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Case Reports

7. Hall R. Popkin M. Kirkpatrick B: Tricyclic eltacerbation of steroid psychosis. J Nerv Ment Dis 1978; 166:738-742 8. Hall R. Popkin M. Stickney S. et a1: Presentation of the steroid psychoses. J Nerv Ment Dis 1979; 167:229--236 9. Dieteh J: Steroid psychosis and tricyclic antidepressants (letter). Arch Oen Psychiatry 1982; 39:236 10. Kershner P. Wang-Cheng R: Psychiatric side effects of steroid therapy. Psychosomatics 1989: 30: 135-139 I I. Lewis D. Smith R: Steroid-induced psychiatric syndromes. J Affective Disord 1983: 5:319--332 12. Ling M. Perry p. Tsuang M: Side effects of corticosteroid therapy: psychiatric aspects. Arch Oen Psychiatry 1981: 38:471~77

13. Judd F. Burrows G. Nonnan T: Psychosis after withdrawal of steroid therapy. Med J Aust 1983: 2:35()"'351 14. Ritchie E: Toxic psychosis under cortisone and corticotrophin. Journal of Mental Science 1956; 102:830-837 15. Alpert E. Seigennan C: Steroid withdrawal psychosis in a patient with closed head injury. Arch Phys Med Rehabil 1986:67:766-769 16. Wolkowitz O. Rapaport M: Long-lasting behavioral changes following prednisone withdrawal (letter). JAMA 1989:261:1731-1732 17. Fleishman S. Lesko L: Delirium and dementia, in Handbook of Psychooncology. edited by Holland J. Rowland

J. New York. Oxford University Press. 1990. pp 342-355 18. Bjerrum K. Prause J: Primary SjOgren's syndrome: a subjective description of the disease. Clin Exp Rheumatol 1990: 3:283-288 19. Drosos A. Angelopoulous N. Liakos A. et a1: Sjogren's syndrome patients: hostility features and psychiatric symptomatology. Abstract presented at the Second International Symposium on Sjogren's Syndrome. Austin. TX. 1988 20. Lishman W: Organic Psychiatry. 2nd Edition. London. Blackwell Scientific Publications. 1987 21. Joffe R. Lippert G. Gray T. et a1: Mood disorder and multiple sclerosis. Arch Neuro11987; 44:376-378 22. Petersen RC. Kokmen E: Cognitive and psychiatric abnonnalities in multiple sclerosis. Mayo Clin Proc 1989: 64:657--«)3 23. Honer W. Hurwitz T. Li D. et a1: Temporal lobe involvement in multiple sclerosis patients with psychiatric disorders. Arch Neuro11987; 44:187-190 24. Alexander E. Alexander GE: Aseptic menigoencephalitis in primary Sjogren's syndrome. Neurology 1983; 33:593598 25. Malone D. Dimeff R: The use of fluoxetine in depression associated with anabolic steroid withdrawal: a case series. J Clin Psychiatry 1922: 53: I3()...1 32

Compulsive Picking and Obsessive-Compulsive Disorder DAN J. STEIN, M.D., CHERYL S. HUTT, M.D. JOEL

L.

SPITZ, M.D.,

C

ompulsive picking, or self-excoriation. has been reported in up to 2% of dermatology clinic patients.'·2 The disorder is produced by ritualistic picking of skin lesions that may be diffuse and chronic. 3 Patients acknowledge the self-inflicted nature of the lesions, unlike patients with other self-inflicted dermatoses, such as dermatitis artefacta and malingering. 2 The etiology of compulsive picking is poorly understood. Classically the disorder has been understood to be a form of neurosis,4 and psychodynamic factors continue to be postulated.s Stress also has been noted to playa role. 1.3 VOLUME 34 • NUMBER 2 • MARCH - APRIL 1993

ERIc HOLLANDER, M.D.

Compulsive picking has been reported to be associated with various psychiatric disorders, including obsessive-compulsive traits. depression, and anxiety, but many of these reports are Received March 18. 1991: revised July I. 1991: accepted July 9. 1991. From the Department of Psychiatry and Department of Dennatology. College of Physicians and Surgeons. Columbia University; and the New York State Psychiatric Institute. New York. Address reprint requests to Dr. Stein. Dept. of Psychiatry. 722 W. 168 St.• New York. NY 10032. Copyright © 1993 The Academy of Psychosomatic Medicine.

