Caroline S. Koblenzer

Psychotherapy for intractable inflammatory dermatoses

BACKGROUND Most patients with inflammatory dermatoses respond to conventional treatment. Recalcitrance may indicate underlying emotional factors after infection, contact allergy, and noncompliance have been ruled out. Psychiatric treatment has been reported to be effective. OBJECTIVE The purpose was to determine whether insight-oriented psychotherapy, by effecting last change, would provide long-term cutaneous and psychiatric improvement. METHODS On the basis of emotional distress attributed to a recalcitrant inflammatory dermatosis, four patients were referred for psychiatric evaluation. The effect of adding insight-oriented psychotherapy as the only change in the treatment regimen of each patient was studied. Each patient served as his or her own control. RESULTS In each patient clearing of the previously recalcitrant dermatosis accompanied psychiatric improvement. CONCLUSION In selected cases of recalcitrant inflammatory dermatoses, insight-oriented psychotherapy may provide lasting cutaneous improvement and improved life adjustment and psychologic well-being.

NEUROTIC EXCORIATIONS AND DERMATITIS ARTEFACTA

Neurotic Excoriations is a psychocutaneous disorder that is characterized by an uncontrollable urge to pick at normal skin or skin with mild irregularities. Dermatitis Artefacta is another psychocutaneous disorder that consists of self-induced skin lesions often involving a more elaborate method for damaging the skin, such as the use of a sharp instrument. Both neurotic excoriations and dermatitis artefacta cause significant disfigurement and anxiety for the patient. Since patients often present to dermatologists first, it is important for dermatologists to be aware of the nature of each condition and the available treatment options. This article provides an update on the clinical features, diagnosis, and treatment options for neurotic excoriations and dermatitis artefacta.

Cutaneous Manifestations of Psychiatric Disease That Commonly Present to the Dermatologist—Diagnosis and Treatment

Patients whose psychopathology is expressed in cutaneous lesions often consult a dermatologist rather than a psychiatrist. Dermatologists may not be interested in working with these difficult patients. The need for liaison dermatology is becoming more widely recognized. This article discusses the place of psychiatric consultation in the dermatology setting, and describes the common dermatologic presentations of psychopathology: cutaneous delusions, obsessive-compulsive symptoms, expressions of depression, and dermatitis-artefacta. Diagnostic criteria for these conditions are outlined and a treatment approach, within the competence of the interested dermatologist, is offered.

Successful treatment of a chronic and disabling dermatosis by psychotherapy: A case report and discussion

It behooves us all to help contain rising medical costs. Accurate diagnosis and institution of appropriate treatment contribute to cost containment. A patient is described who entered psychotherapy after 14 years of competent dermatologic care for incapacitating and painful skin lesions with arthralgias. Drug and alcohol abuse, deteriorating peer and family relationships, and poor job performance had supervened. The successful outcome of her treatment is discussed.

Body dysmorphic disorder in the dermatology patient

Body dysmorphic disorder is primarily a psychiatric disorder, in which the patient believes that some normal or very near normal aspect of his or her physical appearance is distorted or ugly. Should there be a minor abnormality, it is grossly exaggerated in the mind of the patient, causing feelings of shame and embarrassment and leading daily to spending hours at the mirror, or any reflecting surface, as the patient tries to conceal or remove the perceived abnormality through the development of ritualistic behavior. Although other organs can be involved-for example, the shape of the nose or a portion of an ear- the skin, hair, and nails are most commonly involved, while the patient constantly seeks reassurance about appearance from friends and family. There is a broad spectrum of severity in body dysmorphic disorder, ranging from obsessional worry to frank delusion, and the psychiatric comorbidities-anxiety, depression, and personality disorder-are prominent parts of the picture. Unfortunately, the psychiatric comorbidities and the negative impact on every aspect of the patients life may not be recognized by dermatologists and other non-psychiatric physicians, so that effective treatment is often not instituted or appropriate referrals made. This paper describes the incidence, possible etiologies, and clinical picture of body dysmorphic disorder in dermatology patients and discusses interpersonal approaches that may permit appropriate treatment or referral to take place. Specific treatments and prognosis are also discussed.