the stimulus as distressful & not by
the nature of the stimulus itself.
 IMMUNOMODUALATION: Chronic
stress=Immunosupression and acute =immune
enhancement.
 Stress sets off the HPA axis leading to cortisol release.

7.  Characterised by pruritis, erythema,lichenification
and further scratching (itch-sratch-itch cycle)
 Hygiene hypothesis
 Pathophysiology:
1.Genetic predisposition.
2.psychosocial stress
3.B-endorphin levels higher in AD patients
4.Lower itch threshold in response to emotional upsets.

8.  Psychopathology:
-Higher levels of anxiety & depression.
-Higher traits of excitability & inadequate coping
skills.
-Scheich and colleagues: IgE> 100 IU/ml patients
have higher levels of excitability + inadequate coping
skills.
-Severity of pruritis - with severity of depressive
symptoms.
-Anxiety and depression enhance the itch
perception and scratch response
-Adult AD pts: internalize anger in conflicted
relationships.

9.  Treat the associated anxiety and depression
 Behavioral modalities: habit reversal training to
decrease the itch scratch itch cycle.
 5% doxepin cream effective to decrease the pruritis
 Trimipramine: improves sleep and decreases
scratching during night.
 Other modalities: CBT, relaxation training, stress
management.

10. “I am silvery,scaly. Puddles of flakes form wherever I rest
my flesh. Keen-sighted, though we hate to look upon
ourselves. The name of the disease, spiritually
speaking, is Humiliation”
-Writer John Updike

11.  Epidemiology: Li can trigger
alcohol ingestion.
Psychosocial stress- exacerbates.
 Psychopathology:
-Higher prevalance of Generalised anxiety disorder
major depressive disorder, co-morbid personality
disorders. Social deprivation, stigmatization leads to
depression.
-Patients with touch deprivation had higher
depression scores

12.  Psychopathology contd…….
-Severity of pruritis associated with higher
depression scores and higher risk for suicide.
-Early onset associated with greater difficulty in
expression of anger and patient’s vulnerability to
stress and depression
 Treatment: Medications to treat co-morbid psychiatric
conditions, CBT, Hypnosis

13.  Localized loss of hair in circular / oval areas without
inflammation.
 Psychopathology: depression, anxiety , adjustment
disorder.
 Treatment: Rx co-morbid anxiety, depression with
SSRIs. Relaxation techniques, stress management.

14.  Stress increases catecholamine levels - exacerbation of
lesions.
 Higher anxiety levels - higher blood catecholamine
levels - decrease t/t response to acne.

15.  PSYCHOPATHOLOGY:
1.Disfigurement - depression, anger, social phobia, low
self esteem
2. In teenagers: social interactions, academics.
3. Depressive symptoms: Reaction to body image
concerns. Positive association between acne and poor
self image.
4. Primary psychiatric disorders can add to severity: eg
OCD, delusional disorder.( acne excorie)
ACNE EXCORIE

16.  TREATMENT:
1.CBT, Relaxation training, self hypnosis.
2. Isotretinoin used in acne Rx ? Development of
aggressive and violent behavior. No reports confirm.

17.  Aka angioneurotic edema (preceding stressful onset)
 Ch. Urticaria :- females : males= 2:1
 Adrenergic urticaria: In response to emotional stress.
 Chronic angioedema: Antidepressants( Doxepin) more
effective than diphenhydramine (acc to studies)
URTICARIA
ANGIOEDEMA

18.  Aka :Ekbom syndrome/ acarophobia/ entomophobia.
 Delusion of being infested with parasites.
 Single delusion, no impairment of thought process.
 “Matchbox sign”: Bring pieces of hair/skin/cloth for
examination.
MATCH BOX SIGN

19.  Self Rx: repeated washing, checking and cleaning,
excoriation of skin with knives, needles, fingernails,
excessive use of insect repellants.
 Relatives may share the delusion (folie a deux)
REPEATED EXCORIATIONS

20.  Differential diagnosis:
1.Phobia
2.OCD
3.Psychogenic pruritis.
4.Effects of certain drugs can mimic the delusion
(magnan’s sign, formication)

21.  PATHOGENESIS:
1. Psychic factors: Predisposing factors.
2.Cognitive factors: Triggering
3.Social circumstances: maintaining (isolation,
alienation, avoidance)

