Clinical pictures and classification of somatoform disorders in dermatology

ARTICLE

Auteur(s) : W Harth¹, B Hermes¹, V Niemeier², U Gieler²

¹Klinik für Dermatologie und Phlebologie, Vivantes Klinikum, Berlin Friedrichshain, Akademisches Lehrkrankenhaus der Charité – Universitätsmedizin Berlin, Landsberger Allee 49, 10249 Berlin, Germany
²Clinic for Psychosomatic and Psychotherapy, University Giessen and Marburg

accepté le 1 Avril 2006

Somatisation disorders

In dermatology, environment-related physical complaints, the so-called eco-syndromes, play an essential role among the somatisation disorders, a subgroup of somatoform disorders [6]. The patient reports multiple specific and unspecific complaints in various organ systems, of which the purported cause is exposure to environmental toxins, with no proof of direct toxic causal relationship between exposure and extent of the complaints. The various reported physical complaints are headache, burning eyes, runny nose, fatigue, apathy, difficulty concentrating, forgetfulness, pain in the locomotor system, unexplained dizziness, racing heart beat or shortness of breath. Numerous doctors are often consulted.

In the MCS Syndrome (Multiple Chemical Sensitivity Syndrome), the patient complains of various physical symptoms after slight exposure to chemical environmental substances. But no objective proof of increased exposure or causal relationship between exposure and extent of the complaints can be established [6]. In the German-speaking areas, complaints are especially reported in connection with exposure to wood protective, solvents, insecticides, heavy metals, disinfectants or scents (perfume). A number of skin changes are ascribed by patients to an assumed “detergent allergy”. Skin contact with bed linens washed with a new detergent, or spending the night in a strange bed are blamed. In the Gulf-War-Syndrome, radioactive substances or chemical war substances were held responsible for the unspecific syndromes. In electrical hypersensitivity, electrosmog from high-tension wires for example, is held to be the cause of the complaints.

In addition, there are special forms, like the amalgam-related complaint syndrome, whereby multiple complaints are ascribed to tooth fillings with amalgam. The patients often have all fillings removed, or undergo costly detoxifications at their own expense [7].

In one study of 264 environmental patients [8], seventy-five per cent of the patients met DSM-IV criteria for at least one psychiatric disorder and 35% of all patients suffered from somatoform disorders. Other frequent diagnoses were affective and anxiety disorders, and dependence or substance abuse. In 39% a psychiatric disorder, in 23% a somatic condition and in 19% a combination of the two were considered to provide sufficient explanation of the symptoms. Toxic chemicals were regarded as the most probable cause in only five cases.

The concepts of environment-related physical complaints have not yet been generally proven and are contested, whereby biological-physiological explanatory models, stress models with trigger factors, conditioning models and purely emotional/psychiatric phenomenology and beyond to socio-cultural illness behaviour are discussed [9]. Biopsychosocial models assume a possibly conditioned loss of tolerance to chemical exposure with a gradual increase in sensitivity and generalization to the entire organism. Difficulties are, however, encountered in procedures for laboratory-chemical diagnostics and the definition of normal values.

Characteristic for the emotional symptoms of environment-related physical complaints is the coupling of exposure with a varying degree of fears, so that the patients develop a pronounced avoidance behaviour. The avoidance behaviour, often even the anxious anticipation prior to the feared situation, markedly limits living a normal life, professional performance, social activities and social relationships. The broad discussion of “environmental poisons” which often appears in the media leads repeatedly to an increase in individual syndromes [10]. Even close contact persons or partners may be involved in the syndrome. Paranoid psychoses must be contained.
Table 1 Overview of somatoform disorders in dermatology

Hypochondriacal disorders

• 1. Hypochondriacal disorders in the literal sense;
• 2. Dysmorphophobia (body dysmorphic disorders).

The body dysmorphic disorder is subsumed under hypochondriacal disorder in ICD-10 and is separately classified in DSM-IV. The traditional arrangement and classification of ICD- 10 Dysmorphophobia (DSM-IV: body dysmorphic disorder) here will undoubtedly be abandoned in future in favour of the new class of its own, due to today’s understanding of causality.

