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Dermatitis artefacta, a psychodermatologic condition Case report.

Psychodermatology is a term that reflects the complex relationship between skin and brain. Also, psychiatry and dermatology are two medical disciplines which have a close connection and networking. Over a third of patients with dermatological diseases require psychiatric evaluation due to the involvement of psychosocial factors in the occurrence of these medical conditions. On the other hand, patients with mental disorders can present some lesions of the skin, which require a comprehensive, multidisciplinary approach of the case. (1) Thus, there is a direct, causal relation between the occurrence of skin diseases and mental disorders, also the psychiatric symptoms are maintenance by the skin condition and vice versa. In this context, psychodermatology refers to some border diseases, between psychiatry and dermatology. It is represented by three categories of diseases: psychophysiologic disorders, primary psychiatric disorders and secondary psychiatric disorders. Psychophysiologic disorders, like psoriasis and eczema are conditions that occur in response to an emotional state (stress). Primary mental disorders determine cutaneous manifestations, self-inflicted, such as trichotillomania, dermatitis artefacta or delusional ideas focus on skin. Secondary psychiatric disorders are associated with disfiguring skin manifestations, which will cause psychiatric symptoms like depression, social anxiety, decreased self-esteem. On the other hand, alopecia areata, vitiligo, acne are severe illnesses which can determined psychosocial difficulties regarding integration and a maladaptation. (1, 2)

Dermatitis artefacta is considered to be a disease from the group of factitious disorders, which rule out other medical conditions like escoriative injuries, delusional disorders or simulation. This is a condition in which patients produce their own, deliberately, consciously skin lesions in the context of emotional and psychological problems, so it will require a dermatological evaluation, appropriate psychological support and even psychiatric treatment. (3) These skin lesions are considered to represent a nonverbal message, though, often, the patient denies being made by them. In 25-33 % of all dermatological diseases coexist psychiatric disorders like depression, anxiety, personality disorder, delusional disorder and dissociative disorders. (4) Often, these patients had previously a history of chronic dermatoses, personal or family history of psychiatric disorders or chronic medical conditions, including pain. The typical locations of the lesions are on the face (45%), extremities, trunk (24%) or scalp (7%). Regarding the etiology, it is multifactorial one, involving even a genetic predisposition. Most commonly it is associated with other psychiatric disorders like anxiety, depression, dysthymia, factitious, dysmorphic or somatoform disorders. (3,4)

The prevalence for dermatitis artefacta, in the pediatric population, it is one in 23,000 people, with a higher incidence during adolescence and up to young adult. It seems that it is more commonly found in women, without ethnic or racial predisposition. (5) Thus, it is considered a medical condition, difficult to diagnose and little reported, patients are not generally followed-up for a long period of time. (6) Although mild cases, secondary to a identifiable psychosocial factor are considered to have a good prognosis, chronic cases, that are associated with other medical conditions, generally have a worse prognosis.

CASE REPORT

The patient R.V.C., male, 48 years old, from urban medium, unmarried is in the record of the Socola Institute of Psychiatry Iasi, with 37 admissions, made during the years 1974 and 2016.

Family history

His father died at 76 years old, with multiple admissions at Socola Hospital, with chronic alcohol consumption and liver disease. His mother, aged 70 years old had type two diabetes and heart disease. The patient has two brothers (47yo and 54yo), which are chronic consumer of alcohol.

Neurocognitiv development during childhood:

* during pregnancy, the mother was the victim of conjugal violence;

* he went at three years old;

* he talked at four years old, but related words in sentences at six years;

* he attend school with normal program, but with a low yield.

Social history

The patient comes from a disorganized family, with a father, chronic consumer of alcohol, violent, who neglected his children, with multiple hospitalizations in psychiatric department. He has two brothers, alcohol consumers. He graduated the school of professions, skilled steelworker, he has a length of service of 15 years. Currently he is retired on medical condition. He currently lives with his mother in a studio. He is a smoker (10 cigarettes/day). He denies chronic alcohol consumption now, but recognizes in history.