22. 3 SUBGROUPS:
DELUSIONAL
DISORDER
Patients with
predominant
hypochondriacal
states.
Patients with
paranoid
delusions and
without
hypochondriacal
traits.
Hypochondrial as
well as paranoid
delusions

23.  TREATMENT:
1. Very important to establish a rapport.
2. Pharmacotherapy: Pimozide (MC) , Riperidone,
Haloperidol.
Pimozide: opiate antagonist( anti-pruritic
action also)

24.  AKA Cutaneous dysesthesia syndrome.
 Itching,pain, crawling, stinging,burning without
primary skin leison.
 Eg: Chr. Idiopathic pruritis, glossodynia, vulvodynia.
GLOSSODYNIA

25.  CHRONIC IDIOPATHIC PRURITIS: intense desire to
itch.
Causes of prutitis:
1. Medical disorders: Leukemia, melanoma, Pellagra.
2. Neurological conditions: Dementia, Multiple sclerosis
3. Psychogenic Pruritis: anxiety disorder, OCD, Major
depression, chronic idiopathic pruritis.
Psychopathology of Chr. Idiopathic Pruritis:
1.Opioids.
2.Depression.

26. NEUROLOGIC PRURITIS PSYCHOGENIC PRURITIS
Lack of sudden onset. Temporal association with
psychiatric symptoms.
Chronic course Unlikely to occur at night
Greater in intensity Paroxysmal nature: Increase
severity, sudden onset and
resolution, symptom free period
U/L or B/L location
Associated with dysesthesia,
allodynia, hyperpathia
Pain accompanied in the same
area often
Insomnia

27.  GLOSSODYNIA: Altered sensation of pain and
burning at tip and sides of tongue.
-associated with anxiety and depression.
-Rx. SSRI
 VULVODYNIA: Chr. Vulvular discomfort.
-Higher prevalance of anxiety.
-Sexual Discomfort.
-Rx: Amytriptyline

28.  PSYCHOGENIC EXCORIATION/ NEUROTIC
EXCORIATION:
-Excessive scratching, rubbing, squeesing.
-accessible areas.
- mc in females (eg acne excorie)
- Psychiatric co-morbidities: OCD, GAD, MDD,
Impulsive / compulsive fs, borderline, OCPD
personalities
-Rx. Fluoxetine , other SSRIs
If impulsive- Na.Valproate

29.  TRICHOTILLOMANIA : Disorder of impulse control.
-mc in females.
3 age
groups
Infants
+Preschool:
habit. Resolves
without t/t
Preadolescents
and adults:
Persists d/t not
seeking t/t
Adults: Frequently
associated with
psychiatric co-
morbidities.

30.  Subtypes of TTM:
 MDD AND GAD: mc association.
 Co-morbid cluster b and c
• D/t urge , bodily
sensation / thought.
• Compulsive behaviour
Focused
Pulling
• Outside the person’s
awareness, mostly during
sedentary activities
• Impulse control disorder.
Automatic
pulling

31.  Pathophysiology:
- familial association b/w TMM and OCD, anxiety
disorders.
- over-activity of cortico-striatal thalamic-cortical
circuit.
 Rx: Behavioral modification
SSRIs

32.  ONYCHOPHAGIA: (nail biting)
- Repetition-resistance-relief.
- Rx: Behavioral modification
Clomipramine.

33.  Skin - target for self induced injuries.
 Methods: excoriation, lacerations.
 Presence of completely normal skin adjacent.
 Vague history given by patient.
 Areas: Easily reached out by dominant hand.
 Females : Males= 8:1, adolescents.
 Onset: After psychosocial stress.
 Patients assume a sick role: medical attention,
secondary gain

34.  PSYCHOPATHOLOGY:
-Personality: MC= Boderline
- Body dysmorphic disorder: may want invasive
procedures to get “ perfect skin”.
-May present with suicidal behaviour.

35.  TREATMENT
-Resistant to accept psychiatric referral.
-Empathic approach.(avoid direct confrontation).

36.  Gardner-Diaomond Syndrome: Spontaneous repeated
bruising post injury/ surgery
 Normal blood investigations( coagulation profile)
 MC in females.
 Proposed theory: - Conversion reaction.
- Factitious disorder.

37.  CTP: Chapter 24.12 Psychocutaneous Disorders.