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DERMATOLOGIC NONDISEASE
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PSYCHODERMATOLOGY
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DERMATOLOGIC NONDISEASE John A. Cotterill, MD, BSc, FRCP
Some years ago, as a young and increasingly busy dermatologist, the author gradually became aware that he was seeing an increasing number of patients, predominantly women, with rich dermatologic symptomatology but with no objective dermatologic changes on examination. Although dermatologists are used to seeing patients with tiny lesions in significant body areas that cause disparate anxiety and cosmetic distress, those patients, with what the author called dermatologic nondisea~e,~ had no significant dermatologic pathology. They were dysmorphophobic.
DYSMORPHOPHOBIA
Dysmorphophobia can be defined as a preoccupation with some minor bodily defect that the patient thinks is conspicuous to others, whereas objectively the patient has no cause at all for this complaint.’ It is important to realize that a clinical diagnosis of dermatologic nondisease or dysmorphophobia is not the final diagnosis, but only a starting point in reaching the final psychiatric diagnosis. The terminology in this diagnostic area is confusing, and the author believes it is reasonable to regard dermatologic nondisease and body dysmorphic disorder as the same entity, except that the author includes some
pain disorders under the term dermatologic nondisease (cf following discussion). Some psychiatrists use the term primary monosymptomatic hypochondriacal psychosis in the same context.8
Body Image
Patients with dysmorphophobia have a fundamental disturbance in their perception of themselves and of their body image in particular. To a large extent, body image is cutaneous and is important in the development of self-esteem and confidence. As far as body image is concerned, the most important areas are the face, including the eyes, nose, and mouth, the scalp, including the hair, the breasts in women, and the genital area in both sexes. It is interesting that those patients presenting with dermatologic nondisease, that is, with perceived ugliness, usually have symptoms referrable to these important body image areas.
Illustrative Case History
A female teacher and mother, aged 34 years, came to see the author privately, having been referred by her primary care physician because of a constant burning and red-
From the Harrogate Clinic, Lasercare Clinics, Harrogate, North Yorkshire, England
DERMATOLOGIC CLINICS VOLUME 14 * NUMBER 3 * JULY 1996
439
440
COTTERILL
ness on her face. The referring physician mentioned in his letter that he had not been able to detect any obvious abnormality of the facial skin, and the patient herself said, ”It’s like going to the dentist, things are better today.” The primary care physician observed that the patient had visited him on several occasions during the previous 2 weeks because of this complaint but that normally she had been ”a good patient,” by which the author thinks he meant she had consulted him seldom. On examination, there were absolutely no significant dermatologic abnormalities. The patient was well dressed, neat, and tidy and was defensive when the author tried to probe the history. She did say, however, that she had been sleeping badly because one of her father’s relatives had died recently. The patient was adamant that she was allergic to something, and as a young and inexperienced dermatologist at the time, the author arranged for patch tests to be performed. The patch tests were placed on the patient’s back, but she did not attend for follow-up purposes because she had killed herself by throwing herself in front of a railway train just before the patches were due to be read. It emerged subsequently that this woman was angry with her husband, who had been having an extramarital affair. The author believed he had failed the patient because her symptoms were the best she could do at the time to indicate her intense anger and despair about the marital situation in which she found herself. INCIDENCE
The incidence of dermatologic nondisease has not been established properly. It has been claimed that up to 2% of patients requesting plastic surgery have dysmorphophobic symptoms2 Phillipsy has estimated that in the United States up to 1%of the general population may suffer from dysmorphic disorder. SEX AND SOCIAL BACKGROUND
The majority of patients the author sees with dermatologic nondisease are women.
This is certainly true of patients with delusions or overvalued ideas affecting the face and scalp, whereas men tend to be seen more often with symptoms referrable to the genital area. The professions are well represented, especially accountants, teachers, nurses, beauticians, and hairdressers. Marital disharmony is common, as is a previous history of a hysterectomy. The age of presentation varies widely, but presentation in the early or midteens may be indicative of frank psychotic disease such as schizophrenia. The majority of patients seen with dermatologic nondisease are aged between 30 and 50 years, but the writer has seen patients with this syndrome in their late 70s.
