MEDLINE Abstracts: Psychodermatology
Folks DG, Warnock JK
Curr Psychiatry Rep. 2001;3:219-225
Dermatologic conditions are commonly associated with psychiatric sequella, eg, urticaria, alopecia, psoriasis, or acne. Moreover, the onset and course of dermatologic disorders may be significantly influenced by stress, emotional disturbances, or psychiatric disorder. Compulsions involving the skin, excoriations, or hair pulling (trichotillomania) are the more frequently encountered problems. In some cases, skin conditions are self-induced or reflect signs or symptoms of an underlying psychiatric disorder, including psychosis or obsessive-compulsive disorder. Additionally, skin lesions have been frequently described in case reports of factitious dermatitis. Finally, adverse effects of psychotropic drugs may cause dermatologic side effects, mostly idiosyncratic skin eruptions. These problems are discussed with emphasis on clinical features, comorbidity, and psychiatric management.
Picardi A, Abeni D
Psychother Psychosom. 2001; 70:118-136
The possibility of a causal influence of emotional stress, especially of stressful life events, on the course of various skin diseases has long been postulated. Clinical wisdom and experience, as well as many anecdotal observations and uncontrolled case series, support this opinion. We reviewed the available evidence on the role of stressful life events in triggering or exacerbating skin diseases. The role of stressful events in vitiligo, lichen planus, acne, pemphigus and seborrhoeic dermatitis was either controversial or insufficiently explored. The role of stressful events in psoriasis, alopecia areata, atopic dermatitis and urticaria was apparently clearer. However, only a few studies met acceptable methodological standards for stress measurement. Also, few studies considered common potential confounding factors (e.g. age, duration of illness, familial factors), and no study controlled adequately for the influence of other crucial factors (e.g. discontinuation of treatment, seasonal effects). Adding that the large majority of studies were retrospective, it seems wise to conclude that only preliminary evidence has been published so far on the role of stressful life events in bringing on or worsening any dermatological disease. Further research is mandatory, either in the form of prospective studies or, more feasibly, of well-designed case-control studies with adequate statistical power. Future studies should also pay more attention to protective as well as vulnerability factors in stressful events. Further, it would be important to investigate other sources of psychological stress, such as chronic stress and everyday stress. Measuring stress appraisal, although difficult, would also be important.
Garg A, Chren MM, Sands LP, et al
Arch Dermatol. 2001.137:78-82
Background: A large number of skin diseases, including atopic dermatitis and psoriasis, appear to be precipitated or exacerbated by psychological stress. Nevertheless, the specific pathogenic role of psychological stress remains unknown. In 3 different murine models of psychological stress, it was recently shown that psychological stress negatively impacts cutaneous permeability barrier function and that coadministration of tranquilizers blocks this stress-induced deterioration in barrier function.
Objectives and Methods: The relationship between psychological stress and epidermal permeability barrier function was investigated in 27 medical, dental, and pharmacy students without coexistent skin disease. Their psychological state was assessed with 2 well-validated measures: the Perceived Stress Scale and the Profile of Mood States. Barrier function was assessed simultaneously with the stress measures at periods of presumed higher stress (during final examinations) and at 2 assumed, lower stress occasions (after return from winter vacation [approximately 4 weeks before final examinations] and during spring vacation [approximately 4 weeks after final examinations]).
Results: The subjects as a group demonstrated a decline in permeability barrier recovery kinetics after barrier disruption by cellophane tape stripping, in parallel with an increase in perceived psychological stress during the higher vs the initial lower stress occasions. During the follow-up, presumed lower stress period, the subjects again displayed lower perceived psychological stress scores and improved permeability barrier recovery kinetics, comparable to those during the initial lower stress period. Moreover, the greatest deterioration in barrier function occurred in those subjects who demonstrated the largest increases in perceived psychological stress.
Conclusion: These studies provide the first link between psychological status and cutaneous function in humans and suggest a new pathophysiological paradigm, ie, stress-induced derangements in epidermal function as precipitators of inflammatory dermatoses.
Dufresne RG, Phillips KA, Vittorio CC, Wilkel CS
Dermatol Surg. 2001;27:457-462
Background: Dermatologic surgeons frequently see patients with body dysmorphic disorder, a distressing or impairing preoccupation with a nonexistent or slight defect in appearance. Recognition of this disorder is essential to avoid unnecessary and generally unsatisfying surgical outcomes, but no screening tools are available for use in a dermatology setting.
Objective: To develop and validate a brief self-report questionnaire to screen for body dysmorphic disorder in dermatology settings.
Methods: A questionnaire was developed and its sensitivity and specificity determined in 46 subjects, using a reliable clinician-administered diagnostic interview for body dysmorphic disorder. The interrater reliability of a defect severity scale was also determined (n = 50).
Results: The self-report questionnaire had a sensitivity of 100% and a specificity of 93%. The interrater reliability (ICC) of the defect rating scale was.88.
Conclusions: This brief questionnaire was a highly effective screening tool for body dysmorphic disorder in a cosmetic dermatology setting. Use of this questionnaire may help identify patients with this syndrome.
