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Self-Inflicted Lesions in Dermatology A Management and TherapeuticApproach - A Position Paper From the European Society for Derma-tology and 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 Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV Psychiatry, Paris Descartes University, Sorbonne Paris Cité, Faculty of Medicine, of PsychosomaticMedicine,JustusLiebigUniversity,Giessen, Germany 1 Lucía tology andPsychiatry Approach – A Position Paper From the European Society for Derma Self-Inflicted Lesions in Dermatology: A Management and Therapeutic The Netherlands, LINDER Health Science Faculty, University of Science Faculty, University Copenhagen, Copenhagen, Denmark, Health of Dermatology, Oslo, Norway, Edition ( nostic and Statistical Manual of Mental Disorders, Fifth damage totheskin(4–7). been describedasanon-suicidal, consciousanddirect SISLdisorders. related have and obsessive-compulsive “skin picking” as a new category within the spectrum of treatment of patients with skin conditions (2). The classification with regard to therapeutic approaches to the skin. Recent studies have indicated the acceptance of the included severalaspectsofself-harmbehaviourtothe which (SISL), lesions skin self-inflicted of sification S [email protected] E-mail: Spain. Zaragoza, ES-50009 12, Cerbuna Pedro Calle Zaragoza, Corr: Acta DermVenereol 2017;97:159–172. Accepted Aug 22,2016;EpubaheadofprintAug 26,2016 guidelines. practice clinical relationship; doctor–patient treatment; logical psycho- disorder; picking skin injury; self-inflicted Key words: in the treatment of skinpickingsyndromes. and reversal mentalization-based habit psychotherapy, may be beneficial as such techniques, therapeutic new Relatively cases. difficult most the in results best careful use of psychotropic drugs) seem to achieve the the with combined or (alone, psychotherapy analytic psycho and psychodynamic and/or therapy havioural lationship based on trust and confidence. Cognitive be lesions necessitates empathyandadoctor–patient re these disorders. The management of self-inflicted skin with people with dealing for required characteristics drugs without forgetting the most important relational paper integrate new psychotherapies and psychotropic current the in guidelines for therapeutic The cases. berecommended such could that to treatments regard specific with questions generated group (ESDaP) by the European Society for Dermatology and Psychiatry The classification of self-inflicted skin lesions proposed (ESDaP) group(1)proposedaterminologyandclas This isan open access article under the CC BY-NC license.www.medicaljournals.se/acta Journal Compilation ©2017ActaDermato-Venereologica. Department ofPsychology,UniversityZaragozaandAragonHealthSciencesInstitute,Zaragoza,Spain, European SocietyforDermatologyandPsychiatry elf-harming behaviour has many aspects. In2013,the uí TmsAaoe, eatet f scooy Uiest of University Psychology, of Department Tomas-Aragones, Lucía TOMAS-ARAGONES 6 , DSM-5), publishedinMay 2013(3),includes Gregor B. E.JEMEC 8 Department of Dermatology, VenereologyandAllergology, WroclawMedicalUniversity,Wroclaw,Poland, and 4 Université Libre de Bruxelles, Erasme Hospital, Brussels, Belgium, 10 Moscow State Medical University, Moscow, Russia, 1 , M. CONSOLI M. Silla 7 , Jacek C. SZEPIETOWSKI 2 , G. CONSOLI G. Sylvie SPECIAL REPORT Diag- 8 - - - , -

John DE KORTE 6 Oslo Centre for Biostatistics and Epidemiology, University of Oslo, not encompass all skin lesions attributed to pathologi to attributed lesions skin all encompass not group, there was an explanation as to why SISL should For example, in autistic spectrum disorders (8), schi (8), disorders spectrum autistic in example, For occur inaspectrumofprimarilypsychiatricdiagnoses. psychiatric disorder. Self-mutilationsmaytherefore , thediagnosisshouldberelatedtothat well-identified a by explained better is symptoms of set a or symptom a when that requires traditionally cal behaviour (1). In psychiatric practice, classification within the set of SISL, as the purpose of both the pre the both of purpose the as SISL, of set the within categories different describe to helps tree classification step-by-step This disorders. picking skin of categories be­ differentiating thereby pulsive?”, responsible forthesomatic damagecompulsiveorim negative, the next question should be: “Is the behaviour and factitious disorders. If the answer to the question is centives?”, thereby differentiating between malingering the next question should be: “Are there any external in the patient?” If the answer to this by question secret is kept affirmative, or denied damage somatic the for sible answers to an initial question: “Is the behaviour respon the on based classification proposed the of rationale of thisarticle. peutic approachofthesepatientsisoutsidethescope thera dermatological potential The hallucinations. or self-injury seen in patients with various body delusions phlebotomy suicide attempts, skin or even deeper body same principle should be applied to skin damage due Theto effective. be also could SISL in recommended behavioural orpharmacological therapeutic approaches may berequiredinalltheseconditionsandsomeofthe although adermatologicalconsultationandtreatment should not be included in the restricted category of SISL, or neurological disorders inthesepsychiatric seen metabolic abnormalities.Consequently, self-mutilations syndromes, with their neurological, behavioural and/or (12, 13) or Prader-Willi (14, 15) genetically determined Lesch-Nyhan (11), disorders tic chronic and Tourette in as well as (10), retardation mental or (9) zophrenia 9 In the previous classification paper from the ESDaP the from paper classification previous the In In itspreviouspaper, theESDaP groupdisplayedthe Academic Medical Center, University of Amsterdam, Amsterdam, of Amsterdam, Center, University Amsterdam, Medical Academic 3 , 3 Dermatologist and Psychoanalyst, Paris, France, Departments POOTFrançoise 5 University of Halle, Halle, Germany, 9 , Andrey LVOV 4 , Acta DermVenereol 2017;97: 159–172 TAUBEKlaus-Michael 10 2 Department of Consultation Liaison Department ofConsultationLiaison and Uwe GIELER doi: 10.2340/00015555-2522 tween 2 different 2 tween 7 Roskilde Hospital; 5 11 11 , M. , Department Dennis 159 ­ ------

Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV www.medicaljournals.se/acta suffering thatgenerallyunderlies thisbehaviour. Diag ­ should be aware of the importance of the psychological dermatologists SISL, of management correct the For Awareness OF SELF-INFLICTED SKINLESIONS GENERAL PRINCIPLES FOR THE MANAGEMENT should bemanagedbywell-informeddermatologists. these clinical manifestations pose difficult problems and Nevertheless, reasons. ethical for as well as disorders, approaches, duetothefactthattheyarerelativelyrare systematic studies on the efficacy of different therapeutic of SISL, such as factitious disorders, are not suitable for multidisciplinary groupofspecialists. where available, and from the clinical experience of this ESDaP group are derived both from evidence-based data, the of recommendations therapeutic The specialists. health mental with collaboration in patients, of kind this managing better for landmarks some with them terventions without any specific training, but to provide drugs ortoengageinstructuredpsychotherapeutic dermatologists to prescribe a wide range of psychotropic disorders. Nevertheless, our purpose is not to encourage mental and dermatological combined with patients of ispredominantinthemanagementof dermatologists the taxonomy of the aforementioned lesions (1). The role disorders) with some stratified therapeutic principles on the psychiatric classificationsystem (and/or behavioural this paper is to provide skin specialists not familiar with treat patients who exhibit symptoms of SISL. The aim of clear stressregulationdifficulties(18). 