DERMATOLOGIC SY MPTOMATOLOGY
Symptoms occur in three main body areas: the face, including the mouth, the scalp, and the perineum. An occasional patient is seen with undue concern about the axillae. Facial Symptomatology
The most common facial symptom is a complaint of burning, which is persistent morning and night and may be reported to interfere with sleep. There are few dermatologic disorders that present with a burning feeling in the skin. This symptom can occur in patients with porphyria, but the use of the term burning by patients to describe their symptoms is usually emotive and most often denotes psychiatric or emotional problems. A complaint of excessive facial redness or a preoccupation with imagined excessive facial hair and scarring are other common presenting features. It is interesting that a chance remark by a friend or a close relative about facial hair may trigger morbid, obsessional thoughts in individual patients. Other facial symptoms include a complaint of excessive greasiness or facial malodor. Some patients complain about excessive wrinkles or pitting on their faces. The affected woman spends
DERMATOLOGIC NONDISEASE
the majority of her day in a ritual, inspecting her skin in front of a magnifying mirror, and becomes confined to her house because of her anxieties about her perceived ugliness. Perioral folliculitis is seen often in patients, together with superficial scarring because of constant attack with tweezers on an area of imagined excessive facial hair. Some patients become preoccupied about minute thread veins on their cheeks, and such patients may haunt laser clinics in vain for a solution. There may be an undue preoccupation about the shape or size of the nose. This is often a psychotic symptom and an indication for urgent psychiatric advice. Women with facial symptoms are often extremely depressed and may try to commit suicide, sadly sometimes successfully.
Scalp Symptoms
Symptoms in the scalp area include complaints of intense burning that is unremittent, persisting throughout the day and night, often coupled with the complaint that the hair is coming out in handfuls. Early on in the consultation these patients will say that they are frightened of the possibility that they will go bald. They often bring packets of hair rescued from the plughole in the sink to underline their anxieties. Some patients bring annotated books containing daily hair counts, extending back for 2 or 3 years. In the author’s experience, patients in this group are predominantly women, and it is important to question women who complain of excessive hair loss while no evidence of alopecia is evident on examination about depression and marital diffi~ulties.~ Although female patients outnumber male patients in this group, occasionally men are seen who blame their anxieties about their hair on their inability to socialize and meet with the opposite sex. One of the author’s patients was so anxious that he was going to go bald that he had some prophylactic hair transplants placed on his upper forehead by a plastic surgeon. This procedure, however, only gave him short-term relief because when the hair grew it grew horizontally, giving him
441
a rather bizarre appearance. He returned to my clinic asking if his hair transplants could be removed. I also have seen young men complaining of excessive hair loss and asking for antiandrogen therapy as their first step in gender change. Transvestite and transsexual behavior can be regarded as the ultimate rejection of existing body image.
Perineal Symptoms
In the author’s experience, more male patients present with complaints in the genital area than women, and the symptoms sometimes develop following an imagined or genuine exposure to infection in the area and resulting concern about venereal disease. Symptoms complained of include a generalized discomfort in the genital area, often extending on to the anterior, medial, and lateral thighs. Patients may say that this makes it difficult for them to wear clothes and even to sit down, and they may be uncomfortable in bed at night. Some obsessional men complain of an uncomfortable, red, and inflamed scrotum that they find so distressing that they feel unable to walk, work, or wear clothes, and sexual relations become impossible. Male patients may even persuade surgeons to divide the lateral cutaneous nerve of the thigh in an attempt to relieve discomfort felt in the area, and patients with a burning scrotum who come to believe that the only solution is surgical may ask about skin grafting or even castration. Venereologists are used to seeing patients complaining of herpes simplex, urethral discharge, or even of AIDS, when there actually is no significant organic disease present. The female equivalent is the burning vulva syndrome or vulvodynia. Vulvodynia can be distressing and a difficult condition to manage in women. There seems little doubt that the pathogenesis of this condition is multifactorial, but when organic pathology has been excluded, there remains a large group of women who complain of an intolerable burning feeling in the vulva1 area that disturbs sleep and may stop them from going to bed or even sitting down during the day. Sexual
442
COTTERILL
relations become impossible, and any relationship these women have is threatened. Symptoms in this area may follow relatively minor trauma such as a fall or surgery, including hysterectomy or other gynecologic procedures. Any subsequent surgical procedure carried out in the area often makes the symptoms worse.
Mouth Pathology
Dermatologists become accustomed to seeing many patients with symptoms referrable to the mouth, lips, or tongue but in which no significant organic pathology can be found (orodynia or glossodynia). The burning feeling in the mouth may be exacerbated by acid foods or liquids such as fruit juice or vinegar and is often more pronounced toward the end of the day. Although some patients with this disorder may have underlying organic pathology such as allergies to their dentures, the vast majority of patients have no such underlying cause. Diabetes mellitus; iron deficiency; deficiency of vitamins BZ,Bb, BIZ,and folic acid; and steatorrhea have been reported to be associated with orodynia and should be excluded. More commonly, patients have cancerphobia. Combined Clinical Features
It is usual for an individual patient to present with symptomatology referrable to the face and subsequently present with symptomatology referrable to the perineum, mouth, or scalp. Although uncommon, folie a deux, does occur but less frequently than in families with delusions of parasitosis.