Tennyson H, Levine N
Dermatol Clin. 2001. 19:179-197
Several psychotropic and neurotropic agents are useful in treating patients with skin diseases such as obsessive compulsive skin manipulation, delusions of parasitosis, generalized pruritus, and post-herpetic neuralgia. The mechanism of action of these agents is based on their interaction with central and peripheral neuronal receptors. The medications discussed in this article include the tricyclic antidepressants, serotonin reuptake inhibitors, naltrexone, pimozide, and gabapentin. The pharmacology, mechanism of action, adverse effects, drug interactions, and monitoring guidelines are outlined for each of these drugs.
Harris DL, Carr AT
Br J Plast Surg. 2001;54:223-226
Using information gathered in the introductory sections of the Derriford Appearance Scales (DAS24 and DAS59), the prevalence and epidemiological characteristics of concern about physical appearance have been determined for a carefully constructed sample of the general population of southwest Devon (rural and urban). In all, 2108 usable replies were received from a postal survey of a targeted population of 5400 men and women, aged 18 and over and randomly selected with constraints for age, sex and socio-economic status. The prevalence of concern about physical appearance was highest among women through to age 60 and younger men. There was no association with socio-economic status or living status. Concerns about the nose, weight and skin disorders were reported most frequently by both men and women and additionally concerns about breasts and abdomen were reported by women and premature balding by men. The mean DAS24 and DAS59 full-scale scores of 19% of male and 25% of female responders who were concerned about appearance exceeded the mean scores of preoperative patients undergoing reconstructive and cosmetic plastic surgery. Concern about appearance is widespread in the general population. More often than not, concern is about one feature only, which runs counter to the hypothesis that concern about appearance reflects a neurotic trait. The high levels of measured psychological distress and dysfunction found in a substantial minority of those in the general population who are concerned about appearance highlight the need for appropriate services.
Gieler U, Niemeier V, Kupfer J, Brosig B, Schill WB
Hautarzt. 2001;52:104-110
Background and Objective: A questionnaire study of German dermatological clinics was designed to show the situation and development of psychosomatic dermatology 10 years after a similar study.
Patients/Methods: A questionnaire was sent to 170 dermatological clinics. 76 were sent back; 69 of them (40.6%) were evaluable. The questionnaires were mostly answered by the heads of the dermatological clinics (38/69 = 55.1%).
Results: Nearly 85% of the dermatological clinics answered that they take psychosomatic aspects into consideration in the therapy. 5.1% of the dermatologists working in clinics have additional psychotherapeutic certification. The improvement of coping behaviour seems to be the main goal of psychosomatic interventions. The importance of psychic factors increased in the last 10 years in comparison to a former study in regard to most of the dermatological diseases.
Conclusions: Psychosomatic aspects seem to be an obligatory part of inpatient dermatological therapy. The frequency of some diseases was underestimated in comparison with results from literature.
Muhlbauer W, Holm C, Wood DL
Plast Reconstr Surg. 2001;107:319-326
Body dysmorphic disorder describes the preoccupation with an imagined defect of appearance. A subgroup of patients suffer from the so-called Thersites complex, in which a minimal physical deformity causes excessive psychological disturbances and distress. Patients with body dysmorphic disorder tend primarily to visit a plastic surgeon for relief with distinct plans for surgical correction of their "deformity." Psychotherapy is generally refused or ineffective. The plastic surgeon should be familiar with this mental disorder and recognize these patients during consultation. Most of these patients should be excluded from surgery; however, patients of the Thersites complex category might be candidates for plastic surgical correction after careful selection. Only the experienced plastic surgeon should make the decision to operate in this situation. A successful treatment can relieve the patient from his or her distress and improve the quality of life substantially. A surgical result that is not accepted by the patient can end in a tragedy for either the patient or the doctor.
Buske-Kirschbaum A, Geiben A, Wermke C, Pirke KM, Hellhammer D
Psychother Psychosom. 2001;70:86-91
Background: After primary orofacial infection with the herpes simplex virus (type 1, HSV-1), up to 40% of HSV seropositive subjects suffer recurrent herpes infections which are characterized by painful erosions of the involved skin mainly around the lips (herpes labialis). Besides various other factors, there is growing evidence suggesting that psychosocial factors might trigger HSV. The present study was designed to investigate modulation of recurrent HSV infection by experimentally induced emotional distress.
Methods: Among patients with herpes labialis (n = 91), subjects who showed recurrent HSV infection (>5 acute infections/year) and who reported to suffer from HSV symptoms exclusively after confrontation with dirty dishes, i.e. dirty plates or dirty glasses were selected by standardized interview. Subjects (n = 20) were randomly assigned to two treatment groups. The experimental group (n = 10) was first exposed to 5 slides showing dirty glasses and subsequently to the glasses previously presented on the slides in vivo. The control group (n = 10) was exposed to neutral slides and neutral objects. In order to determine the proportion of leukocyte subpopulations and concentrations of tumor necrosis factor alpha (TNF-alpha), blood samples were collected 15 min before as well as 40 min and 48 h after stimulus presentation. Saliva cortisol was obtained 45, 20, 15 and 1 min before and 1, 10, 20 and 30 min after stimulus confrontation.