1.9% regularly indulging in this behaviour and presenting with picking, skin occasional admitted 19.6% children, 18% (17) and in 2013, in a German sample of 266 school lence of skin picking in young people was approximately recent Canadianstudyconcludedthatthelife-timepreva a USA(16); sufferersthe are in adults of 1.4% imately previously believed: a 2010 study suggested that approx . of different psychiatricdiagnoses,suchasborderline class and is supposed to constitute a clinical expression the impulsiveone,doesnotbelongtothisdiagnostic disorders (OCD), the other category of skin picking, i.e. obsessive-compulsive of spectrum the within picking” “skin includes and individualizes classification DSM-5 new the as Moreover, etc. excoriée, pulling, hair compulsive or “” syndromes: picking one category, this being the compulsive spectrum of only skin to dedicated mainly are SISL published research identify and treat these syndromes. Most dermatological vious paperandthecurrentoneistohelpdermatologists 160 Readers should bear in mind that certain categories certain that mind in bear should Readers Dermatologists arethereforeregularlycalleduponto than prevalent more are SISL that evidence is There L. Tomas-Aragonesetal. - - - to theestablishmentofatherapeuticalliance. behaviour. This lack of awareness is a significant obstacle ween their psychological suffering and their pathological bet link the of cognisant not or symptoms their behind causes psychological the of unaware often are they as difficult very be can patients SISL Treating therapist. communication areotherimportantqualitiesforthe demonstrate empathy, and to engage in non-judgemental to ability the skills, listening Good (19). Balint-group of psychodermatologyandparticipationinaso-called knowledge patients, SISL with experience on depend may establishment its relationship; patient–doctor the or evenpsychoanalysis. psychotherapies, such as psychodynamic psycho­ other and (CBT) therapy cognitive-behavioural drugs, psychotropic treatment, dermatological therapies: rent proach impliesacombinationorsuccessionofdiffe potheses on the underlying mechanisms were proposed: risk factors and biographical aspects. The following hy the developmentandmaintenanceofself-harm,including capable ofself-harm. has background knowledge as to why a human being is management of SISL can be made easier if the the specialist to approach therapeutic Ateam. health mental the and have to be motivated before they start working with relationship. Patientsneedtounderstandtheirsituation doctor–patient of kind any established having before evenreferring themtoamentalhealthprofessional, approach istorefusetreatthesepatients,immediately matologists and psychotherapists. The worst therapeutic der both for gratification of source a be can conditions even presentmoreorworseningsymptoms. jects often show little or no improvement, and they may mon among dermatologists treating SISL patients; sub mental health professionals. A multidisciplinary ap multidisciplinary A professionals. health mental often requiringamultidisciplinaryapproachinvolving suffering, psychological the with deal not does lesion the treating simply but dermatologist, the for steps first the often are lesions skin the of treatment and nosis • • • • • • a of repeatedself-injury. tolerance as a dispositional risk factor or a consequence a gulate emotions. non-suicidal self-injury to the point of using it to re an sonal function(seekingpsychologicalhelp). Feelings offrustrationanddiscouragementarecom SISLof is types all of management the for basis The a from feelingsofshame,guiltandself-hate. a doing thesame. a Nock (7) developed an integrated theoretical model of patients’ in improvements difficulties, these Despite pragmatic hypothesis: the use of SISL as a relatively pain-analgesia oropiate social signalling hypothesis: SISL have an interper hypothesis: the behaviour results behaviour the hypothesis: self-punishment hypothesis: recognition of others of recognition hypothesis: social learning implicit identification hypothesis: identifying with hypothesis: the role of pain therapy therapy ------Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV motivating thepatienttoconsiderbroader-based treat one of the first steps in a psychoeducational approach to be would nerves skin of activation the and skin the on life. A basic physiological discussion on -reactions symptoms areaggravatedbystressfulsituationsindaily causes. Patients will often accept the possibility that the other be might there that but skin), (the physical only not is problem the that suggest can dermatologist The Preparing thepatientforamultidisciplinaryapproach of theseapproachescanbe combined,especiallyinthe hereafter dependonthetype ofthedisorder. Several logical andnon-pharmacological approachesdescribed pharmaco the of indications The relationship. patient doctor– good a of establishment the is priority further a lesions; skin the of treatment dermatological the is step first the dermatologist, the For SISL. to applied be can that approaches therapeutic of number a are There THERAPEUTIC APPROACHES (TableI) term, convincethesepatientstochangetheiropinion. therapeutic relationshipcould,inthemedium-to-long the of maintenance The patients. SISL of 15–30% as the ESDaP group estimate that this may occur in as many experience, members’ on Based treatment. psychiatric of kind any refuse will who individuals some be still will there techniques, management these applied rectly be essential. purpose, collaboration with the general practitioner can legal structureinthecountryquestion).Forsucha the on (depending consent without even examination, psychiatric a undergo to subject the forcing in justified offered; in extreme situations, the physician should feel cide. Ifthereisanintent,psychiatrictreatmentmustbe ideation or if there is a specific intention to commit sui determine if the patient’s feelings are limited to suicidal the patientrefusesareferral,dermatologistmust cess toamentalhealthprofessionalisnotpossibleor ac If recommended. is specialist health mental a with suspect) suicidalideation.Inthesecases,co­ self-harm behaviour. their of awareness person’s the determining of way a aggravate the injuries through their own actions, can be lesions appeared,andthesuggestionthatpatientmay the when and how on discussion non-confrontational patients’ the recommended. of also difficulty) is case A the (not complexity the about ments. statement Aclear • mediate relief. in conditionsofintolerabletensionandinduceanim a negative emotions. fast andeasilyaccessiblemethodforregulationof Even when the dermatologist has carried out and cor Some patients may comment on (or the physician will hypothesis: self-harm can occur can self-harm tension-regulationhypothesis: operation ------A therapeuticapproachtoself-inflictedlesionsindermatology will be of a different kind and this can be useful for useful gathering informationandobservingbehaviouralcharac be can this and kind different a of be will offer additionalcontactforthepatients.Conversation patient to continue psychosomatic–psychi­ tionship canbearesourceformotivatinganambivalent bear inmindthatbynottreating aseverelydepressed Dermatologists andother health professionalsshould may therefore,inrarecases, precipitateasuicideattempt. this and mood on effect specific the precede generally the removalofinhibition componentofdepression and effect anxiolytic an that fact the of aware be must physician The effect. take to weeks 2–3 least at need reuptake inhibitors (DNRI) (bupropion). Antidepressants dopamine-norepinephrine and (trazodone); modulators inhibitors (SSNRIs) (venlafaxine, duloxetine); serotonin reuptake norepinephrine and serotonin selective line); roxetine, fluvoxamine, citalopram, escitalopram, sertra pa (fluoxetine, (SSRIs) inhibitors reuptake serotonin (TeCAs)selective – (mirtazapine); antidepressants clic (TCAs) (amitriptyline, clomipramine, doxepin); tetracy monly used in dermatology are: tricyclic antidepressants Antidepressants ( Psychotropic drugs(20) dermatological approach. also give an indication as to the effectiveness of a psycho- can This problems. underlying about talk to readiness or awareness sufferer’s the about information provide can disorders, skin and conflicts emotional patients’ abuse and/orapost-traumaticstressdisorder(PTSD)). some cases this might be a symptom of physical or sexual teristics; for example, an aversion to physical contact (in lack of apparent progress. A trusting dermatological rela the or difficulties with faced when professional health an alreadystartedpsychologicalapproachbyamental follow-up consultations: many patients criticise or reject helpful tocontinuethedermatologicaltreatmentin is It emotions. repressed and self-harm about speaking avoid to prefer would who patient the for intimidating or threatening less be can lesions skin the of treatment the on concentrating by Starting lesions. skin the yond be­ topics other about talk to patients of resistance the lower help sometimes can emollients and treatments about other issues in their lives. The use of basic topical relationship with the patient and encourage them to talk the opportunitytobegindevelopacommunicative dermatologist the give can therapy, healing wound as such approaches, technical using and skin the Treating Dermatological treatment appropriate. Most importantly, amultidisciplinaryapproachisoften treatment. second-line a in or patients difficult more Involving other health professionals (e.g. nurses) may Involving otherhealthprofessionals(e.g.nurses)may The use of indirect speech, by referring to other to referring by speech, indirect of use The ). The antidepressants com antidepressants The Table II). Acta DermVenereol 2017 atric treatment. 