OCD Patients May Seek Help From Dermatologists

Compulsive hand washers may scrub their hands dozens of times daily, even after they develop rough, reddened, and bleeding skin. Some people bathe several times a day.

Some individuals compulsively pull out eyelashes and hairs from their eyebrows, scalp, and other areas of the body.

Eighteen of 92 consecutive patients referred to a dermatology clinic (20 percent) had an obsessive-compulsive disorder (OCD), according to a report in the February 2003 Journal of Clinical Psychiatry. Only one patient previously had been diagnosed with the disorder. An estimated 2.5 percent of the general population—men and women equally—develop OCD over their lifetime.

Four in five people with OCD initially present to a physician other than a psychiatrist, according to Thelda Kestenbaum, M.D., who discussed the diagnosis and treatment of OCD by dermatologists at the annual meeting of the American Academy of Dermatology in Washington, D.C., in February. Kestenbaum is an associate professor of medicine in the Division of Dermatology at the University of Kansas Medical Center in Kansas City.

Patients May Shun Treatment

Many people with OCD have symptoms for years before seeking treatment. Embarrassment, guilt, or fear of being considered “crazy” make many strive to keep their behavior secret. Many resist discussing their obsessions and compulsions with a physician or family members. It often takes time and sympathy from the physician to elicit candor, Kestenbaum said.

Some present to dermatologists with extreme concerns about cleanliness. Some report fears of contamination or infestation, or of having an unacceptable body odor. Others worry, despite lack of evidence, that they have a life-threatening or sexually transmitted illness such as AIDS.

Some people are preoccupied with slight or imagined flaws in their appearance, fretting over age-related thinning hair, ordinary moles, or minor skin irregularities. They may insist they look unattractive, even offensive, to others. The focus for such complaints varies across cultures, Kestenbaum said. In Japan, for example, preoccupation with the shape of eyelids is more common than it is in the United States.

People with excessive concerns over defects in their appearance, or body dysmorphic disorder (BDD), may spend hours a day in self-examination and grooming. BDD reportedly occurs in 6 percent to 15 percent of dermatologic and cosmetic-surgery patients. Surgical treatment may not improve symptoms, and may even make them worse.

Patterns of skin damage may help pinpoint the diagnosis of OCD, Kestenbaum said. The “butterfly sign,” a pattern of inflammation and hyperpigmentation on the outer aspects of the upper back, serves as a classic indicator of neurotic excoriations, for example. The inflammation occurs only in areas patients can reach, leaving the middle of the back clear. This problem appears most often in women aged 30 to 50.

People with acne excoriée, more often women than men, may spend two hours or more picking skin daily, causing ulcers, infections, and scars more unsightly than the initial blemishes.

Controversy Surrounds Diagnosis

Some people who scratch and pick their skin excessively have delusions of infestation by parasites. Specimens brought to the dermatologist, Kestenbaum said, often prove to be lint from clothing or ordinary sloughed off skin cells.

Self-diagnosed Morgellons disease is a relatively new phenomenon in the dermatologist's office, she said, fueled by media reports and the Internet. People who believe they have this disorder commonly report crawling, stinging, and biting sensations. Some claim that fibers emerge from intact skin (Psychiatric News, December 15, 2006).

While all symptoms demand a careful workup, Kestenbaum said,“ patients with such complaints whom I have seen appeared to have a delusional parasitosis.”

Meanwhile, a multidisciplinary task force at the Centers for Disease Control and Prevention (CDC) is developing an instrument to investigate the symptoms these patients present. “There is no credible evidence at present to implicate any pathogen in Morgellons disease,” CDC spokes-person Dan Rutz told Psychiatric News. Several different mechanisms may account for patients' distress, he said.

Writing in the November 2006 Journal of the American Academy of Dermatology, Philadelphia dermatologist/psychoanalyst Caroline Koblenzer, M.D., suggested that “Morgellons syndrome” may be a more apt name for this symptom complex than “Morgellons disease.”

Symptoms Often Arise in Childhood

About one-third to one-half of adults with OCD, Kestenbaum said, developed it as children. The most common childhood OCD manifestations seen in dermatology practices include hair pulling, nail biting, and nail picking. Children with OCD often have other psychiatric disorders, she said. Nine percent of their mothers and 25 percent of their fathers meet criteria for OCD.

First-line treatment for skin-related OCD symptoms in adults includes selective serotonin reuptake inhibitors and other antidepressants at full dosage or the highest tolerated dose for 12 weeks, she said. Behavioral therapies, including exposure to trigger stimuli and response reduction, have demonstrated efficacy in these patients. She urges patients to try to put five minutes—if that is not possible, even one minute—between thought and action.

People with OCD who have chosen to see a dermatologist rather than a psychiatrist often resist referral to a psychiatrist, Kestenbaum said. Psychiatrists interested in treating such patients, she suggested, could contact the dermatology department at medical centers in their communities or join the Association for Psychocutaneous Medicine of North America (see box on Original article: page 18).

More information about dermatological manifestations of OCD is posted at<ocfoundation.org> and<www.trich.org>; information about delusional parasitosis is posted at<http://delusion.ucdavis.edu/delusional.html>; and information on Morgellons disease is posted at<www.morgellons.org>.▪