Results: Medical examination of the volunteers 48 h after the experiment indicated that four experimental subjects showed HSV-1 symptoms while not a single herpetic infection could be determined in the control subjects (p = 0.033). Moreover, significantly elevated concentrations of TNF-alpha were observed in the experimental, but not in the control group. No significant alterations of the number of leukocyte subpopulations were found 30 min or 48 h after stimulus presentation. Further, cortisol concentrations were found to be unchanged after the treatment.
Conclusions: The present findings suggest that experimentally induced emotional stress such as disgust may be associated with reactivation of HSV.
Buske-Kirschbaum A, Geiben A, Hellhammer D.
Psychother Psychosom. 2001;70:6-16
Atopic dermatitis (AD) is a chronic, pruritic inflammatory skin disease with increasing incidence characterized by eczematous inflammation of the skin, a chronically relapsing course and severe pruritus. In the last decade, there has been growing evidence indicating that psychological factors such as personality and stress may play an important role in the pathogenesis of AD. While there is only little consensus on an AD-specific personality profile and its etiological significance, a growing number of reports support the role of psychosocial stress in the onset and the course of AD symptomatology. However, although a close association between psychosocial stress and skin condition in AD patients has been demonstrated by several investigators, pathological models that integrate stress and its effect on atopy-relevant biological processes, e.g. immune processes, are still missing. This overview summarizes the role of immunological and psychological factors in AD pathogenesis and discusses potential psychobiological pathways of stress-related modulation of AD symptoms.
Phillips KA, Dufresne RG Jr, Wilkel CS, Vittorio CC
J Am Acad Dermatol. 2000;42:436-441
Background: Dermatologists appear to be the physicians most often seen by patients with the psychiatric condition body dysmorphic disorder (BDD), a distressing or impairing preoccupation with a nonexistent or slight defect in appearance. The frequency of BDD among patients seeking dermatologic treatment is unknown, however.
Objective: This study determined the percentage of patients seeking dermatologic treatment who screened positive for BDD.
Methods: A validated self-report questionnaire and a reliable defect severity scale were used to determine the rate of BDD in 268 patients seeking dermatologic treatment.
Results: A total of 11.9% (95% confidence interval [CI], 8.0%-15.8%) of patients screened positive for BDD. Rates were similar in a community general dermatology setting (14.4% [95% CI, 8.5%-20.3%]) and a university cosmetic surgery setting (10. 0% [95% CI, 6.1%-13.9%]).
Conclusion: BDD appears relatively common among patients seeking dermatologic treatment. Further research is needed to confirm these findings and to assist dermatologists in identifying these potentially high-risk patients.
Garnis-Jones S, Collins S, Rosenthal D
J Cutan Med Surg. 2000;4:161-163
Background: Self-mutilation or dermatitis artefacta is a facet of a much broader spectrum of factitial disease. Three nonpsychotic patients with self-mutilation are presented in this article who were successfully treated with low dose olanzapine when all other modalities of therapy had failed, including trials with numerous antidepressants and antipsychotics.
Objective: The patients were simultaneously evaluated and treated by a dermatologist and a psychiatrist who run the psychodermatology or consultation-liaison clinic based at McMaster University. After dermatologic conditions had been excluded as a cause of the clinical findings, olanzapine was prescribed on a trial basis due to its low risk of parkinsonian side-effects and its antihistaminic properties.
Conclusions: The excellent clinical response of the patients can be attributed to the low side-effect profile of the drug but also to the anti-impulsive effect which stems not only from antihistaminic properties but also from its antidopamine and serotonin-blocking action.
Gupta MA, Gupta AK
Dermatol Clin. 2000;18:711-725
In approximately one third of dermatology patients, the effective management of a skin condition also involves consideration of associated emotional and psychosocial factors. Psychotropic drugs are an important part of the dermatologist's therapeutic armamentarium. This article reviews some of the salient pharmacologic guidelines and important drug-drug interactions involved in the use of the major classes of, for example, antidepressants and antipsychotic drugs, in the dermatologic patient.
Elmer KB, George RM, Peterson K.
J Am Acad Dermatol. 2000; 43:683-686
Monosymptomatic hypochondriacal psychoses such as delusions of parasitosis are often difficult to treat. For the past two decades, pimozide has been considered the drug of choice. Although a few controlled studies have been done to support the efficacy of pimozide, the recommendation of treatment of choice is largely based on case reports. Pimozide has significant side effects, including cardiac and extrapyramidal abnormalities, which are of most concern in the treatment of the elderly. Although pimozide does appear to be effective in some cases of somatic delusional disorders, newer antipsychotics such as risperidone have also been shown to be beneficial in treating this perplexing cluster of disorders. Risperidone is generally considered safer than pimozide and should be considered as first-line therapy for monosymptomatic hypochondriacal psychoses.
Bhatia MS, Jagawat T, Choudhary S
Int J Psychiatry Med. 2000;30:83-91
Objective: Delusional parasitosis is a form of monohypochondriacal psychosis, a condition sometimes encountered in psychiatric or primary care practice. The outcome of this condition is not well known.
