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Fitzpatrick's Dermatology, 9th Edition (Entrance Exam / Board Exam Prep) > 100: Delusional, Obsessive-Compulsive, and Factitious Skin Diseases > Flashcards

100: Delusional, Obsessive-Compulsive, and Factitious Skin Diseases Flashcards

1
Q

What are the primary psychiatric skin disorders and their characteristics?

A

Primary psychiatric skin disorders are conditions where there is an underlying psychiatric component that leads to self-induced physical findings on the skin. These disorders result in destructive manipulation of the skin, hair, or nails, often as an expression of highly dysregulated emotions. Examples include:
- Delusional disorders
- Morgellons disease
- Body dysmorphic disorder
- Trichotillomania
- Excoriation disorder
- Dermatitis artefacta

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2
Q

What are the clinical features of delusions of parasitosis and Morgellons disease?

A

The clinical features include:
- Sensations of formication, such as crawling, biting, and stinging, believed to be caused by cutaneous infestation by parasites or fibers.
- Attempts to pick at perceived ‘parasites’ or ‘fibers’.
- Collection of specimens claimed to be extracted from the skin, including scabs, skin flakes, and even real insects.
- Evidence of self-mutilation, with excoriations and irregular ulcers typically sparing areas out of reach.

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3
Q

What is the treatment of choice for delusions of parasitosis?

A

The treatment of choice is pimozide, followed by atypical antipsychotics. Establishing rapport with the patient is crucial, as they often have low levels of insight and may be resistant to psychiatric treatment.

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4
Q

How is the diagnosis of delusions of parasitosis made?

A

The diagnosis is a diagnosis of exclusion, made only when the patient has an encapsulated delusion of infestation without the presence of any organic cause.

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5
Q

What are primary psychiatric skin disorders characterized by?

A

They are characterized by an underlying psychiatric component that causes self-induced physical findings on the skin, resulting in destructive manipulation of the skin, hair, or nails.

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6
Q

What are the clinical features of delusions of parasitosis?

A

Sensations of formication, including crawling, biting, and stinging, and attempts to pick the ‘parasites’ or ‘fibers’.

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7
Q

What is Morgellons disease a variant of?

A

It is a variant of delusions of parasitosis, characterized by a fixed belief that there are fibers or solid material extruding from the skin.

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8
Q

What is the matchbox sign in delusions of parasitosis?

A

It refers to the collection of specimens that patients claim to have extracted from their skin, including scabs, skin flakes, and even real insects.

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9
Q

How are delusions of parasitosis diagnosed?

A

It is considered a diagnosis of exclusion, made only when there is an encapsulated delusion of infestation without the presence of any organic cause.

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10
Q

What are cutaneous sensory disorders?

A

Conditions in which the patient has abnormal sensations on the skin, such as itching, burning, stinging, biting, and crawling, without any diagnosable cause.

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11
Q

What are secondary psychiatric disorders associated with psychodermatology?

A

Anxiety, depression, and social phobia.

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12
Q

What is the challenge in treating delusional skin disorders?

A

Patients often have low to absent levels of insight and are not open to psychiatric treatment or referral, making establishing rapport key.

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13
Q

What are the primary characteristics of delusional skin disorders?

A

Delusional skin disorders are characterized by:
- Monosymptomatic hypochondriacal diseases with a fixed, false belief.
- Delusions of parasitosis: belief of infestation by parasites or fibers without objective proof.
- Morgellons disease: belief that fibers or solid materials are extruding from the skin.
- Secondary skin findings include excoriation and manipulation of the skin, hair, or nails.

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14
Q

What are the clinical features associated with delusions of parasitosis and Morgellons disease?

A

Clinical features include:
- Sensations of formication: crawling, biting, and stinging.
- Attempts to pick at perceived parasites or fibers.
- Collection of specimens: scabs, skin flakes, hair, and even real insects (matchbox sign).
- Photographic evidence of their supposed infestation.
- History of antiparasitic therapies attempted without success.
- Self-mutilation: evidence of excoriations and irregular ulcers, often in hard-to-reach areas.

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15
Q

What is the diagnostic approach for delusions of parasitosis?

