Annotations by J. Jewel Shim, MD, FAPM
January 2017
Of interest:
Tomas-Aragones L, Consoli SM, Consoli SG, Poot F, Taube KM, Linder MD, et al: Self-inflicted lesions in dermatology: A management and therapeutic approach – a position paper from the European Society for Dermatology and Psychiatry
Acta Derm Venereol 2016 Aug 26 [Epub ahead of print]While the target audience for this paper is the dermatologist, it nevertheless provides a comprehensive summary of the general psychological characteristics of patients who engage in self-inflicted skin lesions (SISL) and approaches to management, both somatic and psychotherapeutic treatments, which are also helpful for the PM psychiatrist who may be consulting to a dermatology or primary care clinic.
Smulevich AB, Lvov AN, Romanov DV: Hypochondriasis circumscripta: A neglected concept with important implications in psychodermatology
Acta Derm Venereol 2016; 96(217):64-68This is an interesting paper that describes “hypochondriasis circumscripta” as a specific clinical entity, in which individuals engage in “conscious repetitive autodestruction of focal skin loci.” The authors assert that this disorder is distinct from other phenotypically similar disorders involving the skin, including dermatitis artefacta, which is a type of factitious disorder where individuals self-inflict skin lesions, excoriation disorder, an OCD spectrum disorder, and delusional parasitosis in that the motivations underlying the destruction of the skin are conscious, individuals lack other OCD symptoms, and there is an absence of psychotic or delusional thinking. The authors describe this condition as being characterized by primary and secondary components. Primary symptoms are represented by sensory phenomena, including somatoperceptive disturbances (“coenasthesiopathy”), intradermal dysesthesia where there may be sensations of penetration or violation of skin integrity, idiopathic pain, tactile illusions, and somatic fantasies (not unlike that experienced in Morgellon’s disease) where there may be “fantastic visual phenomena” in that people will visualize foreign bodies in their own tissue fragments. Secondary symptoms are represented as “over-valued ideas” falling short of delusional in which individuals may perceive skin abnormalities as “alien” and want to “exorcise” them from the skin. Lesions are typically unifocal, self-inflicted ulcers affecting the dermis and subdermal tissues. The course is typically chronic. The study investigators identified 22 consecutive subjects in a dermatology clinic and were diagnosed with hypochondriasis circumscripta by a consultation psychiatrist. They were referred to a multidisciplinary treatment program, including treatment of their skin conditions by a dermatologist, psychotropic medications and cognitive behavioral therapy. Treatment occurred over at least 4 weeks; 8 out of 22 subjects (47.2%) achieved full remission, as measured by VAS-S = 0 (Visual analog scale for skin). Five (29.4%) had partial remission (VAS-S < 50%) and 4 (23.5%) did not respond.
While the quality of the study was not high, it describes a clinical phenomenon distinct from other psychodermatological disorders which may be responsive to psychiatric treatment.
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