Method: In the present study, a series of fifty-two consecutive cases of delusional parasitosis is reported.
Results: A majority of cases (92%) had insidious onset. The duration of symptoms in all but two cases was six months or more. Twenty-six cases presented with a delusion of infestation by insects over the body and twenty-three cases with a delusion of insects crawling over the scalp. Three cases had associated diabetes mellitus, five cases had leprosy, five cases dementia, four cases had depression, and three cases presented with trichotillomania. Pimozide was used in forty-six cases, amitriptyline and fluoxetine in three cases each. Twenty-eight cases (54%) showed complete remission while receiving pharmacotherapy, eighteen cases showed partial improvement, and six cases did not respond to treatment.
Conclusion: Further studies are warranted to study the treatment and outcome of this important psychiatric disorder.
Onder M, Cosar B, Oztas MO, Candansayar S.
Biomed Pharmacother. 2000;54:258-262
We investigated skin problems of musicians (N = 117) working in a professional orchestra. The results of this survey suggest a significant incidence of occupational and stress-related skin problems in musicians such as hyperhydrosis, lichen planus, psoriasis, seborrheic dermatitis and urticaria. It was thought that emotional factors exacerbate their problems. This article discusses the importance of psychiatric consultations in dermatologic problems.
Keuthen NJ, Deckersbach T, Wilhelm S, et al
Psychosomatics. 2000;41:210-215
The prevalence of skin-picking and its associated characteristics were documented in a nonclinical sample of 105 college students. Subjects completed a self-report skin-picking inventory and several paper-and-pencil scales. Students who endorsed skin-picking were compared to a clinical sample of self-injurious skin-pickers (n = 31) reported on previously. Of the student subjects, 78.1% (n = 82) endorsed some degree of skin-picking and four subjects satisfied criteria for severe, self-injurious picking. Student subjects significantly differed from the clinical sample of self-injurious skin-pickers in the duration, focus, and extent of picking, techniques used, reasons for picking, associated emotions, and picking sequelae.
O'Sullivan RL, Mansueto CS, Lerner EA, Miguel EC
Psychiatr Clin North Am. 2000;23:587-604
Multiple approaches to characterization of TTM have been developed, including categoric definitions and dimensional considerations.When TTM is viewed in the context of other disorders with common comorbidities and overlapping similar phenomenologies, such as OCD, body dysmorphic disorder, skin picking, TS, and olfactory reference syndrome, clinical approaches to assessment and differential diagnosis are more complex. This article presents a general overview of TTM included as a background for a heuristic clinical framework for assessing obsessive-compulsive spectrum disorders. A comprehensive behavioral model of TTM as a template is presented in the context of a broader, phenomenologic approach to assessment of several other disorders. These additional conditions were chosen on clinical grounds because they seem to share some phenomenologic characteristics with TTM. It is hoped that combining a phenomenologic approach to the differentiation of repetitive behaviors (as has been valuable in advancing the understanding of repetitive behaviors in TS and OCD), coupled with a paradigmatic comprehensive behavioral assessment and treatment model of TTM, may foster the validation of such approaches for other putative obsessive-compulsive spectrum disorders. Also, the relative intensity and frequency ascribed to the various behavioral and phenomenologic components of the conditions depicted represent clinical impressions, with varying degrees of empiric support, and require objective validation. This approach is meant to serve as a point of departure for clinical assessment of these complex, interesting, and sometimes incompletely diagnosed and inadequately treated conditions. It is hoped that empiric validation or refutation of this conceptualization will stimulate additional research and provide clinicians with a general framework for assessing patients suffering from these difficult conditions.
Nakamura Y, Mulliken JB, Belfer ML
Aesthetic Plast Surg. 2000;24:283-288
This review describes the historical development of aesthetic surgery in Japan and parallels with the development of the specialty in the United States. The focus is on the consequences of aesthetic surgery in the male patient when collaboration between mental health clinicians and surgeons lags. The cultural, social, and psychological issues raised are relevant to the diverse cultural groups now seeking aesthetic surgery in the United States. Case illustrations are a reminder to aesthetic surgeons of the potential need for more comprehensive evaluation in the group of male patients who may be at added risk for negative outcomes in terms of satisfaction.
MEDLINE Abstracts: Psychodermatology
Psychocutaneous Disorders
Folks DG, Warnock JK
Curr Psychiatry Rep. 2001;3:219-225
Dermatologic conditions are commonly associated with psychiatric sequella, eg, urticaria, alopecia, psoriasis, or acne. Moreover, the onset and course of dermatologic disorders may be significantly influenced by stress, emotional disturbances, or psychiatric disorder. Compulsions involving the skin, excoriations, or hair pulling (trichotillomania) are the more frequently encountered problems. In some cases, skin conditions are self-induced or reflect signs or symptoms of an underlying psychiatric disorder, including psychosis or obsessive-compulsive disorder. Additionally, skin lesions have been frequently described in case reports of factitious dermatitis. Finally, adverse effects of psychotropic drugs may cause dermatologic side effects, mostly idiosyncratic skin eruptions. These problems are discussed with emphasis on clinical features, comorbidity, and psychiatric management.
