On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.84 no.5 Rio de Janeiro Sept./Oct. 2009
Cinthia Janine Meira AlvesI; Antônio Carlos Ceribelli MartelliII; Renata Bilion Ruiz PradoIII; Mariane da Silva FonsecaIV
IResident Physician in Dermatology,
Instituto "Lauro de Souza Lima" Bauru (SP), Brazil
IIDermatologist, Head of the Technical Section in Dermatology, Instituto "Lauro de Souza Lima" Bauru (SP), Brazil
IIIMaster in Psychology Scientific Researcher, Instituto "Lauro de Souza Lima" Bauru (SP), Brazil
IVMaster in Psychology Psychologist, Instituto "Lauro de Souza Lima" Bauru (SP), Brazil
Among psychiatric dermatoses, the psychogenic excoriation is characterized by patient's confession to provoking the lesions, without presenting any dermatological underlying pathology. This topic has been rarely approached in the literature, focusing on the diversity of psychological diagnoses. Epidemiological data indicated that prevalence varies from 2 to 3% in the general population, 2% among dermatological patients and 9% in patients with itching, with significant prevalence in women. The present article report three Brazilian cases and discusses the therapeutic plan based on multidisciplinary teamwork,including indications of psychotherapy and specific drug therapy to each case.
Keywords: Dermatology; Diagnosis; Psychology; Therapeutics
The interface between health care areas has become a fertile field for investigations of complex phenomena. The need to add relevant knowledge between different fields led to Integrative Dermatology, focus on Psychoneuroimmunology, which aims at the interrelation between body and soul of subjects and management of alternative ways to minimize stress and to optimize efficiency of treatment1.
Committed with the task to integrate the work of psychologists and dermatologists, Psychodermatology intends to investigate and treat dermatoses that present susceptible factors to psychological determinants 2,3.
Torres emphasized the importance of understanding psychiatric manifestations present in dermatoses; thus, the case discussion in interdisciplinary team may reveal an effective strategy for the complexity of symptoms that the patients have 4,5.
Martelli6 clarified about the psychiatric disorders associated with obscure dermatological presentations, in which lab tests presented negative results. Among these disorders, psychogenic excoriation is a study target considering the scarcity of literature data about it. It is characterized by the patient admission to having caused the lesions, which is the key for the differential diagnosis with dermatitis artifacta 6. The same disorder is also known under other names 6-8.
Epidemiological data indicate a prevalence of 2 to 3% in the general population, 2% among dermatological patients and 9% in patients with pruritus. Excoriations are self-inflicted in the areas easily accessed by the hands. The predominance of this disorder is significant in women, and may affect them at any age range 6.
The most common underlying psychopathological conditions are depression and anxiety, borderline personality disorder, body dimorphic disorder, substance abuse disorder, eating disorders, trichotillomania and kleptomania. Other elements that may be identified are self-destructive behavior, difficulty to express anger and obsessive-compulsive disorders 6.
According to the Diagnostic and Statistical Mental Disorder Manual, psychogenic excoriation may be classified in the chapter of Impulse Control Disorders, whose act of self-inflicting lesions is a response to the feeling of increased tension or associated with attempts to resist this feeling 9.
To present, medical treatment of psychogenic excoriation consists in the indication of antidepressants or anti-psychotics. Among the non-drug based therapeutic alternatives, the literature refers behavioral psychotherapy, either focal or brief 10-12.
Case 1: Female Caucasian patient, 45 years old, married, presented psychogenic excoriations, onychophagia and onychotillomania. Laboratory tests presented negative results. The physicians prescribed tricyclic antidepressant and psychotherapy. After two-year follow-up, she still maintained excoriations and lip biting (Figure 1), which also required prescription of selective serotonin reuptake inhibitor. To present, the patient has only lip biting and has been taking selective serotonin reuptake inhibitor and psychotherapy. The final diagnosis was obsessive-compulsive personality disorder 9. The patient shows great concern for organization, perfectionism and control over the others; she is excessively dedicated to her work, excluding all leisure activities; excessive compliance with rules and lists; she follows strict moral principles. Her repressed feelings are perceived by her ambivalence to satisfy the others and at the same time her wish to keep them apart. Now the patient realizes her limits, completes home chores without strict rules, has improved her self-esteem and reduced the clinical symptoms.
