1. SEMINARDR. DEEPAK KUMAR MATHUR

2. INTRODUCTION Psychodermatology or psychocutaneous medicineencompasses disorders prevailing on the boundary between psychiatry and dermatology. Approximately 30-40% patients seeking treatment for skindisorders have an underlying psychiatric or a psychological problem that either causes or exacerbates a skin complaint. 3. Skinpsyche interactions:- An essential component ofdermatological illness is relationship that somatic dermatology has to psychological status of sufferer at time. The influence that these psychological, psychosocial and sometimes psychiatric factors play can be conveniently assessed as: 1. 2. 3. 4.Multifactorial dermatological disorders which can be substantially influenced by psychological factors, e.g. psoriasis Dermatological disorders as a result of psychiatric illness, e.g. factitious dermatoses, body dysmorphic disorder Psychiatric illness developing as a result of skin disease, e.g. depression, adjustment disorder Co-morbidity with another psychiatric disorder, e.g. alcoholism 4. Stigma Term describes situation of an individual who isdisqualified from full social acceptance. Commonest dermatological situations where stigma is encountered may be:1. Physical deformities:Congenital naevae, e.g. port-wine stain II. Acquired deformities from developmental disorders, e.g. tuberose sclerosis III. Widespread inflammatory skin disease. IV. Surgical or post-traumatic deformities I. 5. Implications of inferred character deficiencies:-2. I.II.III. IV. V. VI. VII.Psychiatric disorder, i.e. their views on the skin disease are disqualified because they also have a psychiatric diagnosis Learning disability, i.e. they have limited emotional capacity to respond to their dermatosis, e.g. Downs syndrome Persistent treatment noncompliance, i.e. an assumption of a fickleness of character, e.g. depressive illness Alcoholism and drug addiction, e.g. the cutaneous signs of substance abuse are a labelling of character weakness Unemployment Imprisonment HIV status 6. 3. Stigma of: Race, e.g. implications of vitiligo for marriage Religion, e.g. allowing the naked body to be seen by a stranger 7. Classification A. Psychiatric disorders without significantdermatological disease:Delusional syndromes:-1. i. ii. iii. iv. v.Parasitosis Smell Impregnation and contamination Folie deux Other hypochondriasis, e.g. so-called Morgellons 8. B. Disorders of awareness of the body:1. Phobias and obsessive compulsive disorders:i. ii.iii. iv. v.vi. vii.Disorders of body image:- body dysmorphic disorder (BDD) (synonyms dysmorphophobia, dermatological non-disease) Disturbance of body size and eating:- e.g. anorexia nervosa, bulimia Phobias:- mole phobia, venereophobia, wart phobia, erythrophobia, electrophobia and steroid phobia Obsessivecompulsive behaviours:- hand washing, hair plucking Atypical pain disorders:- glossodynia, vulvodynia and scrotodynia, anodynia Pruritis sine materia Other dermatologic hypochondriases:- botoxophilia, tanorexia 9. Mental disorders and dermatological disorders:-B.Classical psychosomatic disorders:-Dermatoses in which emotional precipitating or perpetuating factors may be important:-1.i. ii. iii. iv. v. vi. vii. viii. ix. x.Vesicular eczema of palms and soles AD Seborrhoeic dermatitis Psoriasis Some cases of localized or generalized pruritus AA Aphthosis Flushing reactions and rosacea Hyperhidrosis Urticarias.2.Dermatoses primarily factitious in origin:Dermatitis factitia Artefact by proxy Witchcraft syndrome Dermatological pathomimicry v. Dermatitis simulata vi. Malingering vii. Compensation neurosis viii. Mnchausens syndrome ix. Fabricated and induced illness (Mnchausens syndrome by proxy) x. Deliberate self-cutting xi. Self-mutilation i. ii. iii. iv. 10. 3.Dermatoses in association with harmful habits and compulsions:i. ii. iii. iv. v. vi. vii. viii. ix. x. xi.Lichen simplex Neurotic excoriations Prurigo nodularis Acne excorie Hair plucking Trichotillomania Trichophagia Nail destruction Onychotillomania Lip-licking cheilitis Knuckle bitingThe psychogenic purpura syndromes4 i.ii. iii. iv.5. 6.Autoerythrocyte sensitization (GardnerDiamond syndrome) Autosensitivity to DNA Psychogenic purpura (idiopathic) StigmataDisorders of neglect of selfcare (synonym Diogenes syndrome) Drug-dependence syndromes i. ii.Alcohol-related syndromes Substance abuse 11. 