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DR PRERNA KHARJUNIOR RESIDENT-1
NEUROPSYCHIATRIC MANIFESTAIONS OF
CUTANEOUS DISORDERS
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.
INTRODUCTION
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 lesionsEg:Trichotillomania
delusional parasitosis, psychogenic excoriation,onychophagi
a,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
CLASSIFICATION OF PSYCHOCUTANEOUS DISORDERS
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.
PSYCHOSOCIAL STRESS AND COPING IN SKIN DISORDERS
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.
PSYCHONEUROIMMUNOLOGY
Characterised by pruritis, erythema,lichenification and further scratching (itch-sratch-itch cycle)
Hygiene hypothesisPathophysiology: 1.Genetic predisposition.2.psychosocial stress3.B-endorphin levels higher in AD patients4.Lower itch threshold in response to
emotional upsets.
ATOPIC DERMATITIS
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.
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
pruritisTrimipramine: improves sleep and decreases
scratching during night.Other modalities: CBT, relaxation training,
stress management.
Treatment:
“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
PSORIASIS
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
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
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.
ALOPECIA AREATA
Stress increases catecholamine levels - exacerbation of lesions.
Higher anxiety levels - higher blood catecholamine levels - decrease t/t response to acne.
ACNE VULAGARIS
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
TREATMENT:1.CBT, Relaxation training, self hypnosis.2. Isotretinoin used in acne Rx ? Development
of aggressive and violent behavior. No reports confirm.
Aka angioneurotic edema (preceding stressful onset)
Ch. Urticaria :- females : males= 2:1Adrenergic urticaria: In response to
emotional stress.Chronic angioedema:
Antidepressants( Doxepin) more effective than diphenhydramine (acc to studies)
URTICARIA AND ANGIOEDEMA
URTICARIAANGIOEDEMA
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.
DELUSIONAL DISORDER SOMATIC TYPE:DELUSIONAL PARASITOSIS
MATCH BOX SIGN
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
Differential diagnosis:1.Phobia2.OCD3.Psychogenic pruritis.4.Effects of certain drugs can mimic the
delusion (magnan’s sign, formication)
PATHOGENESIS:1. Psychic factors: Predisposing factors.2.Cognitive factors: Triggering3.Social circumstances: maintaining (isolation,
alienation, avoidance)
3 SUBGROUPS:
DELUSIONAL
DISORDER
Patients with predominant
hypochondriacal states.
Patients with paranoid delusions
and without hypochondriacal
traits.
Hypochondrial as well as paranoid delusions
TREATMENT:1. Very important to establish a rapport.2. Pharmacotherapy: Pimozide (MC) ,
Riperidone, Haloperidol. Pimozide: opiate antagonist( anti-
pruritic action also)
AKA Cutaneous dysesthesia syndrome.Itching,pain, crawling, stinging,burning
without primary skin leison.Eg: Chr. Idiopathic pruritis, glossodynia,
vulvodynia.
CUTANEOUS SENSORY DISORDERS : UNDIFFERTIATED SOMATOFROM DISORDERS
GLOSSODYNIA
CHRONIC IDIOPATHIC PRURITIS: intense desire to itch.
Causes of prutitis:1. Medical disorders: Leukemia, melanoma,
Pellagra.2. Neurological conditions: Dementia, Multiple
sclerosis3. Psychogenic Pruritis: anxiety disorder, OCD,
Major depression, chronic idiopathic pruritis.
Psychopathology of Chr. Idiopathic Pruritis:
1.Opioids.2.Depression.
NEUROLOGIC PRURITIS
PSYCHOGENIC PRURITIS
Lack of sudden onset. Temporal association with psychiatric symptoms.
Chronic course Unlikely to occur at nightGreater in intensity Paroxysmal nature: Increase
severity, sudden onset and resolution, symptom free period
U/L or B/L locationAssociated with dysesthesia, allodynia, hyperpathiaPain accompanied in the same area oftenInsomnia
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
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
OC SPECTRUM DISORDERS
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: Frequentl
y associated
with psychiatri
c co-morbiditie
s.
Subtypes of TTM:
MDD AND GAD: mc association.Co-morbid cluster b and c
Focused Pulling
• D/t urge , bodily sensation / thought.
• Compulsive behaviour
Automatic pulling
• Outside the person’s awareness, mostly during sedentary activities
• Impulse control disorder.
Pathophysiology: - familial association b/w TMM and OCD,
anxiety disorders. - over-activity of cortico-striatal thalamic-
cortical circuit.
Rx: Behavioral modification SSRIs
ONYCHOPHAGIA: (nail biting) - Repetition-resistance-relief. - Rx: Behavioral modification Clomipramine.
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
FACTITIOUS DISORDERS / FACTITIOUS DERMATITIS
PSYCHOPATHOLOGY: -Personality: MC= Boderline - Body dysmorphic disorder: may want
invasive procedures to get “ perfect skin”. -May present with suicidal behaviour.
TREATMENT -Resistant to accept psychiatric referral. -Empathic approach.(avoid direct
confrontation).
Gardner-Diaomond Syndrome: Spontaneous repeated bruising post injury/ surgery
Normal blood investigations( coagulation profile)
MC in females.Proposed theory: - Conversion reaction. - Factitious disorder.
PSYCHOGENIC PURPURA
CTP: Chapter 24.12 Psychocutaneous Disorders.
REFERENCES