The Pass, Manitoba
Abstract: Twenty-two yo homemaker with three to four year history of excoriations on face, arms and chest.
HPI: This woman's chief complaint was "itching and pimples." She grew up in a dysfunctional family ~ 100 miles from where she now lives . Her father was an alcoholic who was physically and verbally abusive to her mother, her younger sister and herself. She denies sexual abuse. She was diagnosed with ADHD at age eight and has been treated for that since then with Ritalin. The also suffers from migraines. The patient went to college for two years and was studying sociology but ran out of money and dropped out. She is now married with an 18 month old child and her husband is deployed in Afghanistan with the Canadian forces.
O/E: The patient is an obese somewhat unkempt young woman. She has excoriations on her face, arms and chest. Many (mostly atrophic) scars on arms and chest. Back spared. Many of the excoriations have serous crusts.
Photographs:
Diagnosis: Excoriations in a young woman. This is more serious than acne excoriee. These type of lesions are self-inflicted but the patient is often not aware of doing this or will deny having done so. Many of these patients (who are almost always woman) have a history or abusive childhoods (physical and/or sexual). This is a form of "self-harm" behavior. These patients often fall into a no-man's zone between dermatology and psychiatry and prove difficult to treat.
Questions: How would you approach a similar patient?
Special Comments: Here are in-depth comments from two experts in this area, Drs. Anna Luise Kirkengen and Caroline Koblenzer.
Special Comments: Here are in-depth comments from two experts in this area, Drs. Anna Luise Kirkengen and Caroline Koblenzer.
References:
1. Shenefelt PD. Using hypnosis to facilitate resolution of psychogenic excoriations in acne excoriée. Am J Clin Hypn. 2004 Jan;46(3):239-45. pshenefe@hsc.usf.edu
Abstract: Hypnotic suggestion successfully alleviated the behavioral picking aspect of acne excoriée des juenes filles in a pregnant woman who had been picking at the acne lesions on her face for 15 years. Acne excoriée is a subset of psychogenic or neurotic excoriation. Conventional topical antibiotic treatment was used to treat the acne. Compared with other treatments for uncomplicated acne excoriée, hypnosis is relatively brief and cost-effective and is non-toxic in pregnancy.
2. Arnold LM, Auchenbach MB, McElroy SL. Psychogenic excoriation. Clinical features, proposed diagnostic criteria, epidemiology and approaches to treatment. CNS Drugs. 2001;15(5):351-9.
Women's Health Research Program, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA. arnoldlm@email.uc.edu
Abstract: Psychogenic excoriation (also called neurotic excoriation, acne excoriée, pathological or compulsive skin picking, and dermatotillomania) is characterised by excessive scratching or picking of normal skin or skin with minor surface irregularities. It is estimated to occur in 2% of dermatology clinic patients and is associated with functional impairment, medical complications (e.g. infection) or substantial distress. Psychogenic excoriation is not yet recognised in the DSM. We propose preliminary operational criteria for its diagnosis that take into account the heterogeneity of behaviour associated with psychogenic excoriation and allow for subtyping along a compulsivity-impulsivity spectrum. Psychiatric comorbidity in patients with psychogenic excoriation, particularly mood and anxiety disorders, is common. Patients with psychogenic excoriation frequently have comorbid disorders in the compulsivity-impulsivity spectrum, including obsessive-compulsive disorder, body dysmorphic disorder, substance use disorders, eating disorders, trichotillomania, kleptomania, compulsive buying, obsessive-compulsive personality disorder, and borderline personality disorder. There are few studies of the pharmacological treatment of patients with psychogenic excoriation. Case studies, open trials and small double-blind studies have demonstrated the efficacy of selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors in psychogenic excoriation. Other pharmacological treatments that have been successful in case reports include doxepin, clomipramine, naltrexone, pimozide and olanzapine. There are no controlled trials of behavioural or psychotherapeutic treatment for psychogenic excoriation. Treatments found to be effective in case reports include a behavioural technique called 'habit reversal'; a multicomponent programme consisting of self-monitoring, recording of episodes of scratching, and procedures that produce alternative responses to scratching; and an 'eclectic' psychotherapy programme with insight-oriented and behavioural components.
