current concepts in psychodermatology

COMPLEX MEDICAL-PSYCHIATRIC ISSUES (MB RIBA, SECTION EDITOR)

Current Concepts in Psychodermatology

Madhulika A. Gupta & Aditya K. Gupta

Published online: 17 April 2014# Springer Science+Business Media New York 2014

Abstract Several diagnoses in the new DSM-5 chapteron ‘Obsessive-Compulsive and Related Disorders’ di-rectly relate to psychodermatology. The new excoriation(skin-picking) disorder (SPD) and trichotillomania(TTM) both manifest as recurrent body-focused repeti-tive behaviors that have compulsive and dissociativefeatures, the latter being more prevalent in TTM thanSPD. The DSM-5 refers to SPD and TTM occurringwithout full awareness or preceding tension, howeverdoes not specifically mention the possible role of disso-ciation. This has important treatment implications, aspatients with high dissociative symptoms are not likelyto respond to the standard treatments for obsessive-compulsive disorder. Body dysmorphic disorder (BDD),which is frequently associated with cutaneous bodyimage (CBI) dissatisfaction, is present in 9 %-15 % ofdermatology patients. Treatment guidelines in dermato-logy are increasingly considering the psychosocial mor-bidity related to CBI in their treatment outcome mea-sures. The presence of BDD, if unrecognized, maytherefore directly affect the dermatologic treatment re-gimens offered to the patient.

Keywords Skin . Dermatology . Itch . Psoriasis . Atopicdermatitis . Pruritus . Nails . Psychodermatology .

Psychocutaneous . Psychosomatic . Psychology . Psychiatry .

Dissociation . Obsessive compulsive . DSM-5 . Body image .

Excoriation . Trichotillomania . Onychophagia . Bodydysmorphic disorder . Delusional disorder . Sleep . Circadianrhythm . Classification

Introduction

The skin is the largest organ of the body, which functions asboth (1) a metabolically active interface and immune organseparating the self from the outside world, during both sleepand wakefulness, and (2) an organ of communication acrossthe lifespan—at social, psychological and neurobiologicallevels [1]. The skin is a large sensory organ [2] with afferentsensory nerves conveying sensations of itch, touch, pain,temperature and other physical stimuli to the central nervoussystem (CNS) and the efferent autonomic, mainly sympatheticnerves playing a role in the maintenance of cutaneous homeo-stasis by regulating vasomotor and pilomotor functions andthe activity of the apocrine and eccrine sweat glands.

Psychological stress and psychiatric and psychosocial mor-bidity are important in one-third of dermatology patients [1, 3,4]. The skin can manifest psychosomatic reactions secondaryto autonomic nervous system (ANS) and immune dysregula-tion, e.g., pruritic states [5], idiopathic urticaria [6, 7] andunexplained hyperhidrosis. Excessive manipulation of theskin and its appendages (hair, nails) may be used to managehighly dysregulated emotions and high levels of anxiety [8] indissociative and obsessive-compulsive states, and can result inself-induced dermatoses such as dermatitis artefacta, skin-picking disorder, onychophagia and trichotillomania [4,9–11]. Excessive manipulation of the integument can alsoexacerbate an underlying dermatologic disorder, for example,

This article is part of the Topical Collection on Complex Medical-Psychiatric Issues

M. A. Gupta (*)Department of Psychiatry, Schulich School of Medicine andDentistry, University of Western Ontario, 585 Springbank Drive,Suite 101, London, Ontario N6J 1H3, Canadae-mail: [email protected]

A. K. GuptaDivision of Dermatology, Department of Medicine, University ofToronto, Toronto, Ontario, Canada

Curr Psychiatry Rep (2014) 16:449DOI 10.1007/s11920-014-0449-9

as a result of the Koebner phenomenon, or by exacerbation ofpruritus and other cutaneous sensory disorders [2, 4].

In this article we have reviewed some neurobiologicalfactors in the interface between dermatology and psychiatryand focused on the psychodermatologic disorders that havebeen directly implicated in the recent changes in classificationin the Diagnostic and Statistical Manual of Mental Disorders,5th edition (DSM-5) [12].