7.Mental disorders due to dermatological treatment i. ii.8.Cortisone psychosis Interferon depressioniii.Lithium-induced psoriasis Tranquillizer hyperpigmentation Anti-depressant hyperhidrosisDual non-associated disease, dermatological and psychiatric i. ii.disorders Skin cancer in patients with major psychosisDermatological patients with psychic symptoms not amounting to a disorder:i. ii. iii.Dermatological disorders due to psychopharmacological treatment:i. ii.9.C.D.Troublesome patients Dysthymic responses to illness Cosmetology associated worriesGroup and mass population reactions:i. ii.Sick building syndrome Epidemic hysteria 12. Delusions of parasitosis:- unshakeable conviction that his or her skin is infested by parasites. Causes: Neurological: Cerebrovascular disease, Dementia and neurodegenerative diseases, Parkinsons disease, Huntingdons disease, CNS tumours, Head injury, Encephalitis, Meningitis, Multiple sclerosis, Learning disability, Cardiovascular disorders: Arrhythmias, Heart failure, Coronary artery bypass Renal disease:- CRF, Dialysis Liver disease:- Hepatitis Endocrine disease: Diabetes mellitus, Hyperthyroidism, Hypothyroidism, Panhypopituitarism, Hypoparathyroidism, Acromgaly, Nutritional disorders: Pellagra ,Folate deficiency, Vitamin B12 deficiency, Anorexia nervosa 13. Infectious diseases:- Syphilis, AIDS, Tuberculosis(pulmonary), Leprosy Malignancy:- Breast cancer, Colon cancer, Lung cancer, Lymphoma, CLL. Substance abuse:- Amphetamines, Cannabis, Cocaine, Ecstasy, Opiates. Medicines:- Corticosteroids, Ciprofloxacin, Mefloquine. 14. Monosymptomatic hypochondriacalpsychosis. Middle aged/elderly females . Visual and tactile hallucinations of parasites crawling, burrowing, and biting all over their body. Excoriations are usual and, sometimes, extensively produced in an attempt to extricate organism. 15. Management Patients with anxiety, social isolation or depression:- psychotherapy, or antidepressants such as doxepin, citalopram or venlafaxine. Pimozide:- initial dose 2 mg, is increased weekly by 2 to a maximum of 12 mg daily. Sulpiride:- 200400 mg/day Amisulpride:Respiridone:-18 mg/day Olanzapine in small doses 16. Bromidrosiphobia:- A/K Delusions of smell M:F= 4-5: 1 Most patients complain that smell comes from groin orsometimes armpit. Other beliefs:- Flatus, halitosis Organic syndromes:-cerebral tumours, epilepsy, alcoholism and substance abuse T/t:- Psychotherapy, antidepressants and antipsychotics. 17. Morgellons syndrome:-Fibre-like filaments, granulesand crystals that appear on or under the skin lesions 18. Disorder of Body Image BODY DYSMORPHIC DISORDER A patient is preoccupied and distressed with an imagined defect in appearance or an excessive concern over a trivial defect. BDD is defined in DSM-IV and classified as a somatoform disorder. There is an underlying co-morbid mental disorder including mood disorders such as depression, OCD, social phobia, and/or avoidant personality disorder. Most patients are females in their 30's. These patients are rich in symptoms, while poor in signs of organic skin disease. 19. Complaints related to mainly face, breast, hair, nose, and stomach, while men presented with concern related to hair, nose, ear, genitals, and body build. Distress, poor self esteem, and impairment in social, occupational, and domestic functioning. Repetitive compulsive behavior to hide their imaginary/trivial defect. BDD patients are doctor shoppers, they repeatedly undergo procedures to find solution for their flaws and majority are dissatisfied with results and consultation. Suicidal ideation and suicide attempts are common in BDD patients. 20. Treatment: SSRIs:- 50% of patients may respond completely orpartially . clomipramine fluoxetine 50 mg/day and fluvoxamine260 mg/day for 2-4 months Venlafaxine 37.5 mg/day for 1 year Cognitive behavioural therapy 21. Anorexia nervosa and bulimia Definitions:- Anorexianervosa must satisfy the criteria for:1.2.3.An inability to maintain the normal or minimum weight for age and height coupled with an intense fear of gaining weight; the BMI is less than 17.5 kg/m2 A distorted perception of weight, size and body configuration- essential features Amenorrhoea Bulimia nervosa is definedby the following: 1.2.3.4.Recurrent and compulsive overeating episodes (binge eating) Recurrent and inappropriate compensatory behaviour in order to avoid gaining weight; these include induced vomiting and abuse of diuretics and laxatives Binge eating and weight reduction behaviours occurring at least twice per week for 3 months Self-esteem affected by weight and body configuration. 22. Harmful cutaneous habits Lichen simplex and neurodermatitis:-Lichenification describes characteristic pattern of response of predisposed skin to repeated rubbing. Treatment:- antihistamines, TCA doxepin in doses as low as 2550 mg/day thalidomide 50100 mg/daily for up to 2 months Pathological skin picking(Dermatotillomania):recurrent picking accompanied by visible tissue damage and functional impairment. Clinical features:-lesions are polymorphic, newer lesions are angular excoriated erosions with a serosanguineous crust. 