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hampered by a lack of operational defmitions. 2 Many disorders traditionally thought of as neurotic are now conceptualized differently. Obsessive-compulsive disorder (OCD), for example, has been found to have a neurobiological substrate and to respond to pharmacotherapeutic intervention.6 Furthermore, the notion of a spectrum of obsessive-compulsive-related disorders has been established. 7.8 A variety of disorders, such as Tourette's syndrome,9 trichotillomania,lo body dysmorphic disorder, II and eating disorder,12 appear to share aspects of phenomenological presentation, neurobiological underpinning, and pharmacotherapeutic response. Indeed, it is possible to argue that compulsive picking is not a neurotic disorder but is rather an obsessive-compulsive-related disorder. Picking is repetitive and ritualistic and leads to tension reduction, as do compulsions. Patients do not invariably report that the behavior is designed to prevent or neutralize future harm, but they do often admit that the urge to scratch themselves is senseless and intrusive, in the same way that obsessive-compulsive symptoms are often egodystonic. Although little is known about the biology of compulsive picking, it is possible to posit an ethological model that accounts for both compulsive picking and the symptoms of OCD. Ethologists '3.'4 have described displacement behaviors (i.e., excessive or inappropriate stereotyped motor or grooming acts) to be perhaps triggered by frustration or conflict. Scratching in humans IS and symptoms in OCD '6.17 have been suggested to be similar to displacement behaviors. A model of various compulsive symptoms as excessive grooming behaviors may explain why they are seen so frequently by dermatologists. Thus, washing leads to dermatitis,18.19 hairpuIIing to a1opecia,20 nailbiting to infection,21 and picking to excoriations. If compulsive picking and OCD are related, then it may be surmised that compulsive picking would respond to standard pharmacotherapy for OCD. OCD responds selectively to serotonin reuptake blockers.6 It is interesting that certain animal displacement behaviors also respond to these medications. 22 Although there are no con178

trolled studies of treatment for compulsive picking, the disorder has been reported to respond to several medications,23-27 including c1omipramine 2 and fluoxetine. 28 In this report we describe two further cases of compulsive picking that responded to treatment with fluoxetine.

Case Reports Case 1. The patient was a 29-year-old married woman who had an IS-month history of compulsive picking. The picking began after the birth of her fmt son, at which time she felt increasingly abandoned by her husband. She reported that her picking had continued since then but became worse when marital tensions rose. The patient had multiple excoriations on her face, chest, back, arms, and legs. Tension would rise as she tried to resist picking, and removal of scabs would lead to a feeling of relief. Some s0cial dysfunction resulted as the patient was reluctant to socialize in view of her obvious disfigurement. She presented to the dermatology clinic and was referred for a psychiatric consultation. A scm I and 1129 revealed that the patient did not have an Axis I diagnosis but did meet criteria for personality disorder not otherwise specified, with obsessivecompulsive and borderline features. The patient agreed to begin fluoxetine, which was initiated at 20 mg qd. In Week 3 of treatment, the patient reported a decrease in her urge to pick. A repeat dermatological examination at the end of Week 4 of treatment confirmed a marked response to medication. Auoxetine was increased to 40 mg, but the patient experienced increased anxiety and some jineriness on that dose, and it was decreased to 20 mg. The patient continued on the medication for an additional 6 weeks. During that time she sustained her overall improvement but still reported that at times of marital fighting she would pick at herself. For administrative reasons it was not possible to follow the patient on a long-term basis in the clinic. Case 2. The patient was a 36-year-old single woman who initially presented to the dermatology clinic with a 2-month history of erythematous plaques on her face. At biopsy these were proven to be lymphocytoma cutis. Treatment with topical and intralesional steroids was initiated, with a gradual but steady response. Two months after presentation, the patient admitted to new onset of picking, with PSYCHOSOMATICS