General Neurobiological Factors

Sleep and Circadian Rhythms

Sleep disturbances (sleep deprivation, circadian rhythm disrup-tion) are an important mediating factor in psychodermatology,especially in inflammatory skin disorders [13]. Sleep-wakefactors and the skin interface at several levels:

(1) Sleep onset: The skin plays a primary role in thermoreg-ulation and sleep onset [14]. Sleep is most likely to occurduring the most steeply declining portion of the corebody temperature curve. The decrease in core bodytemperature occurs by increasing heat loss through in-creased peripheral vasodilatation and sweating duringthe late evening and early morning hours. The timingof the circadian component of core body temperature,which plays a central role in sleep onset, is determined bythe suprachiasmatic nucleus. If the thermoregulatoryfunction of the skin is affected as a result of a dermato-logic disorder and heat is not dissipated as easily throughthe periphery, sleep onset may be prolonged, and thepatient may experience a decrease in their restorativeslow wave sleep, which in turn can result in complaintssuch as fatigue and ill-defined pain syndromes.

(2) Circadian rhythms: Various skin-related factors showcircadian rhythmicity, with one of the most importantones being the stratum corneum barrier of the humanskin [15]. There is circadian rhythmici ty intransepidermal water loss (TEWL), skin surface pH,and skin temperature at most anatomic sites, with skinpermeability being higher in the evening and night thanin the morning [16]. Higher TEWL in the evening sug-gests that the epidermal barrier function at this time is notoptimal, and TEWL is associated with greater itch inten-sity, which is typically higher in the evening beforebedtime. Up to 65 % of patients with inflammatorydermatoses, including psoriasis, atopic dermatitis andchronic idiopathic urticaria, report increased pruritusduring the night. This diurnal pattern of pruritus whereinthe threshold for pruritus is lower during the night ismost likely a reflection of complex circadian-mediatedfactors, e.g., lower cortisol levels, decreased epidermal

barrier function and increased skin temperature [17]. Insome disorders such as atopic dermatitis, scratching maybecome a conditioned response to being in bed at night[18], even in the absence of significant pruritus. Rotatingnight-shift work has been associated with a significantlyincreased risk of psoriasis (adjusted hazards ratio=1.19,95 % CI 1.07-1.32) [19]. There is an emerging literatureon the central role of the circadian clock in metabolism,immunity and inflammation [20], which has direct im-plications for psychosomatic medicine.

(3) Sleep deprivation and/or restriction can cause a height-ened proinflammatory state (e.g., elevated levels of in-terleukin 1-β and TNF-α) [21•]. The skin generates thecutaneous permeability barrier, localized in the externalstratum corneum, which prevents entry of foreign sub-stances and excessive water loss. One night of sleepdeprivation can inhibit recovery (e.g., after tape strip-ping) of skin barrier function in humans [22]. Repeatedarousals and high sympathetic tone in obstructive sleepapnea (OSA) can also be associated with a heightenedproinflammatory state.

(4) Sleep disorders and skin disease: Pruritus (includingnocturnal pruritus) is one of the most common and both-ersome symptoms of dermatologic disease. Scratchingduring sleep, which may be proportional to the overalllevel of sympathetic nervous activity during the respectivestages of sleep, usually occurs most frequently duringnon-rapid eye movement (NREM) stages 1 and 2 (versusstages 3 and 4 when the sympathetic tone is the lowest)and in rapid eye movement (REM) sleep, where theseverity of scratching is similar to stage 2 sleep [13].

The recent literature suggests an essentially bi-directionalrelationship between sleep disorders and inflammatory skindiseases. Epidemiologic studies have shown a higher frequencyof OSA [odds ratio (OR)=3.89, 95 % CI 2.26-6.71] [23] inpsoriasis patients and a higher frequency of psoriasis (hazard ofpsoriasis 2.30, 95%CI 1.13-4.69) [24] in polysomnographicallydiagnosed OSA. Epidemiologic studies have further shown thatatopic dermatitis (OR=1.80, 95 % CI 1.28-2.54) [25] is anindependent risk factor for habitual snoring in children; OSApatients, especially male and younger patients, are at an in-creased risk (OR=1.5, 95 % CI 1.15-1.95) [26] for developingatopic dermatitis. Psychiatric disorders such as posttraumaticstress disorder (PTSD) that are associated with high levels ofautonomic nervous system (ANS) dysregulation can play amediating role in this relationship. For example, in PTSD,ANS hyperarousal and insomnia have been related to nocturnalhyperhidrosis, idiopathic urticaria and nocturnal pruritus [27].An underlying hyperarousability and overactive sympatheticresponse to itch and scratching in atopic dermatitis [18] has beenassociated with increased arousals from sleep even when thedermatologic disorder is not active during the daytime [28].