Other Clinical Features
The first clue to diagnosis may be in the initial referral letter from the primary care physician. This referral letter is usually much longer than normal and usually mentions that the patient has had many investigations with negative results and has seen several doctors
on account of the symptoms, with negative results as far as organic pathology is concerned. When they see such patients, many dermatologis’ts or plastic surgeons are compelled to write a long letter back. These letters are in sharp contrast to those short, ”one or two liners” written about patients with organic pathology such as skin tumors. It is unusual for dermatologists to be troubled with women who are concerned about the size or shape of their breasts and who usually visit plastic surgeons. Beale et a1,2 in a study of women seeking augmentation mammaplasty, found distortions of body image in lo%, with higher ratings on measures of sensitivity and insecurity. Eighty-one percent felt unfeminine, and a significant proportion were less self-confident and more passive. Relationships with parents were rated less positively, and patients tended to come from homes with insecurity and criticism. There were also anxieties about present attitudes to their husbands. Most patients with dermatologic nondisease are ”doctor shoppers,” and one of the author’s patients saw 27 consultants because of discomfort in his genital area. Hospital and medical records of these patients tend to be voluminous. Most remain loyal to an individual hospital. It is common for them to have difficulties in making appointments, and these patients often cancel appointments at the last minute. Patients with dermatologic nondisease consult a dermatologist or plastic surgeon because of their conviction that they have dermatologic pathology’ and so they react badly to the suggestion that they should be referred to a psychiatrist. A consultation with a patient with dermatologic nondisease always takes much longer than a consultation with a patient with organic skin disease. It is characteristic that the same ground is covered during the consultation on many occasions. The patient usually fails to recognize any of the nonverbal cues that the consultation is over, and even if the patient is guided with care to the door and out of the door, it is usual for the door to fly open again as the patient comes back with the same questions, looking for the same reassurance about the same
DERMATOLOGIC NONDISEASE
problem. It is also common for the dermatologist or plastic surgeon to be phoned shortly after the consultation for further reassurance. As a group, patients with dermatologic nondisease fail to respond completely to a wide range of topical or oral therapy, and a placebo response is never seen. Some patients develop a nocebo response (side effects attributed to a placebo). It is usual for dysmorphophobic patients to become completely isolated socially. They refuse to go out and meet other human beings, and work becomes impossible for them. They are preoccupied completely about their imagined skin problem and devote all their energies to this supposed problem. The rituals may take so long that the day is over before the patient feels ready to go out.
PSYCHIATRIC ASPECTS OF DERMATOLOGIC NONDISEASE
A diagnosis of dermatologic nondisease, dysmorphophobia, or body dysmorphic disorder is just a starting point in accurate psychiatric diagnosis. Patients with dermatologic nondisease may have many differing psychological and psychiatric problems, varying from marital problems to borderline personality disorder, personality disorder, obsessive-compulsive disorder, depression, schizophrenia, and dementia. The most common psychiatric problem present is depression: The clinical spectrum is wide, and many patients with this disorder are at the neurotic end of the spectrum and merely have overvalued ideas about their dermatologic status, whereas a smaller minority of patients truly are deluded. These patients lie at the psychotic end of the psychiatric spectrum. Munro8 has proposed that patients with true delusions should be given a diagnostic label of primary monosymptomatic hypochondriacal psychosis, in which the one predominating symptom is a delusional preoccupation with some aspect of health. The delusional quality of the belief makes the condition psychotic. Perhaps patients with overvalued ideas could be given a diagnostic label of primary monosymptomatic hypochondria-
443
cal neurosis. Munro thought that patients with primary monosymptomatic hypochondriacal psychosis had a personality relatively unaffected by the psychotic process and that a proportion of patients with this disorder responded favorably to pimozide.
PERSONALITY FEATURES OF PATIENTS WITH DYSMORPHOPHOBIA
There has been a general stress in the literature on the relationship between dysmorphophobia, hypochondriasis, and obsessional traits.' Phillips et allo have stressed that patients with dysmorphophobia could be included in the obsessive-compulsive spectrum disorder. Hardy5 proposed that a disturbance in body image would be reflected in the person's self-concept and their interpersonal relationships. In a comparative study, using repertory grids, it was found that dysmorphophobic patients were less happy with their body image, self-concept, and relationships than a control group. A psoriatic group also rated their body image as unacceptable. They rated their relationships as more acceptable than the dysmorphophobic group, however. It also was found that dysmorphophobic patients thought that if they looked different their sense of personal and social inadequacy could be overcome. Hardy also investigated four measures of obsessionality in patients with dysmorphophobia and control subjects and found that although dysmorphophobic patients had elevated obsessional symptom scores, they were not significantly different from the psoriatic patients and were of a similar profile to that of a neurotic depressed group. This study did not support the hypothesis that dysmorphophobic symptoms were part of an obsessional state. Hardy and CotterilP found that depression was common, however, and may be severe in dysmorphophobic patients. It is unusual, however, for individual patients to volunteer spontaneously that they feel depressed, although early morning wakening is common and as a rule
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COTTERILL
dysmorphophobic patients score highly on depression inventories.