Case Reports

excoriations on her arms and chest. The patient reported tension reduction on removal of scabs but also felt that the picking was senseless. The patient admitted to chronic stress resulting from having a mentally retarded child but not to recent stressors. The patient expressed distress at her picking but refused psychiatric consultation. The treating dermatologist did not feel that she met DSM-III-R criteria for major depression, but there was a chronic history of depressed mood, insomnia, and low energy, consistent with dysthymia. The patient agreed to begin fluoxetine at 20 mg qd. During Week 3 of treatment, the patient reported a decreased need to pick at herself and began to show marked improvement in her skin. Despite persistence of psychosocial stressors, she also reported a marked improvement in her mood, insomnia, and low energy. She elected to continue on the medication and has sustained significant improvement in the subsequent 6 months.

Discussion Both our patients described their symptoms in terms reminiscent of OCD. Picking was described as repetitive and tension reducing. Although there was no associated idea about the prevention of future harm, picking was experienced as ego-dystonic. However, the cases also illustrate several differences between compulsive picking and OCD. OCD frequently begins in childhood or adolescence, and early-onset OCD patients are predominantly male, although adult onset of OCD is equalIy common in males and females. 3O Compulsive picking, on the other hand, may present early or lateS and is more common in females. 3,25 While increased presentation in females may only be indicative of increased concern with cosmetic appearance, it may also reflect the role of hormonal differences or sociocultural factors in the pathogenesis of this disorder. The response of compulsive picking to a serotonin reuptake blocker does suggest involvement of the serotonin system in this disorder. Nevertheless, there are differences in the treatment response of compulsive picking and OCD to serotonergic medication. 2.28 In the present cases, response occurred on a lower dose and VOLUME 34· NUMBER 2· MARCH - APRIL 1993

more rapidly than is usual in OCD.J1 Our data confirm previous reports of response of compulsive picking to serotonergic medication. 2.28 If the response of compulsive picking to fluoxetine is not on an anti-OCD basis, other explanations for the efficacy of fluoxetine may be offered. For example, psychogenic dermatological disorders have been regarded as depressive equivalents that respond to antidepressant medication. 32 Compulsive picking has been associated with depression;2,25 this was seen in our second patient. However, in our first patient, therapeutic response appeared independent of improvement in mood. A second hypothesis is that effective medication may work peripherally. It has been suggested that chronic pruritic states respond to antidepressant medication on the basis of histaminic blockade of dermal vasculature. 32 Others have suggested that skin serotonin also plays a role in prurituS. 33.34 Nevertheless, although the patients here did report an urge to pick, they did not describe this urge as invariably accompanied by itching. A final explanation for the response of compulsive picking to serotonin reuptake blockers lies in the hypothesis that serotonin is involved in autoaggressive behavior. 3s According to this model, alterations in the serotonin system may lead to decreased autoaggression. In summary, there are both similarities and differences between compulsive picking and OCD. There may, however, be some heuristic value in regarding compulsive picking as related to obsessive-compulsive disorder. This provides the clinician with a framework for understanding the phenomenology of the symptoms and suggests that anti-OCD medication may be helpful. Such a framework may also encourage patients, who frequently refuse psychiatric treatment,36 to consent more readily to intervention. Adequate double-blind, controlled medication trials remain a priority in the field of psychocutaneous disorders. 32 Further work is also necessary to determine whether the concept of an obsessivecompulsive spectrum has application to patients with dermatitis artefacta or pruritic dermatological disorders. 179