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Skin-Brain Connection

A large number of psychodermatologic disorders involveexcessive/compulsive manipulation of the integument by thepatient [12]. The compulsive manipulation of the skin is oftentriggered by a disagreeable skin sensation, e.g., itching, burn-ing or stinging [2]. Skin regions that normally have a greaterdensity of epidermal innervation (e.g., face, scalp, perineum)tend to be more susceptible to the development of disagree-able cutaneous sensations. The cutaneous sensory neuronstransmit modality-specific information to the CNS and areassociated with specialized receptors (mechanoreceptors, ther-moreceptors and chemoreceptors) and transducers for highlyspecific sensory functions. Regions with a high density ofnerve endings include the genitalia, finger pads and lips andother regions of the face innervated by the three branches (V1,V2, V3) of the trigeminal nerve [29, 30••]. It is noteworthythat the face and scalp (largely innervated by V1) tend to besome of the most frequent sites for some of the body-basedrepetitive behaviors such as skin-picking and trichotillomania.The epidermis is innervated with thin axonal nerve endings orneurites that constitute most of the pain-sensing (nociceptive)and autonomic fibers [29]. The sensation of itch is carried tothe CNS primarily by a subgroup of nociceptive unmyelinatedC-fibers; anatomically, the C-fibers are the same as the nervefibers associated with the mediation of pain, but they arefunctionally different [31]. Second-order histamine-specificitch neurons have been identified in the dorsal horn of thespinal cord [32], suggesting that there may be a separate itchpathway, which has been implicated in neuropathic itch syn-dromes [29, 31]. The spinothalamic neurons project to thethalamus and higher CNS structures including the anteriorcingulate cortex and the insula [33]. The insula containsinteroceptive representation that provides the basis for allsubjective feelings from the body. Some of the interoceptivestimuli that can originate from the skin and have been shownto be associated with activation of the insular cortex includepain from skin, itch [34], burning and pricking sensations,vasomotor flush, touch, sexual arousal, coolness and warmth[35, 36]. It is therefore conceivable that individuals who havedifficulties with emotional regulation and interoceptive aware-ness resort to engaging in the body-based repetitive behaviors.

DSM-5: Changes in Diagnostic Classification and Criteria

Some of the most salient changes (from the DSMIV-TR[37])in the new chapter on ‘Obsessive-Compulsive and RelatedDisorders’(OCRD) in the DSM-5 [12] relate to disorders witha major psychodermatologic component. Table 1 summarizessome of the major changes involving the recurrent body-focused repetitive behaviors that largely affect the skin andits appendages, i.e., the new excoriation (skin-picking)

disorder (SPD) diagnosis and trichotillomania (hair-pullingdisorder) (TTM) as well as body dysmorphic disorder (BDD),which are all classified under the new chapter on OCRD [12].

An epidemiologic study [38•] of 5,409 female members ofthe TwinsUK adult population-based twin register using mul-tivariate twinmodels examined the degree to which genetic andenvironmental risk factors are shared and/or unique to the fivedimensionally scored disorders (obsessive-compulsive disorderor OCD, BDD, hoarding disorder or HD, TTM, SPD) underthe new OCRD [12] in the DSM-5. Individuals were givenratings for all five disorders classified under the OCRD [12].According to the best-fitting model, the covariance between thefive OCRD phenotypes was best explained by a two-latentfactor structure: the first factor loaded particularly highly onOCD, HD and BDD, while the second factor loaded on TTMand SPD. The heritability of all OCRD was moderate [38•],ranging from 32 % (TTM), 43 % (BDD), 47 % (SPD), 48 %(OCD) to 51 % (HD); non-shared environmental factorsaccounted for the remaining variance, and shared environmen-tal factors appeared to be negligible [38•]. Disorder-specificgenetic factors moderately contributed to the risk for OCD,BDD andHD symptoms, but not for SPD and TTM symptoms,suggesting that the genetic influences on SPD and TTM aremostly shared [38•]. Environmental influences were largelydisorder specific [38•]. These results are consistent with theclinical observation that more than one body-focused repetitivebehaviour, e.g., SPD, TTM and/or compulsive nail-biting, maybe encountered in the same patient [8].

