Neal E. Krupp, M.D.
Self-caused skin ulcers Because of its availability, displayability, and deep emotional significance, the skin is a common target for self-destructive behavior. And because self-caused skin lesions can be clearly identified, the dermatologic office or clinic offers a magnificent opportunity to study those whofor one reason or another-hurt themselves and then come to the physician for help. During a five-year period, I examined 26 patients referred to me by my colleagues in dermatology because of self-caused skin ulcerations. Diagnosis was based on characteristic appearance, elimination of other possible causes, response to treatment and, ofttimes, from ready or reluctant admission by the patient. Selection of patients depended on the dermatologist's interest in referral, the patient's willingness to see me, and my own availability. Because of these and other factors, "simple scratchers" were largely eliminated and many of the more bizarre patients fled. The final group of 26 comprised patients with significant, worrisome, and persistent self-caused ulceration of the skin.
Because of the variables of selection, statistical findings are only of speculative value. Of the 26 patients, all but three were women. Their ages ranged from 12 to 73 years, but more than half of them were in the fourth and fifth decades of life. Of the three men, two were in their eighth decade. The third (age 22) was involved in a medicolegal suit. Location and duration
In most cases the lesions were in areas visible to the public: on the face, head, or scalp of 19 patients, on the extremities of II, and on the trunk of only six. In most cases the ulceration was intermittent, and some periods of quiescence were long. By overall duration (from first onset until our examination) the cases were rather evenly distributed. Six patients had lesions for one year or less: and similar numbers had recurrent lesions for one to three years, three to six years, and six to ten years. Only two had been troubled for more than a decade. Almost half the patients, however, had had symptoms for more than five years.
DR. KRUPP is consultant in psychiatry. associate professor ofpsychiatry. Mayo Medical School. Rochester. Minn.
PSYCHOSOMATICS
Psychosocial factors
In the histories of these patients, certain factors appeared with more than casual frequency. Almost 20% (five) had suffered the loss of a parent or sibling by death or separation in the first decade of life. One third had experienced recent loss or threatened loss of a loved one, and this was significantly related in time to the onset of symptoms. In two women the lesions appeared in the month of the first anniversary of their fathers' deaths. Eight of the 18 married patients were currently experiencing serious marital conflicts or family problems. Three of these were women whose symptoms began during unwanted pregnancies. More than half of all t he patients had numerous additional functional complaints and a prior history of multiple illnesses, organic and functional. Psychiatric findings
I saw each of these patients for at least one I-hour consultation in the dermatologist's office or in the corresponding hospital unit. In each case I reviewed the medical history and derma to logic notes thoroughly. In most cases the der-
15
Self-caused skin ulcers
matologist and I discussed the case before and after the consultation. I considered only one of these 26 patients psychotic: a 48-year-old woman who also demonstrated trichotillomania and delusions of infestation with parasites. Two others. age 31 and 34. were possibly psychotic. Each had had onset of ulceration during pregnancy. One had a disabling panneurosis and schizoid personality features. The other. who had recently attempted suicide. smiled inappropriately from her wheelchair. virtually disabled by foulsmelling. secondarily-infected excoriations. The incidence of psychosis in this group may be low because of previously mentioned selection variables. Depr...lon
Most of the patients with self-caused skin ulcers had two or more apparent neurotic symptoms. The most frequent of these was depression. present in 12. In some cases the depression was virtually indistinguishable from the type common in late middle age. A 56-year-old childless nurse sought help for recurrent ulcers of the forehead, cheeks, and upper shoulders, which s"e had had for 10 months. With antibiotic treatme"t at home, these had healed and recurred numerous times. The woman admitted to frequently scratching them "to let the pressure out." At age 10 she
16
from
had lost her beloved mother to influenza. and at age 47 her "good" husband to a coronary occlusion (after 18 years of marriage). Her current illness began six months after a second marriage to a well-to-do, divorced, prematurely retired man of 56. After the wedding, she discovered that this handsome. active gentleman had obsessive, persecutory delusions that his first wife was trying to poison him. Along with skin ulcers. the patient developed feelings of fatigue, lack of energy, and discouragement. Her appetite decreased and she began to lose sleep. She had thoughts of suicide, but no intent. While she was waiting for a hospital bed to become available, she was started on therapeutic doses of a tricyclic antidepressant. Within a few weeks she had improved remarkably and was dismissed to the care of her family physician. Psychiatric referral was arranged so that she could have further help with her marital problem.