Past psychiatric history

First hospitalization was at the age of seven years old, in February 1974, and the diagnosis was "nocturnal enuresis with demodulation on electroencephalography". Electroencephalography reveals a basic alpha rhythm, theta waves (30-40%) and slow waves with sinusoidal aspect (34 cycles/sec, 150[ohm]V). Neuropsychological development in childhood was poor, he went at three years old, spoke at four years, attend school with normal program, but low efficiency. Between the years 1981 and 1990 he does not appear for any medical consultation. In 1990, he returns to the psychiatrist, presenting polymorphic symptoms, in the context of tonico-clonic seizures, but these are not covered by clinical or electroencephalography signs. The patient accuses marked fussiness and irritability, depressive symptoms, fatigue, decreased work capacity. The patient also describes, for the first time, disorders of the perception, especially illusions. He said "sometimes I feel like going on the waves", "sometimes objects appear to remove or approach to me", "sometimes, even alone in the room, I had the impression that someone is in", associated with phenomena of "deja vu", "deja connu". During this hospitalization, the patient did not present any seizures and the electroencephalography is normal. Diagnosis was "the personality disorder borderline type".

In the following period (1990-2010) the patient had 19 admissions in Socola Hospital for a polymorphic symptomatology like anxious-depressive symptoms, cenestopatic manifestations, based on unstable traits of personality. During this time the patient declares a suicidal attempt by ingestion of 20 tablets of Diazepam and a period when he abused of alcohol. In 2011, the patient describes the emergence of numbness and painful sensations in the hands, claiming he had something under the skin, which causes pain. Clinical examination shows on the back sides of the hand, erythematous lesions with scratching areas, reason for seeking advice of a dermatologist, where it was established the following diagnoses "Ulceration on the dorsal side of the hands", "Chronic impetigo on the hands" and "Patomimie". For psychiatric symptoms the patient receives treatment with atypical antipsychotics (Risperidonum 2mg/day).

In November 2011, the patient presents at the Dermatology Clinic, with round-oval and linear ulcers on the back side of the hands, infected, which it has caused by a nail clipper. It is recommended a local treatment and the lesions have a favourable evolution. In January 2012, he is hospitalized in a psychiatric clinic presented symptoms of delusional aspect, claiming that feels something under the skin and tries to remove the nail, but it's still there. Later on the period 2012-2013 he continues psychiatric treatment (with Valproic acidum 900mg/day and

Risperidonum 2mg/day) and a series of consultations at dermatology, plastic surgery and reconstructive microsurgery. In November 2013, he was presented again in Dermatology Clinic for an ulcer on the dorso-lateral side of the right hand and the dorsal side of the right auricle. The diagnosis at discharge was "Dermatitis artefacta". From 2014 and until now the patient had six hospitalizations in a psychiatric clinic, during which scarring lesions are observed, but the patient says it no longer had pain since 2013. The patient maintained these unrealistic ideas, but in another form, because it argues that the symptoms have disappeared due to its interventions on lesions with a nail clipper.

The clinical examination reveals a good general conditions with sever myopia, polyarthralgias and cicatriciale injuries on the back side of the hands.

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The psychiatric examination highlights: Psycho-diagnosis of expression--the patient response to all the questions, with a depressive facial aspect, voice with a low tone and intensity, avoidant mobile sight, intermissive eye contact with the doctor, hypo-mobile mimicry, reduced gesturing, clothing care and proper hygiene.

Cognitive functions--the patient presents hyperesthesia, with irritability and reduced tolerance to frustration, disorders of the perception, especially illusions ("sometimes I feel like going on the waves", "sometimes objects appear to remove or approach to me", "sometimes, even alone in the room, I had the impression that someone is in"), phenomena of "deja vu", "deja connu". Also, the patient experience cenestopatic manifestations represented by numbness and painful sensations in the hands, claiming he had something under the skin, which causes pain. Attention reveals spontaneous and voluntary hypoprosexia, difficulties in focusing and evoking. Also, he has difficulties of evocation and fixation. Thought reveals ideation and verbal slowness, auto-depreciative and demobilizing ideation. Low levels of imagination.

Affective and motivational functions--the patient manifests a depressive mood, psycho-emotional lability, shyness, generalized anxiety, physical and mental asthenia, fatigue, anhedonia, apathy, feelings of incapacity and helplessness. Instincts highlight eating instinct disorders, with its reduction, sexual instinct disorders with decreased libido and an exaggerated defence instinct, manifested through the fear of disease.

Effector functions--his volition is manifested through hypobulia, with lack of initiative and impaired self-control. Communication is relatively difficult, because of his bradypsychia and a lower level of intelligence. Verbal language disorders are not present. Motoric conduct reveals hypokinesia with slowness and episodes of psychomotor restlessness, bradikynezia. The patient presents sleeping disorders such as mixed type insomnias.

Synthesis functions--The patient is space-time oriented, auto and allopsychic. The insight is partially present. He has a low intellectual capacity.

