Mohammad Jafferany

A Review of Body Dysmorphic Disorder and Its Presentation in Different Clinical Settings

OBJECTIVE Body dysmorphic disorder (BDD) is a relatively common psychiatric disorder characterized by preoccupations with perceived defects in physical appearance. This review aimed to explore epidemiology, clinical features, comorbidities, and treatment options for BDD in different clinical settings. DATA SOURCE AND STUDY SELECTION A search of the literature from 1970 to 2011 was performed using the MEDLINE search engine. English-language articles, with no restriction regarding the type of articles, were identified using the search terms body dysmorphic disorder, body dysmorphic disorder clinical settings, body dysmorphic disorder treatment, and body dysmorphic disorder & psychodermatology. RESULTS BDD occurs in 0.7% to 2.4% of community samples and 13% of psychiatric inpatients. Etiology is multifactorial, with recent findings indicating deficits in visual information processing. There is considerable overlap between BDD and obsessive-compulsive disorder (OCD) in symptom etiology and response to treatment, which has led to suggestions that BDD can be classified with anxiety disorders and OCD. A recent finding indicated genetic overlap between BDD and OCD. Over 60% of patients with BDD had a lifetime anxiety disorder, and 38% had social phobia, which tends to predate the onset of BDD. Studies reported a high level of comorbidity with depression and social phobia occurring in > 70% of patients with BDD. Individuals with BDD present frequently to dermatologists (about 9%-14% of dermatologic patients have BDD). BDD co-occurs with pathological skin picking in 26%-45% of cases. BDD currently has 2 variants: delusional and nondelusional, and both variants respond similarly to serotonin reuptake inhibitors (SRIs), which may have effect on obsessive thoughts and rituals. Cognitive-behavioral therapy has the best established treatment results. CONCLUSIONS A considerable overlap exists between BDD and other psychiatric disorders such as OCD, anxiety, and delusional disorder, and this comorbidity should be considered in evaluation, management, and long-term follow-up of the disorder. Individuals with BDD usually consult dermatologists and cosmetic surgeons rather than psychiatrists. Collaboration between different specialties (such as primary care, dermatology, cosmetic surgery, and psychiatry) is required for better treatment outcome.

Psychogenic Purpura (Gardner-Diamond Syndrome).

Psychogenic purpura, also known as Gardner-Diamond syndrome or autoerythrocyte sensitization syndrome, is a rare condition characterized by spontaneous development of painful edematous skin lesions progressing to ecchymosis over the next 24 hours. Severe stress and emotional trauma always precede the skin lesions. The condition is most commonly seen in women, but isolated cases have been reported in adolescents and in males. Psychodermatologic evaluation and dermatology and psychiatry liaison have been successful in the treatment of these patients. This report provides an overview of psychogenic purpura and presents the case of a 15-year-old girl.

The PHQ-2 in Dermatology—Standardized Screening for Depression and Suicidal Ideation