For this woman the skin ulcers. symbolically letting her "get the pressure out." were only one manifestation of an otherwise rather typical depressive reaction. Interestingly. they began to heal as soon as she reached the clinic. and were gone at the time of dismissal. We can only wonder how much of her general improvement came from the tricyclic antidepressant and how much of it was a result of being separated
her paranoid husband. Most of the depressed patients had reasons for repressed hostility and rage. Most blamed depression on the skin problem. rather than the contrary. Three patients gave histories of previous suicide attempts. Three others displayed evidence of unresolved grief reactions. Compulsion
Almost three quarters of the patients (18 of 26) had prominent obsessive-compulsive personality traits. They were perfectionistic. moralistic. prone to criticize themselves and others. and highly intolerant of anyone or anything (including their skin) being "out of order." Virtually all the patients whose ulceration was severe and long-standing fell into this category. A 51-year-old schoolteacher was referred because of severe self-eaused ulceration of the face and elsewhere. which she had suffered for 15 years. The lesions followed treatments for acne. which had appeared at age 18 and troubled her for many years. She cleansed. soaked, expressed blackheads. and drained pustules with sterile puncture. As time went on she worked harder "to get out small fat globules" which. she felt. "stop the lesion from healing." Resultant recurrent ulcers resisted the efforts of many dermatologists who (much to her resentment) often accused her of molesting her skin. She is an extremely obsessive-compulsive person who feels she must do everything perfectly and who washes clean things "just to be sure." She works regularly and productively at school but must limit her so-
JUNE 1977
cial life, avoid irritants, and restrict her trav'el. She saw her life as totally "fine" except for the ulcers a nd resisted all efforts to get her to reconsider that judgment. This woman gave no evidence of a serious psychiatric disorder. She was the compulsive product of a compulsive family. Other illnesses earlier in
her life served as an excuse for her inability to compete with her numerous siblings. That life stance was still being maintained with her ulcers. But generally. with a narrower life and fewer challenges. she could do all things perfectly and feel secure. And she didn't want doctors interfering with her pattern! Obsessive people feel com-
PSYClIOSOl\\-\TICS
pelled to take care of everything themselves. In contrast. hysterical people must get someone else to take care of them. The second most common pattern. noted in more than half (14) of the entire group. bore close resemblance to that seen in conversion reaction. In this condition a physical complaint. such as a nonorganic paralysis. de-
fuses. replaces. or explains away the patient's a nxiety or depression (primary gain) and permits the patient to seek aid and accept t he gratification of being dependent (secondary gain). The skin lesions performed that function for many of these patients. thus justifying a diagnosis of contrived conversion reaction.
A 38-year-old mother of three claimed she was told by her family physician to come to the Mayo Clinic for evaluation of "serious kidney disease." No evidence of that disease was found, but she was noted to have typical ulcers on her forehead, which had recurred intermittently for the previous four years. She readily admitted "bothering" them at night (had to wear gloves to bed) and "treating" them during the day (cleaning, recleaning, pulling off "loose parts"). At the time of their onset, her son (then aged eight) had hemorrhagic measles with subsequent encephalitis. her husband was overworked and unhappy with his job, and she suffered a spontaneous abortion of an unwanted pregnancy. A physician had prescribed a sulfa drug that caused a rash on her forehead, and the ulcers developed from her attention to the rash. A former model, the woman had always placed great emphasis on physical beauty. As a child she had missed much school because of "pyelitis," and the family doctor allegedly predicted she would have "real trouble" when she grew up and became pregnant. This woman was an hysterical. exhibitionistic person. buffeted by many stresses and unable to deal with her feelings-particularly anger. Her lesions served as a distraction from other issues. a self-directed means of expressing anger and an ongoing symbolic exercise of her compulsive need to make herself better. By being sick. she was "out of schoo'" once again. and was able to solve. or at least evade. other emotional problems. With encouragement she was able to verbalize many feel-
17
Self-caused skin ulcers
ings of anxiety and anger. A steroid ointment and prohibition of touching resulted in prompt and thorough healing of her skin. Separation anxiety
Only three patients were less than 20 years old. Each was a girl and each suffered from separation anxiety. An attractive, feminine young lady of 14 traveled with her mother from a Latin American country for treatment of eroded lesions on the forehead and lower lip. She gave a very bland description of herself, her family, and her life, and attributed the skin ulcers to "fever." Oose questioning of the mother revealed, however, that the girl's lesions had been occurring every spring for four years. The timing always coincided with the mother's spring attack of peptic ulcers, which annually dictated a trip to the Mayo Clinic for evaluation and treatment, and the lesions always healed within a few weeks after the mother's healthy return. The girl had a history of school phobia and multiple functional illnesses that compelled her mother's care and attention, which were lacking when the girl was well. Her illness earned her companion status in her mother's annual medical pilgrimage. The mother joked prophetically, "She'll be one of the few girls in (our country) to go from pediatrician to internist rather than from pediatrician to obstetrician...