1. Shenefelt PD. Using hypnosis to facilitate resolution of psychogenic excoriations in acne excoriée. Am J Clin Hypn. 2004 Jan;46(3):239-45. pshenefe@hsc.usf.edu
Abstract: Hypnotic suggestion successfully alleviated the behavioral picking aspect of acne excoriée des juenes filles in a pregnant woman who had been picking at the acne lesions on her face for 15 years. Acne excoriée is a subset of psychogenic or neurotic excoriation. Conventional topical antibiotic treatment was used to treat the acne. Compared with other treatments for uncomplicated acne excoriée, hypnosis is relatively brief and cost-effective and is non-toxic in pregnancy.
2. Arnold LM, Auchenbach MB, McElroy SL. Psychogenic excoriation. Clinical features, proposed diagnostic criteria, epidemiology and approaches to treatment. CNS Drugs. 2001;15(5):351-9.
Women's Health Research Program, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA. arnoldlm@email.uc.edu
Abstract: Psychogenic excoriation (also called neurotic excoriation, acne excoriée, pathological or compulsive skin picking, and dermatotillomania) is characterised by excessive scratching or picking of normal skin or skin with minor surface irregularities. It is estimated to occur in 2% of dermatology clinic patients and is associated with functional impairment, medical complications (e.g. infection) or substantial distress. Psychogenic excoriation is not yet recognised in the DSM. We propose preliminary operational criteria for its diagnosis that take into account the heterogeneity of behaviour associated with psychogenic excoriation and allow for subtyping along a compulsivity-impulsivity spectrum. Psychiatric comorbidity in patients with psychogenic excoriation, particularly mood and anxiety disorders, is common. Patients with psychogenic excoriation frequently have comorbid disorders in the compulsivity-impulsivity spectrum, including obsessive-compulsive disorder, body dysmorphic disorder, substance use disorders, eating disorders, trichotillomania, kleptomania, compulsive buying, obsessive-compulsive personality disorder, and borderline personality disorder. There are few studies of the pharmacological treatment of patients with psychogenic excoriation. Case studies, open trials and small double-blind studies have demonstrated the efficacy of selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors in psychogenic excoriation. Other pharmacological treatments that have been successful in case reports include doxepin, clomipramine, naltrexone, pimozide and olanzapine. There are no controlled trials of behavioural or psychotherapeutic treatment for psychogenic excoriation. Treatments found to be effective in case reports include a behavioural technique called 'habit reversal'; a multicomponent programme consisting of self-monitoring, recording of episodes of scratching, and procedures that produce alternative responses to scratching; and an 'eclectic' psychotherapy programme with insight-oriented and behavioural components.
3. Arnold LM, McElroy SL, et. al. Characteristics of 34 adults with psychogenic excoriation. J Clin Psychiatry. 1998 Oct;59(10):509-14.
Biological Psychiatry Program, University of Cincinnati Medical Center, Ohio 45267-0559, USA.
Abstract: BACKGROUND: Psychogenic excoriation, characterized by excessive scratching or picking of the skin, is not yet recognized as a symptom of a distinct DSM-IV disorder. The purpose of this study was to provide data regarding the demographics, phenomenology, course of illness, associated psychiatric comorbidity, and family history of subjects with psychogenic excoriation. METHOD: Thirty-four consecutive subjects were recruited from an outpatient dermatology practice and by advertisement. Subjects completed the Structured Clinical Interview for DSM-IV augmented with impulse control disorder modules, the Yale-Brown Obsessive Compulsive Scale, and a semistructured interview for family history, demographic data, and clinical features. RESULTS: Most subjects were women who described a mean age at onset of 38 years and a chronic course. Subjects excoriated multiple sites, most frequently the face. The behavior caused substantial distress and dysfunction. All 34 subjects met criteria for at least 1 comorbid psychiatric disorder, with a mood disorder the most common. Family histories were notable for depressive disorders and psychoactive substance use disorders. Most subjects experienced both mounting tension before excoriation and relief after excoriation as in impulse control disorders. A minority of subjects excoriated skin as part of obsessive-compulsive disorder. Body dysmorphic disorder with preoccupation about the skin's appearance precipitated excoriation in about a third of subjects. CONCLUSION: Psychogenic excoriation is chronic, involves multiple sites, and is associated with a high rate of psychiatric comorbidity. The behavior associated with the excoriation is heterogeneous and spans a compulsive-impulsive spectrum. Most subjects in this sample described features of an impulse control disorder.
