Psychocutaneous disorders

Question 1

Epidemiology of delusions of parasitosis?

Answer 1

Average onset 50-60 y/o, in younger patients they tend to be lower socioeconomic status w/ hx of substance abuse (more likely an etiology of this condition in this age group) -Older patients tend to be a higher socioeconomic status

Question 2

Key component of delusions of parasitosis?

Answer 2

Fixed false belief that they are infested w/ parasites in absence of clinical findings; may describe sensations of biting, crawling, or stinging; “matchbox sign” (patient brings in bits of skin and other materials he/she believes are parasites)

No amount of evidence will convince the pt’s that they don’t have it by definition, these discussions are usually futile

Question 3

What is it called when the delusion (like delusions of parasitosis) is shared between two people?

Answer 3

folie a deux

Question 4

Treatment for delusions of parasitosis?

Answer 4

antipsychotic such as pimozide is classic treatment of choice (be aware of QT prolongation on EKG, extrapyramidal side effects, and drug-drug interactions); -newer atypical antipsychotics (more recent 1st line is risperidone)) appear effective w/ improved side-effect profile

Question 5

What is body dysmorphic disorder?

Answer 5

Patients are preoccupied by appearance of their bodies and start to obsessively checking in mirrors for perceived imperfections and may have repeated cosmetic procedures

Question 6

What areas are generally of concern in body dysmorphic disorder?

Answer 6

face, hair, breasts, and genitalia

Question 7

Treatment for body dysmorphic disorder?

Answer 7

SSRI for OCD variant and antipsychotics for delusional variant.

Question 8

What is dermatitis artefacta?

Answer 8

Patient self-inflict cutaneous lesions and deny personal involvement *denial of personal involvement is a key distinguisher from neurotic excoriations and acne excoriee

Question 9

Epidemiology of dermatitis artefacta?

Answer 9

Occurs in adolescents/young adult females who may work in healthcare fields or have personal disorders

Question 10

Treatment of dermatitis artefacta?

Answer 10

supportive wound and psych care; antidepressants, antianxiety, or antipsychotic medications may be necessary

Question 11

Clinical of neurotic excoriations?

Answer 11

Excoriations in different stages of evolution w/ geographic /angulated shapes; favors extensor arms, scalp, face, upper back, buttocks

Question 12

Cause of neurotic excoriations?

Answer 12

Caused by conscious, repetitive, and uncontrollable picking/scratching Patients admit to picking, but cannot control their behavior

Question 13

Tx for neurotic excoriations?

Answer 13

Doxepin (TOC), SSRI, behavior modification, behavior and CBT, topical antipruritics, wound care

Question 14

What is acne excoriee?

Answer 14

Scratching and picking directed at acne lesions Frequently seen in young women Part of broader spectrum of neurotic excoriations

Question 15

What conditions is acne excoriee a/w?

Answer 15

OCD

Question 16

Treatment for acne excoriee?

Answer 16

Treatment includes doxepin & SSRIs as well as treatment of underlying acne

Question 17

What is trichotillomania?

Answer 17

Hair pulling impulse control or OCD p/w large, irregular/geometric areas of alopecia (scalp> eyebrows> eyelashes> genital hair) w/ coexistent areas of completely nl, uninvolved scalp A/w trichophagy (chewing and swallowing of hair) may cause intestinal obstruction and trichobezoars

Question 18

Most common areas affected by trichotillomania?

Answer 18

Scalp> eyebrows> eyelashes> genital hair

Question 19

One key diagnostic clue to trichotillomania?

Answer 19

Affected areas contain hair of varying lengths

Question 20

Sex predilection for trichotillomania?

Answer 20

Female>male (5:1)

Question 21

Age of onset for trichotillomania?

Answer 21

Avg age of onset: 8yo (boys), 12yo (girls)

Question 22

Histology of trichotillomania?

Answer 22

huge “catagen/telogen shift” (increased catagen/telogen hairs; often >50% of hairs in catage or telogen phase), pigmented hair casts, empty anagen follicles (due to hair shafts being pulled out), trichomalacia (distorted hair shafts), and hemorrhage

Question 23

What will trichoscopy of trichotillomania show?

Answer 23

mult broken hairs of diff lengths and shapes w/o perifollicular changes

Question 24

What is a confirmatory test that can be done for trichotillomania?

Answer 24

hair growth window During repeated shaving of a specific area, hair of nl density regrows (since hairs are too short to manipulate)

Question 25

Tx for trichotillomania?

Answer 25

behavior modification therapy, clomipramine (TOC), SSRI, prognosis better in younger children than older children/ adolescents

Question 26

What are psychophysiologic disorders?

Answer 26

Exacerbation of a skin disorder (psoriasis, AD) by emotional factors

Question 27

What are secondary psychiatric disorders?

Answer 27

Somatic symptom disorder, illness anxiety disorder, adjustment disorder, other specific anxiety or depressive disorders that are occurring on top of cutaneous findings

Question 28

What are primary psychiatric disorders in the setting of cutaneous dz?

Answer 28

So these are primary psychiatric disorders that then trigger cutaneous dz. I.e OCD –> body dysmorphic, or schizophrenia and delusions of parasitosis

Question 29

Whawt is Gardner-Diamond syndrome?

Answer 29

Pts traumatically induce lesions causing sudden onset of painful, swollen, ecchymosis at sites of trama

Question 30

Treatment for Gardner-Diamond syndrome?

Answer 30

Difficult, can try antidepressants and psychotherapy