MANAGEMENT OF PATIENTS WITH DYSMORPHOPHOBIA
A more detailed account of therapy is given in the article on ”Body Dysmorphic Disorder” in this volume. Patients with dysmorphophobia are among the most difficult patients that dermatologists have to manage. They are demanding and time consuming. Some patients, particularly women with facial symptomatology, have a definite risk of suicide. In addition, there are dermatologists and psychiatrists who know little about this aspect of practice and may be unsympathetic to individual patients. Patients see their problems in strictly dermatologic terms, and any attempts to refer the patient to a psychiatric clinic may meet with immediate hostility. A liaison clinic within a dermatology department is one solution for management of these difficult patients. The writer believes that a strong psychiatric input from an experienced psychiatrist is important, particularly in recognizing those patients who are significantly depressed and likely to kill themselves. Most patients are happy to see a dermatologist with a psychiatrist in the dermatology department. Moreover, those patients with significant and severe depression may accept admission to a dermatology ward and later transfer to a psychiatric ward when they come to know and trust the psychiatrist concerned. It must be remembered that a minority of patients with dermatologic nondisease are angry, and these patients can direct this anger at themselves or at the attending physician. In the majority of cases, the violence usually is directed inward at the patients themselves with a suicide attempt. The author was under threat of death, however, for 8 months from one of his dysmorphophobic female patients before the patient killed herself, rather than him. Noteworthy in this particular case was a reluctance by the police and forensic psychiatrists to get involved in this young woman’s care, and a long-distance diagnosis of person-
ality disorder was made by the psychiatrist after he had seen the patient’s mother rather than the patient herself, whom he never saw. Many different treatments have been advocated to treat dysmorphophobic patients, and those patients with overvalued ideas may respond to a sympathetic dermatologist or plastic surgeon who has enough time to spend doing superficial psychotherapy. Patients with dermatologic nondisease are poor communicators, however, and may take several years to express the strong feelings that they undoubtedly have about some aspects of their life. It is evident in talking to nondeluded dysmorphophobic patients that their problems go back to early childhood. In particular, they usually have poor relationships with their parents, other siblings, and their mother in particular. In many, the symptoms are protective to some extent, preventing the patient from experiencing those things in life that cause him or her the most distress. This usually is socializing with other people. From time to time, however, the dysmorphophobic patient becomes so depressed by isolation that he or she may emerge from the selfimposed cocoon, asking for dermatologic help. The result is often a depressed dermatologist and a patient who eventually defaults from follow-up. Those patients in whom it is thought there is a definite risk of suicide should be admitted initially to a dermatologic unit and treated with a selective serotonin reuptake inhibitor.
References 1. Andreasen N, Bardach J: Dysmorphophobia: Symptom or disease? Am J Psychiatry 134:673475, 1977 2. Beal S, Lispen H, Palm B: A psychological study of patients seeking augmentation mammaplasty. Br J Psychiatry 136:133-138, 1980 3. Cotterill JA: Dermatological non-disease: A common and potentially fatal disturbance of cutaneous body image. Br J Dermatol 104:611-618, 1981 4. Eckert G: Diffuse hair loss and psychiatric disturbance. Acta Derm Venereol (Stockh) 55:147-149,1975 5. Hardy GE: Body image disturbance in dysmorphophobia. Br J Psychiatry 141:181-185, 1982 6. Hardy GE, Cotterill JA: A study of depression and obsessionality in dysmorphophobic and psoriatic patients. Br J Psychiatry 140:19-20, 1982
DERMATOLOGIC NONDISEASE 7. Hay GG: Dysmorphophobia. Br J Psychiatry 116:399406, 1970 8. Munro A Monosymptomatic hypochondriacal psychosis manifesting as delusions of parasitosis. Br J Hosp Med 24:34-38, 1980 9. Phillips KA: Data presented at the Sixth International
445
Congress and Meeting of the European Society for Dermatology and Psychiatry, Amsterdam, 1995 10. Phillips KA, McElroy SL, Hudson JI, et a 1 Body dysmorphic disorders: An OCD-spectrum disorder, a form of affective spectrum disorder or both? J Clin Psychiatry 56(suppl4):41-51, 1995
Address reprint requests to John A. Cotterill, MD, BSc, FRCP 56, Broomfield Leeds LS16 7AD United Kingdom
PSYCHODERMATOLOGY
+
.20
DERMATOLOGIC NONDISEASE John A. Cotterill, MD, BSc, FRCP
Some years ago, as a young and increasingly busy dermatologist, the author gradually became aware that he was seeing an increasing number of patients, predominantly women, with rich dermatologic symptomatology but with no objective dermatologic changes on examination. Although dermatologists are used to seeing patients with tiny lesions in significant body areas that cause disparate anxiety and cosmetic distress, those patients, with what the author called dermatologic nondisea~e,~ had no significant dermatologic pathology. They were dysmorphophobic.