Body-Focused Repetitive Behaviors

Excoriation (Skin-Picking) Disorder

Excoriation (skin-picking) disorder (SPD) is one of the newdiagnoses in DSM-5 [12] and is characterized by recurrentpicking at one’s own skin resulting in skin lesions and repeat-ed attempts to decrease or stop skin picking. The most com-monly picked sites are the face, arms and hands, but patientsmay pick from multiple body sites. The skin picking may beaccompanied by a range of rituals or behaviors involving theskin or scabs, and some individuals engage in skin-pickingthat is more focused, i.e., with preceding tension and subse-quent relief [12], features that are consistent with obsessive-compulsive symptoms. Some individuals may engage in moreautomatic picking with the picking seeming to occur withoutfull awareness and without preceding tension. The DSM-5[12] does not specifically mention that such patients may bedissociative. The DSM-5 [12] mentions that many patientshave a mix of both (i.e., obsessive-compulsive and dissocia-tive) behavioral styles.

In patients where skin picking occurs without precedingtension or full awareness, there tend to be much higher levels

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of emotional dysregulation [8] and dissociation without nec-essarily meeting the criteria for a dissociative disorder[12]. Itis important to recognize the dissociative component, as thestandard approaches to treating obsessive-compulsive skinpicking with habit reversal therapy and selective serotoninreuptake inhibitor (SSRI) antidepressants [9] are not sufficientwhen high levels of dissociation are present [8]. The morehighly dissociative patients with skin-picking require stabili-zation first [8] and assessment for suicide risk.

The DSM-5 [12] describes that SPD most often has onsetduring adolescence and frequently begins with the onset ofdermatologic conditions such as acne; this describes one of themost common presentations of skin picking encountered inacne excoriée. SPD can occur in all age groups and may havefirst onset in a previously active person who loses mobility,e.g., because of aging, illness or accident. In such instances,the excoriation is not primarily due to the underlying medicaldisorder or injury.

The DSM-5 [12] ‘Obsessive-Compulsive and RelatedDisorder Due to Another Medical Condition’ refers to obses-sive compulsive symptoms best explained by the direct path-ophysiological consequence of another medical condition ex-cluding acne and includes a specifier ‘With skin-pickingsymptoms.’ This diagnosis is applicable in a wide range ofdermatologic disorders, e.g., with pruritic lesions. In somecases, the SPD may exacerbate the course of the underlyingdermatologic disorder, e.g., psoriasis and atopic eczema [4]. Indermatologic disorders, the direct psychosocial impact of achronic cosmetically disfiguring disorder and the consequentdisease-related stress may also contribute to excessive exco-riation of the primary dermatologic lesion by the patient [39].

Trichotillomania (Hair-Pulling Disorder)

Trichotillomania (hair-pulling disorder) (TTM) [12] is char-acterized by recurrent pulling out of one’s hair resulting in hair

Table 1 Changes in the DSM-5 classification of some psychiatric disorders with a major psychodermatologic component

Disorder withpsychodermatologic features(some other names used todenote disorder)

DSM-5 (2013) Classification DSMIV-TR (2000) Classification Comment

Skin- picking disorder (alsopathological skin picking,neurotic excoriations,psychogenic excoriation,dermatillomania, acne excoriée)

Excoriation (skin-picking) disorder[codes 698.4, (L98.1)].

Stereotypic movement disorderwith self-injurious behavior[code 307.3], under majorheading of ‘Other Disordersof Infancy, Childhood, orAdolescence’

New classification a significantimprovement as motoric aspects ofskin-picking are not an importantfeature of the disorder and skinpicking does not necessarily havefirst onset mainly in the pediatricage groupA new separate diagnostic group

in DSM-5 under ‘ObsessiveCompulsive and RelatedDisorders’(OCRD)

Impulse control disorder nototherwise specified [code312.30], ‘skin-picking’ usedas an example of disorder

Trichotillomania (TTM)(hair-pulling disorder)(similar disorders involvingself-inflicted hair lossinclude trichotemnomania,trichoteiromania,trichodaknomania,trichorrhizophagia)

Trichotillomania (hair-pullingdisorder) [codes 312.39, (F63.3)],classified under ‘ObsessiveCompulsive and RelatedDisorders’

Trichotillomania [code 312.39],classified under ‘Impulse-Control Disorders NotElsewhere Classified’

New classification significantimprovement, as increasingtension (Criterion B, DSMIV-TR)not always associated with hairpulling in TTM. The frequentassociation of TTM withdissociative states however needsto be emphasized