A

The diagnosis is a diagnosis of exclusion, which involves: 1. Confirming the presence of an encapsulated delusion of infestation without any organic cause. 2. Assessing if the delusional ideation is part of a broader psychosis (e.g., schizophrenia). 3. Biopsy: while non-diagnostic, it can provide objective evidence against infestation and help build therapeutic rapport with the patient.

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16
Q

What treatment options are available for delusions of parasitosis, and what challenges are associated with management?

A

Treatment options include:
- Pimozide: first-line treatment for delusions of parasitosis.
- Atypical antipsychotics: used as a follow-up treatment.
Challenges in management:
- Patients often have low insight and may resist psychiatric treatment.
- Establishing rapport is crucial for effective management.

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17
Q

What underlying psychopathology is associated with Body dysmorphic disorder?

A
  • Obsession about a physical flaw
  • Comorbid depression, anxiety, or OCD
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18
Q

What are the differential diagnoses for Trichotillomania?

A
  • OCD
  • Comorbid anxiety, depression, psychosis
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19
Q

What treatments are available for Neurotic excoriations?

A
  • Wound care
  • SSRIs
  • Antipsychotics
  • Psychotherapy (including DBT)
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20
Q

What is a common characteristic of Dermatitis artefacta?

A
  • Self-induced injury using instruments (sharp objects, lighters, cigarettes, corrosive chemicals)
  • Deny self-inflicted nature of skin lesions
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21
Q

What underlying psychopathology is associated with Body dysmorphic disorder?

A
  • Obsession about a physical flaw, often with comorbid depression, anxiety, or OCD.
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22
Q

What are some differential diagnoses for Trichotillomania?

A
  • OCD, comorbid anxiety, depression, and psychosis.
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23
Q

What treatments are recommended for Dermatitis artefacta?

A
  • Wound care, SSRIs, and psychotherapy including DBT.
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24
Q

What is a common characteristic of Neurotic excoriations?