161 ------Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV www.medicaljournals.se/acta effect profile. A serotonin syndrome can develop when develop can profile.effect syndrome serotonin A antidepressants due to tolerability andafavourable side- adverse effect isweightgain. peripheral histamine H1 receptors (21, 22). However, an and central to affinity high a has Mirtazapine pruritus. on effects significant have can and receptors 5-HT3 and 5-HT2 as well as α2-heteroreceptors and α2-auto- effect islimited. anti-pruritic andsedativeeffects, buttheantidepressant SISL linked to pruritus. Lower dosages of doxepin have and excoriations psychogenic for treatment “off-label” histamine-blocking activity and represents the first-line H2 and H1 potent a has which doxepin, is dermatology in TCA used commonly most The effects. adverse their to due nowadays used less are they but pressants, symptoms. front a patient presenting with both SISL and depressive cost-benefit assessment might help dermatologists con a Such properties. disinhibitory with antidepressant an patient the risk of suicide is much higher than prescribing Table I.Overviewoftherapeuticapproachesinself-inflictedskinlesions(SISL) 162 Other indications in dermatology other thanSISL, forexample,delusional parasitosis or glossodynia, arenotmentioned in this Table. Dermatological treatment Category Psychotropic drugs Psychotherapeutic approaches Psychoeducation Relaxation techniques Benzodiazepines Anti-opioids Anticonvulsive drugs N-acetyl cysteine Antidepressants psychotherapy Psychodynamic psychotherapy Transference-focused behavioural therapy Third-wave cognitive Mindfulness reprocessing desensitization and Eye movement treatment Mentalization-based SSRIs and SSNRIs are currently the most prescribed most the currently are SSNRIs and SSRIs Mirtazapine is a TeCA, which antagonizes adrenergic antide efficacious and long-established are TCAs L. Tomas-Aragonesetal. Characteristics in acne excoriée). treatment of theunderlyingdisease, when needed(e.g. Wound-healing techniques, topical treatments and emollients. Basic withdrawal syndromes. recommendations rarely respected. Dependency and Too frequently prescribed,but short-term prescription Unusual prescription. Compulsory psychiatric follow-up. psychiatrist. Risk of pooradherence,duetoside-effects. They generally need a referral to or atleast an advice of a stress. A glutamate modulator with theproperty of ameliorating oxidative a suicide attempt. the specificeffect on mood and this may thereforeprecipitate the inhibition component of generally precedes They needat least 2–3weekstotake effect. The removal of are analysed. Transference andcounter-trans­­ processes. Childhoodexperiences, personal fantasies and dreams Patient’s free associations encouraged. Focused onuncon­­ psychoanalytic object relations theory. Manualized treatment for severe personality disorders, basedon from psychodynamic psychotherapy. Comprehensive therapies, including some approaches derived personal homeexercises. psychological distress.Shorttreatment duration. Training relay by of somatic sensations, physical pain, thoughts, memories,or Links withmeditationtechniques. Non-judgmental acceptance stress disorders. Short treatmentduration. Cognitive-behavioural technique, developed in post-traumatic work. 18 months, with weekly individual sessions and additional group major role. problem-solving recommendations. Not really tested in SILS. Encompasses patient’s information, relaxation techniques, and Focused onbodily sensations. Efficacy per se not proved in SISL. ference play a ference play a - -

tion) suchashaloperidol or pimozide,andatypical genera (first antipsychotics typical are dermatology in Antipsychotics. The antipsychotics most commonly used replicated (24,25). be to have disorders, picking skin type compulsive or compulsive relateddisorders,suchastrichotillomania in the treatment of OCD (23). Recent results in obsessive- oxidative stress and has demonstrated promising effects modulatorthathasthepropertyofameliorating tamate glu a is (NAC) cysteine N-acetyl N-acetyl cysteine. behaviour. picking skin to contributes image body for concern obsessive SISLan compulsive-type when all as well as compulsive means that they are a first-line treatment for anti- are they that fact The disorder. anxiety neralized ge and social PTSD, OCD, disorder, panic in: or antipsychotics(e.g.risperidone). dopaminergic agents(e.g.metoclopramidefornausea) triptans (e.g.sumatriptanformigrainetreatment),anti used concomitantly with monoamine oxidase inhibitors, are SSNRIs, and SSRIs as such drugs, serotoninergic scious scious

TCAs and SSRIs have other properties and are used are and properties other have SSRIs and TCAs

Main indications approach andpreparing referral. helpful. Especially useful for lowering resistances to a psychological referral to a mental healthspecialistwas accepted and proved Always recommended,even during the follow-up and whenthe patients with personality disorders. Anxiolytic effect. Watch for a paradoxical removal of inhibition in Severe pruritus. SISL, or associated borderlinepersonality disorder. Mood disorders, especially , whenassociatedwith tendency to repeat self-harm associated withSISL. Severe obsessive-compulsive disorder or impulsiveness and trichotillomania and compulsive type skinpicking. Obsessive compulsive and related disorders, suchas complicated by socialphobias. symptoms, SISLwith an obsessive concernforbodyimageor compulsive type skin picking and relatedskin damaging SISL complicatedby or facilitated by a depressive state, SISL associatedwith borderline personality disorders. dysmorphic disorder. Self-inflicted excoriations. SISL associatedwith obsessive compulsive disorders orbody Patient’s desireto better manage stressfulsituations. bullying andhumiliation. Adverse life experiencesinchildhood, household dysfunction, Impulsive type skin picking andrelated skin damaging symptoms. by their emotional states. Patients with borderlinepersonality disorders, easily overwhelmed psychic life. adverse experiences. Patient’s motivation for exploringhis/her Associated personality disorders. Childhood traumas andlife or comprehensive psychotherapeutic approaches proposed in SISL. Often integrated in more complexcognitive behavioural techniques symptoms. Useful in compulsive type skin picking and related skin damaging - - - - Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV guidelines forpruritustreatment (26)). European (see pruritus severe with associated dromes syn in effects positive has Naltrexone Anti-opioids. health professionals. considered prescription and follow-up by trained require mental but SISL, with associated conditions some in pine and lamotrigine). They can, nevertheless, be useful multi forme erythema and Stevens-Johnson therapy); syndrome (with lithium carbamaze (with psoriasis and suppurativa hidradenitis conglobata, acne gain, weight in borderlinepersonalitydisorders.Side-effects include problems andthebehaviourinstabilityusuallypresent andforsevereaffectiveto antidepressants regulation as anaugmentationstrategyfordepressionresistant treating mooddisorders(especiallybipolardisorder), lamotrigine, etc.)arecommonlyusedinpsychiatryfor acid, valproic oxcarbamazepine, carbamazepine, salts, (lithium drugs Anticonvulsive Anticonvulsive drugs. the involvement of apsychiatrist is highly recommended. self-harm that is also associated with SISL. In these cases, repeat to tendency and impulsiveness the SISLor with treating delusoryparasitosis, severeOCDassociated caemia, diabetesmellitusandlipidabnormalities. metabolic side-effects, including weight gain, hypergly extrapyramidal effects), even though many of them have third-generation antipsychoticsarebettertolerated(less psychological component of their problem. Second- and the recognize to reluctant are who patients with count ac into taken be must This patients. the of part the on treatment adherence(orinterruptionofthetreatment) norrhea). This has limited their use and explains the low constipation, urinaryhesitancy, galactorrheaandame side-effects, orthostatichypotension,blurredvision, antipsychotics haveseveralside-effects (extrapyramidal peridone, olanzapine,andaripiprazole.First-generation antipsychotics (secondandthirdgeneration)suchasris Table II.Antidepressants inhibitors (DNRI) Dopamine-norepinephrine reuptake Serotonin modulators reuptake