Nail biting (onychophagia),onychotillomania; lip chewing

Classified as an example of aBody-Focused RepetitiveBehavior Disorder under‘Unspecified Obsessive-Compulsive and RelatedDisorder’ [codes 300.3, (F42)]

No specific diagnostic category Recognition of other disordersmanifesting as body-focusedrepetitive behaviors is a positivedevelopment as it will encouragefurther research

Body dysmorphic disorder (BDD)(also dysmorphophobia,dermatologic non-disease)

Body dysmorphic Disorder[codes 300.7 (F45.22)],classified under ‘ObsessiveCompulsive and RelatedDisorders’

Body dysmorphic Disorder[code 300.7], classified under‘Somatoform Disorders’

In DSM-5 a diagnosis of delusionaldisorder, somatic type cannot bemade in the same patient who alsomeets the criteria for BDD withabsent insight/delusional beliefs.Clinically, sometimes it may bedifficult to distinguish between anOCRD such as BDD and a primarydelusional disorder


loss, and repeated attempts to decrease or stop hair pulling.Hair pulling may occur from any region of the body wherehair grows, the most common sites being the scalp, eyebrowsand eyelids. Hair pulling may be accompanied by a range ofrituals and behaviors involving the hair [12], hence the variousterminologies [40] that are used to denote behaviors thatoverlap with TTM, e.g., trichotemnomania (obsessive-compulsive habit of cutting or shaving hair), trichoteiromania(perpetual rubbing of the scalp resulting in fracturing of thehair shafts and hair loss), trichodaknomania (compulsive hab-it of biting ones’ own hair leading to hair loss) andtrichorrhizophagia (eating the hair root after pulling out thehair in a specific way so that so that the root comes out intact).

As in the case of skin picking, the hair-pulling behaviormay involve varying degrees of conscious awareness [12]with some individuals displaying a more purely obsessive-compulsive style with focused attention on their hair pullingwith preceding tension and subsequent relief, while otherindividuals display more dissociative features with automaticbehavior in which the hair pulling appears to occur withoutfull awareness. TTM patients tend to have much greaterdissociative features than SPD [4, 41]. As discussed in thecase of SPD, when the patient is highly dissociative they firstrequire stabilization [8] and are not likely to respond to thestandard behavior therapies and SSRI antidepressants that areused to treat an OCRD. In patients who deny hair pulling,other dermatologic causes of alopecia should be ruled out[12], and the denial should not be attributed only to dissocia-tive psychopathology.

Figure 1 uses the emotional regulation model [42], oftenused in patients with posttraumatic stress disorder who presentwith a high level of autonomic nervous system dysregulation,to conceptualize an approach for the clinical assessment ofpatients presenting with skin lesions due to body-focusedrepetitive behaviors.

Body Dysmorphic Disorder (BDD)

BDD is characterized by preoccupation with one or moreperceived defects or flaws in physical appearance that arenot observable or appear only slight to others, and by repeti-tive behaviors (e.g., mirror checking, excessive grooming,skin picking, or reassurance seeking) or mental acts (e.g.,comparing one’s appearance with that of other people) inresponse to the appearance concerns [12]. Preoccupationscan focus on one or many body areas, most commonly theskin (e.g., perceived acne, scars, lines, wrinkles, paleness),hair (e.g., “thinning” hair or “excessive” body or facial hair),or nose (e.g., size or shape) [12]. In DSMIV-TR [37],obsessive-compulsive disorder had the ‘With poor insight’specifier; in DSM-5 [12], this specifier has been further re-fined with the ‘With good or fair insight,’ ‘With poor insight’

and ‘With absent insight/delusional beliefs’ specifiers, whichhave also been included for BDD.

In contrast to the DSMIV-TR [37], in DSM-5 [12], thedelusional variant of body dysmorphic disorder (which iden-tifies individuals who are completely convinced that theirperceived flaws or defects are truly abnormal appearing) isno longer coded as both a delusional disorder, somatic type,and BDD. In DSM-5 [12] this presentation is coded only asBDD with the ‘Absent insight/delusional beliefs’ specifier.