A
  • Self-induced scratching, picking, or rubbing of the skin, often with a relatively high level of insight.
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25
What is the differential diagnosis for Delusions of parasitosis?
- Real infestations, scabies, arthropod bites, and various endocrine and nutritional deficiencies.
26
What treatments are suggested for Body dysmorphic disorder?
- SSRIs and CBT.
27
What is the underlying psychopathology of Dermatitis artefacta?
- Psychosocial stressors and a history of physical, emotional, or sexual abuse.
28
What are the treatments for Trichotillomania?
- SSRIs and habit reversal therapy.
29
What is a key characteristic of Neurotic excoriations?
- Self-induced injury with a relatively high level of insight and associated shame.
30
What differential diagnoses should be considered for Body Dysmorphic Disorder?
**Differential Diagnoses:** - Concern about a real physical defect. - Anorexia nervosa. - Bulimia nervosa. - Primary psychiatric disease (depression, anxiety, psychosis).
31
What treatments are recommended for Trichotillomania?
**Treatments:** - SSRIs (Selective Serotonin Reuptake Inhibitors). - Cognitive Behavioral Therapy (CBT).
32
What are the characteristics and potential treatments for Dermatitis artefacta?
**Characteristics:** - Self-induced injury using instruments (sharp objects, lighters, cigarettes, corrosive chemicals). - Deny self-inflicted nature of skin lesions. **Treatments:** - Wound care. - SSRIs. - Antipsychotics. - Psychotherapy (including DBT).
33
What underlying psychopathology is associated with Neurotic Excoriations?
**Underlying Psychopathology:** - Psychosocial stressor. - Comorbid depression, anxiety, OCD, BPD, or psychosis.
34
What are the medical conditions that can be associated with formication, pruritus, or paresthesia?
- **Endocrine disorders** (diabetes mellitus, hyperthyroidism, hypothyroidism) - **Renal disease** (uremic pruritus) - **Nutritional deficiencies** (B1, B3, folic acid, B12, iron) - **Neurologic disorders** (neuropathy, multiple sclerosis) - **Infections** (syphilis)
35
What is the significance of early intervention in patients with delusions of parasitosis?
Early intervention is important as patients with a shorter duration of active delusion have an increased probability of remission.
36
What are the common adverse effects of Pimozide (Orap) used for treating delusions of parasitosis?
- **Extrapyramidal symptoms** such as akathisia and pseudoparkinsonian symptoms - **QT prolongation** (for older/cardiac history, baseline EKG and medical clearance is recommended)
37
What are the characteristics of Body Dysmorphic Disorder (BDD)?
- Preoccupation with a nonexistent or minor physical flaw - Affects **1.8% to 2.4%** of the general population - Higher prevalence in women - Onset as early as childhood, mean age **16 years old** - Patients experience embarrassment and avoid confiding in providers.
38
What are the clinical features of Body Dysmorphic Disorder?
- Fixation on a specific aspect of appearance perceived as unattractive or deformed - Commonly involves the face, skin, or hair - Excessive time spent thinking about the defect and attempting to conceal it - Perform repetitive behaviors like mirror checking and skin picking - Seek reassurance but receive little to no relief from it.
39
What must be ruled out in the differential diagnosis of formication?
Real infestation with parasites, such as scabies, and organic causes of symptoms of formication.
40
What medical conditions can be associated with formication, pruritus, or paresthesia?
Endocrine disorders, renal disease, nutritional deficiencies, neurologic disorders, and infections.
41
What is the importance of early intervention in patients with delusions?
Patients with a shorter duration of active delusion have an increased probability of remission.
42
What is the most studied pharmacologic agent for the treatment of delusions of parasitosis?
Pimozide (Orap).
43
What are common adverse effects of Pimozide?
Extrapyramidal symptoms such as akathisia and pseudoparkinsonian symptoms, and QT prolongation.
44
What is the primary therapy that works for patients with delusions of parasitosis?
Antipsychotic medications.
45
What characterizes Body Dysmorphic Disorder (BDD)?
Preoccupation with a nonexistent or minor physical flaw, often leading to embarrassment and avoidance of confiding in providers.
46
What are the clinical features of Body Dysmorphic Disorder?
Fixation on an aspect of appearance perceived as unattractive, excessive time spent on the defect, and performing repetitive behaviors.
47
What is the prevalence of Body Dysmorphic Disorder in the general population?
Affects 1.8% to 2.4% of the general population.
48
What are the characteristics of Obsessive-Compulsive Disorders (OCDs)?
Characterized by intrusive thoughts or urges that are experienced as unwanted, necessitating repetitive behaviors or rituals to alleviate anxiety.
49
What are the key medical conditions that must be ruled out when diagnosing formication?