inhibitors (SSNRIs) Selective serotonin and norepine­ (SSRIs) Selective serotonin reuptake inhibitors Tetracyclic antidepressants (TeCAs) Tricyclic antidepressants (TCAs) Class Antipsychotics are prescribed in dermatology for dermatology in prescribed are Antipsychotics phrine phrine smoking. For example, bupropion. Alsoused to helppeoplequit For example, trazodone. Useful in somatic painful syndromes. The most used antidepressants nowadays, with SSRIs. compulsive spectrumdisorders. for nausea)orantipsychotics (e.g. risperidone). Useful in treatment), antidopaminergic agents (e.g.metoclopramide oxidase inhibitors, triptans (e.g. sumatriptan for migraine Be carefulwhenusedconcomitantlywith monoamine The most used antidepressants nowadays, with SSNRIs. in pruritus associated SISL. peripheral histamine H1 receptors. Usefulness of mirtazapine Easier to manage than TCAs. High affinity for central and due to their cardiac toxicity. SISL linked to pruritus. Harmful in caseof suicide attempt, have potent H1 andH2 histamine-blocking activity, useful in due to their adverse effects. Some TCAs, especiallydoxepin, Long-established and efficacious, butlessusednowadays General dataandmanagementrules ------A therapeuticapproachtoself-inflictedlesionsindermatology frequency of withdrawal symptoms (depression, seizu (depression, symptoms withdrawal of frequency driving disturbances, agitation, ), the concentration, of lack intolerance, alcohol (sedation, tions arerecommendedbutrarelyrespected.Side-effects monly prescribed anxiolytic drugs. Short-term prescrip specific and sometimes even manualized psychody manualized even sometimes and specific therapeutic techniquesthat canbeusedassuch,more her ownfamily, personalandprofessionalexperience. or his with accordance in subject, the to reaction cious concerns the doctor’s emotional, conscious and uncons infancy during early bonding (27). “Countertransference” in formed were which psychotherapists), and doctors in adulthood,ofmodesrelatingtoothers(including “Transference” refers to the patient and is the repetition, transference andcounterphenomena. of advantage takes and environment non-judgmental behaviour. present on past the of influence the understanding and self-awareness improving help can dreams, and tasies of early childhood experiences, as well as personal fan as they are manifested in a person’s behaviour. Analysis oriented therapy” and focuses on unconscious processes theory. Psychodynamic therapy is also known as “insight- chodynamic therapyhasitsoriginsinpsychoanalytic Psychodynamic psychotherapy Psychotherapeutic approaches personality disorders,facilitatingself-harmbehaviour. with patients in especially for, watched be should and observed be can inhibition of removal paradoxical A count, especially for patients with personality disorders. the risk of dependence or abuse should be taken into ac symptoms (anxiety, sleep disturbances, restlessness) and res, autonomicnervoussystemdisturbances),rebound Benzodiazepines. arethemostcom Whilst psychodynamictherapy isoneofthepsycho­ Psychodynamic therapyusesfreeassociationina weight loss. Blood pressure raise. hyperventilation, increasedsweating, dry mouth, unusual Anxiety, irritability, restlessness,troublesleeping,shaking, TCAs and less cardiotoxicity. Similar butfewer anticholinergic and adrenolytic effects than pressure raise. Same side-effects thanwithSSRIs. Increasedsweating. Blood cytochrome P450 pathway. interactions caused by hepatic metabolismthrough the when additional serotoninergic agents are prescribed. Drug vomiting. Hyponatraemia. Possible serotoninsyndrome disturbances such as constipation,diarrhoea, nausea and Sleep changes, sexual dysfunction andgastrointestinal Weight gain. abnormalities and arrhythmias. that include QTc interval prolongation,conduction lowering of theseizurethreshold and cardiac disturbances angle glaucoma; adrenolytic effects: orthostatic hypotension; decreased gastrointestinal motility, blurred vision, narrow- Anticholinergic effects: sedation, dry mouth, urine retention, Principal side-effects . The concept of psy of concept The . Acta DermVenereol 2017 163 ------Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV www.medicaljournals.se/acta improve OCD symptomsand cingulate neurochemistry OCD (40) and small-group intensive CBT was found to couple therapy (39). Schema therapy has been used with behavioural integrative and psychotherapy; analytic havioural analysis system of psychotherapy; functional dialectical behaviour therapy (Linehan); cognitive be (Young), therapy schema (Hayes); therapy mitment com and acceptance include: that therapies havioural is denominatedasagroupofcognitive-emotionalbe wave” “third the nowadays, 1990; and 1980 between CBTsthe be to considered is wave” popularwere that “second the 1980s; the to 1950s the from developed therapies behavioural scientific the comprised wave” Third-wave cognitive behavioural haviour, bodilydistresssyndrome(37)andPTSD(38). be addictive disorders, somatization with effective as described been has Mindfulness (36). self-perspective one’s in change and regulation, emotional awareness, body regulation, attention mechanisms: 4 are There sical pain,thoughts,memories,orpsychologicaldistress. non-judgmental acceptanceofsomaticsensations,phy Mindfulness isinspiredbyBuddhismandbasedonthe who haveexperiencedsexualviolence(35). been suggested that EMDR is useful for treating women ehold dysfunction,bullyingandhumiliation.Ithasalso hous childhood, in experiences life adverse to related shoving, slapping, hitting). These are behaviours that are with physically aggressive behaviour (pushing, grabbing, indealing concluded thatthetechniquecanbesuccessful erapy intreating psychological andsomaticdisorders th EMDR on studies randomized the all reviewed (34) ment oftraumavictims(33).Inarecentarticle,Shapiro is apsychotherapeuticmethoddevelopedforthetreat Eye movementdesensitizationandreprocessing (EMDR) of suicideattempts(32). follow-up, efficacy was demonstrated by a lower8-year number an with (31) studies randomized-controlled In work. group additional and sessions individual weekly with months, 18 over place takes Therapy situations. thoughts and emotions, especially in emotionally tense of mentalization the with deal to able be to subject the viour. The goal of psychodynamic psychotherapy is for beha self-harm one’s of management and derstanding states, inoneselfandothers,shouldleadtoabetterun It isbasedontheideathatconsiderationofmental loped for patients with borderline personality disorders. deve was (30) (MBT) Mentalization-based treatment approach isincreasing(29). issue. Nonetheless, the evidence for the efficacy of such evidence-based practiceofmedicineisalong-debated timacy ofintegratingapsychodynamicapproachinan disorders (28). psychiatric underlying other or SISL with patients with tested and applied been have techniques namic 164 At this stage it should be mentioned that the legi the that mentioned be should it stage this At L. Tomas-Aragonesetal. . The “first The therapy. ------non-pharmacological treatments recommended by der first the of one was body.Relaxation the of awareness attention, concentratingontranquillityandincreasing refocusing involve techniques relaxation general, In Relaxation techniques achieve positiveresults. training andavoidanceoftriggeringsituationscould skills on), further (see techniques reversal habit PTSD, tions for the unknown origin of some skin symptoms. In neurogenic inflammation may offer additional explana and situations helpless in problem-solving relaxation, tension-relief axis, stress-symptom The reactions. skin understanding for important is it although SILS, with Psychoeducation hasnotreallybeenstudiedinpatients Psychoeducation which is often the personality disorder (45), underlying SISL. disorders personality borderline treat to used is It TFPof (44). components critical 3 are process tative frame, managingcountertransference,andtheinterpre the contracting/setting treatment The theory. relations nality disordersthatisbasedonpsychoanalyticobject defines 4maincategories(1): ESDaP Group the by proposed SISLclassification The SISL classification SELF-INFLICTED SKIN LESIONS TO APPROACHES THERAPEUTIC SPECIFIC component ofCBT andinhabitreversal. music and art-therapy. Relaxation techniques are a main meditation, massage, Tainosis, biofeedback, yoga, chi, hyp as such approaches, therapeutic similar other with features overlapping present or combined be can They relaxation (Jacobson); visualization; and deep breathing. clude: autogenic relaxation (Shultz); progressive muscle in techniques Relaxation (47). depression and anxiety stand-alone therapyseemstohavealittleeffect