18
Obviously the dynamics in many of these cases overlap. This young woman was certainly heading for an hysterical future but, for the moment, her lesions (like a kindergartner's stomachache) served to keep her near her mother in a mutually protective relationship. The stronger sex
Of the three men we saw, both of the older two (age 70 and 73) were obsessive characters, "fixers" in regard to their lesions and "deniers" in regard to their depressions, which would have been apparent to almost any observer. The one young man (age 22) was seeking medical support for a legal suit. He had hoped to be compensated further for ulcers attributed to a trivial work injury two years earlier. When prospects for that support began to look dim, he did not return for follow-up examination. Why the skin?
The skin is an envelope that physically protects the body, and we tend to equate its protective function with psychologic defenses. Thus, we speak of people as being "thinskinned" or "thick-skinned"; when something "gets under our skin," we already are partially undone. As a barrier, skin takes a beating from pressures both within and without. Few claim that emotional stress causes most skin disease, but the
psychoneuroses alone are believed to playa significant role in half of all skin conditions.) The frequent correlation between recent stress and the onset of disease is obvious. Further, the time intervals from significant stress to tissue change are often consistent: a few minutes in urticaria, one to two days in hand dermatitis. two weeks in alopecia areata. Moreover, reduction of stress seems to mitigate such illnesses. 2 The skin is a medium for many messages. The flush of rage, the blush of shame or excitement, and the blanching of fear are obvious. if unintended. communications. We read even our own emotions in skin sensations. We "sweat out" difficulties, feel the "slow burn" of frustration, are "tickled" by less distressing events. and sometimes have "an itch" to run. Sensations like these constitute the psychodermatopathology of life. In patients with selfcaused skin ulcers. integumental as well as psychologic defenses have been breached. The cause of the disease is definable, but the reasons for it are often less than apparent. The communication is obvious: both the patient and his skin shout, "Help me!" Diagnosis of self-infliction is essential to prevent ineffective, expensive, and time-consuming treatment. And diagnosis gives the sensitive clinician an opportunity to ask, "How can I help you? What can I do for you as a person?" Dermatologists list self-induced eruptions as true dermatoneuroses. 1 They variously include in this category neurotic excoriations. aggravation of
JUNE 1977
Skin 1..lonl In a 12-year-old girl were at first mistaken for ecthyma. but the lesions remained localized and no systemic symptoms developed. A dermatologist pointed out the trailing off of some of the lesions. their lack of progression. and their discreteness. and the girl admitted inducing the lesions herself with a liquid drain cleaner. phOto by James G. Ramsey. Jr.. M.D.
