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University of Copenhagen View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Copenhagen University Research Information System Self-Inflicted Lesions in Dermatology A Management and TherapeuticApproach - A Position Paper From the European Society for Derma-tology and Psychiatry Tomas-Aragones, Lucía; Consoli, Silla M; Consoli, Sylvie G; Poot, Francoise; Taube, Klaus- Michael; Linder, M Dennis; Jemec, Gregor B E; Szepietowski, Jacek C; de Korte, John; Lvov, Andrey N; Gieler, Uwe Published in: Acta Dermatovenereologica DOI: 10.2340/00015555-2522 Publication date: 2017 Document license: CC BY-NC Citation for published version (APA): Tomas-Aragones, L., Consoli, S. M., Consoli, S. G., Poot, F., Taube, K-M., Linder, M. D., ... Gieler, U. (2017). Self-Inflicted Lesions in Dermatology: A Management and TherapeuticApproach - A Position Paper From the European Society for Derma-tology and Psychiatry. Acta Dermatovenereologica, 97(2), 159-172. https://doi.org/10.2340/00015555-2522 Download date: 08. Apr. 2020 159 SPECIAL REPORT Self-Inflicted Lesions in Dermatology: A Management and Therapeutic DV Approach – A Position Paper From the European Society for Derma- tology and Psychiatry cta 1 2 3 4 5 A Lucía TOMAS-ARAGONES , Silla M. CONSOLI , Sylvie G. CONSOLI , Françoise POOT , Klaus-Michael TAUBE , M. Dennis LINDER6, Gregor B. E. JEMEC7, Jacek C. SZEPIETOWSKI8, John DE KORTE9, Andrey LVOV10 and Uwe GIELER11 1Department of Psychology, University of Zaragoza and Aragon Health Sciences Institute, Zaragoza, Spain, 2Department of Consultation Liaison Psychiatry, Paris Descartes University, Sorbonne Paris Cité, Faculty of Medicine, 3Dermatologist and Psychoanalyst, Paris, France, Departments of Dermatology, 4Université Libre de Bruxelles, Erasme Hospital, Brussels, Belgium, 5University of Halle, Halle, Germany, 7Roskilde Hospital; Health Science Faculty, University of Copenhagen, Copenhagen, Denmark, 9Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands, 10Moscow State Medical University, Moscow, Russia, 6Oslo Centre for Biostatistics and Epidemiology, University of Oslo, Oslo, Norway, 8Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, Wroclaw, Poland, and 11Department of Psychosomatic Medicine, Justus Liebig University, Giessen, Germany enereologica The classification of self-inflicted skin lesions proposed In the previous classification paper from the ESDaP V by the European Society for Dermatology and Psychiatry group, there was an explanation as to why SISL should (ESDaP) group generated questions with regard to not encompass all skin lesions attributed to pathologi- specific treatments that could be recommended for cal behaviour (1). In psychiatric practice, classification such cases. The therapeutic guidelines in the current traditionally requires that when a symptom or a set ermato- paper integrate new psychotherapies and psychotropic of symptoms is better explained by a well-identified D drugs without forgetting the most important relational mental disorder, the diagnosis should be related to that characteristics required for dealing with people with psychiatric disorder. Self-mutilations may therefore cta these disorders. The management of self-inflicted skin occur in a spectrum of primarily psychiatric diagnoses. A lesions necessitates empathy and a doctor–patient re- lationship based on trust and confidence. Cognitive be- For example, in autistic spectrum disorders (8), schi- havioural therapy and/or psychodynamic and psycho- zophrenia (9) or mental retardation (10), as well as in analytic psychotherapy (alone, or combined with the Tourette and chronic tic disorders (11), Lesch-Nyhan careful use of psychotropic drugs) seem to achieve the (12, 13) or Prader-Willi (14, 15) genetically determined best results in the most difficult cases. Relatively new syndromes, with their neurological, behavioural and/or DV therapeutic techniques, such as habit reversal and metabolic abnormalities. Consequently, self-mutilations mentalization-based psychotherapy, may be beneficial seen in these psychiatric or neurological disorders cta in the treatment of skin picking syndromes. should not be included in the restricted category of SISL, A although a dermatological consultation and treatment Key words: self-inflicted injury; skin picking disorder; psycho- logical treatment; doctor–patient relationship; clinical practice may be required in all these conditions and some of the guidelines. behavioural or pharmacological therapeutic approaches Accepted Aug 22, 2016; Epub ahead of print Aug 26, 2016 recommended in SISL could also be effective. The same principle should be applied to skin damage due to Acta Derm Venereol 2017; 97: 159–172. phlebotomy suicide attempts, skin or even deeper body Corr: Lucía Tomas-Aragones, Department of Psychology, University of self-injury seen in patients with various body delusions Zaragoza, Calle Pedro Cerbuna 12, ES-50009 Zaragoza, Spain. E-mail: or hallucinations. The potential dermatological thera- [email protected] peutic approach of these patients is outside the scope of this article. elf-harming behaviour has many aspects. In 2013, the In its previous paper, the ESDaP group displayed the SEuropean Society for Dermatology and Psychiatry rationale of the proposed classification based on the (ESDaP) group (1) proposed a terminology and clas- answers to an initial question: “Is the behaviour respon- sification of self-inflicted skin lesions (SISL), which sible for the somatic damage denied or kept secret by included several aspects of self-harm behaviour to the the patient?” If the answer to this question is affirmative, skin. Recent studies have indicated the acceptance of the the next question should be: “Are there any external in- classification with regard to therapeutic approaches to the centives?”, thereby differentiating between malingering treatment of patients with skin conditions (2). The Diag- and factitious disorders. If the answer to the question is nostic and Statistical Manual of Mental Disorders, Fifth negative, the next question should be: “Is the behaviour Edition (DSM-5), published in May 2013 (3), includes responsible for the somatic damage compulsive or im- “skin picking” as a new category within the spectrum of pulsive?”, thereby differentiating between 2 different obsessive-compulsive and related disorders. SISL have categories of skin picking disorders. This step-by-step been described as a non-suicidal, conscious and direct classification tree helps to describe different categories dvances in dermatology and venereology damage to the skin (4–7). within the set of SISL, as the purpose of both the pre- A This is an open access article under the CC BY-NC license. www.medicaljournals.se/acta doi: 10.2340/00015555-2522 Journal Compilation © 2017 Acta Dermato-Venereologica. Acta Derm Venereol 2017; 97: 159–172 160 L. Tomas-Aragones et al. vious paper and the current one is to help dermatologists nosis and treatment of the skin lesions are often the identify and treat these syndromes. Most dermatological first steps for the dermatologist, but simply treating the research published SISL are mainly dedicated to only lesion does not deal with the psychological suffering, DV one category, this being the compulsive spectrum of skin often requiring a multidisciplinary approach involving picking syndromes: “trichotillomania” or compulsive mental health professionals. A multidisciplinary ap- cta hair pulling, acne excoriée, etc. Moreover, as the new proach implies a combination or a succession of diffe- A DSM-5 classification individualizes and includes “skin rent therapies: dermatological treatment, psychotropic picking” within the spectrum of obsessive-compulsive drugs, cognitive-behavioural therapy (CBT) and other disorders (OCD), the other category of skin picking, i.e. psychotherapies, such as psychodynamic psycho therapy the impulsive one, does not belong to this diagnostic or even psychoanalysis. class and is supposed to constitute a clinical expression The basis for the management of all types of SISL is of different psychiatric diagnoses, such as borderline the patient–doctor relationship; its establishment may personality disorder. depend on experience with SISL patients, knowledge There is evidence that SISL are more prevalent than of psychodermatology and participation in a so-called previously believed: a 2010 study suggested that approx- Balint-group (19). Good listening skills, the ability to enereologica imately 1.4% of adults in the USA are sufferers (16); a demonstrate empathy, and to engage in non-judgemental V recent Canadian study concluded that the life-time preva- communication are other important qualities for the lence of skin picking in young people was approximately therapist. Treating SISL patients can be very difficult 18% (17) and in 2013, in a German sample of 266 school as they are often unaware of the psychological causes children, 19.6% admitted occasional skin picking, with behind their symptoms or not cognisant of the link bet- ermato- 1.9% regularly indulging in this behaviour and presenting ween their psychological suffering and their pathological D clear stress regulation difficulties (18). behaviour. This lack of awareness is a significant obstacle Dermatologists are therefore regularly called upon to to the establishment of a therapeutic alliance. cta treat patients who exhibit symptoms of SISL. The aim of Feelings of frustration and discouragement are com- A this paper is to provide skin
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