- Real infestation with parasites, such as **scabies** - Organic causes of symptoms of formication - Endocrine disorders (e.g., diabetes mellitus, hyperthyroidism, hypothyroidism) - Renal disease (uremic pruritus) - Nutritional deficiencies (e.g., B1, B3, folic acid, B12, iron) - Neurologic disorders (e.g., neuropathy, multiple sclerosis) - Infections (e.g., syphilis)
50
What is the significance of early intervention in patients with delusions of parasitosis?
Early intervention is crucial as patients with a shorter duration of active delusion have an increased probability of **remission**. This highlights the importance of timely management and establishing rapport with patients who may be hesitant to seek psychiatric help.
51
What are the common adverse effects associated with the antipsychotic medication Pimozide (Orap)?
- **Extrapyramidal symptoms** such as akathisia (restlessness) and pseudoparkinsonian symptoms - **QT prolongation** (especially in older patients or those with cardiac history) - Can be treated with as-needed **diphenhydramine** (Benadryl) or **benztropine** (Cogentin)
52
How does Body Dysmorphic Disorder (BDD) manifest in patients?
Patients with BDD fixate on a specific aspect of their appearance that they find unattractive or 'deformed.' Common features include: - Complaints about skin (e.g., wrinkles, scarring, color), hair (e.g., excessive hair, loss), or other body parts (e.g., breasts, abdomen) - Excessive time spent thinking about the perceived defect and attempting to conceal it - Performing repetitive behaviors such as mirror checking and skin picking - Seeking reassurance but receiving little to no relief from it.
53
What distinguishes Olfactory Reference Syndrome from other delusional disorders?
Olfactory Reference Syndrome is characterized by a **preoccupation with body odor** that is not perceived by others, leading to significant distress and disability.
54
What are the common adverse reactions associated with the use of Pimozide (Orap) for psychodermatologic conditions?
The common adverse reactions associated with Pimozide include **sedation**, **arrhythmia**, **orthostatic hypotension**, **seizures**, **EPS**, **NMS**.
55
What are the common adverse reactions associated with Pimozide (Orap) for psychodermatologic conditions?
The common adverse reactions associated with Pimozide include sedation, arrhythmia, orthostatic hypotension, seizures, EPS, NMS, leukopenia, and neutropenia.
56
What is the maximum dosage for Olanzapine (Zyprexa) in the management of primary psychodermatologic conditions?
The maximum dosage for Olanzapine (Zyprexa) is 20 mg/day.
57
What monitoring is recommended for patients taking Sertraline (Zoloft)?
Recommended monitoring for patients taking Sertraline includes observing for clinical signs of suicidality.
58
What is the starting and maximum dosage of Fluoxetine (Prozac)?
The starting dosage of Fluoxetine (Prozac) is 10 mg/day, while the maximum dosage is 80 mg/day.
59
What are the common adverse reactions associated with Clomipramine (Anafranil)?
Common adverse reactions associated with Clomipramine include headache, constipation, orthostatic hypotension, anticholinergic effects, QT prolongation, and seizures.
60
What is the starting dosage for Pimozide (Orap)?
0.5 mg/day.
61
What are the common adverse reactions associated with Olanzapine (Zyprexa)?
Common adverse reactions include weight gain, hyperglycemia, hyperlipidemia, galactorrhea, seizures, EPS, NMS, and leukopenia.
62
What is the maximum dosage for Sertraline (Zoloft)?
200 mg/day.
63
What monitoring is recommended for patients taking Clomipramine (Anafranil)?
EKG, LFT, clinical signs of suicidality.
64
What is the titration schedule for Risperidone (Risperdal)?
0.5 mg every 2-4 weeks.
65
What are the common adverse reactions for Doxepin (Sinequan)?
Sedation, anticholinergic effects, QT prolongation, seizures, xerostomia, increased appetite.
66
What is the starting dosage for Paroxetine (Paxil)?
20 mg/day.
67
What is the maximum dosage for Fluvoxamine (Luvox)?
300 mg/day.
68
What is the recommended monitoring for patients taking Aripiprazole (Abilify)?
Weight, fasting glucose, CBC.
69
What are the common adverse reactions associated with the use of Olanzapine (Zyprexa) in the management of primary psychodermatologic conditions?
Common adverse reactions include weight gain, hyperglycemia, hyperlipidemia, galactorrhea, seizures, EPS, NMS, and neutropenia.
70
How should the dosage of Sertraline (Zoloft) be titrated for patients with primary psychodermatologic conditions?
The dosage of Sertraline should be started at 25 mg/day, titrated to 25-50 mg/day weekly, with a maximum dosage of 200 mg/day.
71
What monitoring is recommended for patients taking Clomipramine (Anafranil) for psychodermatologic conditions?
Recommended monitoring includes checking for clinical signs of suicidality, EKG, and LFT (liver function tests).
72
What are the recommended monitoring parameters for patients on Risperidone (Risperdal)?
Recommended monitoring includes EKG, weight, fasting glucose, prolactin, and CBC (complete blood count).
