Randy Jacobs, M.D. Patient Education

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Psych Skin Education



Words For The Family.






Many disorders of the skin are very difficult to diagnose with certainty, and may often have multiple causes. Sometimes there is a psychological factor involved as either the principle or contributing cause of the problem. The psychological factors may be very mild or they may be severe, and a person's awareness of these factors as important in their skin disorder may range from acknowledgment to absolute denial.


There are three principle categories of psychogenic skin disorders. In each case the skin lesions are caused or at least exacerbated by the patient. Care must be taken when offering any of these three diagnoses that every attempt is made to find any evidence of even the smallest initiating lesion due to primary skin infection, inflammation, or other cause. While it often happens that a patient can make a treatable skin condition appear much worse by nervously picking at the lesions, this is to be differentiated from primary psychogenic lesions which are in each case initiated by the patient.


Before describing the various kinds of conditions that can result in psychogenic lesion, let us consider parallels to more common behaviors, seen every day. Have you ever known someone who nervously pulled out strands of their hair? Or someone who always chewed off their fingernails, often leading to infections? How many of us grind or clench our teeth at times of stress - thinking subconsciously that we can relieve the stress by doing damage to our teeth? The skin disorders that we are discussing here are not so different from the above examples of common behaviors. But, as with everything, there can be extremes of behavior that can have unfortunate consequences - these behaviors must be understood and treated.


What causes it?


As mentioned above, there are three categories of psychogenic skin disorders, represented by the people who tend to be involved. They may be described as follows: Type A, generally an obsessive-compulsive individual, insisting on perfection; Type B, a person who is given to spells of depression or mania, mostly the type of depression that leads to agitation rather than lethargy; and Type C, generally involving a person with strong psychotic tendencies, with more profound mental disturbances. Type C usually shows distorted behavior of a different character from that seen for Types A and B. While types A and B are more of the anxious, depressed or manic types, type C includes those with organic brain conditions such as Alzheimer's, dementia, and schizophrenia.


One must realize that for each of these three types of individuals, there are specific types of chemical imbalances or deficiencies that can be identified in the central nervous system. The skin disorders are usually a manifestation of a mental disorder which is chemical in nature, and is a disease where the organ involved happens to be the most complex of all organs, the brain.


The cause of the brain dysfunction is generally not known, but since the disorders are sometimes well treated by the use of medications, it seems clear that chemical imbalances are involved. For some individuals it appears that certain regions of the brain are not as active as they should be, or sometimes are more active than desired. In any event, a chemical imbalance may lead to an undesirable stress reaction and thus result in behaviors, that in susceptible individuals, generate sites of chronic skin infection or inflammation.


How does it progress?


In many people it is the onset of a depressed state or an anxious state that leads to initiation of skin lesions - by scratching or picking generally. In the most severe Type C person, other methods of damaging the skin may be seen, including the use of heat or chemical agents. In this latter case, surprisingly, the person is the most convinced that they themselves have nothing to do with their skin disorder. For most, when the lesions are generated at a time of depression or stress, the lesions themselves can then make a secondary contribution to the stress or depressed state, and thus, the disorder feeds on itself, is self-perpetuating, and promotes a viscious cycle.


How is it diagnosed?


Failing to find any evidence of primary skin disease, the most thorough psychological evaluation of the patient is necessary. Years can be spent trying to treat a skin disorder using antibiotics, anti-inflammatory agents, and antifungal drugs, only to find out that a complete cure is effected with an anti-anxiety drug. For the depressive, Type B disorder, one looks for decreased mood, feelings of helplessness, insomnia (particularly toward dawn), and loss of appetite. An irritable or agitated demeanor would be expected, and the patient is often found to ascribe their skin condition to other causes, even parasitic infections. The Type B patient doesn't adhere strongly to this parasitic conviction when shown evidence to the contrary. The Type A, obsessive-compulsive, person generally will be aware of their behavior toward their skin. Often they describe an "itch", but upon observation it is generally found that they look and feel for self perceived imperfections in their skin which they then seek to eliminate. The signs of a generalized anxiety disorder, common for this type, are worry, muscle tension, and palpitations. The episodes may be triggered by events, but the condition is chronic and slowly evolves. The Type B depressive or manic individual described above is more likely to have a sudden onset of the condition. The more severe Type C individual will display all of the signs of serious psychosis, and will generally deny any activity which could lead to the observed skin condition. The diagnosis is made, then, on the basis of an observed skin condition without infectious, inflammatory, or neoplastic cause, along with the observation of associated psychologic states known to possibly predispose to initiation of skin lesions. Often, the pattern of the lesions is a supplemental diagnostic aid, in that lesions are generally found only where the person can easily reach.


How is it treated?


In general, all three of these psychogenic disorders are treated with psychopharmacologic drug therapy. For Type A, the anti anxiety drugs are often effective. For Type B, antidepressants or lithium find great success. And for the Type C, more serious case, antipsychotic drugs are often combined with group, recreational, and occupational therapy.


What to expect.


The treatments suggested above are continued for some number of months, and can then be tapered off with no recurrence of the disorder. For those patients who denied the cause of the skin lesions before treatment, most recover with no awareness of the true nature of their previous illness. Occasionally such a patient will gain a sudden insight into their role in the disorder. Sound psychiatric evaluation, diagnosis, drug treatment, and psychotherapy can be expected to take these people from a state of near incapacity to full function in fairly short order. The most important factor in providing such a cure is the awareness of the potential nature of the problem.

Photos of excoriations due to stress