onstress, a as relaxation of use the However, (46). matologists based treatmentforborderlineandothersevereperso focused psychotherapy (TFP) is a manualized, evidence- Transference-Transference. focusedpsychotherapy CBT (43). dysmorphic disorders(BDD)(42). body treating in management anxiety than effective more is it that argued been has it Furthermore, (41). • • impulsive spectrum. – symptoms damaging skin related and picking skin behaviour: underlying non-denied and Non-hidden compulsive spectrum. – symptoms damaging skin related and picking skin behaviour: underlying non-denied and Non-hidden Self-inflicted excoriations have been improved with improved been have excoriations Self-inflicted ------Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV compulsive behaviours as the cause of the skin symp skin the of cause the as behaviours compulsive obsessive- SISLindicates of spectrum compulsive The compulsive spectrum Skin pickingandrelated skindamagingsyndromes – INFLICTED SKIN LESIONS SELF- OF MANAGEMENT THE FOR NIQUES TECH­ SPECIFIC AND RECOMMENDATIONS in SISL. to offer recommended or specific therapeutic approaches shared decision-making regarding options for avoiding for options regarding decision-making shared be useful. can support external state), (dissociative consciousness behaviour occurs when the patient is in a state of altered the patient to be aware of the behaviour; if the repetitive helps which reached is relative his/her and patient the to prohibitthebehaviour, unlessanagreementbetween are nothelpful.Familymembersshouldbeadvised behaviour, so comments like “You the should stop doing resist it” to tried often have will Patients essential. is communication non-judgmental Principles”); “General step is to develop an open and confident relationship (see behaviour. Subjects may not trust the doctor, so the first refore reluctanttospontaneouslydiscloseoradmitthis the are guilt. They and shame of feelings have usually behaviour athomeorinstressful situations. Patients about asking on doctor the by diagnosed easily is that The patient probably has an obsessive behaviour disorder Communication optionsandemotionalstructure trichotillomania (48). as such syndromes, picking skin compulsive other in acne disorder (BDD), which is related to face skin picking in dysmorphic body and disorder; personality borderline disorder; personality obsessive-compulsive disorders; dissociation depression; OCD); of spectrum whole the derlying comorbidities are: anxiety disorders (including un frequent most The onychotillomania). (e.g. lesions skin previous no with picking skin start can patients onset oftheobsessive-compulsivebehaviouralthough acne (e.g. lesions skin be may There Comorbidities onychotillomania. (acne toms. Examples of such behaviour would be face picking • • This sequence of clinical categories will be followed be will categories clinical of sequence This incentives: malingeringindermatology. Hidden or denied underlying behaviour with external ternal incentives: factitious disorders in dermatology. Hidden or denied underlying behaviour with no ex no with behaviour underlying denied or Hidden Doctor–patient communication should be aimed at aimed be should communication Doctor–patient excoriée. BDDis also apossible comorbid disorder ), nose picking, trichotillomania and trichotillomania picking, nose excoriée), excoriée) before - - - - A therapeuticapproachtoself-inflictedlesionsindermatology consists of 4 main components: (i components: main 4 of consists control). regulation; “B” – behavioural addiction; “C” – cognitive affect – (“A” picking skin and pulling hair for reversal habit of model” “A-B-C the advanced (55) al. et Stein therapy for skin picking is the most effective treatment. In general,studiesindicatethatcognitivebehavioural Cognitive behaviouraltherapy Specific therapeuticoptions not frequentwiththistypeofSISL. disorders). Suicidalideationandattemptedsuicideare factitious with case the not is (this patient the for relief ning theobsessive-compulsivemechanismcanprovide or thoughts that lead to the skin lesions. Naming and defi behaviour arises or the identificationobsessive of specificthe emotions where situations the of analysis vioural of guilt and shame. A basic therapy option is the beha the is option shame. therapy Aand basic guilt of the obsessive behaviour and focusing on the emotions • • • including obsessive-compulsivebehaviour, antide disorders, anxiety underlying with Antidepressants: other cosmeticoptionsmaybeconsidered. and manicure nails, situations). Artificial stressful in when the behaviour occurs (usually in the evening or onychotillomania, unless dressing the nails at times mended unless there is infection. The same is true for medication orspecialhaircosmeticsarenotrecom hair pulling, hair With patient). the (not skin the manage should or nurse aesthetician dermatologist, cosmetician, excoriée). The (acne picking face avoid reful cleaningandgoodhygiene(anti-acne)canhelp if severedepressionhasalreadybeendiagnosed.Ca treatment, suchasisotretinoin,isnotrecommended systemic A sufficient. be not may (alone) they that ploy their usual treatment strategies but must be aware The “habit-reversal therapy” for trichotillomania for therapy” “habit-reversal The cal OCD, but also in pathological skin picking (23–25). also shown some promising results, not only in classi has cysteine N-acetyl account. into overweight) and (obesity side-effects possible the take always should zapine for the same condition. The use of these drugs olan neuroleptic using results positive reported (54) (53) in trichotillomania patients; Van Ameringen et al. with oxcarbazepine was shown to have limited success therapy drug antiepileptic drugs: psychotropic Other antidepressant therapywithhairpulling(seebelow). ficant efficacy. Case-controlled studies have analysed signi demonstrate not did picking skin pathological (50–52), although a double-bind trial of fluoxetine in faxine may produce positive results with skin picking randomized) have indicated that fluoxetine and venla (49). Some recent studies (not well controlled and not recommended are SSRIs, especially drugs, pressant Dermatological treatment: dermatologists should em Acta DermVenereol 2017 ) self-monitoring 165 ------Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV www.medicaljournals.se/acta availability ofsuchtherapists. the and time-frame the on depend will course of This SISL might benefit from psychodynamic psychotherapy. another disorder belonging to the compulsive spectrum of or trichotillomania excoriée, acne appear,with patients anxieties underlying if or communication, emotional statistically significant. effect sizes relative to SSRIs, but the difference was not larger exhibited Clomipramine techniques. therapeutic for behaviourtherapytrialsthatusedmood-enhanced beha viour therapy of to pharmacological treatments; superiority especially the confirms (60) al. et McGuire (57). A more recent meta-analysis published in 2014 by only clomipramine (not SSRIs), was superior to placebo to pharmacotherapy. Furthermore,itdemonstratedthat that the effect size of habit reversal therapy was superior (habit reversaltherapy)fortrichotillomania demonstrated treatments behavioural and SSRIs) or (clomipramine pharmacological comparing studies randomized 7 on sional, specialistnurses,etc.isrecommended. includes ageneralpractitioner, amentalhealthprofes that team a of organization The contacted. be should these kinds of therapy options, a mental health specialist give themselvessomekindofreward. could beagreed,ifthepatientcompliesthentheymay period 3-day or 2- a example for behaviour; pulling hair or picking skin the from desisting of goal the set increases when the patient and the dermatologist jointly cognition positive The self-treatment. conscious more allergy sufferers) isanotheroptionforestablishing hed, thusevidenceislimited. papers with small numbers of patients have been publis treatment for the same problem. However, few scientific (59) studiedacceptanceandcommitmenttherapyasa al. et Twohig and picking skin chronic in treatment reversal habit on investigation pilot a undertook (58) al. et Teng 2006, in outcomes: positive have to seem goes away)(55–57). pulling for a short fixed period of time or until the urge (engaging inaphysicallyincompatiblebehaviourtothe hair pullingoccurs)orcompetingresponseintervention muscle relaxation or taking a walk, when the desire for vention (developingactivitiestosubstitute,suchasdeep (iv) stimulus-responseinter and situations), high-risk in gloves wearing example for as pulling, prevent or with interfere to or hair pull to opportunities crease stimulus control(techniquesdedicatedeithertode