Stressful Life Events and Skin Diseases: Disentangling Evidence From Myth
Picardi A, Abeni D
Psychother Psychosom. 2001; 70:118-136
The possibility of a causal influence of emotional stress, especially of stressful life events, on the course of various skin diseases has long been postulated. Clinical wisdom and experience, as well as many anecdotal observations and uncontrolled case series, support this opinion. We reviewed the available evidence on the role of stressful life events in triggering or exacerbating skin diseases. The role of stressful events in vitiligo, lichen planus, acne, pemphigus and seborrhoeic dermatitis was either controversial or insufficiently explored. The role of stressful events in psoriasis, alopecia areata, atopic dermatitis and urticaria was apparently clearer. However, only a few studies met acceptable methodological standards for stress measurement. Also, few studies considered common potential confounding factors (e.g. age, duration of illness, familial factors), and no study controlled adequately for the influence of other crucial factors (e.g. discontinuation of treatment, seasonal effects). Adding that the large majority of studies were retrospective, it seems wise to conclude that only preliminary evidence has been published so far on the role of stressful life events in bringing on or worsening any dermatological disease. Further research is mandatory, either in the form of prospective studies or, more feasibly, of well-designed case-control studies with adequate statistical power. Future studies should also pay more attention to protective as well as vulnerability factors in stressful events. Further, it would be important to investigate other sources of psychological stress, such as chronic stress and everyday stress. Measuring stress appraisal, although difficult, would also be important.
Psychological Stress Perturbs Epidermal Permeability Barrier Homeostasis: Implications for the Pathogenesis of Stress-Associated Skin Disorders
Garg A, Chren MM, Sands LP, et al
Arch Dermatol. 2001.137:78-82
Background: A large number of skin diseases, including atopic dermatitis and psoriasis, appear to be precipitated or exacerbated by psychological stress. Nevertheless, the specific pathogenic role of psychological stress remains unknown. In 3 different murine models of psychological stress, it was recently shown that psychological stress negatively impacts cutaneous permeability barrier function and that coadministration of tranquilizers blocks this stress-induced deterioration in barrier function.
Objectives and Methods: The relationship between psychological stress and epidermal permeability barrier function was investigated in 27 medical, dental, and pharmacy students without coexistent skin disease. Their psychological state was assessed with 2 well-validated measures: the Perceived Stress Scale and the Profile of Mood States. Barrier function was assessed simultaneously with the stress measures at periods of presumed higher stress (during final examinations) and at 2 assumed, lower stress occasions (after return from winter vacation [approximately 4 weeks before final examinations] and during spring vacation [approximately 4 weeks after final examinations]).
Results: The subjects as a group demonstrated a decline in permeability barrier recovery kinetics after barrier disruption by cellophane tape stripping, in parallel with an increase in perceived psychological stress during the higher vs the initial lower stress occasions. During the follow-up, presumed lower stress period, the subjects again displayed lower perceived psychological stress scores and improved permeability barrier recovery kinetics, comparable to those during the initial lower stress period. Moreover, the greatest deterioration in barrier function occurred in those subjects who demonstrated the largest increases in perceived psychological stress.
Conclusion: These studies provide the first link between psychological status and cutaneous function in humans and suggest a new pathophysiological paradigm, ie, stress-induced derangements in epidermal function as precipitators of inflammatory dermatoses.
A Screening Questionnaire for Body Dysmorphic Disorder in a Cosmetic Dermatologic Surgery Practice
Dufresne RG, Phillips KA, Vittorio CC, Wilkel CS
Dermatol Surg. 2001;27:457-462
Background: Dermatologic surgeons frequently see patients with body dysmorphic disorder, a distressing or impairing preoccupation with a nonexistent or slight defect in appearance. Recognition of this disorder is essential to avoid unnecessary and generally unsatisfying surgical outcomes, but no screening tools are available for use in a dermatology setting.
Objective: To develop and validate a brief self-report questionnaire to screen for body dysmorphic disorder in dermatology settings.
Methods: A questionnaire was developed and its sensitivity and specificity determined in 46 subjects, using a reliable clinician-administered diagnostic interview for body dysmorphic disorder. The interrater reliability of a defect severity scale was also determined (n = 50).
Results: The self-report questionnaire had a sensitivity of 100% and a specificity of 93%. The interrater reliability (ICC) of the defect rating scale was.88.
Conclusions: This brief questionnaire was a highly effective screening tool for body dysmorphic disorder in a cosmetic dermatology setting. Use of this questionnaire may help identify patients with this syndrome.
Neurotropic and Psychotropic Drugs in Dermatology
Tennyson H, Levine N
Dermatol Clin. 2001. 19:179-197
Several psychotropic and neurotropic agents are useful in treating patients with skin diseases such as obsessive compulsive skin manipulation, delusions of parasitosis, generalized pruritus, and post-herpetic neuralgia. The mechanism of action of these agents is based on their interaction with central and peripheral neuronal receptors. The medications discussed in this article include the tricyclic antidepressants, serotonin reuptake inhibitors, naltrexone, pimozide, and gabapentin. The pharmacology, mechanism of action, adverse effects, drug interactions, and monitoring guidelines are outlined for each of these drugs.