DYSMORPHOPHOBIA
Dysmorphophobia can be defined as a preoccupation with some minor bodily defect that the patient thinks is conspicuous to others, whereas objectively the patient has no cause at all for this complaint.’ It is important to realize that a clinical diagnosis of dermatologic nondisease or dysmorphophobia is not the final diagnosis, but only a starting point in reaching the final psychiatric diagnosis. The terminology in this diagnostic area is confusing, and the author believes it is reasonable to regard dermatologic nondisease and body dysmorphic disorder as the same entity, except that the author includes some
pain disorders under the term dermatologic nondisease (cf following discussion). Some psychiatrists use the term primary monosymptomatic hypochondriacal psychosis in the same context.8
Body Image
Patients with dysmorphophobia have a fundamental disturbance in their perception of themselves and of their body image in particular. To a large extent, body image is cutaneous and is important in the development of self-esteem and confidence. As far as body image is concerned, the most important areas are the face, including the eyes, nose, and mouth, the scalp, including the hair, the breasts in women, and the genital area in both sexes. It is interesting that those patients presenting with dermatologic nondisease, that is, with perceived ugliness, usually have symptoms referrable to these important body image areas.
Illustrative Case History
A female teacher and mother, aged 34 years, came to see the author privately, having been referred by her primary care physician because of a constant burning and red-
From the Harrogate Clinic, Lasercare Clinics, Harrogate, North Yorkshire, England
DERMATOLOGIC CLINICS VOLUME 14 * NUMBER 3 * JULY 1996
439
440
COTTERILL
ness on her face. The referring physician mentioned in his letter that he had not been able to detect any obvious abnormality of the facial skin, and the patient herself said, ”It’s like going to the dentist, things are better today.” The primary care physician observed that the patient had visited him on several occasions during the previous 2 weeks because of this complaint but that normally she had been ”a good patient,” by which the author thinks he meant she had consulted him seldom. On examination, there were absolutely no significant dermatologic abnormalities. The patient was well dressed, neat, and tidy and was defensive when the author tried to probe the history. She did say, however, that she had been sleeping badly because one of her father’s relatives had died recently. The patient was adamant that she was allergic to something, and as a young and inexperienced dermatologist at the time, the author arranged for patch tests to be performed. The patch tests were placed on the patient’s back, but she did not attend for follow-up purposes because she had killed herself by throwing herself in front of a railway train just before the patches were due to be read. It emerged subsequently that this woman was angry with her husband, who had been having an extramarital affair. The author believed he had failed the patient because her symptoms were the best she could do at the time to indicate her intense anger and despair about the marital situation in which she found herself. INCIDENCE
The incidence of dermatologic nondisease has not been established properly. It has been claimed that up to 2% of patients requesting plastic surgery have dysmorphophobic symptoms2 Phillipsy has estimated that in the United States up to 1%of the general population may suffer from dysmorphic disorder. SEX AND SOCIAL BACKGROUND
The majority of patients the author sees with dermatologic nondisease are women.
This is certainly true of patients with delusions or overvalued ideas affecting the face and scalp, whereas men tend to be seen more often with symptoms referrable to the genital area. The professions are well represented, especially accountants, teachers, nurses, beauticians, and hairdressers. Marital disharmony is common, as is a previous history of a hysterectomy. The age of presentation varies widely, but presentation in the early or midteens may be indicative of frank psychotic disease such as schizophrenia. The majority of patients seen with dermatologic nondisease are aged between 30 and 50 years, but the writer has seen patients with this syndrome in their late 70s.