pre-existing dermatoses, lesions from compulsive movements, delusions of parasitic infestation, trichotillomania, and factitial dermatitis.3.4 From a psychiatric point of view. delusions of parasitic infestation would better be classified as dermatopsychosis. for the patient exhibits true paranoid projection. Our series included one such case. This 48-year-old woman, who had grown up with obsessive pride in her silky hair, also exhibited trichotillomania. She was literally pulling her hair out over her problems. We saw no cases of lesions caused by compulsive movements. Examples of such would be the tissue responses to chronic lip-biting or fingerchewing. Neither did we see examples of aggravation of preexisting dermatoses. Disorders of almost any target organ can be aggravated by emotional factors and related behaviors-in this case, scratching. The majority of our patients fell into the category of neurotic excoriation. These were the "fixers," well aware of and admitting their scratching and "treating," although unconscious of the underlying neurotic and characterologic dynamics. Most of them were incredibly unaware of the causeeffect relationship between their behavior and disease. In factitial dermatitis, the patient denies any and all responsibility for the damage he has brought upon himself. The
PSYCHOSOMATICS
denial may be conscious or unconscious. 5 Six of our 26 patients made such denials. In these cases it is always difficult to rule out conscious malingering. Only one, however-the young man with compensation neurosis-was truly suspect. Even he may have been using unconscious conversion mechanisms, the obvious major dynamic pattern in four others. Ulceration was not the primary problem in any of our patients. In every case, the painfully injured skin was a ticket of admission to our multispecialty clinic-but through the wrong door. The signal for help distracted from the basic distress. In these 26 cases of self-induced ulceration. the skin was the medium: and in this brief clinical study we have tried to discern some of its messages. # REFERENCES
I. Sulton RL. Waisman M: The Practitioners' Dermatology. New York. Yorke Medical Books. 1975. pp 290. 521. 2. Griesemer RD. Mehlman RD: The Emotional Aspect of Cutane· ous Disease. in Fitzpatric TB et al (eds): Dermatology in General Medicine. New York. McGraw·Hill Book Co. 1971. pp 1581·1591. 3. Demis DJ. Dobson RL. McGuire J: Clinical Dermatolog}'. New York. Harper & Row. 1976. vol 4. unit 29.7. 4. Honigman J: The Psycho· cutaneous Disorders. in Moschella SL. Pillsbury DM. Hurley HJ (eds): Derma· tology. Philadelphia. WB Saunders Co. 1975. vol 2. pp 1556·1560. 5. Fras I. Coughlin BE: The Treatment of Factitial Disease. Psycho· .l'Omatics 12: 117·122. 1971.
19
Self-caused skin ulcers Because of its availability, displayability, and deep emotional significance, the skin is a common target for self-destructive behavior. And because self-caused skin lesions can be clearly identified, the dermatologic office or clinic offers a magnificent opportunity to study those whofor one reason or another-hurt themselves and then come to the physician for help. During a five-year period, I examined 26 patients referred to me by my colleagues in dermatology because of self-caused skin ulcerations. Diagnosis was based on characteristic appearance, elimination of other possible causes, response to treatment and, ofttimes, from ready or reluctant admission by the patient. Selection of patients depended on the dermatologist's interest in referral, the patient's willingness to see me, and my own availability. Because of these and other factors, "simple scratchers" were largely eliminated and many of the more bizarre patients fled. The final group of 26 comprised patients with significant, worrisome, and persistent self-caused ulceration of the skin.
Because of the variables of selection, statistical findings are only of speculative value. Of the 26 patients, all but three were women. Their ages ranged from 12 to 73 years, but more than half of them were in the fourth and fifth decades of life. Of the three men, two were in their eighth decade. The third (age 22) was involved in a medicolegal suit. Location and duration
In most cases the lesions were in areas visible to the public: on the face, head, or scalp of 19 patients, on the extremities of II, and on the trunk of only six. In most cases the ulceration was intermittent, and some periods of quiescence were long. By overall duration (from first onset until our examination) the cases were rather evenly distributed. Six patients had lesions for one year or less: and similar numbers had recurrent lesions for one to three years, three to six years, and six to ten years. Only two had been troubled for more than a decade. Almost half the patients, however, had had symptoms for more than five years.
DR. KRUPP is consultant in psychiatry. associate professor ofpsychiatry. Mayo Medical School. Rochester. Minn.