Prevalence of Concern About Physical Appearance in the General Population
Harris DL, Carr AT
Br J Plast Surg. 2001;54:223-226
Using information gathered in the introductory sections of the Derriford Appearance Scales (DAS24 and DAS59), the prevalence and epidemiological characteristics of concern about physical appearance have been determined for a carefully constructed sample of the general population of southwest Devon (rural and urban). In all, 2108 usable replies were received from a postal survey of a targeted population of 5400 men and women, aged 18 and over and randomly selected with constraints for age, sex and socio-economic status. The prevalence of concern about physical appearance was highest among women through to age 60 and younger men. There was no association with socio-economic status or living status. Concerns about the nose, weight and skin disorders were reported most frequently by both men and women and additionally concerns about breasts and abdomen were reported by women and premature balding by men. The mean DAS24 and DAS59 full-scale scores of 19% of male and 25% of female responders who were concerned about appearance exceeded the mean scores of preoperative patients undergoing reconstructive and cosmetic plastic surgery. Concern about appearance is widespread in the general population. More often than not, concern is about one feature only, which runs counter to the hypothesis that concern about appearance reflects a neurotic trait. The high levels of measured psychological distress and dysfunction found in a substantial minority of those in the general population who are concerned about appearance highlight the need for appropriate services.
Psychosomatic Dermatology in Germany: A Survey of 69 Dermatologic Clinics
Gieler U, Niemeier V, Kupfer J, Brosig B, Schill WB
Hautarzt. 2001;52:104-110
Background and Objective: A questionnaire study of German dermatological clinics was designed to show the situation and development of psychosomatic dermatology 10 years after a similar study.
Patients/Methods: A questionnaire was sent to 170 dermatological clinics. 76 were sent back; 69 of them (40.6%) were evaluable. The questionnaires were mostly answered by the heads of the dermatological clinics (38/69 = 55.1%).
Results: Nearly 85% of the dermatological clinics answered that they take psychosomatic aspects into consideration in the therapy. 5.1% of the dermatologists working in clinics have additional psychotherapeutic certification. The improvement of coping behaviour seems to be the main goal of psychosomatic interventions. The importance of psychic factors increased in the last 10 years in comparison to a former study in regard to most of the dermatological diseases.
Conclusions: Psychosomatic aspects seem to be an obligatory part of inpatient dermatological therapy. The frequency of some diseases was underestimated in comparison with results from literature.
The Thersites Complex in Plastic Surgical Patients
Muhlbauer W, Holm C, Wood DL
Plast Reconstr Surg. 2001;107:319-326
Body dysmorphic disorder describes the preoccupation with an imagined defect of appearance. A subgroup of patients suffer from the so-called Thersites complex, in which a minimal physical deformity causes excessive psychological disturbances and distress. Patients with body dysmorphic disorder tend primarily to visit a plastic surgeon for relief with distinct plans for surgical correction of their "deformity." Psychotherapy is generally refused or ineffective. The plastic surgeon should be familiar with this mental disorder and recognize these patients during consultation. Most of these patients should be excluded from surgery; however, patients of the Thersites complex category might be candidates for plastic surgical correction after careful selection. Only the experienced plastic surgeon should make the decision to operate in this situation. A successful treatment can relieve the patient from his or her distress and improve the quality of life substantially. A surgical result that is not accepted by the patient can end in a tragedy for either the patient or the doctor.
Preliminary Evidence for Herpes Labialis Recurrence Following Experimentally Induced Disgust
Buske-Kirschbaum A, Geiben A, Wermke C, Pirke KM, Hellhammer D
Psychother Psychosom. 2001;70:86-91
Background: After primary orofacial infection with the herpes simplex virus (type 1, HSV-1), up to 40% of HSV seropositive subjects suffer recurrent herpes infections which are characterized by painful erosions of the involved skin mainly around the lips (herpes labialis). Besides various other factors, there is growing evidence suggesting that psychosocial factors might trigger HSV. The present study was designed to investigate modulation of recurrent HSV infection by experimentally induced emotional distress.
Methods: Among patients with herpes labialis (n = 91), subjects who showed recurrent HSV infection (>5 acute infections/year) and who reported to suffer from HSV symptoms exclusively after confrontation with dirty dishes, i.e. dirty plates or dirty glasses were selected by standardized interview. Subjects (n = 20) were randomly assigned to two treatment groups. The experimental group (n = 10) was first exposed to 5 slides showing dirty glasses and subsequently to the glasses previously presented on the slides in vivo. The control group (n = 10) was exposed to neutral slides and neutral objects. In order to determine the proportion of leukocyte subpopulations and concentrations of tumor necrosis factor alpha (TNF-alpha), blood samples were collected 15 min before as well as 40 min and 48 h after stimulus presentation. Saliva cortisol was obtained 45, 20, 15 and 1 min before and 1, 10, 20 and 30 min after stimulus confrontation.