Approximately 30% of all dermatology patients experience a psychiatric disorder or some form of notable psychosocial morbidity.1 When the psychiatric concern is related to skin disease, dermatologists are in a unique position to identify the problem and help patients seek treatment. Psychodermatology is a growing field that includes both primary and secondary psychiatric conditions. Primary psychiatric conditions associated with skin findings include disorders where self-induced skin lesions result from an emotional disturbance (eg, acne excoriée).2 In contrast, secondary psychiatric disorders involve emotional disturbances that manifest in response to the psychologic stress caused by the skin condition (eg, major depression induced by severe psoriasis).2 This article will focus on these secondary conditions. We do not know how often dermatologists screen for secondary psychiatric concerns in at-risk patients. Dermatologists do have difficulty perceiving psychological distress in patients3 and some may feel uncertain about the diagnosis of psychiatric conditions secondary to skin disease.4 Patients may not volunteer mental health information, and dermatologists do not always pursue further action even when mental health problems are identified in a consultation.3 It is unclear if this is owing to lack of clear guidelines, lack of time in busy clinics, or the perception that secondary psychiatric disorders fall outside of the dermatology domain. Taken together, these studies3,4 suggest that both dermatologists and patients may benefit from a simple and quick screening tool to identify patients experiencing secondary emotional distress. This article aims to provide a simple approach for dermatologists to screen and refer patients with psychiatric conditions secondary to skin disease. It is not suggested that dermatologists manage psychiatric conditions. However, it is important to screen dermatology patients for mental health concerns because conditions with high disease burden such as psoriasis (particularly with comorbidities), severe atopic dermatitis, and hidradenitis suppurativa, which are associated with increased suicidal ideation.4 Patients with chronic facial lesions or facial scarring secondary to a dermatologic conditions are also at higher risk of depression and suicide, particularly when the lesions develop early in life.5 This is especially true of severe acne vulgaris in adolescence.5 Regardless of the specific diagnosis, depression is often related to the patient’s experience of the skin disease rather than the objective disease severity. Dermatologic conditions and any secondary scars can impact socialization, leading to isolation and depression. Less obvious symptoms, such as pruritus, can cause insomnia. Insomnia is an independent suicide risk factor and pruritic severity is directly correlated with degree of depression.6 A broader list of risk factors for depression and suicidal ideation is provided in the Figure. When these dermatologic-specific risk factors are paired with additional high-risk features, depression and suicidal ideation screening become increasingly necessary. A patient’s degree of suffering is subjective; therefore, objective documentation of skin disease severity and negative psychiatric history is insufficient. Moreover, dermatologic conditions can trigger new psychiatric illness, so a negative history does not preclude a patient from risk of depression and suicide. Although quality-of-life assessments are useful, depression and suicide screens are a separate entity. Based on standard psychiatric screening in a clinical setting when the risk of depression and/or suicide is suspected, we suggest that dermatologists ask the following 2 questions (Patient Health Questionnaire-2 [PHQ-2])7: Over the past 2 weeks, how often have you been bothered by either of the following problems? • Little interest or pleasure in doing things. • Feeling down, depressed, or hopeless. The patient’s answers should be documented in their medical record. Each question should be scored 0 if not at all; 1, several days; 2, more than half the days; 3, nearly every day. The total score ranges from 0 to 6, with 3 or greater considered positive and requiring follow-up.7 If the PHQ-2 is positive, dermatologists should ask the following 2 questions while the patient is still in their office to gain an idea of urgency for follow-up: • Do you ever think about ending your own life? • (If the answer to 1 is “yes”) Do you currently have a plan to commit suicide? If the patient screens negative for the 2 follow-up questions or screens positive for suicidal ideation but does not have a plan, dermatologists should refer the patient to his or her primary care physician by an urgent referral letter or a call to directly address the concern for depression. Dermatologists can provide the patient with resources such as the US National Suicide Prevention Lifeline (1-800-273-8255) or the Canadian Association for Suicide Prevention website that lists provincespecific crisis lines (https://suicideprevention.ca/needhelp/). If the patient screens positive for question 1 and 2, an additional urgent referral should be made to psychiatric emergency department for further assessment (Figure). The discussion with the patient and the referral recommendation should be documented. The PHQ-2 and brief follow-up screen may help catch the unrecognized patients who fall between the dermatology and psychiatry domains. The simplicity and brevity of the PHQ-2 makes it an appropriate option for VIEWPOINT

Psychodermatology: Knowledge, Awareness, Practicing Patterns, and Attitudes of Dermatologists in Turkey.

OBJECTIVE Approximately, 1 in 3 patients in dermatology settings has psychiatric comorbidity. Thus, we conducted a survey in Turkey to explore the awareness, knowledge, practicing patterns, and attitudes of dermatologists toward psychocutaneous disorders. METHOD The questionnaire-based study was performed from March 1, 2013, to May 20, 2013. Study participants included 115 dermatologists. The questionnaire consisted of 9 multiple-choice questions and 2 open-ended questions. RESULTS Of the 115 dermatologists in the study, 38 were men and 77 were women. More than 85% of dermatologists indicated that they examine > 30 patients per week in their practice, while only 2% saw < 10 patients per week. The most frequent dermatologic condition associated with psychiatric involvement seen by dermatologists was acne (49.1%). The top 3 diagnoses referred by dermatologists to psychiatrists were psoriasis (42.6%), alopecia areata (38.2%), and pruritus (27.8%). CONCLUSIONS A need for collaboration between primary care, psychiatry, and dermatology disciplines in handling patients with psychocutaneous conditions is widely accepted. Investigating the knowledge, attitudes, and awareness of dermatologists about psychocutaneous disorders might contribute to the development of new educational strategies and elicit qualified biopsychosocial approaches.

