Neuropsychiatric manifestaions of cutaneous disorders

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