that frequentlytriggerhair-pulling behaviours),(iii) of both hair-pulling behaviour and high-risk situations ( hair-pullingbehaviour), of record a keeps patient (the 166 ii) awareness training (increasing patient’s awareness If there are life-long problems, specific problems with based A2007, in published meta-analysis systematic If the dermatologist feels it is impossible to introduce food with (as diary a using interaction Cognitive Habit reversal techniques aimed at stopping the OCD L. Tomas-Aragonesetal. - - - - - frequently offer rapid, but short-lived, relief froma va of uncontrolled aggression to the skin. These behaviours acts are syndromes damaging skin related and picking skin impulsive group, ESDaP the by mentioned As impulsive spectrum Skin pickingandrelated skindamagingsyndromes – both scientificandlogicalgrounds(63). related disorders (OCRDs) and along with its content on the DSM-5’s new category of obsessive-compulsive and contrarily toclassicalOCD,ledsomeauthorsreject thoughts and can begin without the person’s awareness, these behaviours are not always triggered that by obsessional fact the especially picking, skin pathological and trichotillomania of phenomenology The (62). disorder disorder, ratherthananobsessivecompulsiverelated rization of skin picking disorders as an impulsive control (61) and pushes some psychiatrists to support the catego disorders is generally considered as an index of severity picking skin type compulsive in component impulsive an of presence The factor. prognostic important most the probably is dermatologist the with relationship The considered. be SISL should of aspects therapeutic cific more frequent in this group. In 2007, an observational an 2007, In group. this in frequent more are they although populations, psychiatric to specific burning. and hitting not are self-injuries of kinds These The most common forms are biting, cutting, scratching, intent. suicidal conscious without tissue body of tion “non-suicidal self-injury”: the deliberate, direct destruc as to referred be also can lesions SISL Impulsive-type Communication optionsandemotionalstructure mood disorders. subjects. Less severe impulsive SISLs can correlate with have impaired the emotional regulation capacity ofthese may stress post-traumatic with puberty) and childhood in (especially abuse emotional and/or physical sexual, present. be also Acould disorders of eating history and etc.) sex, unprotected promiscuity, use, drug illegal , risk-taking behaviour (binge drinking, mes andantisocialpersonalitydisordersarefrequent. personality disorders,narcissisticsyndro disorders than the obsessive-compulsive type; borderline Impulsive skin picking usually involves more personality Comorbidities most commoninadolescence. is disorders of spectrum This (1). state” pathological a the patient, aiding their psychological survival, albeit in riety ofintolerable conditions, providing vital support for indicate more severe personality problems and the spe prognosis is generally favourable. Non-acceptance may If patientsareabletoacceptthediagnosisofOCD Prognostic aspects - - - - - Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV personality disorders,narcissistic personalitydisorders with severe destructive personality problems: borderline of theimpulsivebehaviour. cause the be could frustration and Intolerance wounds. standing thepotentiallong-lasting effects ofscarsand self-harm in imitation of their peer-group without under not psychologicallydisturbed,butindulgeinimpulsive that the patient will not be aware of it. Some patients are and thephysicianshouldraisethisissue,asitispossible motivator typical a is tension of behaviour.Relief sive to harbourfeelingsofshameorguilt. not repeated chronically. It is also unusual forthe patient obsessive-compulsive behaviour, theimpulsivestateis ferent options for ending the harmful behaviour. Unlike of impulsive behaviour, the first step is to discuss the dif After unambiguous diagnosis and definition of the type Specific therapeuticoptions suicidal self-injurybehaviour. incite repetition, trivialization and amplification of non- that positiveandnegativereinforcementacceptance loneliness. or differences,gender from Aside appears it of intra-punitiveissues,suchasself-hatred,depression females are more likely to engage in self-harm for relief self-harm as a means to communicate or influence others; to likely more seem Males relief. tension of mean a as tain for some, and may lead to self-inflicted behaviours sexual arousal, which can be difficult to handle and con puberty isaccompaniedbybodytransformationsand of securityorcontrol,togetattention,etc.Ofcourse, to feel something (even if it is pain), to provide a sense others, with boundaries set to self-punish, to thoughts, such astorelievenegativeemotions, attribute multiplefunctionstonon-suicidalself-injury, to tried have (64–66) authors Some attempts. suicidal and ideation suicidal as well as etc., jumping, falling, breaking, bone behaviour, taking risk disorders, eating and otherself-harmbehaviours,suchasdrugabuse, forms are generally associated with personality disorders expression of teen culture. However, moderate and severe logical behaviour as it would correspond to a normative injury is often not recognized or may be denied as patho can rangefromminortosevereself-injury. Minorself- among youngpeopletotrivializethisbehaviour, which approaching theseissues.Ingeneral,thereisatendency portant tohaveestablishedarelationshipoftrustbefore asked to inquire about the behaviour. Therefore, it is im be overlooked unless open-ended questions are tactfully clinical population,indicatesthatthisphenomenoncan self-injury observedinacommunitysample,andnot non-suicidal of prevalence high This cases. severe or self-injury during the past year and 28% were moderate non-suicidal of form some committed had 46.5% to up that found (6) adolescents of population a on study Impulsive behaviourisalso characteristicofpatients Patients are generally willing to talk about their impul ------A therapeuticapproachtoself-inflictedlesionsindermatology especially ifeating disordersarealsopresent. based approach (70) is another option for psychotherapy. personality disorders are recommended. A mindfulness- transference-focused psychotherapy (44) for borderline communicating withothersetc.). stimuli; external to attention turning philosophy”; box “treasure the place”, “safe a in emotions putting hand; arm/ the at skin the to band elastic an pulling skin; the pinching hand; the in ball small a (squeezing begins self-harm the before seconds or minutes some return” could lead to a strategy for dealing with the “point of no This actions. the for triggers emotional determining of aim the with situations, impulsive on discussion a recommended. therefore is assessment risk self-harm a attempted; is suicide before patient the from signal final the be can lesion, even if it is not a severe dermatological symptom, skin of impulsive-type the Sometimes management). the patient(seegeneralprincipalsonsuicidalideation should always take this into account when dealing with physician the and self-harm, of type this with frequent Suicidal ideationandsuicideattemptsaremuchmore (67). adolescents male in especially suicide, for factor symptom ofthecondition. and PTSD in which the impulsive self-harm is only one • • • antipsychotics canreducetensionandcontrolimpul disorders, personality borderline with As of SISL. Psychotropic drugs treatment for impulsive spectrum prognosis; topicaltreatmentshouldbeoffered. Asking for help with the scars is a positive sign for the picking behaviour will appear as secondary symptom. treatment of scars or another skin problem and the skin the for dermatologist the to come often will Patients tological treatment for the impulsive spectrum of SISL. In adolescents, family therapy should be considered, and (69) therapy behavioural dialectic Linehan’s with begin could approach behavioural cognitive A encouraging thepatientwiththiskindoftherapy. role ofthedermatologistisvitalformotivatingand The option. treatment long-term effective most the their problems. However, psychotherapy seems to be trivialize patients when difficult more made is SISL psychotherapeutic treatmentoftheimpulsivetype The Psychotherapy in impulsive spectrum of SISL. evidence ofareductionself-harmbehaviour. paroxetine) compared with placebo controls, found no studies with antidepressants (mianserin, nomifensine, clinically employed. A Cochrane review (68) states that haloperidol, valproate acid, starting at low dosages are specialist: risperidone, promethazine, carbamazepine, health mental a with liaise should dermatologist the is often poor. If psychotropic