Disease Severity, Quality of Life, and Psychiatric Morbidity in Patients with Psoriasis with Reference to Sociodemographic, Lifestyle, and Clinical Variables: A Prospective, Cross-Sectional Study from Lahore, Pakistan

BACKGROUND Psoriasis is an immune-mediated, chronic disease with a genetic background that involves skin, nails, and joints. The incidence of psoriasis varies from 2.0% to 4.0% depending on the geographical location, ethnic background, and environmental conditions. Recent research has proved that psoriasis is a systemic inflammatory disease with extensive systemic implications. Objectives of the study were to explore the severity of psoriasis, dermatology-related quality of life, and psychiatric health of the patients with reference to sociodemographic, lifestyle, and clinical characteristics. METHOD Consecutive patients with psoriasis (ICD-10 criteria) from skin outpatient clinics of 3 tertiary care hospitals in Lahore, Pakistan, between November 1, 2012, and December 31, 2012, were assessed in this prospective cross-sectional study. The final sample includes 87 patients who were evaluated for severity of psoriasis (Psoriasis Area Severity Index [PASI]), dermatology-related quality of life (Dermatology Life Quality Index [DLQI]), and psychiatric morbidity (12-item General Health Questionnaire [GHQ-12]) and were assessed on 23 sociodemographic, lifestyle, and clinical variables. RESULTS Of the 23 variables, the PASI was significantly associated with education and habit of drinking alcohol (P < .05), the DLQI was significantly associated with disturbed eating (P < .05), and the GHQ-12 score was significantly associated with hair disease (P < .05), current income (P < .05), and disturbed eating and sleeping (P < .01). The PASI, DLQI, and GHQ-12 were not usually affected by sociodemographic, lifestyle, and clinical factors, except for some variables such as education of the patient, alcohol intake, eating and sleeping disturbance, and income status. A statistically significant correlation (P < .01) was found between all 3 scores (ie, PASI, DLQI, and GHQ-12). The correlation coefficients of the PASI with the DLQI and GHQ-12 are 0.345 and 0.460, respectively, and that of the DLQI with the GHQ-12 is 0.635. A moderating effect of the DLQI score was found on the relationship between the PASI and GHQ-12 scores. CONCLUSIONS Psoriasis has an immense impact on the life of patients and common comorbidities in psoriasis including coronary heart disease, depression, cerebrovascular disease, and metabolic syndrome. Screening for these comorbidities in psoriasis patients is essential. Impaired quality of life negatively affects the psyche of patients and initiates coping mechanisms, which may lead to depression and anxiety, social dysfunction, and loss of confidence, and the psychosocial burden of the disease may become more than the physical burden. The dermatologist usually manages physical disease and fails to address the social, emotional, and psychological aspects. Quality of life improves if these psychological aspects are also properly dealt with.

Diagnosis of Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is characterized by an excessive preoccupation with one or more perceived defects in appearance that are not observable or appear only as minor to others. It is also characterized by repetitive behaviors or mental acts in response to these perceived appearance flaws. Diagnostic criteria are met when these appearance concerns are not better explained by weight concerns and an associated eating disorder. BDD is associated with significant personal, social, and occupational impairment and often involves many unnecessary medical and surgical procedures. This chapter focuses on diagnosing body dysmorphic disorder, the differential diagnosis, comorbidities, and offers a brief introduction to various rating scales used to diagnose and manage BDD.

Psychiatric and Psychological Impact of Chronic Skin Disease

Chronic skin disease has a devastating effect on a persons physical and psychological well-being. Skin disease significantly impacts all aspects of a patients life including school, relationships, career choices, social and leisure activities, and sexual life. The physical, psychological, and social consequences affect not only the patients, but also caregivers and family members as well. Common psychological problems associated with skin disease include, but are not limited to, feelings of stress, anxiety, anger, depression, shame, social isolation, low self-esteem, and embarrassment. Besides psychopharmacology, multiple psychotherapeutic techniques have proved to be helpful in addressing the psychological sequelae of skin disease.