Hypochondrias (ICD-10: F45.2) consist of persistent, excessive preoccupation with the fear or conviction of suffering from one or more serious, progressive physical diseases. In preoccupation with a normal physical event, the patient’s sensations are often interpreted as abnormal and stressful, which arises from a misinterpretation.

In dermatology, differing heterogeneous patterns of complaint are present which are directed especially to the skin and mucosae. A central focus falls on the fear of suffering from a venereal disease or carcinophobia. The patient can name the feared physical disease or disfiguration (table 2( Table 2 )). The hypochondrias have undergone a change in recent years under the influence of the media. While syphilis was in the foreground a few decades ago, it has been replaced by an AIDS- phobia and later Mycophobia, Amalgamphobia and currently Borreliaphobia.
Table 2 Dermato-Venerological Hypochondrias

Body dysmorphic disorders (Dysmorphophobia)

The central criterion for body dysmorphic disorders is excessive preoccupation with a deficit or a disfiguration in physical appearance. This deficit either does not exist at all, or is only extremely slight. The excessive preoccupation leads to marked limitations in social, professional and also functional areas [12].

The prevalence of body dysmorphic disorders according to criteria of the DSM-IV [4] is estimated at ca. 1% of the general American population and up to 4% among American and German students [13-15]. In dermatology clinics and in dermatological practices, body dysmorphic disorders are found with an incidence of 11.9%-15.6% and in various dermatological cosmetology practices up to 23% [16-18]. Especially affected are women between the ages of 35 and 50 and men younger than 35 years of age.

Clinical dermatological examination shows no pathological findings or only minimal norm variants. The spectrum of the purported deficits in outward appearance is unendingly variable (table 3)( Table 3 ). This includes quality and quantity of the skin and integumentary systems, as well as asymmetries or disproportionality of nose, eyelids, eyebrows, lips, teeth, breasts or genitals. Hair loss or hypertrichosis, pigment complaint, pore size, vascular signs, paleness, skin reddening or sweating are also cited as anomalies ( (figure 1) ).

Various theories attempt to make the onset of a body dysmorphic disorder understandable. The cognitive behavioural model of body dysmorphic disorder and “Self-Discrepancy Theory (SDT)” is an approach proposed by Veale et al. [19], in which patients with body dysmorphic disorders (BDD) present conflicting self beliefs, with discrepancies in their own self and wanting to be. BDD patients have an unrealistic ideal or demand as to how they should look. BDD patients are more concerned with a failure to achieve their own aesthetic standard than with the perceived ideals of others. In addition, media-induced factors are considered to predispose to body dysmorphic disorders by ingraining presented ideals of beauty.

The psychodynamic explanatory approach assumes a possible conflict model at the basis of the symptoms, whereby separation and dependency conflicts in early childhood may be the origin of a hypochondriacal development, disintegrative states of anxiety, autistic and self-deprecatory feelings of disgust. Frequently there is an eliciting event (such as hurt feelings) in an emotional conflict on the basis of an inconstant binding pattern and doubts of self-worth [12].

Patients with hair loss have lower self-confidence, higher depression scores, greater introversion, higher neuroticism and feelings of being unattractive [20]. Patients with objectively normal hair often report, for example, subjectively disfiguring hair loss, and suffer greatly under their assumed disease. In an excessive preoccupation with an imagined deficit with objectively normal telogenic effluvium, there is psychogenic pseudoeffluvium in the sense of a body dysmorphic disorder.

A special form of BDD is the wish of the patients to stay young forever, termed the “Dorian Gray Syndrome” [21]. The name of the syndrome was taken from an 1891 novel by Oscar Wilde. The Dorian Gray-Syndrome is associated with narcissistic regression, sociophobia and the strong desire to maintain youth. Frequently lifestyle-medicaments are used to deter the natural aging process.
Table 3 Body dysmorphic disorders in dermatology

Somatoform autonomic disorders (Function disorders)

Blushing for shame is a wide-spread phenomenon in our cultural area. The erythema is usually localized in the cheeks and neck. The physiological and predisposing reactivity in Erythema e pudore is, however, usually emotionally well compensated and differs thereby from erythrophobia.