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References I. Greisemer RD: Emotionally triggered disease in a dermatological practice. Psychiatric Annals 1978; 8:407412 2. Gupta MA, Gupta AK, Haberman HF: Neurotic excoriations: a review and some new perspectives. Compr Psychiatry 1986; 27:381-386 3. Freunsgaard K: Neurotic excoriations: a controlled psychiatric examination. Acta Psychiatr Scand Suppl 1984; 69:1-52 4. Zaidens SH: Self-inflicted dermatoses and their psychodynamics. J Nerv Ment Dis 1951; 113:388-395 5. Koblenzer CS: Psychocutaneous Disease. New York, Grone & Stranon, 1987 6. Zohar J, Insel TR: Obsessive-compulsive disorder: psychobiological approaches to diagnosis, treatment, and pathophysiology. Bioi Psychiatry 1987; 22:667-$7 7. Stein OJ, Hollander E: The spectrum of obsessive-compulsive-related disorders, in Obsessive-Compulsive-Related Disorders, edited by Hollander E. Washington, DC, American Psychiatric Press, 1993, pp 241-271 8. Hollander E: Serotonergic drugs and the treatment of disorders related to obsessive-compulsive disorder, in Current Treatments of Obsessive-Compulsive Disorder, edited by Pato MT. Zohar J. Washington, DC, American Psychiatric Press, 1991, pp 173-191 9. Hollander E. Liebowitz MR, DeCaria C: Conceptual and methodological issues in studies of obsessive-compulsive and Tourene's disorders. Psychiatr Dev 1989; 4:267296 10. Swedo SE, Leonard HL, Rapoport JL, et a1: A doubleblind comparison ofclomipramine and desipramine in the treatment oftrichotillomania (hair-pulling). N Engl J Med 1989; 321:497-500 II. Hollander E, Liebowitz MR, Winchel R, et a1: Treatment of body dsymorphic disorder with serotonin reuptake blockers. Am J Psychiatry 1989; 146:768-770 12. Kaye W, Wletzin T, Hsu G: An open trial offluoxetine in adolescent weight recovered anorexics. Presented at the Annual Meeting of the American College of Neuropsychopharmacology, San Juan, PR, December 9-14, 1m 13. Lorenz K: On Aggression. New York, Bantam, 1966 14. Tinbergen N: "Derived" activities; their causation, biological significance, origin, and emancipation during evolution. Q Rev Bioi 1952; 27:1-32 15. Musaph H: Psychodynamics in itching states. Int J Psychoanall968; 49:336-339 16. Holland HC: Displacement activity as a form of abnormal behavior in animals, in Obsessional States, edited by Beech HR. London, Methuen, 1974 17. Swedo SE: Rituals and releasers: an ethological model of o,bsessive-compuisive disorder, in Obsessive-Compulsive Disorder in Children and Adolescents, edited by Rapoport JL. Washington, DC, American Psychiatric Press, 1989, pp 269-288

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18. Rasmussen SA: Obsessive-compulsive disorder in dermatologic practice. J Am Acad Dermato11985; 13:965-967 19. Katz RJ, Landau P, DeVeaugh-Geiss J, et a1: Pharmacological responsiveness ofdermatitis secondary tocompulsive washing. Psychiatry Res 1m; 34:223-226 20. Krishnan ORR, Davidson JRT, Guajardo C: Trichotillomania: a review. Compr Psychiatry 1985; 26: 123128 21. Leonard H, Rapoport J, Swedo S: Clomipramine vs. desipramine treatment of onychophagia. Presented at the Annual Meeting of the American College of Neuropharmacology, San Juan, PR, December 9-14, 1m 22. Goldberger E, Rapoport JL: Canine acral lick dermatitis: response to the anti-obsessional drug clomipramine. Journal of the American Animal Hospital Association 1991; 22:179-182 23. Levy SW: A psychosomatic approach to the management of recalcitrant dermatoses. Psychosomatics 1963; 4:334337 24. Fisher BK: Neurotic excoriations. Can Med Assoc J 1971; 105:937-939 25. Fisher BK, Pearce KI: Neurotic excoriations: a personality evaluation. Cutis 1974; 14:251-254 26. Jenike MA: Illness related to obsessive-compulsive disorder, in Obsessive-Compulsive Disorders: Theory and Management, 2nd Edition, edited by Jenike MA, Baer L, Minichiello WE. Chicago, IL, Year Book Medical Publishers, 1m, pp 39-60 27. Duke EE: Clinical experience with pimozide: Emphasis on its use in post-herpetic neuralgia. J Am Acad Dermatol 1983; 8:845-850 28. Stout RJ: Fluoxetine for the treatment of compulsive facial picking (letter). Am J Psychiatry 1m; 147:370 29. Spitzer RL, Williams JBW, Gibbon M, et a1: Instruction Manual for the Structured Clinical Interview for DSMIII-R. Biometrics Research Department, New York State Psychiatric Institute, 1989 30. Rasmussen SA, Eisen JL: Epidemiological and clinical features of obsessive-compulsive disorder, in ObsessiveCompulsive Disorders: Theory and Management, 2nd Edition, edited by Jenike MA, Baer LB, Minichiello WE. Chicago, IL, Year Book Medical Publishers, 1m. pp