23. Healing witherythematous, white and atrophic centrally and commonly hypertrophic and hyperpigmented at the periphery Site:-face, hair margins, sides of neck, chin, upper chest, shoulders, upper arms and thighs. Management:-supportive psychotherapy Cognitive behavioural therapy Compulsive nature of disorder:antidepressants:-SSRI A-B-C model of habit disorders, that is Affect regulation, Behavioural regulation and Cognitive control Lamotrigine 24. Acute excoriations and chronic, scarred, atrophic lesions due to pathological picking on face, neck and shouldersAcne excoriee 25. Trichotillomania:-term was first used by Hallopeau in 1889 derived from the Greek thrix hair, tillein pull out and mania madness. Morbid craving to pull out hair. Revised DSM-IV diagnostic criteria:a. b. c. d. e.Recurrent pulling out of ones own hair resulting in hair loss An increasing sense of tension immediately before pulling out hair or when attempting to resist behaviour Pleasure, gratification or relief when pulling out the hair Disturbance is not better accounted for by another mental disorder and Disturbance provokes clinically marked distress and/or impairment in occupational, social or other areas of functioning. 26. C/F:-short, irregular, brokenand distorted hair. plucking activity are centrifugal from a single starting point or linear, in wave-like activity. Trichobezoar and the Rapunzel syndrome:-balllike aggregations of fibre-like materials( hair) in stomach and small intestine. Swallowed hair is retained within folds of gastric mucosa.Trichotillomania 27. Investigations: Scalp biopsy: normally hairs amongst empty hair follicles in a noninflamed dermis. Follicular plugging with keratin debris is evident. deep distortion and curling of hair bulb. Barium contrast and CT scan:-gastrointestinal bezoars Management:-cognitive behavioural therapy (CBT) iseffective alone and combined CBT and TCA or SSRIs. Clomipramine more useful than SSRI alone. 28. Psychogenic Pruritus Psychogenic pruritus (PP) is a poorly defined entity in which the patient has intractable or persistant itch, not ascribed to any physical or dermatological illness. Pruritic episodes are unpredictable with abrupt onset and termination, predominantly occurring at the time of relaxation. PP can be generalized or localized. The commonest sites of predilection are legs, arms, back, and genitals. A significant number of patients have associated anxiety and or depression. Detailed cutaneous and systemic examination and routine baseline investigation should be performed to rule out cutaneous and systemic causes of pruritus before diagnosing PP. 29. Cutaneous phobias Fear of contamination, e.g. dirt phobia, germ phobia, wart phobia 2. Fear of malignancy, e.g. cancer phobia, mole phobia 3. Fear of emotional display, e.g. blushing, sweating 1. 30. Factitious skin disease DSM-IV-TR criteria:1. Intentional feigning of physical or psychological signs or symptoms 2. Motivation is to assume the sick role 3. External incentives for behaviour (such as economic gain, avoiding legal responsibility, or improving physical well-being, as in malingering) are absent. 31. Dermatitis factitia:- caused entirely by actions of fullyaware (i.e. not consciously impaired) patient on the skin, hair, nails or mucosae. F>m, children, from age of 8 years, pre-pubertal children having an equal sex ratio, rising to 3 : 1 female predominance in early teens Etiology: psychosocial stress of a major life neurotic and react to adverse situations in an immature,impulsive manner. Depression personality disorder:-borderline or hysterical in females and paranoid in males 32. C/F:- 2 characteristics:1. physical signs 2. fabricated story that accompanies it patient often describes : Sudden appearance of lesions with little or no prodrome. No complete description of genesis of individual skin lesions. 33. Clinical signs: Commonest site are face (cheeks) in 50% children, Dorsa of hands, forearms most frequently of non-dominant limb, mostly on covered skin lesions are polymorphic, bizarre, clearly demarcated from surrounding normal skin and can resemble many inflammatory reactions in skin crude, angulated, destructive processes with a tendency to a linear configuration, Circular erosions or blisters of a uniform size, as result of thermal, chemical or instrumental injury Secretans syndrome:-Oedema of limbs from constricting bands and hysterical dependent posture has been described. 34. Drip-sign:- corrosive liquids. Excoriations:- nail files, sanding boards, cheese graters or wire brushes Punched out necrotic areas:- cigarettes, soldering irons Dramatic dermal induration and necrosis occur from foreign body injection of milk, oil, or grease into breasts, thighs, abdomen and penis . The other common presentation is chronic, non-healing infected wounds. A patient is unable to provide clear history of evolution of the lesions and typically denies any role in the production of the lesions. 