Trichotillomania: a psychopathological perspective and the psychiatric comorbidity of hair pulling

Trichotillomania, or hair-pulling disorder, is classified as an obsessive-compulsive spectrum disorder and is seen predominantly in females. This is a non-systematic review article focusing on the psychopathological features of hair pulling. It is speculated that hair pulling may function to provide short-term relief from stress and other unwanted emotional states, thus serving as a method of emotion regulation. The prevalence of trichotillomania ranges from 1 to 3%. The most targeted site is the scalp, and other common areas include pubic hair and facial regions such as the eyebrows, eyelashes, and beard. Individuals suffering from this disorder tend to avoid social environments due to embarrassment regarding their appearance and fears of being judged by peers. Trichotillomania is associated with significant functional impairment and increased risks of comorbid psychiatric disorders such as other body-focused repetitive behaviors, depression, anxiety, and addictive disorders. This article reviews the epidemiology, clinical features, diagnostic criteria, and psychopathology of trichotillomania with an emphasis on psychopathology and psychiatric comorbidity.

Therapeutic Aspects of Trichotillomania: A Review of Current Treatment Options

Trichotillomania (TTM) is a disorder characterized by recurrent episodes of hair pulling that affects a growing and diverse patient population. The behavior is a result of conscious or unconscious stimuli aimed at alleviating stress. TTM can be diagnosed, typically by a psychiatrist or dermatologist, with various assessment tools and scales. Although researchers continue to discover new pharmacologic regimens and nonpharmacologic therapies, there is no single, effective, US Food and Drug Administration-approved option available for patients. Treatment of TTM with the least occurrence of relapse consists of a combination of pharmacologic and nonpharmacologic options and calls for the involvement of a multidisciplinary team along with family members and friends. This review provides an analysis of the current treatment modalities in the management of TTM and highlights the need for further epidemiologic, genetic, neuroimaging, and dietary research to better understand the complicated nature of the disorder.

Itch and psyche: psychiatric aspects of pruritus

Itch, also referred to as pruritus, is an unpleasant cutaneous sensation provoking the desire to scratch. It is often an uncomfortable, subjective sensation responsible for decreased quality of life in a variety of psychodermatological conditions. Comorbid psychiatric conditions, including depression and anxiety, are frequently associated with itch and scratch cycle. The reciprocal and intricate relationship between the psyche and itch has been widely studied. The neurobiology of itch involves the complexity of specific mediators, itch-related neuronal pathways, and central processing of itch. The connection between itch and the psyche can be grouped under three headings: pruritic diseases with psychosocial sequelae, pruritic diseases aggravated by psychosocial factors, and psychiatric disorders causing pruritus. Itch and pain modulation go together in most circumstances and involve various substances including histamine, interleukins, protease-activated receptors, transient receptor potential receptors, opioids, and cannabinoids. The close interaction between keratinocytes and nerve endings modulating pain and itch also play a major role. Management of itch associated with its psychosomatic components is directed at an underlying cause and adopting a holistic approach to address not only dermatologic and somatosensory aspects, but also the cognitive, emotional, and psychosocial components. An integrated multidisciplinary team consisting of a dermatologist, psychiatrist, psychologist, and social worker is vital in addressing the multifaceted aspects of pruritus.

Psychiatric and Psychological Impact of Chronic Skin Disease

Chronic skin disease has a devastating effect on a person's physical and psychological well-being. Skin disease significantly impacts all aspects of a patient's 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.

Psychological Aspects of Factitious Disorder

Factitious disorder can present in multiple health care settings, with patients intentionally producing symptoms to assume the sick role. This assumption of the sick role can result in multiple hospitalizations with unnecessary diagnostic workup, as well as invasive diagnostic procedures that can lead to worrisome side effects. Differential diagnoses that should be ruled out include malingering, somatic symptom disorder, and anxiety disorders. For many providers, patients with factitious disorder can be a challenge to treat because the etiology of the disorder remains unclear. There are multiple psychological theories that attempt to explain the motivation and thought process behind the voluntary production of symptoms. Some of these theories have addressed disruptive attachments during childhood, possible intergenerational transfer of the disorder, personal identity conflicts, somatic illness as a form of masochistic activity toward oneself, and intrapsychic conflicts. Confrontation and psychotherapy with a multidisciplinary team has been proposed as a form of treatment. An understanding of the psychological factors associated with factitious disorder can help providers understand the rationale behind the patient's presentation and aid in the formulation of a treatment plan.

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.

Psychodermatology: Basics Concepts

Psychodermatology is a relatively new field of medicine. It encompasses the interaction of mind and skin. The role of psychoneuroimmunology in the causation of psychocutaneous disorders and psychosocial aspects of skin disease have gained momentum lately. The treatment of psychodermatological disorders focus on improving function, reducing physical distress, diagnosing and treating depression and anxiety associated with skin disease, managing social isolation and improving self esteem of the patient. Both pharmacological and psychological interventions are used in treating psychocutaneous disorders. The interest in Psychodermatology around the world is increasing and there are several organizations holding their regular meetings.

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.

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.

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.

Geriatric dermatoses: a clinical review of skin diseases in an aging population

Geriatric dermatoses are a challenging job for the physician in terms of diagnosis, management, and followup. Since skin of the elderly population is going through a lot of changes from both an intrinsic and extrinsic point of view, it is imperative for the physician to have a better understanding of the pathophysiology of geriatric skin disorders and their specific management, which differs slightly from an adult population. This review focuses on a brief introduction to the pathophysiological aspects of skin disorders in elderly, the description of some common geriatric skin disorders and their management and the new emerging role of psychodermatological aspects of geriatric dermatoses is also discussed. At the end, ten multiple choice questions are also added to further enhance the knowledge base of the readers.

Lithium and psoriasis: what primary care and family physicians should know

OBJECTIVE

This review focuses on the association of lithium treatment and psoriasis. The mechanism of action of lithium in causing psoriasis and the clinical presentation of psoriasis secondary to lithium treatment are considered.

DATA SOURCES

A search of the literature from 1949 to 2007 was performed using MEDLINE, with the following search terms: lithium, psoriasis, skin, dermatology, and psychodermatology.

DATA SYNTHESIS

Lithium is involved in a variety of cutaneous reactions including psoriasis, which may present as exacerbation of preexisting psoriasis, induction of de novo psoriasis, pustular psoriasis, nail changes, and psoriatic arthropathy. The appearance of psoriatic lesions may occur at normal therapeutic serum lithium levels. The refractory period for the development of psoriatic lesions is variable and generally longer in induction and shorter in exacerbation of psoriasis. Lithium-induced psoriasis is often resistant to conventional treatment modalities, and some cases may require dose reduction or discontinuation of lithium treatment.

CONCLUSION

Lithium is the mainstay of treatment in bipolar disorder and is associated with a variety of cutaneous side effects including psoriasis. Primary care providers and family physicians should be knowledgeable about the association of lithium and its dermatologic side effects. Early recognition and management could be beneficial in avoiding the issues of noncompliance and further deterioration of mood symptoms secondary to obviously disfiguring skin appearance. Primary care, psychiatry, and dermatology liaison services will prove helpful in managing these patients.