drugs are indicated, siveness. Adherence can be a problem and compliance Dermatological treatment risk a as considered be can SISLs Impulsive-type . There is no specific derma Acta DermVenereol 2017 167 - - Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV www.medicaljournals.se/acta the careproviders. Munchausen’s syndrome, self-harm is often delegated to tious disorders, more frequent in men than in women. In facti Munchausen’sof of subtype clinical a syndrome, characteristic is This shopping”). hospital and (“doctor procedures surgical from scars numerous show and stays hospital many of speak may they fantastica”); gia false informationontheirmedicalhistory(“pseudolo describe demonstrativeanddramaticproblemsgive difficult toestablish. may complicate and delay the diagnosis, which is always associations These thermometer. the of manipulation the to due fever chronic a example, for disorders; tious Cutaneous lesionscanbeaccompaniedbyotherfacti Comorbidities twice asfrequentinwomenmen. benefits. Factitious disorders in dermatology are at least tangible immediate no with role sick the for preference a and background psychological severe a with coping cause askindiseaseinherownchild. where asubject,mostoftenthemother, mayartificially proxy, by syndrome Munchausen or syndrome Polle’s escents, butthissyndromehastobedifferentiated from Factitious disorderscanalsooccurinchildrenandadol frequently affected sitesaretheface,armsandlegs. most the patient; the of handedness the to available are inflammation (1). Lesions are usually seen in areas that underlying suggests dermatitis since dermatology”, in and theirreplacementbytheterm“factitiousdisorders We alreadyrecommendedtheavoidanceoftheseterms often synonymouslyreferredtoasfactitiousdisorders. arte facta, factitiousdermatitisorare Dermatitis awareness. patient’s the outside state dissociative a in place take may activity the instances that heorsheisdriventocreatethelesions,insome aware be may subject The established. is caregiver a with relationship appropriate an until secret kept is induction this patient: the by lesions skin of induction the as defined are dermatology in disorders Factitious FACTITIOUS DISORDERS INDERMATOLOGY personality problems. this obviouslydependsontheseverityofunderlying mental healthtreatment,theprognosisispositive,but accept to able are and to, access have patients If (6). al. tely 46.5% of patients, according to Lloyd-Richardson et and the self-harm will probably continue (in approxima poor, suicidalideationandsuicideattemptsarecommon impulsive behaviour. Without therapy, theprognosisis The first-line goal should be to lower the frequency of the Prognostic aspects 168 Patients presentingfactitioussymptomssometimes for method a be to assumed is motivation main The L. Tomas-Aragonesetal. ------than in those involving indirect self-harm (use of medica involving directself-harm(scratching,cutting,burning) disorders factitious with associated frequently more abuse, eatingdisordersandpersonalityare Substance 72). (71, disorders factitious with associated disorders, and suicide attempts are frequently somatoform pain disorder, conversion disorders, sexual towards their physicians. Although a good initial relation ambivalent attitudeofmanyfactitiousdisorderpatients abandonment and even aggression. This can explain the see anycloserelationshipasbearingathreatofbetrayal, may They relatives. or figures parental with had have they relationships on doctor the with relationship their providers. Patients with a factitious disease often model Communication betweenthepatientandhealthcare Communication optionsandemotionalstructure disease occursinaman. factitious a when personality paranoid a of possibility is acommonassociation(74). disease (especiallyifitaffects aclosefamilymember) wounds of abandonment. Concomitant or family physical disappointment. These situations very often re-open old of thesepatentstoseparation,mourningandemotional sensitivity the explains which dependency, affective hospitalization intheirchildhood,resultingintense or separation family abandonment, experienced often Depression canprecedetheonsetofafactitiousdisorder. (73). disorders factitious of types both in common be disorders are more frequent. Mood disorders seem to anxiety disorders, adaptation disorders and somatoform tion, chemicals or infectious substances); in these cases, may establish a relationship, if only with a healthcare a with only if relationship, a establish may subject the illness, Through emptiness. internal their for camouflage a is that identity” “patient or identity” their own limits, but also acquire an identity: a “surface sease”, patients with factitious skin lesions not only reset their skin and by lying about the cause of their “skin di damaging By damaged. as perceive they which daries, sufferingbodily andpsychologicalboun torestoretheir lesion seek painful sensations to create an “envelope” of perceived asunreliableorevendangerous. are who those manipulating aggressively and defying for care and love, and a means ofdistancing from others, Damaged skin represents both a call for help, an appeal skin disorder on others will reproduce this ambivalence. factitious a by produced effects The coexist. therefore may hate, and love rejection, and expectation attitude; by disappointment,ignoranceandevenanaccusatory followed often is This medication. and care, attention, ship may develop, sufferers will demand more and more Borderline personalitydisorder, substanceabuse, Some participants in the ESDaP Group suggest the suggest Group ESDaP the in participants Some have disorder personality borderline with Patients It has been suggested that patients with a factitious skin - - - - Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV between the various healthcare providers; they should they providers; healthcare various the between determine a common approach and to maintain the links hospitalized, the healthcare team must work together to is lesion skin factitious a with person a When teams. Communication between a dermatologist and healthcare the patienttoconfessresponsibilityforlesions. specialist could beinterpretedas a subtle means toforce health mental a to Referring consultation. psychiatric a be arationalefortheintroductionofpsychotherapyor ator; this may be easier medi for probable the the as patient “stress” to on accept focus to and and could lesions, any referencetothephysicalmechanismscausing avoid to preferable is It (74). consultation the during schedules andtocreateasafeacceptingenvironment the basisofa request forhelp to amental health specialist. patient with a factitious skin lesion and it may be used as subject ofthepsychologicalandemotionalstate condition isameansforthedermatologisttobroach their dermatologist. or psychologist,aslongtheydonotfeelrejectedby refuse a first meeting with a psychiatrist–psychotherapist rarely lesions skin factitious with Patients self-harm. to admit to patient the forces who person the as viewed mental healthspecialistmaycausethetherapisttobe be done as soon as possible because a latereferral to a should This psychologist. or chiatrist–psychotherapist psy a to pathology,or this in experienced more is that in theinitialstages)referpatienttoadermatologist that theysuspectisself-produced,should(atleast to manage the psychological aspects of a skin condition screening forfactitiousdisorders(73). improve can supervisor) psychoanalytical a example, pervision by an external mental health professional (for the doctor–patient relationship. In a hospital setting, su enables earlydiagnosisandavoidsthedeteriorationof fering, it is easier to diagnose a . This that self-produced lesions are the expression of that suf possibility ofpsychological suffering andunderstanding production oflesions. patient’sthe the increase to them cause and masochism reality oftheirconditionandthis,inturn,canstrengthen of the patient’s position, allowing them to believe in the reinforcement the risks possibility wever,this avoiding physician may feel that they have been manipulated. Ho means jeopardizing the doctor–patient relationship as the acknowledgement lesions; own their for responsible is patient a that accept to dermatologist the for ficult Patient–dermatologist communication.Itcanbedif or completelylackinginchildhood. with the skin and body care that was acutely inadequate provider. The healthcare provider will provide the patient Attempts should be made to adhere to appointment to adhere to made be should Attempts Screening and objectively identifying adepressive If a dermatologist does not feel sufficiently confident If thedermatologistiscapableofcontemplating ------A therapeuticapproachtoself-inflictedlesionsindermatology