PSYCHOSOMATICS
Psychosocial factors
In the histories of these patients, certain factors appeared with more than casual frequency. Almost 20% (five) had suffered the loss of a parent or sibling by death or separation in the first decade of life. One third had experienced recent loss or threatened loss of a loved one, and this was significantly related in time to the onset of symptoms. In two women the lesions appeared in the month of the first anniversary of their fathers' deaths. Eight of the 18 married patients were currently experiencing serious marital conflicts or family problems. Three of these were women whose symptoms began during unwanted pregnancies. More than half of all t he patients had numerous additional functional complaints and a prior history of multiple illnesses, organic and functional. Psychiatric findings
I saw each of these patients for at least one I-hour consultation in the dermatologist's office or in the corresponding hospital unit. In each case I reviewed the medical history and derma to logic notes thoroughly. In most cases the der-
15
Self-caused skin ulcers
matologist and I discussed the case before and after the consultation. I considered only one of these 26 patients psychotic: a 48-year-old woman who also demonstrated trichotillomania and delusions of infestation with parasites. Two others. age 31 and 34. were possibly psychotic. Each had had onset of ulceration during pregnancy. One had a disabling panneurosis and schizoid personality features. The other. who had recently attempted suicide. smiled inappropriately from her wheelchair. virtually disabled by foulsmelling. secondarily-infected excoriations. The incidence of psychosis in this group may be low because of previously mentioned selection variables. Depr...lon
Most of the patients with self-caused skin ulcers had two or more apparent neurotic symptoms. The most frequent of these was depression. present in 12. In some cases the depression was virtually indistinguishable from the type common in late middle age. A 56-year-old childless nurse sought help for recurrent ulcers of the forehead, cheeks, and upper shoulders, which s"e had had for 10 months. With antibiotic treatme"t at home, these had healed and recurred numerous times. The woman admitted to frequently scratching them "to let the pressure out." At age 10 she
16
from
had lost her beloved mother to influenza. and at age 47 her "good" husband to a coronary occlusion (after 18 years of marriage). Her current illness began six months after a second marriage to a well-to-do, divorced, prematurely retired man of 56. After the wedding, she discovered that this handsome. active gentleman had obsessive, persecutory delusions that his first wife was trying to poison him. Along with skin ulcers. the patient developed feelings of fatigue, lack of energy, and discouragement. Her appetite decreased and she began to lose sleep. She had thoughts of suicide, but no intent. While she was waiting for a hospital bed to become available, she was started on therapeutic doses of a tricyclic antidepressant. Within a few weeks she had improved remarkably and was dismissed to the care of her family physician. Psychiatric referral was arranged so that she could have further help with her marital problem.
For this woman the skin ulcers. symbolically letting her "get the pressure out." were only one manifestation of an otherwise rather typical depressive reaction. Interestingly. they began to heal as soon as she reached the clinic. and were gone at the time of dismissal. We can only wonder how much of her general improvement came from the tricyclic antidepressant and how much of it was a result of being separated
her paranoid husband. Most of the depressed patients had reasons for repressed hostility and rage. Most blamed depression on the skin problem. rather than the contrary. Three patients gave histories of previous suicide attempts. Three others displayed evidence of unresolved grief reactions. Compulsion
Almost three quarters of the patients (18 of 26) had prominent obsessive-compulsive personality traits. They were perfectionistic. moralistic. prone to criticize themselves and others. and highly intolerant of anyone or anything (including their skin) being "out of order." Virtually all the patients whose ulceration was severe and long-standing fell into this category. A 51-year-old schoolteacher was referred because of severe self-eaused ulceration of the face and elsewhere. which she had suffered for 15 years. The lesions followed treatments for acne. which had appeared at age 18 and troubled her for many years. She cleansed. soaked, expressed blackheads. and drained pustules with sterile puncture. As time went on she worked harder "to get out small fat globules" which. she felt. "stop the lesion from healing." Resultant recurrent ulcers resisted the efforts of many dermatologists who (much to her resentment) often accused her of molesting her skin. She is an extremely obsessive-compulsive person who feels she must do everything perfectly and who washes clean things "just to be sure." She works regularly and productively at school but must limit her so-
JUNE 1977
cial life, avoid irritants, and restrict her trav'el. She saw her life as totally "fine" except for the ulcers a nd resisted all efforts to get her to reconsider that judgment. This woman gave no evidence of a serious psychiatric disorder. She was the compulsive product of a compulsive family. Other illnesses earlier in
her life served as an excuse for her inability to compete with her numerous siblings. That life stance was still being maintained with her ulcers. But generally. with a narrower life and fewer challenges. she could do all things perfectly and feel secure. And she didn't want doctors interfering with her pattern! Obsessive people feel com-
PSYClIOSOl\\-\TICS
pelled to take care of everything themselves. In contrast. hysterical people must get someone else to take care of them. The second most common pattern. noted in more than half (14) of the entire group. bore close resemblance to that seen in conversion reaction. In this condition a physical complaint. such as a nonorganic paralysis. de-
fuses. replaces. or explains away the patient's a nxiety or depression (primary gain) and permits the patient to seek aid and accept t he gratification of being dependent (secondary gain). The skin lesions performed that function for many of these patients. thus justifying a diagnosis of contrived conversion reaction.