Cutaneous Body Image

Cutaneous body image (CBI), defined as the individuals’mental perception of the appearance of their integument (skin,hair and nails), is an important core dermatologic construct.CBI is not only important in BDD [12], it is also a centralfactor in cosmetically disfiguring skin disorders where CBIdissatisfaction can have a profound impact upon quality of lifein dermatology patients and patient satisfaction with treatmentoutcome [43]. There is a 9 %-15 % prevalence of BDD indermatology patients and 7 %-8 % prevalence among UScosmetic surgery patients in comparison to a 2.4 % pointprevalence of BDD among US adults [12]. This has importantimplications in dermatology, as clinical treatment guidelinesfor dermatologic disorders have increasingly tended to high-light the importance of assessing psychosocial comorbidity,including aspects of CBI, in order to achieve optimal treat-ment outcomes [44]. For example, current treatment guide-lines for acne almost universally address the importance ofpsychosocial issues in the guidelines from the Global Allianceto Improve Outcomes in Acne [45], and from the US [46] andEurope [47]. Similarly, treatment guidelines for psoriasis fromthe US [48, 49], Britain [50] and Europe [51] have allhighlighted the impact that psoriasis can have on quality oflife and psychological well-being largely due to the cosmeti-cally disfiguring aspects of the disorder. The presence ofBDD, if unrecognized, can therefore significantly affect pa-tient satisfaction with their CBI, which in turn may directlyaffect the dermatologic treatment regimens offered to thepatient.

BDD is associated with a high rate of suicidal ideation andsuicide attempts, especially among the adolescent age group,which is also most likely to have acne [12]. High levels ofinterpersonal sensitivity, defined as feelings of personal inad-equacy and inferiority, and marked discomfort during inter-personal interactions have been shown to play a mediatingeffect in the relation between CBI dissatisfaction and suicidalideation in general [52]. These findings have potentially im-portant clinical implications in a wide range of situations in-volving cosmetically disfiguring cutaneous disorders, ranging,for example, from bullying [53], cultural differences [54] andsocial exclusion faced by the adolescent with acne to the social


stigma and marginalization faced by individuals with chronicdisfiguring skin disorders [52].

Sleep deprivation as a result of sleep restriction [55, 56] orobstructive sleep apnea [57] has been shown to be associatedwith more ratings of aging-related changes of the skin byblinded raters. Underlying insomnia has also been associatedwith a less favorable self-rating of CBI [44].

Delusional Disorder

The classic psychodermatologic disorders [4] of delusions ofinfestation (parasitosis) or delusions of bromhidrosis have beentypically classified as delusional disorders. There are two sig-nificant changes in DSM-5: (1) DSM-5 no longer differentiatesdelusional disorder from shared delusional disorder [37], and ifthe criteria are met fordelusional disorder, the diagnosis is made

[12]. This has implications for delusions of infestation, whichcan be associated with a shared delusional disorder or folie àdeux where identical delusions arise in another person in thecontext of a close relationship with the person with the delusionsof infestation. It should be recognized that a marked decrease ordisappearance of symptoms of the shared delusional disorderoccurs when the individual with the shared delusional disorderis separated from the individual with the primary delusionaldisorder; (2) in DSM-5, a clear demarcation is made betweenan OCRD such as OCD or BDD with the ‘Absent insight/delusional beliefs’ specifier and delusional disorder; if the pa-tient meets the criteria for an OCRD with the ‘Absent insight/delusional beliefs’ specifier, a diagnosis of an OCRD rather thana delusional disorder, somatic type should be made [12]. This isin contrast to DSMIV-TR [37] where both diagnoses of BDDand delusional disorder, somatic type could be made in BDDpatients who held their beliefs with delusional intensity.

STATE OF HYPERAROUSAL AND HIGH SYMPATHETIC TONE

- Patient is able to regulate stressful emotions within this range without

engaging in excessive manipulation of the skin and its appendages. In most instances, upon cessation of a

stressful situation autonomic nervous system reactivity returns to baseline level and homeostasis is

maintained.

STATE OF HYPOAROUSAL AND HIGH PARASYMPATHETIC TONE

.

Numbed ‘collapsed’ state typically preceded by high level of arousal where patient may chronically

self- induce lesions eg., dermatitis artefacta, chronic skin-picking. Patient may develop medical

complications with their self- induced dermatoses, eg, infection etc., because of self-neglect and lack of

self-care.

High level of dissociation is associated with numbing and relative anesthesia of the skin. It is most likely a factor in dermatitis artefacta, where patients can self- induce extensive lesions with the aid of chemicals, sharp objects, etc. and report no recollection of having self- induced the lesions and in trichotillomania where the patient first becomes aware of the self-induced nature of their problem only after their hair pulling has resulted in extensive hair loss.