objectives are more easily achieved when the dermato the when achieved easily more are objectives Treatment lesions. skin self-inflicted all of complex Factitious cutaneousdisordersareprobablythemost Specific therapeuticoptions thereby jeopardizingthetherapeuticapproach. diagnosis ofself-harmistheideadermatologist, the possibility of a SISL and may tell the patient that the that somegeneralpractitionersarereluctanttoconsider aware be should Dermatologists themselves). relatives for their own lesions (unless this is first suggested by the tives arenottoldthatitisthepatientresponsible in resolving family conflicts. It is important that the rela suffering ofthepatientandcanplayaroleasmediator is incompetent (75). The relatives may have noticed the andbelievethatthephysician often angryandaccusatory hips with relatives can be uncomfortable: the family are suffering that is expressed through the SISL. Relations should emphasizetheseriousnessofpsychological general practitioner), of the condition. The dermatologist be taken when informing relatives (and even the patient’s latives andhis/hergeneralpractitioner.Precautionsmust tients with Munchausen’s syndrome should be avoided. bacteraemia orsepticaemia. tions of the skin, subcutaneous tissues and, occasionally, testing, antibioticsmaybeused totreatsecondaryinfec susceptibility antimicrobial After prescribed. be may solutions, antibioticointmentsandhealing may beappliedandlocaltreatmentssuchasantiseptic self-infliction) (confirming completely heal to lesions (especially standard plaster casts), which allow the skin are notusuallyhiddenordenied.Occlusivedressings with factitious skin lesions because the underlying causes the lesions. have beendirectlyquestionedontheirresponsibilityfor even suicide have been reported in cases where patients contact with the healthcare team, becoming delirious and dangerous (76–78). Aggravation of the lesions, breaking authors argue that conflict is counter-productive and even confront patients suspected of self-harm behaviour: most to physician the encourage that publications few very and has acquired specific skills for treating it. There are condition patient’s the about non-judgmental is logist Communication between the dermatologists, patient’s re skin lesionpatientandthehealthcareprovider. of a sadomasochistic relationship between the factitious patient. This could ultimately result in the development even surgical procedures that could be dangerous forthe medicationor can leadtotheprescriptionofunnecessary ambivalence. Ifthesefeelingsarenotaddressed,they patient that can be caused bya sense ofmanipulation and feelings of irritation, aggression or rejection towards the any with deal and workers fellow to support offer also Surgical proceduresthat areoftenrequestedbypa Dermatological treatmentisofparticularimportance Acta DermVenereol 2017 169 ------Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV www.medicaljournals.se/acta the patient will rarely admit to the behaviour.the doc tor–patient to The admit rarely relationship will patient is the therefore complicated and the and self-harm of history prior no be will There lesion. new a of creation the or symptom subjective a feigning to refers “simulation” whilst lesion, pre-existing a of “malingering” is often used to describe the aggravation lesions. term skin The but theymayalsocausedenovo aggravate the symptoms of pre-existing skin conditions, advantage. Indermatology, patientsmayintentionally responsibility with the aim of deny gaining a will social but or financial self-inflicted, is lesion the that aware is patient The patient. the by lesion or symptom known well- a of feigning or production the is Malingering MALINGERING INDERMATOLOGY relationship isasignificantfactor. psychotherapeutic the of quality the always, As state. cases in which the lesions are produced in a dissociated also true with mild forms of factitious skin lesions is and This in onset. late than prognosis better a has disorder factitious a of onset early the general, In help”. for cry “a oftenrepresent disorders In adolescents,factitious Prognostic aspects positive outcomes. more in result can period follow-up the in supervision counter-transference feelingsand supportorindividual of awareness psychotherapist’s The (81). persevere to is convincedofthepossibilitysuccessandprepared cessful with these patients, as long as the psychotherapist psychological andpsychodynamicapproachcanbesuc a that believes ESDaPGroup the 80), (79, publications in verbalizingtheirfeelingsandconflicts. ders; progress is slow and sufferers have great difficulties very special personality of patients with factitious disor treating this type of condition and be able to adapt to the in experience have must therapist The applied. be can SISL underlying disorders personality borderline ging up betweenthedoctorandpatient. of abuseanddamagingthetrustthathasbeenbuilt risk a is there consideration: careful after used be only severe comorbid personality disorders, but they should emotion regulation disorders, especially in cases of antipsychotics cantreatunderlyingimpulsivenessor and Tranquillizers approach. psychological a accept pressive syndromesandforencouragingthepatientto psychological state. a marked improvement that has been observed in condition the patient’s the on and healed has skin the after only psychiatrist-psychotherapist, a with collaboration Reparative plastic surgery should only be considered in 170 In contrasttothedefeatistpositionfoundinsome Several, previouslydescribed,approachesformana de associated with useful be can Antidepressants L. Tomas-Aragonesetal. - - - - - should beinitiatedduringthedermatologyconsulta treatment Ideally, patients. such with deal to training psychotherapeutic without dermatologists help to aims article This SISL. present who patients with dealing for strategies therapeutic lack often Dermatologists CONCLUSION the prognosisisnotfavourable. If thepatientcannotbeconvincedtoundergo therapy, Prognostic aspects approach withclosesupervisionisadvisable. malingering. Eachcaseisdifferent andanindividual for described been have options therapy specific No Specific therapeuticoptions is recommended. the generalpractitionerandotherhealthprofessionals with Collaboration problem. underlying the about talk jective isthatthepatientbecomesabletodiscloseand based on the classification, using prospective and com and prospective using classification, the on based therapy. family of research, benefits More potential the about thefamilymembers ofself-harmpatientsand written been has little very now, until example, For effective. be to known are they but exhaustive, not are specialists. recommendations health These mental with experience of a group of dermatologists, in collaboration paper are based on the review of this the literature and in on the forward put recommendations therapeutic The treat. to difficult more and more it making behaviour, tion, anddelayingthistreatmentmayleadtorepetitive and suggesting explanations for the condition. The ob The condition. the for explanations suggesting and Communication should beaimed atoffering comfort Communication optionsandemotionalstructure patient wasabletodiscusstheproblem. the and recognized was this before years of a number took It work. avoid to able was she meant oedema Quincke’s and anaphylaxis of symptoms consequent husband was an apiculturist) and the presentation of the (her insects the with contact instigated deliberately she an allergy to bee stings suffered sexual abuse at her job, of the authors of this paper: a middle-aged woman with one before brought was that case real-life a be would example illustrative An syndrome. Munchausen’s and antisocialpersonalitydisorders especially disorders, Comorbidities coverthefullspectrumofpersonality Comorbidities more difficult,etc.). self-harm make that dressings behaviour,patient’s the first step is to validate diagnosis (careful observation of - - - Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV 10. 13. 17. 15. 12. 19. 18. 16. 14. 11. REFERENCES The authorsdeclare noconflictsofinterest. of thedermatologist. work day-to-day the in functioning is classification the literature. These studies would also help to confirm that be forthcoming, something that is clearly lacking in the may SISL of type each for prognosis accurate more a classification, the to reference with diagnostics employ that developed be can studies new If complex. mewhat is thecornerstoneforimprovement,comparisonso relationship doctor–patient the as However, condition. parative studies is needed to refine the strategies for each 6. 5. 4. 9. 3. 8. 2. 7. 1. 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