Results: Medical examination of the volunteers 48 h after the experiment indicated that four experimental subjects showed HSV-1 symptoms while not a single herpetic infection could be determined in the control subjects (p = 0.033). Moreover, significantly elevated concentrations of TNF-alpha were observed in the experimental, but not in the control group. No significant alterations of the number of leukocyte subpopulations were found 30 min or 48 h after stimulus presentation. Further, cortisol concentrations were found to be unchanged after the treatment.
Conclusions: The present findings suggest that experimentally induced emotional stress such as disgust may be associated with reactivation of HSV.
Psychobiological Aspects of Atopic Dermatitis: An Overview
Buske-Kirschbaum A, Geiben A, Hellhammer D.
Psychother Psychosom. 2001;70:6-16
Atopic dermatitis (AD) is a chronic, pruritic inflammatory skin disease with increasing incidence characterized by eczematous inflammation of the skin, a chronically relapsing course and severe pruritus. In the last decade, there has been growing evidence indicating that psychological factors such as personality and stress may play an important role in the pathogenesis of AD. While there is only little consensus on an AD-specific personality profile and its etiological significance, a growing number of reports support the role of psychosocial stress in the onset and the course of AD symptomatology. However, although a close association between psychosocial stress and skin condition in AD patients has been demonstrated by several investigators, pathological models that integrate stress and its effect on atopy-relevant biological processes, e.g. immune processes, are still missing. This overview summarizes the role of immunological and psychological factors in AD pathogenesis and discusses potential psychobiological pathways of stress-related modulation of AD symptoms.
Rate of Body Dysmorphic Disorder in Dermatology Patients
Phillips KA, Dufresne RG Jr, Wilkel CS, Vittorio CC
J Am Acad Dermatol. 2000;42:436-441
Background: Dermatologists appear to be the physicians most often seen by patients with the psychiatric condition body dysmorphic disorder (BDD), a distressing or impairing preoccupation with a nonexistent or slight defect in appearance. The frequency of BDD among patients seeking dermatologic treatment is unknown, however.
Objective: This study determined the percentage of patients seeking dermatologic treatment who screened positive for BDD.
Methods: A validated self-report questionnaire and a reliable defect severity scale were used to determine the rate of BDD in 268 patients seeking dermatologic treatment.
Results: A total of 11.9% (95% confidence interval [CI], 8.0%-15.8%) of patients screened positive for BDD. Rates were similar in a community general dermatology setting (14.4% [95% CI, 8.5%-20.3%]) and a university cosmetic surgery setting (10. 0% [95% CI, 6.1%-13.9%]).
Conclusion: BDD appears relatively common among patients seeking dermatologic treatment. Further research is needed to confirm these findings and to assist dermatologists in identifying these potentially high-risk patients.
Treatment of Self-Mutilation With Olanzapine
Garnis-Jones S, Collins S, Rosenthal D
J Cutan Med Surg. 2000;4:161-163
Background: Self-mutilation or dermatitis artefacta is a facet of a much broader spectrum of factitial disease. Three nonpsychotic patients with self-mutilation are presented in this article who were successfully treated with low dose olanzapine when all other modalities of therapy had failed, including trials with numerous antidepressants and antipsychotics.
Objective: The patients were simultaneously evaluated and treated by a dermatologist and a psychiatrist who run the psychodermatology or consultation-liaison clinic based at McMaster University. After dermatologic conditions had been excluded as a cause of the clinical findings, olanzapine was prescribed on a trial basis due to its low risk of parkinsonian side-effects and its antihistaminic properties.
Conclusions: The excellent clinical response of the patients can be attributed to the low side-effect profile of the drug but also to the anti-impulsive effect which stems not only from antihistaminic properties but also from its antidopamine and serotonin-blocking action.
The Use of Psychotropic Drugs in Dermatology
Gupta MA, Gupta AK
Dermatol Clin. 2000;18:711-725
In approximately one third of dermatology patients, the effective management of a skin condition also involves consideration of associated emotional and psychosocial factors. Psychotropic drugs are an important part of the dermatologist's therapeutic armamentarium. This article reviews some of the salient pharmacologic guidelines and important drug-drug interactions involved in the use of the major classes of, for example, antidepressants and antipsychotic drugs, in the dermatologic patient.
Therapeutic Update: Use of Risperidone for the Treatment of Monosymptomatic Hypochondriacal Psychosis
Elmer KB, George RM, Peterson K.
J Am Acad Dermatol. 2000; 43:683-686
Monosymptomatic hypochondriacal psychoses such as delusions of parasitosis are often difficult to treat. For the past two decades, pimozide has been considered the drug of choice. Although a few controlled studies have been done to support the efficacy of pimozide, the recommendation of treatment of choice is largely based on case reports. Pimozide has significant side effects, including cardiac and extrapyramidal abnormalities, which are of most concern in the treatment of the elderly. Although pimozide does appear to be effective in some cases of somatic delusional disorders, newer antipsychotics such as risperidone have also been shown to be beneficial in treating this perplexing cluster of disorders. Risperidone is generally considered safer than pimozide and should be considered as first-line therapy for monosymptomatic hypochondriacal psychoses.