With high levels of arousal, some patients may dissociate and have little or no recollection of having self- induced their lesions. This is most often encountered in trichotillomania and dermatitis artefacta.

High sympathetic tone may be associated with recurrent ‘idiopathic’ urticaria, cholinergic urticaria, and high skin autonomic reactivity with dermographism. This can predispose the patient to scratch the skin and perpetuate the ‘itch-scratch cycle’.

Compulsive rubbing, picking, scratching of skin, onychophagia, onychotillomania , and trichotillomania which may be recurrent if patient is in a sustained state of hyperarousal.

Skin conductance is increased secondary to elevated sweat gland activity with sympathetic nervous system arousal.

Fig. 1 Emotional dysregulation,autonomic nervous systemreactivity and the self-induceddermatoses. Adapted from GuptaMA. ClinDermatol 2013; 31: 110-117 with permission of publisherand author


Somatic Symptom and Related Disorders

In this new DSM-5 [12] category, the diagnoses of somaticsymptom disorder and psychological factors affecting othermedical conditions are potentially applicable to a wide rangeof psychodermatologic disorders. (1) Somatic symptomdisorder (SSD): The skin is a highly visible organ that func-tions as a vital organ of communication throughout the lifespan. The skin also reacts readily to psychosocial stress. Thesefactors render a wide range of dermatologic disorders vulner-able to the development of chronic psychiatric reactions thatcould be classified as a SSD; (2) Psychological factors affect-ing other medical conditions: This diagnosis describes a widerange of primary dermatologic disorders [3, 58–65] wherepsychosocial and psychiatric comorbidity plays an importantrole.

Conclusion

Sleep disorders can be an important mediating factor in in-flammatory dermatoses because sleep deprivation due to in-somnia, and repeated arousals and high sympathetic tone inobstructive sleep apnea can lead to a heightened proinflam-matory state. The diurnal pattern of pruritus wherein thethreshold for pruritus is lower during the night is most likelya reflection of complex circadian-mediated factors, e.g., lowercortisol levels, decreased epidermal barrier function and in-creased skin temperature during the night. In some disorderssuch as atopic dermatitis, scratching may become a condi-tioned response to being in bed at night, even in the absence ofsignificant pruritus. The earlier literature had focused primar-ily on the effect of dermatologic disorders on sleep, e.g., dueto pruritus. Recent epidemiologic studies in fact suggest a bi-directional relation between sleep and inflammatory skin dis-orders such as psoriasis and atopic dermatitis, which is likelyrelated to a heightened proinflammatory state associated withcommon sleep disorders.

Several diagnoses in the DSM-5 have direct treatmentimplications in psychodermatology. The new excoriation(skin-picking) disorder (SPD) and trichotillomania (TTM)are both recurrent body-focused repetitive behaviors that havecompulsive and dissociative features, the latter being moreprevalent in TTM than SPD. The DSM-5 refers to SPD andTTM occurring without full awareness or preceding tension,however does not specifically mention the possible role ofdissociation. This has important treatment implications aspatients with high dissociative symptoms are not likely torespond to the standard treatments for obsessive-compulsivedisorder. Body dysmorphic disorder (BDD), which is fre-quently associated with cutaneous body image (CBI) dissat-isfaction, is present in 9 %-15 % of dermatology patients.Treatment guidelines for dermatologic disorders are

increasingly considering, as part of their treatment outcomemeasures, the psychosocial morbidity related to CBI that isreported by the patient. Unrecognized BDD, which is likely tobe associated with reports of CBI dissatisfaction by the pa-tient, may therefore directly impact the dermatologic treat-ment regimens offered to the patient. In DSM-5, delusionaldisorder no longer specifically addresses shared delusionaldisorder or folie à deux, which is an important component ofthe clinical presentation in many patients with delusions ofinfestation (parasitosis). It should be recognized that a markeddecrease or disappearance of symptoms of the shared delu-sional disorder occurs when the individual with the shareddelusional disorder is separated from the individual with theprimary delusional disorder.

Compliance with Ethics Guidelines

Conflict of Interest Madhulika A. Gupta and Aditya K. Gupta declarethat they have no conflict of interest.

Human and Animal Rights and Informed Consent This article doesnot contain any studies with human or animal subjects performed by anyof the authors.

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Papers of particular interest, published recently, have beenhighlighted as:• Of importance•• Of major importance

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