Case 2: Female Caucasian patient, 40 years old, married, lived with her two children and husband, and presented extensive area of excoriation for eight years (Figure 2). She reported that her son and her husband had similar lesions. Laboratory tests were negative. During childhood, the patient produced the same lesions on her mother's back, especially during the night, and she had compulsiveness for spending money and eating. As a result of the diagnosis of psychogenic excoriations, she was prescribed selective serotonin reuptake inhibitor and tricyclic antidepressants and referred to psychotherapy. The diagnosis was borderline personality disorder, owing to instability in interpersonal relationships, self-image, affection and impulsiveness.
Currently, the patient understands that the excoriation is a process to express repressed emotional contents.
Case 3: Female Caucasian patient, 49 years old, single, lived with her mother, presented excoriations in the limbs (Figure 3), periungueal and ungueal affections of haluxes (Figure 4), followed by weight gain. The diagnosis of psychogenic excoriation was made and she was prescribed tricyclic antidepressant with appropriate control of lesions. During follow-up, she presented significant worsening with onset of excoriations of the face and dorsum associated with a car accident and job loss, for which she was prescribed selective serotonin reuptake inhibitor. During follow-up, she had worsening of her manifestations, anxiety, contact dermatitis of the hands (contact test was positive for thimerosal and nickel sulfate). Follow-up was irregular with dissatisfactory response to prescribed medications, and then an atypical antidepressant was introduced. The diagnosis was impulse control disorder and eating disorder. She had instability of interpersonal relationships and impulsiveness since adolescence and a borderline personality disorder was diagnosed. Currently, the patient has better sense of control, improved her self-expression skills and family communication.
In the analysis of these three cases, symptoms may be understood as a form of symbolic manifestation of the psychic. Disease is a way that the body reacts to psychophysiological imbalances, leading the subject towards the integration of repressed, denied or suffered psychological contents. When psychological processes find barriers to be approached by verbal representation, the organisms tends to express through somatic terms and the emotional content finds as a symbolizing body correspondent 12.
The diagnostic criteria for psychogenic excoriation were defined for the three reported cases, but through meetings with the interdisciplinary teams, common and uncommon aspects were detected in the three patients.
Even though different psychological diagnoses were made, some aspects are common among the cases: emotional trauma suffered during childhood development, experienced as abandonment; poorly-adapted childhood with restricted affective links; adult age with difficulty to perform tasks that required emotional maturity and skills to control the impulses.
Another converging aspect concerns poor commitment with medical treatment, which initially limited the action of the team and efficacy of treatment. Therefore, drug therapy should consider the peculiarities of each patient, and for its definition it is essential to review clinical cases as part of a multidisciplinary team.
The uncommon points of the cases reported here referred to mental disorder type: borderline personality disorder, obsessive compulsive disorder, and impulse control disorder. The variation in psychological components involved different psychological therapies in each situation. The use of brief psychotherapy in these three cases enabled professionals to investigate the use of other therapeutic possibilities. Another uncommon aspect between the cases concerned the medication therapy, which should always consider the specificities of each patient.
The analysis of these three cases represents a source of research for later studies, both to investigate the guidelines for diagnostic assessment and to analyze treatment alternatives.
To Prof Dr Dejair Caitano do Nascimento, Ph.D. in Pharmacology, Scientific Researcher of Instituto Lauro de Souza Lima, for his contributions with the discussions related with pharmacological aspects of the drugs referred by this paper.
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Cinthia Janine Meira Alves
Endereço completo: Rodovia Comandante João
Ribeiro de Barros, Km 225/226
17034 971 Bauru, SP
Tel./Fax: 14 3103-5887 / 8122-7372 / 3103-5914
Conflict of interest: None
Financial funding: None
How to cite this article: Alves CJM, Martelli ACC, Prado RBR, Fonseca MS . Variabilidade de diagnósticos psicológicos frente à avaliação dermatológica da escoriação psicogênica. An Bras Dermatol. 2009;84(5):534-7.