DERMATOLOGIC SY MPTOMATOLOGY
Symptoms occur in three main body areas: the face, including the mouth, the scalp, and the perineum. An occasional patient is seen with undue concern about the axillae. Facial Symptomatology
The most common facial symptom is a complaint of burning, which is persistent morning and night and may be reported to interfere with sleep. There are few dermatologic disorders that present with a burning feeling in the skin. This symptom can occur in patients with porphyria, but the use of the term burning by patients to describe their symptoms is usually emotive and most often denotes psychiatric or emotional problems. A complaint of excessive facial redness or a preoccupation with imagined excessive facial hair and scarring are other common presenting features. It is interesting that a chance remark by a friend or a close relative about facial hair may trigger morbid, obsessional thoughts in individual patients. Other facial symptoms include a complaint of excessive greasiness or facial malodor. Some patients complain about excessive wrinkles or pitting on their faces. The affected woman spends
DERMATOLOGIC NONDISEASE
the majority of her day in a ritual, inspecting her skin in front of a magnifying mirror, and becomes confined to her house because of her anxieties about her perceived ugliness. Perioral folliculitis is seen often in patients, together with superficial scarring because of constant attack with tweezers on an area of imagined excessive facial hair. Some patients become preoccupied about minute thread veins on their cheeks, and such patients may haunt laser clinics in vain for a solution. There may be an undue preoccupation about the shape or size of the nose. This is often a psychotic symptom and an indication for urgent psychiatric advice. Women with facial symptoms are often extremely depressed and may try to commit suicide, sadly sometimes successfully.
Scalp Symptoms
Symptoms in the scalp area include complaints of intense burning that is unremittent, persisting throughout the day and night, often coupled with the complaint that the hair is coming out in handfuls. Early on in the consultation these patients will say that they are frightened of the possibility that they will go bald. They often bring packets of hair rescued from the plughole in the sink to underline their anxieties. Some patients bring annotated books containing daily hair counts, extending back for 2 or 3 years. In the author’s experience, patients in this group are predominantly women, and it is important to question women who complain of excessive hair loss while no evidence of alopecia is evident on examination about depression and marital diffi~ulties.~ Although female patients outnumber male patients in this group, occasionally men are seen who blame their anxieties about their hair on their inability to socialize and meet with the opposite sex. One of the author’s patients was so anxious that he was going to go bald that he had some prophylactic hair transplants placed on his upper forehead by a plastic surgeon. This procedure, however, only gave him short-term relief because when the hair grew it grew horizontally, giving him
441
a rather bizarre appearance. He returned to my clinic asking if his hair transplants could be removed. I also have seen young men complaining of excessive hair loss and asking for antiandrogen therapy as their first step in gender change. Transvestite and transsexual behavior can be regarded as the ultimate rejection of existing body image.
Perineal Symptoms
In the author’s experience, more male patients present with complaints in the genital area than women, and the symptoms sometimes develop following an imagined or genuine exposure to infection in the area and resulting concern about venereal disease. Symptoms complained of include a generalized discomfort in the genital area, often extending on to the anterior, medial, and lateral thighs. Patients may say that this makes it difficult for them to wear clothes and even to sit down, and they may be uncomfortable in bed at night. Some obsessional men complain of an uncomfortable, red, and inflamed scrotum that they find so distressing that they feel unable to walk, work, or wear clothes, and sexual relations become impossible. Male patients may even persuade surgeons to divide the lateral cutaneous nerve of the thigh in an attempt to relieve discomfort felt in the area, and patients with a burning scrotum who come to believe that the only solution is surgical may ask about skin grafting or even castration. Venereologists are used to seeing patients complaining of herpes simplex, urethral discharge, or even of AIDS, when there actually is no significant organic disease present. The female equivalent is the burning vulva syndrome or vulvodynia. Vulvodynia can be distressing and a difficult condition to manage in women. There seems little doubt that the pathogenesis of this condition is multifactorial, but when organic pathology has been excluded, there remains a large group of women who complain of an intolerable burning feeling in the vulva1 area that disturbs sleep and may stop them from going to bed or even sitting down during the day. Sexual
442
COTTERILL
relations become impossible, and any relationship these women have is threatened. Symptoms in this area may follow relatively minor trauma such as a fall or surgery, including hysterectomy or other gynecologic procedures. Any subsequent surgical procedure carried out in the area often makes the symptoms worse.
Mouth Pathology
Dermatologists become accustomed to seeing many patients with symptoms referrable to the mouth, lips, or tongue but in which no significant organic pathology can be found (orodynia or glossodynia). The burning feeling in the mouth may be exacerbated by acid foods or liquids such as fruit juice or vinegar and is often more pronounced toward the end of the day. Although some patients with this disorder may have underlying organic pathology such as allergies to their dentures, the vast majority of patients have no such underlying cause. Diabetes mellitus; iron deficiency; deficiency of vitamins BZ,Bb, BIZ,and folic acid; and steatorrhea have been reported to be associated with orodynia and should be excluded. More commonly, patients have cancerphobia. Combined Clinical Features
It is usual for an individual patient to present with symptomatology referrable to the face and subsequently present with symptomatology referrable to the perineum, mouth, or scalp. Although uncommon, folie a deux, does occur but less frequently than in families with delusions of parasitosis.