10-27 31. Liebowitz MR, Hollander E, Campeas R. et al: Fluoxetine treatment ofobsessive-compulsive disorder: an open clinical trial. J Clin Psychopharmacol 1989; 9:423-427 32. Gupta MA, Gupta AK, Ellis CN: Antidepressant drugs in dermatology: an update. Arch Dermato11987; 123:647652 33. Essman WB: Serotonin in skin and skin disorders. in Serotonin in Health and Disease, Clinical Applications, V, edited by Essman WB. New York, Spectrum. 1979 34. Garvey MJ, Tollefson GO: Association of affective disorder with migraine headaches and neurodermatitis. Gen Hosp Psychiatry 1988; 10: 148-149

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35. Van Praag HM. Plutchik R. Conte H: The serotonin hypothesis of (auto)aggression: critical appraisal of the evidence, in Psychobiology of Suicidal Behavior, edited by Mann JJ. Stanley M. New York, New York Academy

of Sciences. 1987 36. Cormia F: Basic concepts in the production and management of the psychosomatic dermatoses. Br J Dermatol 1951;63:129-151

Organic Anxiety Disorder Iatrogenic Hyperthyroidism M.D., MICHAEL BURKE, M.D. DIANE MEaLIN, M.S.W., ANDREW FULLER, R.N. K. RANOA R. KRISHNAN, M.D., CHARLES B. NEMEROFF, M.D., PH.D. JOHN BEYER,

H

yperthyroidism or thyrotoxicosis is the hypermetabolic state resulting from the clinical and physiological effects of tissue exposure to unbound or free thyroid hormones. Common causes are Graves' disease, toxic multinodular goiter, thyroiditis, and hyperthyroidism caused by exogenous iodide. Less common causes are trophoblastic tumors, hyperfunctioning adenomas, factitious thyrotoxicosis, and ectopic thyroid tissue (e.g., stroma ovarii).1 In the United States, the prevalence of this relatively common disorder is 0.1 %-0.23%. Thus, approximately 300,000 Americans will require treatment for hyperthyroidism this year alone. Common physiological signs and symptoms occur in more than 70% of hyperthyroid patients. These include nervousness, weight loss, heat intolerance, warm skin, excessive perspiration, easy fatiguability, muscular weakness, diarrhea, fine tremor, and a wide-eyed stare with possible protrusion of the eyes. Because many of these symptoms are also seen in psychiatric patients, many thyroid disorders may be mistaken for psychiatric disorders, especially anxiety disorders. 2 The purpose of this report is to present the case of a young woman who presented to one of us with marked symptoms of anxiety and who was found to suffer not from a primary anxiety disorder, but from iatrogenic VOLUME 34 • NUMBER 2 • MARCH - APRIL 1993

hyperthyroidism. The report highlights how to evaluate such a problem and rationally use thyroid function testing.

Case Report A 28-year-old single white woman was admitted to the Affective Disorders Unit at Duke University Medical Center following referral from her outpatient clinical psychologist. Her presenting symptoms included feeling "physically and emotionally worn out." She complained of feeling anxious, nervous, irritable, and angry at her family and co-workers. She also reported feeling sad, hopeless, helpless, and socially withdrawn, with frequent crying spells, initial insomnia, and vague suicidal ideations. The patient was living with her parents and a younger sister. Her parents were interviewed and corroborated that her mood and behavior were "very different" from baseline. She was "irritable and argumentative." They reported that her appetite was large, saying she was Received March 7, 1991; revised June 24. 1991; accepted July 10. 199 J. From the Depanments ofPsychiatry and Pharmacology, Duke University Medical Center, Durham. NC. Address reprint requests to Dr. Nemeroff, Dept. of Psychiatry, Emory University School of Medicine, Box AF, Atlanta, OA 30322. Copyright © 1993 The Academy of Psychosomatic Medicine. 181