The psychological examination reveals emotional lability, shyness, emotionalaffective immaturity, impaired self-control, infantile behaviour, difficulty in managing the intensity or duration of emotional reactions, excessive concern related to health, trend toward affective inhibition, rapid psyhosomatisation of negative emotional states, difficulties of adaptation and social integration. At the cognitive level, we found a low intellectual capacity, cognitive slowness, difficulties of memory evocations, low capacity of representation and imagination, low purchase level.

Raven Progressive Matrices (general intelligence level): IQ = 72, underdevelopment of intellectual functions. The test of personality Karl Leonhard assesses personality traits, which means those qualities, tend to slip towards pathological. When these traits reach a certain intensity exceeding average, they leave their mark on the personality and when it emphasizes even more, come to disturb the structure of personality: emotivity = 87.5%; anxiety = 75%.

Woodworth Mathew's questionnaire assesses psychoneurotic trends, respectively, excessive fatigue, adaptation to the environment, abnormal fears, mood, obsessions, aggression, etc. Scores exceeding the threshold of 200 have pathological significance: emotivity = 280p; depression = 280p; impulsive tendencies = 216p; interpretative trends = 200p. Hamilton Rating Scale for Depression has a total score of 21 points, moderate severity of the depressive episode, with depressed mood, low tolerance to minor frustration, inner tension, fatigue, general psychosomatic discomfort, hypobulia, disrupted sleep and poor quality of sleep, psychic anxiety, somatic concerns.

Quality of life assessment SFS-36 comprises two components: the physical component of quality of life, which it is obtained by calculating the arithmetic average of the first five dimensions of quality of life: physical functioning, physical role, bodily pain, general health, vitality. The mental component of quality of life is obtained by calculating the arithmetic average of the last five dimensions of quality of life: general health, vitality, social function, emotional role and mental health. The patient assessed, yielded the following values:

* 2014 total score = 54

* 2016 total score = 92

The score of the physical component on the quality of life is around 40-50, which does not show a significant difference, between evaluations.

The score of the mental competence of the quality of life is 44 in 2014 and 71 in 2016. So, in 2014 the patient gets a very low score on the mental component, but in 2016 the score increases significantly. Thus, the total score at the SFS-36, in 2016, almost doubled, approaching the maximum of 100, which means a much better functionality.

The perception of the quality of life is considered a valuable adjunct clinical activity, so find what the patients think about their condition, to provide adequate information and improve emotional distress of patients are methods of increasing compliance to therapy, reduce the risk of hospitalization, and improving cost-benefit analysis.

EVOLUTION AND PROGNOSIS

The evolution in this case it is particular, considering both the onset in early childhood and its manifestations belonging to a broad range of psychiatric disorders (personality disorders, anxiety, depression, psychosis). Dermatological conditions occurs much later, at 44 years old, when the psychiatric syndrome it was already outlined and represent a secondary psychiatric disorders. Prognosis is variable and depends on the evolution of mental disorder and future collaboration between psychiatrist and dermatologist.

This case represents a good example of multidisciplinary approach, in present, the patient is in a partial remission and skin lesions are healed. But, that patient still maintained these unrealistic ideas that the symptoms have disappeared due to its interventions on injuries represents a starting point for a new exacerbation of psychodermatological symptoms. This can be triggered by any psychologically disturbing factor.

DISCUSSIONS

Dermatitis artefacta is a form of factitious disorder, characterized by causing the patient's skin lesions, which denies that would be produced. It is associated with obsessive-compulsive disorder, borderline personality disorder, depression, psychotic disorder. The therapeutic management targets a supportive approach without "fining" behaviour itself, as well as relaxation therapy, anxiolytics, antidepressant SSRI type, low doses of atypical antipsychotics. The quality of life of these patients is influenced by several factors, namely: physiological factors such as itching, pain, difficulties in hands and feet. Psychological and social impact is important and includes frustration, stigma, lowering self-esteem, camouflage lesions, social inhibition, and rejection.

Patomimia or Munchausen syndrome consists in determining consciously, some pathological conditions (scratches, wounds, burns, etc.) upon which the patient requires consultation or hospitalization in specialized medical institutions. Instead, when asked about what happened, they are invoked the most bizarre cases.

At diagnosis, we will account for another similar pathology, namely dermatozoic delusional disorder or Ekbom syndrome.

This is a psychosis which implicated the skin, characterized by stating that the patient is infected with parasites, which he feels is moving under the skin. Patient experiences numbness and itching, at various sites in those areas there are numerous injuries caused by scratching. Often, we can observe signs of skin irritation (iatrogenic dermatitis), produced by different antiparasitic substances or disinfectants. Sometimes patients may experience delusional ideas and tactile or visual hallucinations.

