Evaluation and treatment of 'psychogenic' pruritus and self-excoriation
ABSTRACT Psychogenic pruritus and self-excoriation are diagnoses of exclusion. Elimination of traditional organic causes often leads the clinician to label a symptom as psychogenic in origin and limits treatment options. This article examines the organic and psychologic causes and concomitants of dermatologic conditions associated with pruritus and self-excoriation. An organized cognitive framework is presented to guide the clinician in the evaluation and treatment of these patients. Specific treatment options are offered and relevant psychopharmacologic agents are reviewed.
- SourceAvailable from: Elisabetta Palagi
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- "In primates, there is strong behavioral evidence that scratching increases in anxiogenic situations. In Homo sapiens, for example, tense situations increase rates of body scratching (Morris 1977; Fried 1994; Troisi et al. 2000; Tran et al. 2010). In chimpanzees, Pan troglodytes, scratching levels were particularly high in crowding conditions (Aureli and de Waal 1997) as well as among females and subordinate males when a nonaffiliative group member was in their proximity (Kutsukake 2003). "
ABSTRACT: Scratching has been successfully used to detect anxiety, a proxy for stress, in primates, from strepsirrhines to Homo sapiens. Here, we investigated the fluctuation of scratching in Lemur catta during the mating season. In particular we evaluated whether scratching (1) varied according to sex and rank differences, (2) increased in the period of maximum stress (around the mating days), and (3) was reduced by grooming. At Berenty (South Madagascar), we followed two lemur groups (23 adult/subadult individuals) and gathered data on self-scratching, aggression, and grooming. Based on perineal area features, we recognized two periods: low swelling (LS), with no estrus female, and high swelling (HS), when at least one female was in estrus. We predicted that aggressive behaviors and anxiety-related scratching would covary. Indeed, scratching peaked in HS, when aggression was also highest. In agreement with previous literature, this result suggests that conflicts around estrus days may raise anxiety levels in the social group. We expected scratching levels to be highest in males because they aggressively compete for females and are subject to mate choice and repeated attacks by dominant females. Instead, the scratching rates were similar in males and females, probably because the high competition, which involves both sexes, dampened intersexual differences. In contrast to our prediction, scratching was not rank dependent, probably because animal ranking positions changed from LS to HS. Finally, we showed that, in ring-tailed lemurs, as well as in other primates, scratching decreases after reciprocal grooming in both periods. This finding provides the first evidence that grooming could assist in reducing anxiety in strepsirrhines.Primates 01/2012; 53(3):247-54. DOI:10.1007/s10329-012-0294-6 · 1.40 Impact Factor
- "Although this is by no means an exhaustive review of medication side effects, it does show that symptoms experienced by delusory parasitosis sufferers may have valid physiological causes, either in medical conditions or in the drugs prescribed for their treatment. Psychologists and dermatologists have noted that organic causes must be excluded before a diagnosis of psychogenic pruritus can be made (Freyne and Wrigley 1994, Gupta 1995). Because of the numerous potential physiological causes of pruritus, urticaria, and paresthesia, it is understandable that physicians often do not attempt to treat underlying causes but, instead, prescribe palliatives or advise the patient to pursue entomological possibilities (which fits with the patient's inclinations, anyway). "
Article: Delusory parasitosis[Show abstract] [Hide abstract]
ABSTRACT: HE CALLER SAYS THAT SHE IS BEING ATTACKED by invisible mites. The attack has been going on for months and she has visited a half dozen physicians, but none was able to help her. Two prescribed Kwell lotion (see Glossary), but the sensations persist. She has treated her skin with alcohol, vinegar, Lysol, bleach, kerosene, and various home remedies. She has boiled her bed linens and clothing daily. She can describe the life cycle of the pest and has been able to extract specimens from some of the wounds. She offers to send you samples. She says the irritation is driving her crazy and you are her last hope. How do you respond? At some time nearly everyone experiences a sensation of something burrowing in, crawling on, or pricking the skin (Potter 1992). These tactile perceptions may be caused by a variety of causes, because different stimuli evoke the same limited range of neurocutaneous responses. The conviction that insects are crawling on, biting, or burrowing in the skin, when no arthropod is involved, is termed "delusory parasitosis." The medical profession defines "delusion" as referring to "a fixed belief" unswayed by evidence to the contrary. By comparison, the term "illusion" refers to situations in which the individual perceives stimuli as produced by arthropods but acknowledges other explanations once they are demonstrated. Although there are some problems with terminology, delusory parasitosis is the phrase used most commonly in the literature, so will be perpetuated here. These cases typically are bewildering to pest control operators, professional entomologists, and medical professionals, who shuffle these sufferers back and forth. Physicians examining the patient determine that the lesions were produced by an insect and recommend calling a pest control company to have the patient's house treated. Conscientious pest control operators perform an inspection and are unable to locate a pest, so refuse to make an insecticide application (St. Aubin 1981). (7) mutilate body attempting to remove offending vermin (St. Aubin 1981, Lyell 1983, Zanol et al. 1998) D. Provide skin scrapings, bits of debris (in paper, small jars) (Pomerantz 1959, Waldron 1962, Lyell 1983, Goddard 1995) "One characteristic sign in delusory parasitosis is the complainant's eagerness to provide samples of their alleged parasites in small containers" (May and Terpenning 1991). Samples provided in adhesive tape, plastic bags, or vacuum bags (Webb 1993, Koblenzer 1993, White 1997) "there are millions of them"-yet specimen cannot be obtained E. Can provide extensive, elaborate, involved descriptions of the pests, their life cycle, and behaviors (Lynch K. Reject possibility of psychological or other explanations (Trabert 1995) "I'm not crazy." "I am not imagining this." Vehemence indicative of DP (Zanol et al. 1998). " Exceptional strength of conviction regarding infestation" (Lynch 1993) almost diagnostic for DP (Webb 1993) L. Express desperation, "you are my last hope" (Nutting and Beerman 1983, Lynch 1993) M. Delusion eventually shared by another family member (St. Aubin 1981) in up to 1/3 of cases (Koblenzer 1993) a Citations are illustrative of some of the published descriptions.01/1983;
Article: Psychogenic Excoriation[Show abstract] [Hide abstract]
ABSTRACT: Psychogenic excoriation (also called neurotic excoriation, acne excoriée, pathological or compulsive skin picking, and dermatotillomania) is characterised by excessive scratching or picking of normal skin or skin with minor surface irregularities. It is estimated to occur in 2% of dermatology clinic patients and is associated with functional impairment, medical complications (e.g. infection) or substantial distress. Psychogenic excoriation is not yet recognised in the DSM. We propose preliminary operational criteria for its diagnosis that take into account the heterogeneity of behaviour associated with psychogenic excoriation and allow for subtyping along a compulsivity-impulsivity spectrum. Psychiatric comorbidity in patients with psychogenic excoriation, particularly mood and anxiety disorders, is common. Patients with psychogenic excoriation frequently have comorbid disorders in the compulsivity-impulsivity spectrum, including obsessive-compulsive disorder, body dysmorphic disorder, substance use disorders, eating disorders, trichotillomania, kleptomania, compulsive buying, obsessive-compulsive personality disorder, and borderline personality disorder. There are few studies of the pharmacological treatment of patients with psychogenic excoriation. Case studies, open trials and small double-blind studies have demonstrated the efficacy of selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors in psychogenic excoriation. Other pharmacological treatments that have been successful in case reports include doxepin, clomipramine, naltrexone, pimozide and olanzapine. There are no controlled trials of behavioural or psychotherapeutic treatment for psychogenic excoriation. Treatments found to be effective in case reports include a behavioural technique called ‘habit reversal’ a multicomponent programme consisting of self-monitoring, recording of episodes of scratching, and procedures that produce alternative responses to scratching; and an ‘eclectic’ psychotherapy programme with insight-oriented and behavioural components.CNS Drugs 01/2001; 15(5). DOI:10.2165/00023210-200115050-00002 · 4.38 Impact Factor