4. Mohammad Jafferany, M.D. Psychodermatology: A Guide to Understanding Common Psychocutaneous Disorders. Prim Care Companion J Clin Psychiatry. 2007; 9(3): 203–213.
Abstract: More than just a cosmetic disfigurement, dermatologic disorders are associated with a variety of psychopathologic problems that can affect the patient, his or her family, and society together. Increased understanding of biopsychosocial approaches and liaison among primary care physicians, psychiatrists, and dermatologists could be very useful and highly beneficial. This article is available free Full Text.
Given the clinical picture and the history of this patient, the diagnosis of acne excoriee is appropriate. In my experience some self picking of lesions is common among acne patients; it becomes problematic when it becomes a repetitive behaviour despite advice not to indulge in it. In this scenario I have seen that patients unconsciously and sometimes even consciously do it as a stress relieving mechanism. Very rarely (in my experience), it is a component of body dysmorphic disorder. I would like to agree with the concept of it being a subset of neurotic excoriations.Dermatillomania is a convincing concept for me to include all such self picking behaviour.
ReplyDeleteNow as far as therapy for such patients is concerned, they do need anti-acne medications however more important is a frank discussion with the patient about his/her 'behaviour'.In my experience referral to a psychiatrist is not perceived receptively by the patient; I have seen patients rebelling against this by indulging in more severe picking. Repeated discussions with the patient by the treating dermatologist in a relaxing confidential environment of the OPD might yield better results than referring the patient to a psychiatrist. However if skin picking is just a part of a more generalized behavioural/mental disorder then a referral is indeed warranted.
I agree this is on the spectrum of acne excoriee to body dysmorphic syndrome. I used to go progressively from sertraline to pimozide - now I go straight to risperidone. Also, they insist on touching their face - so I prescribe Aknemycin ointment, to make their fingers more slippery!
ReplyDeleteYour patient has dermatitis artefacta (vs acne excoriee, dermatitis paraartefacta or delusions). By definition she appears to have periods of dissociation. Explaining to her that she is doing it will not work. You will have to approach it from the point of view that this must be very distressing for her, and she must suffer a lot. You need to establish a very good rapport, and I do it in many sessions. You can always punt to the next one by ordering blood tests, scape skin and tell her you will examine and study the material and need time to do it. AND keep pressing the issue of suffering. Maybe at one point you can slowly introduce the notion that she is doing it herself. At one point you must introduce antidepressants and Abilify (with the risk that she already has metabolic syndrome). I sell Abilify as an antidepressant (as advertised on TV). I agree that most probably she was abused as a child. That may be part of her dissociative disorder. She needs therapy with a very skilled psychotherapist (hard to find) since her insight is zero and her self image is very deteriorated.
ReplyDeleteBottom line: Convince her that she is doing it while she sleeps (nobody can argue against that...). Have her trim her nails real short, and press the need to address other aspects of her life. Treat what she thinks is acne. But I don’t think that you can succeed. These are very very difficult patients. They are up there with the delusional ones. Pancho Tausk
From Anna Luise Kirkengen, author of The Lived Experience of Violation: "I have read your case-description and have the following comments:
ReplyDeleteCertainly has this young woman been seriously violated as a child, no matter how the combination of adversities. She has learned that she is not worth being respected and taken care of - and she is seriously distressed, as expressed in her obesity, indicating a constant increased HPA-axis activity, and implying the risk of metabolic syndrome, diabetes II, and cardiovascular disease. Her husband is in a war zone, which certainly causes her both fear, distress, and constant reactivation of "experienced war" at home: this young woman probably feels chronically and deeply endangered. Although married, she is in praxis a single mother of a toddler - who certainly perceives the stress of the mother and most probably is a "demanding child" in his mother's daily life, which, in turn, again fuels her distress and increases her powerlessness.
It is quite logic that a girl growing up in a violent and abusive household expressed her existential fear in "disturbed" behavior. How could one expect that a child, forced to adapt to a disordered life, could behave "as if nothing". Unfortunately, child psychiatrist have such a narrow and limited perspective that diagnosing and medicalizing the child for being "disordered" typically seems to be the only thing they can do or are willing to do. And since she was defined as "diseased", and since nobody interfered as to her home-conditions, she even might conceptualize herself as diseased instead of as violated.