Other Clinical Features
The first clue to diagnosis may be in the initial referral letter from the primary care physician. This referral letter is usually much longer than normal and usually mentions that the patient has had many investigations with negative results and has seen several doctors
on account of the symptoms, with negative results as far as organic pathology is concerned. When they see such patients, many dermatologis’ts or plastic surgeons are compelled to write a long letter back. These letters are in sharp contrast to those short, ”one or two liners” written about patients with organic pathology such as skin tumors. It is unusual for dermatologists to be troubled with women who are concerned about the size or shape of their breasts and who usually visit plastic surgeons. Beale et a1,2 in a study of women seeking augmentation mammaplasty, found distortions of body image in lo%, with higher ratings on measures of sensitivity and insecurity. Eighty-one percent felt unfeminine, and a significant proportion were less self-confident and more passive. Relationships with parents were rated less positively, and patients tended to come from homes with insecurity and criticism. There were also anxieties about present attitudes to their husbands. Most patients with dermatologic nondisease are ”doctor shoppers,” and one of the author’s patients saw 27 consultants because of discomfort in his genital area. Hospital and medical records of these patients tend to be voluminous. Most remain loyal to an individual hospital. It is common for them to have difficulties in making appointments, and these patients often cancel appointments at the last minute. Patients with dermatologic nondisease consult a dermatologist or plastic surgeon because of their conviction that they have dermatologic pathology’ and so they react badly to the suggestion that they should be referred to a psychiatrist. A consultation with a patient with dermatologic nondisease always takes much longer than a consultation with a patient with organic skin disease. It is characteristic that the same ground is covered during the consultation on many occasions. The patient usually fails to recognize any of the nonverbal cues that the consultation is over, and even if the patient is guided with care to the door and out of the door, it is usual for the door to fly open again as the patient comes back with the same questions, looking for the same reassurance about the same
DERMATOLOGIC NONDISEASE
problem. It is also common for the dermatologist or plastic surgeon to be phoned shortly after the consultation for further reassurance. As a group, patients with dermatologic nondisease fail to respond completely to a wide range of topical or oral therapy, and a placebo response is never seen. Some patients develop a nocebo response (side effects attributed to a placebo). It is usual for dysmorphophobic patients to become completely isolated socially. They refuse to go out and meet other human beings, and work becomes impossible for them. They are preoccupied completely about their imagined skin problem and devote all their energies to this supposed problem. The rituals may take so long that the day is over before the patient feels ready to go out.
PSYCHIATRIC ASPECTS OF DERMATOLOGIC NONDISEASE
A diagnosis of dermatologic nondisease, dysmorphophobia, or body dysmorphic disorder is just a starting point in accurate psychiatric diagnosis. Patients with dermatologic nondisease may have many differing psychological and psychiatric problems, varying from marital problems to borderline personality disorder, personality disorder, obsessive-compulsive disorder, depression, schizophrenia, and dementia. The most common psychiatric problem present is depression: The clinical spectrum is wide, and many patients with this disorder are at the neurotic end of the spectrum and merely have overvalued ideas about their dermatologic status, whereas a smaller minority of patients truly are deluded. These patients lie at the psychotic end of the psychiatric spectrum. Munro8 has proposed that patients with true delusions should be given a diagnostic label of primary monosymptomatic hypochondriacal psychosis, in which the one predominating symptom is a delusional preoccupation with some aspect of health. The delusional quality of the belief makes the condition psychotic. Perhaps patients with overvalued ideas could be given a diagnostic label of primary monosymptomatic hypochondria-
443
cal neurosis. Munro thought that patients with primary monosymptomatic hypochondriacal psychosis had a personality relatively unaffected by the psychotic process and that a proportion of patients with this disorder responded favorably to pimozide.
PERSONALITY FEATURES OF PATIENTS WITH DYSMORPHOPHOBIA
There has been a general stress in the literature on the relationship between dysmorphophobia, hypochondriasis, and obsessional traits.' Phillips et allo have stressed that patients with dysmorphophobia could be included in the obsessive-compulsive spectrum disorder. Hardy5 proposed that a disturbance in body image would be reflected in the person's self-concept and their interpersonal relationships. In a comparative study, using repertory grids, it was found that dysmorphophobic patients were less happy with their body image, self-concept, and relationships than a control group. A psoriatic group also rated their body image as unacceptable. They rated their relationships as more acceptable than the dysmorphophobic group, however. It also was found that dysmorphophobic patients thought that if they looked different their sense of personal and social inadequacy could be overcome. Hardy also investigated four measures of obsessionality in patients with dysmorphophobia and control subjects and found that although dysmorphophobic patients had elevated obsessional symptom scores, they were not significantly different from the psoriatic patients and were of a similar profile to that of a neurotic depressed group. This study did not support the hypothesis that dysmorphophobic symptoms were part of an obsessional state. Hardy and CotterilP found that depression was common, however, and may be severe in dysmorphophobic patients. It is unusual, however, for individual patients to volunteer spontaneously that they feel depressed, although early morning wakening is common and as a rule
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dysmorphophobic patients score highly on depression inventories.