73
What are the common clinical features of hair pulling disorder (trichotillomania)?
Common clinical features include irregular and nonscarring alopecia, broken and sparse hair on the scalp, and hairs of different lengths.
74
What is the most effective treatment for hair pulling disorder?
The most effective treatment for hair pulling disorder is habit reversal therapy.
75
What are the psychiatric comorbidities associated with hair pulling disorder?
Approximately 75.5% of patients with hair pulling disorder have psychiatric comorbidities, with the most common being depressive disorder, affecting about 40% of patients.
76
What are the differential diagnoses for hair pulling disorder?
Differential diagnoses for hair pulling disorder include alopecia areata, androgenic alopecia, alopecia mucinosa, tinea capitis, lichen planopilaris, folliculitis decalvans, syphilis-related alopecia, and discoid lupus erythematosus.
77
What pharmacologic treatments are commonly used for hair pulling disorder?
Common pharmacologic treatments for hair pulling disorder include tricyclic antidepressants (TCAs) like clomipramine and selective serotonin reuptake inhibitors (SSRIs) such as sertraline, paroxetine, and fluoxetine.
78
What is the former name of hair pulling disorder?
Trichotillomania.
79
What is the prevalence rate of hair pulling disorder?
Ranging from 0.6% to 13.3%.
80
What is the most effective treatment for hair pulling disorder?
Habit reversal therapy.
81
What are the common psychiatric comorbidities associated with hair pulling disorder?
Anxiety, depression, and OCD.
82
What is the average age of onset for hair pulling disorder?
Average of 10.7 to 13 years old.
83
What are some clinical features of hair pulling disorder?
Irregular and nonscarring alopecia, broken sparse hair, and hairs of different lengths on the scalp.
84
What is trichophagia?
The act of eating whole hair.
85
What is a trichobezoar?
GI hairballs that can be fatal and may cause intestinal bleeding or pancreatitis.
86
What role do SSRIs play in the treatment of hair pulling disorder?
They are frequently used as a treatment option, though their effectiveness is unclear.
87
What are the key aspects of habit reversal therapy for managing hair pulling disorder?
Habit reversal therapy includes increasing awareness of hair-pulling behavior, competing response training, social support, and stimulus control.
88
What is the significance of comorbid psychiatric conditions in patients with hair pulling disorder?
Comorbid psychiatric conditions, such as anxiety, depression, and OCD, are significant in patients with hair pulling disorder as they can complicate the diagnosis and treatment.
89
What are the clinical features of neurotic excoriation?
Neurotic excoriation is characterized by self-inflicted ulcers, abscesses, or disfiguring scars, often with a 'butterfly sign'.
90
What underlying psychiatric illnesses are associated with neurotic excoriation?
Neurotic excoriation may be associated with underlying psychiatric illnesses such as depression, anxiety, OCD, and psychosis.
91
What is the 'butterfly sign' in neurotic excoriation?
The 'butterfly sign' indicates sparing in unreachable areas of the interscapular region.
92
What are the recommended treatments for neurotic excoriation?
Treatment includes topical corticosteroids, antibiotics, addressing comorbid psychiatric disorders, and medications to decrease compulsive tendencies.
93
What are the characteristics of neurotic excoriation?
Self-induced cutaneous lesions from the uncontrollable impulse to excessively pick, rub, or scratch normal skin.
94
What is the typical demographic for neurotic excoriation?
Predominantly female, with an onset between 15 to 45 years of age.
95
What triggers neurotic excoriation?
Stress or anxiety, dermatologic conditions, and minor textural differences on the skin.
96
What is cutaneous dysesthesia?
Abnormal sensations on the skin such as itching, burning, stinging, and crawling, without a diagnosable dermatologic condition.
97
What is the relationship between neurotic excoriation and underlying psychiatric illness?
There may be a notable disconnect between the severity of dermatologic manifestations and the level of distress, often linked to underlying psychiatric conditions.
98
What treatment options are available for patients with neurotic excoriation?
Topical corticosteroids, antibiotics, treatment of comorbid psychiatric disorders, psychotherapy, and medications such as SSRIs and TCAs.
99
What are the characteristics of Factitious Disorders, specifically Dermatitis Artefacta?
Factitious Disorders are characterized by self-inflicted dermatologic lesions. Dermatitis Artefacta, a primary psychocutaneous disorder, involves self-induced injury to the skin using instruments such as sharp objects, cigarettes, and corrosive materials, with a noted female predominance.
100
What clinical features are associated with Dermatitis Artefacta?