According to the literature, her child is at increased risk for being "diagnosed" for the same kind of "mental disorders" within a few years. And the child's situation will not improve when his daddy returns from war, most probably marked in one way or another.
David, as far as I can see, you cannot succeed in "treating her skin disease" as long as this young woman does not receive help to identify the most typical of triggers for her attacks on her own skin. A close and open cooperation between you, the patient, and a psychologist or a Gestalt-therapist might provide an entrance into insight - for the patient and her therapists alike - into what feels most "overpowering" in her daily life and from day to day. Identifying the most obvious - and from there proceeding to the more convoluted - of "intolerable" (because too similar to something frightening, recalling the past) perceptions, she might gradually be able to counteract her destructive and partly dissociated impulses and become enabled to react differently. Increasing self-awareness might enhance her self-respect, making her less self-despising and self-neglecting.
As an insightful and skilled expert you could make the crucial difference in her life by supporting her in a therapeutic triangle aiming at increased self-awareness and self-respect. This, in turn, would be the most efficient preventive intervention with regard to her child's (and future children's) health and cognitive development. By supporting a young mother, you could save a child."
I came here looking at what self induced skin acne looked like; my Dx from a Derm Dr early in the year says I caused my skin issues. OMG I was like no way as you said this woman will say. This led me here today curious since my lesions after 5 years have almost all stopped with in the past few months since I have been using Low Dose Naltrexone (LDN) a endorphin induced / OGF to help with my Fibromyalgia pain and fatigue for the past 8 months. Admit, LDN has some anti depressive properties if you have EDS, (endorphin deficiency syndrome) due to the 300-400 more endorphins your body makes after the 4-6 hours of metabolizing, taken at bedtime, the wee hours of the morning LDN is working and you wake up feeling much better and less pain, this has proven to work on 84% min of patients. THEY SAY exercise helps pain, due to the release of endorphins? WELL GET THEM IN A CAPSULE TOO!! I have less pain and less fatigue, it’s been an amazing treatment for my Fibromyalgia, and in turn, a bonus for my skin too!! I found this treatment from Stanford Medical School’s study on Fibromyalgia. So rather I was doing this to myself or not, bottom line a 3.0 mg treatment of LDN has treated my health and skin issues. I am grateful for my NEVER GIVE UP mind to find something to get me out of bed and feel almost human again. With my success of treatment I have had I belong to a LDN support page on facebook so anyone wanting to know more look up GOT ENDORPHINS? LDN on facebook or go to www.lndscience.org and watch the video and read all about it or many of the other LDN sites on GOOGLE search. Just Google LDN!! THIS LDN was mainly used in the 80s for AIDS and MS patients but has since helped many others since then, is generic and been around many many years as a 50mg treatment, but LOW DOSE of 1.75-4.5 mg helps many other issues!!! Use a trusted compounding pharmacy, regular release must be used and certain fillers can not be used. Skips Pharmacy in Florida has been doing LDN for many years and the owner uses LDN himself for many years for RA. Don’t use a pharmacy that simply grinds up 50 mg tablets, no way will you get an exact dosing that way, use someone trusted who buys pure naltrexone powder and makes up capsules from that... I personally use 50 ml of distilled water and drop a 50 mg naltrexone tablet in the sterile bottle, and dose from there. I keep mine in the fridge and make a fresh batch made every 4 weeks. LDN is still UNKNOWN by many Doctors who don’t continue their education, My Doctor admitted he was TOO LAZY to learn anymore about Fibromyalgia and LDN even with my urging of him to review the Stanford Study, so I had to buy my own from India trusting the source many LDNers have used for years. Join the LDN Yahoo group, lots learn from them too! GOD BLESS and good luck!!
ReplyDeleteI would also like to add, Doctors, please first do no harm to your patients to my LDN comment, LOW DOSE NALTREXONE is a very minor drug treatment, and BIG Pharma will be damned to let this generic drug in low doses get out there in the masses, they will go broke!!! So its a great people powered medicine! YEAH for those who posted on LDN sites how it helped them and for Dr Younger at Stanford who was kind enough to reply to my emails. Cheers
ReplyDelete