A 38-year-old mother of three claimed she was told by her family physician to come to the Mayo Clinic for evaluation of "serious kidney disease." No evidence of that disease was found, but she was noted to have typical ulcers on her forehead, which had recurred intermittently for the previous four years. She readily admitted "bothering" them at night (had to wear gloves to bed) and "treating" them during the day (cleaning, recleaning, pulling off "loose parts"). At the time of their onset, her son (then aged eight) had hemorrhagic measles with subsequent encephalitis. her husband was overworked and unhappy with his job, and she suffered a spontaneous abortion of an unwanted pregnancy. A physician had prescribed a sulfa drug that caused a rash on her forehead, and the ulcers developed from her attention to the rash. A former model, the woman had always placed great emphasis on physical beauty. As a child she had missed much school because of "pyelitis," and the family doctor allegedly predicted she would have "real trouble" when she grew up and became pregnant. This woman was an hysterical. exhibitionistic person. buffeted by many stresses and unable to deal with her feelings-particularly anger. Her lesions served as a distraction from other issues. a self-directed means of expressing anger and an ongoing symbolic exercise of her compulsive need to make herself better. By being sick. she was "out of schoo'" once again. and was able to solve. or at least evade. other emotional problems. With encouragement she was able to verbalize many feel-
17
Self-caused skin ulcers
ings of anxiety and anger. A steroid ointment and prohibition of touching resulted in prompt and thorough healing of her skin. Separation anxiety
Only three patients were less than 20 years old. Each was a girl and each suffered from separation anxiety. An attractive, feminine young lady of 14 traveled with her mother from a Latin American country for treatment of eroded lesions on the forehead and lower lip. She gave a very bland description of herself, her family, and her life, and attributed the skin ulcers to "fever." Oose questioning of the mother revealed, however, that the girl's lesions had been occurring every spring for four years. The timing always coincided with the mother's spring attack of peptic ulcers, which annually dictated a trip to the Mayo Clinic for evaluation and treatment, and the lesions always healed within a few weeks after the mother's healthy return. The girl had a history of school phobia and multiple functional illnesses that compelled her mother's care and attention, which were lacking when the girl was well. Her illness earned her companion status in her mother's annual medical pilgrimage. The mother joked prophetically, "She'll be one of the few girls in (our country) to go from pediatrician to internist rather than from pediatrician to obstetrician...
18
Obviously the dynamics in many of these cases overlap. This young woman was certainly heading for an hysterical future but, for the moment, her lesions (like a kindergartner's stomachache) served to keep her near her mother in a mutually protective relationship. The stronger sex
Of the three men we saw, both of the older two (age 70 and 73) were obsessive characters, "fixers" in regard to their lesions and "deniers" in regard to their depressions, which would have been apparent to almost any observer. The one young man (age 22) was seeking medical support for a legal suit. He had hoped to be compensated further for ulcers attributed to a trivial work injury two years earlier. When prospects for that support began to look dim, he did not return for follow-up examination. Why the skin?