Evaluation and therapeutic management of this case required a complex, multidisciplinary approach, which is reflected in the difficulty of sustaining positive diagnosis as a result of polymorphism of the symptoms. Over a third of patients with dermatological diseases requires a psychiatric evaluation because, in many psychiatric disorders, skin lesions occur, which will require a comprehensive approach to the case. All mental functions are developed having at the base a body function, so that this function is mentally transposed. (7)

CONCLUSIONS

Thus, the existence of various pathologies is warranted at the border between psychiatry and other medical specialties. In this context, the skin has privileged relations with human psyche, having a common embryonic origin and thus it is a closed relationship between dermatologic diseases and psychiatric disorders. (8) Our case illustrates a practical approach of a patient over the course of a mental disorder associated with dermatological diseases. Thus, maintaining a long-term psychotropic medication associated with adequate dermatological treatment, any time when it was necessary, led to a good evolution and prognosis in this case. It also has been proven, once again, the relationship of interdependence between the two types of symptoms, psychiatric and dermatological ones. In our case, the patient considers a great importance to physical appearance, that's why skin lesions represent a factor of stress that maintain the psychiatric symptoms, thus a vicious circle.

The multidisciplinary approach of the case and effective collaboration between specialists in the respective fields caused remission of the symptoms and increased the quality of life with social and family reintegration of the patient, a very important goal for both the psychiatrist and the dermatologist.

ACKNOWLEDGEMENTS AND DISCLOSURES

The authors state that they are no declared conflicts of interest regarding this paper.

REFERENCES

(1.) Koo, J. Y., Lebwohl, A. Psychodermatology: The Mind and Skin Connection. Am Fam Physician. 2001. Dec 1; 64(11):1873-1879.

(2.) Koo, J. Y. Psychodermatology: a practical manual for clinicians. Cur Prob Dermatol. 1995; 6:204-32.

(3.) Koo, J. Y., Dirk M. E. Dermatitis Artefacta. http://emedicine.medscape.com/article/1121933-overview

(4.) Urpe, M., Pallanti, S., Lotti, T. Psychosomatic factors in dermatology. Dermatol Clin. 2005. Oct. 23(4):601-8.

(5.) Ehsani, A. H., Toosi, S., Shahshahani, M. M., Arbabi, M., Noormohammadpour, P. Psycho-cutaneous disorders: an epidemiologic study. J Eur Acad Dermatol Venereol. 2009 Mar 11.

(6.) Baranska-Rybak, W., Cubala, W. J., Kozicka, D., Sokolowska-Wojdylo, M., Nowicki, R., Roszkiewicz, J. Dermatitis artefacta-a long way from the first clinical symptoms to diagnosis. Psychiatr Danub. 2011 Mar. 23(1):73-5.

(7.) Anzieu. Le moi-peau. 1995. Paris. Dunod.

(8.) Masmoudi, J., Feki, I., Sallemi, R., Baati, I., Jaoua, A. Pan African Medical Journal. 2013; 16:25. doi:10.11604/ pamj.2013.16.25.2895.

Andreea Silvana SZALONTAY, Elena UNGUREANU, Manuela PARASCHIV, Alexandra BOLOS

Andreea Silvana SZALONTAY--M. D., Ph. D., Senior Psychiatrist, "Socola" Psychiatry Institute, Lecturer, Department of Psychiatry, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania

Elena UNGUREANU--Five Year Resident, "Socola" Psychiatry Institute Iasi, Romania Manuela PARASCHIV--Clinician Psychologist, "Socola" Psychiatry Institute Iasi, Romania

Alexandra BOLOS--M. D., Ph. D., Senior Psychiatrist "Socola" Psychiatry Institute, Lecturer, Department of Psychiatry, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania

Correspondence:

Elena UNGUREANU

Five Year Resident, "Socola" Psychiatry Institute Iasi, No. 36 $os. Bucium, zip code 700282, Iasi, Romania

E-mail: lagatzy@yahoo.com

Submission: September, 20th, 2016

Acceptance: October, 24th, 2016
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Title Annotation:Case Reports
Author:Szalontay, Andreea Silvana; Ungureanu, Elena; Paraschiv, Manuela; Bolos, Alexandra
Publication:Bulletin of Integrative Psychiatry
Article Type:Clinical report
Date:Dec 1, 2016
Words:2904
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