Patients with Dermatitis Artefacta generally deny self-infliction of their skin injuries. They often provide a 'hollow history' regarding the lesions, which lack recognizable characteristics of primary skin disease. Lesions can range from minor cuts to large areas of trauma, often appearing as abnormally shaped superficial erosions surrounded by normal-looking skin.
101
What psychological factors may trigger self-injurious behavior in patients with Dermatitis Artefacta?
Self-injurious behavior in Dermatitis Artefacta is often triggered by psychosocial stressors, serving as an outlet for expressing anger or satisfying internal emotional needs. This behavior may stem from a conscious or unconscious psychological need for attention due to feelings of abandonment or neglect, and many patients have a history of physical, emotional, or sexual abuse.
102
What is the approach to managing patients with Dermatitis Artefacta?
Management of Dermatitis Artefacta is primarily supportive and includes: 1. Wound care (irrigation, debridement, topical/oral antibiotics) 2. Covering wounds to discourage further self-mutilation 3. Providing emotional support without confronting the patient's role in the lesions 4. Psychiatric therapy, including pharmacologic and nonpharmacologic interventions based on the underlying psychiatric illness.
103
What are some differential diagnoses to consider when evaluating a patient with suspected Dermatitis Artefacta?
Differential diagnoses for Dermatitis Artefacta include: - Malingering: conscious motivation for secondary gain (e.g., disability benefits) - Dermatologic conditions: pyoderma gangrenosum, collagen vascular disorders, vasculitis, arthropod bites - Psychocutaneous conditions: delusions of parasitosis, neurotic excoriations - Primary psychiatric disorders: OCD, depression, Munchausen syndrome.
104
What are factitious disorders characterized by?
Self-inflicted dermatologic lesions.
105
What is Dermatitis Artefacta also known as?
Factitial Dermatitis.
106
What is a common feature of self-injurious behavior in patients with Dermatitis Artefacta?
Patients generally deny that their skin injuries are self-inflicted.
107
What type of history do patients with Dermatitis Artefacta often provide?
A 'hollow history' that is vague and lacking in sufficient detail.
108
What are the common areas of the body affected by lesions in Dermatitis Artefacta?
Face, upper trunk, and extremities.
109
What psychological factors can trigger self-injurious behavior in patients?
Psychosocial stressors, feelings of abandonment or neglect, and a history of abuse.
110
What is the role of skin biopsies in diagnosing Dermatitis Artefacta?
Skin biopsies are nonspecific.
111
What is a key aspect of the management of Dermatitis Artefacta?
Supportive therapy, including wound care and emotional support.
112
What type of therapy is often used for patients with borderline personality disorder and self-injurious behavior?
Dialectical behavioral therapy.
113
What is a common comorbidity in patients with Dermatitis Artefacta?
Generalized anxiety, major depression, or borderline personality disorder.
114
What are the key clinical features of Dermatitis Artefacta that differentiate it from primary skin diseases?
- Patients generally deny self-infliction of skin injuries. - The 'hollow history' indicates vague and insufficient details about how lesions occurred. - Lesions lack recognizable characteristics of primary skin disease and are found on reachable areas (face, upper trunk, extremities). - Lesions can range from minor cuts to large areas of trauma, characterized by abnormally shaped superficial erosions with angulated borders surrounded by normal-looking skin. - Injuries may include chemical or thermal burns, injection of foreign materials, and tampering with old lesions, leading to severe complications like abscesses or gangrene.
115
What are the primary components of the management and treatment approaches for patients with Dermatitis Artefacta?
1. Supportive therapy: Focus on emotional support without confronting the patient's physical role in producing lesions. 2. Wound care: Includes irrigation, debridement, and topical or oral antibiotics as needed. 3. Psychiatric therapy: Involves both pharmacologic (e.g., SSRIs, antipsychotics) and nonpharmacologic interventions tailored to the underlying psychiatric illness. 4. Regular follow-up: Ensures ongoing care and diminishes the need for self-mutilation, addressing the chronic, waxing-and-waning course of the disorder.
116
What differential diagnoses should be considered when evaluating a patient with suspected Dermatitis Artefacta?
- Malingering: Must rule out as it involves conscious motivation for secondary gain (e.g., disability benefits). - Dermatologic conditions: Such as pyoderma gangrenosum, collagen vascular disorders, vasculitis, and arthropod bites. - Psychocutaneous conditions: Including delusions of parasitosis and neurotic excoriations. - Primary psychiatric disorders: Such as OCD, depression, and Munchausen syndrome.

Fitzpatrick's Dermatology, 9th Edition (Entrance Exam / Board Exam Prep) (213 decks)

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