The skin is an envelope that physically protects the body, and we tend to equate its protective function with psychologic defenses. Thus, we speak of people as being "thinskinned" or "thick-skinned"; when something "gets under our skin," we already are partially undone. As a barrier, skin takes a beating from pressures both within and without. Few claim that emotional stress causes most skin disease, but the
psychoneuroses alone are believed to playa significant role in half of all skin conditions.) The frequent correlation between recent stress and the onset of disease is obvious. Further, the time intervals from significant stress to tissue change are often consistent: a few minutes in urticaria, one to two days in hand dermatitis. two weeks in alopecia areata. Moreover, reduction of stress seems to mitigate such illnesses. 2 The skin is a medium for many messages. The flush of rage, the blush of shame or excitement, and the blanching of fear are obvious. if unintended. communications. We read even our own emotions in skin sensations. We "sweat out" difficulties, feel the "slow burn" of frustration, are "tickled" by less distressing events. and sometimes have "an itch" to run. Sensations like these constitute the psychodermatopathology of life. In patients with selfcaused skin ulcers. integumental as well as psychologic defenses have been breached. The cause of the disease is definable, but the reasons for it are often less than apparent. The communication is obvious: both the patient and his skin shout, "Help me!" Diagnosis of self-infliction is essential to prevent ineffective, expensive, and time-consuming treatment. And diagnosis gives the sensitive clinician an opportunity to ask, "How can I help you? What can I do for you as a person?" Dermatologists list self-induced eruptions as true dermatoneuroses. 1 They variously include in this category neurotic excoriations. aggravation of
JUNE 1977
Skin 1..lonl In a 12-year-old girl were at first mistaken for ecthyma. but the lesions remained localized and no systemic symptoms developed. A dermatologist pointed out the trailing off of some of the lesions. their lack of progression. and their discreteness. and the girl admitted inducing the lesions herself with a liquid drain cleaner. phOto by James G. Ramsey. Jr.. M.D.
pre-existing dermatoses, lesions from compulsive movements, delusions of parasitic infestation, trichotillomania, and factitial dermatitis.3.4 From a psychiatric point of view. delusions of parasitic infestation would better be classified as dermatopsychosis. for the patient exhibits true paranoid projection. Our series included one such case. This 48-year-old woman, who had grown up with obsessive pride in her silky hair, also exhibited trichotillomania. She was literally pulling her hair out over her problems. We saw no cases of lesions caused by compulsive movements. Examples of such would be the tissue responses to chronic lip-biting or fingerchewing. Neither did we see examples of aggravation of preexisting dermatoses. Disorders of almost any target organ can be aggravated by emotional factors and related behaviors-in this case, scratching. The majority of our patients fell into the category of neurotic excoriation. These were the "fixers," well aware of and admitting their scratching and "treating," although unconscious of the underlying neurotic and characterologic dynamics. Most of them were incredibly unaware of the causeeffect relationship between their behavior and disease. In factitial dermatitis, the patient denies any and all responsibility for the damage he has brought upon himself. The
PSYCHOSOMATICS
denial may be conscious or unconscious. 5 Six of our 26 patients made such denials. In these cases it is always difficult to rule out conscious malingering. Only one, however-the young man with compensation neurosis-was truly suspect. Even he may have been using unconscious conversion mechanisms, the obvious major dynamic pattern in four others. Ulceration was not the primary problem in any of our patients. In every case, the painfully injured skin was a ticket of admission to our multispecialty clinic-but through the wrong door. The signal for help distracted from the basic distress. In these 26 cases of self-induced ulceration. the skin was the medium: and in this brief clinical study we have tried to discern some of its messages. # REFERENCES
I. Sulton RL. Waisman M: The Practitioners' Dermatology. New York. Yorke Medical Books. 1975. pp 290. 521. 2. Griesemer RD. Mehlman RD: The Emotional Aspect of Cutane· ous Disease. in Fitzpatric TB et al (eds): Dermatology in General Medicine. New York. McGraw·Hill Book Co. 1971. pp 1581·1591. 3. Demis DJ. Dobson RL. McGuire J: Clinical Dermatolog}'. New York. Harper & Row. 1976. vol 4. unit 29.7. 4. Honigman J: The Psycho· cutaneous Disorders. in Moschella SL. Pillsbury DM. Hurley HJ (eds): Derma· tology. Philadelphia. WB Saunders Co. 1975. vol 2. pp 1556·1560. 5. Fras I. Coughlin BE: The Treatment of Factitial Disease. Psycho· .l'Omatics 12: 117·122. 1971.
19
![[Skin ulcers revealing microscopic polyangiitis].](/assets/img/hold.png)