Trichotillomania (hair pulling disorder): Clinical characteristics, psychosocial aspects, treatment approaches, and ethical considerations

Trichotillomania (hair pulling disorder) is a fairly common but underreported disorder characterized by recurrent episodes of pulling hair from different parts of the body. Currently classified in Diagnostic and Statistical Manual of Psychiatric Disorders (DSM‐5) under the heading of the “Obsessive–compulsive spectrum and related disorders.” The estimated prevalence data suggest that 0.5–2% of the general population suffers from this disorder. Stress and anxiety are directly correlated to the production of trichotillomania symptoms. The psychosocial aspects of trichotillomania are greatly underestimated, but recent literature suggests an increased interest in this neglected area. Although no FDA approved medications are available for the treatment of trichotillomania, a variety of medications including N‐acetylcysteine have shown benefit in case reports. Combined liaison clinics, with an interdisciplinary approach, are highly advisable in the treatment of these cases.

Evaluation of the Body Parts That Preoccupy Adolescents With Body Dysmorphic Disorder

Objective To evaluate which body parts preoccupy adolescents with body dysmorphic disorder (BDD). Methods Patients admitted to an inpatient psychiatric hospital who agreed to take part in the study completed the Body Dysmorphic Disorder Questionnaire (child and adolescent version) and Body Dysmorphic Disorder Diagnostic Module. Patients also completed a questionnaire that addressed age at onset, coping strategies, history of sexual abuse, amount of time patients spent thinking about their perceived defects, and the area of the body that the participants were preoccupied with and the specific coping strategy used. All patients met DSM-5 criteria for BDD. The study was conducted from January 17, 2014, to September 29, 2014. Results Patients with BDD (N = 17) were preoccupied with the face: 6 (35.2%), skin: 3 (17.6%), lips: 5 (29.4%), nose: 3 (17.6%), teeth: 3 (17.6%), ears: 1 (5.8%), and eyes: 1 (5.8%), while gender-specific parts included breasts: 5 (50%) and penis: 4 (57.1%). The mean age at onset of BDD was 10.5 years, and the time spent thinking about the imagined defect averaged 3.5 hours per day. Conclusions Patients with BDD are more preoccupied with exposed facial body parts such as skin, lips, nose, teeth, ears, and eyes and body parts with sexual connotations such as breasts in females and the penis in males.

Use of Topiramate in Skin-Picking Disorder: A Pilot Study

Objective Repetitive skin picking that culminates in skin lesions and excoriations has a fairly common prevalence and causes clinically significant distress. Myriads of agents have been used to treat the condition with no convincing results. Methods Ten patients (8 women and 2 men) with skin-picking disorder (per DSM-5 criteria) were enrolled in the study. The study was conducted from December 1, 2013, to December 29, 2014. The patients were treated with 12-week open-label topiramate in a titrating-upward dose (25-200 mg/d). Different measures to evaluate the efficacy of topiramate included subjective and objective assessment, photographs, the Skin Picking Scale modified after the Yale-Brown Obsessive-Compulsive Scale (SPS-Y-BOCS), the Skin Picking Impact Scale, the Clinical Global Impressions-Improvement (CGI-I) and CGI-Severity scales, and the Beck Anxiety Inventory and Beck Depression Inventory. Results Topiramate improved time spent skin picking from 85 minutes to 30 minutes per day. Seven patients (70%) were very much improved (n = 4) and much improved (n = 30) on the CGI-I. The scores on the Skin Picking Impact Scale and SPS-Y-BOCS also improved. The mean time to respond to topiramate was about 8 to 10 weeks. Anxiety and depression symptoms improved after reduction in skin-picking symptoms (the Beck Anxiety Inventory score improved from a mean of 38.8 to 13.8 and the Beck Depression Inventory score from 28.9 to 10.1). Conclusions Topiramate appears to be a promising agent in the treatment of skin-picking symptoms. Double-blind controlled trials are needed to further evaluate the safety and efficacy of topiramate in larger population samples. Trial Registration ISRCTN registry identifier: ISRCTN15791118.