35. Witchcraft syndrome:- Artefact dermatitis can beprovoked on an unknowing and unsuspecting victim by proxy. Dermatological pathomimicry:- patients may intentionally aggravate an existing dermatosis using explanation of its genesis given by their dermatologist Atopic patients reintroduced allergens 36. Factitious cheilitis due to repeated lip sucking.Factitious nail disease 37. Dermatitis passivata Young Diogenes syndrome; accretions of facial keratin and debris 38. Secondary Psychiatric Disorders Skin problems, especially chronic skin diseases, affectingexposed body parts because of the visibility and resultant disfigurement lead to embarrassment, depression, anxiety, poor self image, low self esteem, and suicidal ideation in the patients. Also, patients have to commonly face social isolation and discrimination and, at times, have difficulty getting jobs. Many patients are able to cope up with the disease while few develop secondary psychiatric morbidity. 39. Dermatologist should look into this aspect of chronicdisfiguring dermatoses. If the dermatologist suspects significant secondarypsychological morbidity then interrogation, counseling, psychiatric referral should b done. 40. Management of Psychocutaneous Patients Most of the patients with psychocutaneous disorderscan be broadly categorized under four diagnoses: (a) Anxiety, (b) depression, (c) psychosis, (d) OCD. The choice of a psychotropic medication is based primarily on the nature of the underlying psychopathology. 41. Anxiety Therapeutic modalities for anxiety include BDZ, non-BDZ,and CBT. Risk of dependence on BDZ is quite high; hence, they are indicated only for short-term treatment (2-4 weeks) for severe and disabling symptoms and should be avoided in milder forms. Non-BDZ used in the treatment of anxiety are selective SSRIs (citalopram escitalopram, paroxetine), serotoninnorepinephrine reuptake inhibitors (SNRIs) (venlafaxine XL, duloxetine), antihistamines (hydroxyzine), betablockers (propranolol), and the antiepileptic pregabalin. 42. Depression In mild symptoms, watchful waiting or CBT isrecommended. Moderate symptoms can be managed with SSRI and CBT. In cases with severe symptoms and suicidal ideationadmission, antidepressants with possibly electroconvulsive therapy (ECT) are recommended. 43. Antipsychotics Antipsychotics are used in the therapy of psychocutaneousdisorders such as delusions of parasitosis, dermatitis artefacta, and monosymptomatic hypochondriasis. The goal of the dermatologist is not to relieve the patientsof their delusion, but to help them function better with the delusion. 44. Obsessive Compulsive Disorder Disorders like BDD and impulse control disorder (acneexcoree, trichotillomania, onychotillomania, neurodermatitis) are treated on the lines of OCD. Develop insight into the etiology of their problem, they are more amenable to see a psychiatrist and engage in nonpharmacological management (CBT). For patients who are unwilling or unable to initiate behavioral modification, pharmacological therapy can be helpful. Currently, three SSRIs-fluoxetine, paroxetine, and sertraline-are the first-line therapy for the management of OCD. 45. Non-Pharmacological Treatments There is a significant psychosomatic/behavioral component in many dermatologic conditions hence complementary non-pharmacological psychotherapeutic interventions 1. biofeedback 2. CBT 3. hypnosis 4. placebo Have positive impacts on many dermatologic disorders. 46. Biofeedback Biofeedback is a non-invasive conditioning techniquewith wide applications in the field of medicine. Biofeedback training encompasses a wide variety of progressive muscle-relaxing techniques, autogenic training, imagery techniques, transcendental, and other meditation techniques as well as other relaxation-directed programs (i.e., breathing techniques, self-talk, and others). Relaxation training is primarily directed at minimizing sympathetic reactivity and enhancing parasympathetic function. 47. Cognitive Behavioral Therapy CBT deals with dysfunctional thought patterns (cognitive)or actions (behavioral) that damage the skin or interfere with dermatologic therapy .Hypnosis Hypnosis is an intentional induction, deepening,maintenance, and termination of a trance state for a specific purpose. Hypnotic trance can be defined as a heightened state of focus that can be helpful in reducing unpleasant sensations (i.e., pain, pruritus, dysesthesias), while simultaneously inducing favorable physiologic changes. 48. THANKS