Delusional Parasitosis: A Clinical Profile
Bhatia MS, Jagawat T, Choudhary S
Int J Psychiatry Med. 2000;30:83-91
Objective: Delusional parasitosis is a form of monohypochondriacal psychosis, a condition sometimes encountered in psychiatric or primary care practice. The outcome of this condition is not well known.
Method: In the present study, a series of fifty-two consecutive cases of delusional parasitosis is reported.
Results: A majority of cases (92%) had insidious onset. The duration of symptoms in all but two cases was six months or more. Twenty-six cases presented with a delusion of infestation by insects over the body and twenty-three cases with a delusion of insects crawling over the scalp. Three cases had associated diabetes mellitus, five cases had leprosy, five cases dementia, four cases had depression, and three cases presented with trichotillomania. Pimozide was used in forty-six cases, amitriptyline and fluoxetine in three cases each. Twenty-eight cases (54%) showed complete remission while receiving pharmacotherapy, eighteen cases showed partial improvement, and six cases did not respond to treatment.
Conclusion: Further studies are warranted to study the treatment and outcome of this important psychiatric disorder.
Stress and Skin Diseases in Musicians: Evaluation of the Beck Depression Scale, General Psychologic Profile (The Brief Symptom Inventory [BSI]), Neck Anxiety Scale and Stressful Life Events in Musicians
Onder M, Cosar B, Oztas MO, Candansayar S.
Biomed Pharmacother. 2000;54:258-262
We investigated skin problems of musicians (N = 117) working in a professional orchestra. The results of this survey suggest a significant incidence of occupational and stress-related skin problems in musicians such as hyperhydrosis, lichen planus, psoriasis, seborrheic dermatitis and urticaria. It was thought that emotional factors exacerbate their problems. This article discusses the importance of psychiatric consultations in dermatologic problems.
Repetitive Skin-Picking in a Student Population and Comparison With a Sample of Self-Injurious Skin-Pickers
Keuthen NJ, Deckersbach T, Wilhelm S, et al
Psychosomatics. 2000;41:210-215
The prevalence of skin-picking and its associated characteristics were documented in a nonclinical sample of 105 college students. Subjects completed a self-report skin-picking inventory and several paper-and-pencil scales. Students who endorsed skin-picking were compared to a clinical sample of self-injurious skin-pickers (n = 31) reported on previously. Of the student subjects, 78.1% (n = 82) endorsed some degree of skin-picking and four subjects satisfied criteria for severe, self-injurious picking. Student subjects significantly differed from the clinical sample of self-injurious skin-pickers in the duration, focus, and extent of picking, techniques used, reasons for picking, associated emotions, and picking sequelae.
Characterization of Trichotillomania. A Phenomenological Model With Clinical Relevance to Obsessive-Compulsive Spectrum Disorders
O'Sullivan RL, Mansueto CS, Lerner EA, Miguel EC
Psychiatr Clin North Am. 2000;23:587-604
Multiple approaches to characterization of TTM have been developed, including categoric definitions and dimensional considerations.When TTM is viewed in the context of other disorders with common comorbidities and overlapping similar phenomenologies, such as OCD, body dysmorphic disorder, skin picking, TS, and olfactory reference syndrome, clinical approaches to assessment and differential diagnosis are more complex. This article presents a general overview of TTM included as a background for a heuristic clinical framework for assessing obsessive-compulsive spectrum disorders. A comprehensive behavioral model of TTM as a template is presented in the context of a broader, phenomenologic approach to assessment of several other disorders. These additional conditions were chosen on clinical grounds because they seem to share some phenomenologic characteristics with TTM. It is hoped that combining a phenomenologic approach to the differentiation of repetitive behaviors (as has been valuable in advancing the understanding of repetitive behaviors in TS and OCD), coupled with a paradigmatic comprehensive behavioral assessment and treatment model of TTM, may foster the validation of such approaches for other putative obsessive-compulsive spectrum disorders. Also, the relative intensity and frequency ascribed to the various behavioral and phenomenologic components of the conditions depicted represent clinical impressions, with varying degrees of empiric support, and require objective validation. This approach is meant to serve as a point of departure for clinical assessment of these complex, interesting, and sometimes incompletely diagnosed and inadequately treated conditions. It is hoped that empiric validation or refutation of this conceptualization will stimulate additional research and provide clinicians with a general framework for assessing patients suffering from these difficult conditions.
Cross-Cultural Understanding of Aesthetic Surgery: The Male Cosmetic Surgery Patient in Japan and the USA
Nakamura Y, Mulliken JB, Belfer ML
Aesthetic Plast Surg. 2000;24:283-288
This review describes the historical development of aesthetic surgery in Japan and parallels with the development of the specialty in the United States. The focus is on the consequences of aesthetic surgery in the male patient when collaboration between mental health clinicians and surgeons lags. The cultural, social, and psychological issues raised are relevant to the diverse cultural groups now seeking aesthetic surgery in the United States. Case illustrations are a reminder to aesthetic surgeons of the potential need for more comprehensive evaluation in the group of male patients who may be at added risk for negative outcomes in terms of satisfaction.
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