MANAGEMENT OF PATIENTS WITH DYSMORPHOPHOBIA
A more detailed account of therapy is given in the article on ”Body Dysmorphic Disorder” in this volume. Patients with dysmorphophobia are among the most difficult patients that dermatologists have to manage. They are demanding and time consuming. Some patients, particularly women with facial symptomatology, have a definite risk of suicide. In addition, there are dermatologists and psychiatrists who know little about this aspect of practice and may be unsympathetic to individual patients. Patients see their problems in strictly dermatologic terms, and any attempts to refer the patient to a psychiatric clinic may meet with immediate hostility. A liaison clinic within a dermatology department is one solution for management of these difficult patients. The writer believes that a strong psychiatric input from an experienced psychiatrist is important, particularly in recognizing those patients who are significantly depressed and likely to kill themselves. Most patients are happy to see a dermatologist with a psychiatrist in the dermatology department. Moreover, those patients with significant and severe depression may accept admission to a dermatology ward and later transfer to a psychiatric ward when they come to know and trust the psychiatrist concerned. It must be remembered that a minority of patients with dermatologic nondisease are angry, and these patients can direct this anger at themselves or at the attending physician. In the majority of cases, the violence usually is directed inward at the patients themselves with a suicide attempt. The author was under threat of death, however, for 8 months from one of his dysmorphophobic female patients before the patient killed herself, rather than him. Noteworthy in this particular case was a reluctance by the police and forensic psychiatrists to get involved in this young woman’s care, and a long-distance diagnosis of person-
ality disorder was made by the psychiatrist after he had seen the patient’s mother rather than the patient herself, whom he never saw. Many different treatments have been advocated to treat dysmorphophobic patients, and those patients with overvalued ideas may respond to a sympathetic dermatologist or plastic surgeon who has enough time to spend doing superficial psychotherapy. Patients with dermatologic nondisease are poor communicators, however, and may take several years to express the strong feelings that they undoubtedly have about some aspects of their life. It is evident in talking to nondeluded dysmorphophobic patients that their problems go back to early childhood. In particular, they usually have poor relationships with their parents, other siblings, and their mother in particular. In many, the symptoms are protective to some extent, preventing the patient from experiencing those things in life that cause him or her the most distress. This usually is socializing with other people. From time to time, however, the dysmorphophobic patient becomes so depressed by isolation that he or she may emerge from the selfimposed cocoon, asking for dermatologic help. The result is often a depressed dermatologist and a patient who eventually defaults from follow-up. Those patients in whom it is thought there is a definite risk of suicide should be admitted initially to a dermatologic unit and treated with a selective serotonin reuptake inhibitor.
References 1. Andreasen N, Bardach J: Dysmorphophobia: Symptom or disease? Am J Psychiatry 134:673475, 1977 2. Beal S, Lispen H, Palm B: A psychological study of patients seeking augmentation mammaplasty. Br J Psychiatry 136:133-138, 1980 3. Cotterill JA: Dermatological non-disease: A common and potentially fatal disturbance of cutaneous body image. Br J Dermatol 104:611-618, 1981 4. Eckert G: Diffuse hair loss and psychiatric disturbance. Acta Derm Venereol (Stockh) 55:147-149,1975 5. Hardy GE: Body image disturbance in dysmorphophobia. Br J Psychiatry 141:181-185, 1982 6. Hardy GE, Cotterill JA: A study of depression and obsessionality in dysmorphophobic and psoriatic patients. Br J Psychiatry 140:19-20, 1982
DERMATOLOGIC NONDISEASE 7. Hay GG: Dysmorphophobia. Br J Psychiatry 116:399406, 1970 8. Munro A Monosymptomatic hypochondriacal psychosis manifesting as delusions of parasitosis. Br J Hosp Med 24:34-38, 1980 9. Phillips KA: Data presented at the Sixth International
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Congress and Meeting of the European Society for Dermatology and Psychiatry, Amsterdam, 1995 10. Phillips KA, McElroy SL, Hudson JI, et a 1 Body dysmorphic disorders: An OCD-spectrum disorder, a form of affective spectrum disorder or both? J Clin Psychiatry 56(suppl4):41-51, 1995
Address reprint requests to John A. Cotterill, MD, BSc, FRCP 56, Broomfield Leeds LS16 7AD United Kingdom