Erythrophobia is present if there is pronounced anxiety with respect to Erythema e pudore, or even in some cases only an anxiety disorder without visible blushing. Erythrophobia may cause considerable impairment of social, partnership, professional or other important function areas and lead to pronounced avoidance behaviour against certain situations, in dealing with other persons and to social withdrawal in private or professional life.

Psychodynamically there are characteristically two types of reaction. On the one hand, blushing or fear of blushing for rage and second blushing for embarrassment. The feeling of “being caught out” may occur in a situation of intimacy with concurrent fear of contempt or criticism. Usually, the capacity for self-assertion and self-perception is damaged and fear of commitment coupled with inhibited aggression arises [1].

Gooseflesh is caused by contraction of hair follicle muscles in the skin, pulling the fine hairs, which are everywhere and sometimes almost invisible – the vellus hair – to an upright position. Gooseflesh is a phenomenon which can only rarely be consciously elicited, but is rather an unconscious or only vegetatively controllable event. It can be elicited by physical stimuli such as cold or electricity and directly influenced by emotional reactions.

Moreover, in the framework of certain individually-differing situations with vegetative lability, hyperhidrosis often occurs, predominately in the hands, feet or also axillae. This occurs usually in stress situations, such as examinations, public speaking or other anxiety-laden situations. Hippocrates (ca. 460 – ca. 370 B.C.) already reported that fear may lead to sweating. Differential-diagnostics must differentiate between secondary hyperhidrosis due to organic disease and metabolic impairments.

Persistent somatoform pain disorders (Cutaneous Dysesthesias)

In dermatology, mainly regional cutaneous dysesthesias and mucosal dysesthesias occur in somatoform pain disorders. Among the primary forms here are glossodynia (orofacial pain syndrome), vulvodynia, phallodynia, trichodynia and anodynia (table 4)( Table 4 ).

In glossodynia (ICD-10: K14.6, F45.4 or F22.0) there are dysesthesias with burning pain or tingling in the tongue and other parts of the oral mucosa. The complaints in the mouth show no organically-definable pathology. If somatic impairments are present, they do not explain the type and extent of the symptoms, the suffering and the inner involvement of the patient. About 50% of the patients with glossodynia present with personality disorders. In 33% to 82%, life events especially the loss of a partner, can be demonstrated [23]. There is frequent association with depressive moods and anxiety disorders. In addition, there is evidence that glossodynia patients present with symptoms of alexithymia [24]. The patients are incapable of expressing emotions [25].

Glossodynia patients are found in all psychological test inventories of self-evaluation to be rather inconspicuous compared to other disorder groups [26]. Doctors, however, rate the importance of emotional factors highest for the course of illness in glossodynia [27]. This discrepancy in rating between patient and doctor can be explained psychodynamically by the patient’s pronounced defence mechanisms (denial, repression).

In scalp dysesthesia, there are painful dysesthesias of the scalp. The term trichodynia, used frequently in the literature, does not appear to always be precise, since the scalp is usually also painful (Scalp Dysesthesia) and the pain is rather projected to the hair [28]. In 34% of patients with hair loss, both chronic telogenic effluvium and also androgenetic alopecia, there are painful scalp sensations [29]. The frequency of trichodynia in relation to the complaint of hair loss is different depending on the study [29-31]. Due to the dysesthesias, a para-artefact in the sense of a Skin Picking Syndrome on the hairy part of the head may also occur in some patients. 76% of the patients show emotional abnormalities, especially depression, compulsive disorders and anxiety disorders [32].

Pelvic complaints, urogenital and rectal pain syndromes are frequent psychosomatic syndromes. Vulvodynia, phallodynia (phallalgia, penile pain syndrome), orchiodynia, urethral syndrome, prostatodynia, urodynia, perianal pain syndrome, coccygodynia, anodynia, proctodynia and Proctalgia fugax belong to this symptom complex. These patients frequently suffer from a depressive, compulsive or hypochondriacal disorder [33]. Genital pain in men refers mainly to the testicles and perianum. More rarely, isolated pain in the penis occurs. Usually, a dragging, long-lasting pain of shifting intensity is reported. The patients report qualitatively varying complaints like a feeling of pressure in the anus, pulling in the groin, sometimes radiating to the testicles, increased urge to urinate, burning in the distal urethra, dripping, feeling of pressure or burning behind the pubis or tension in the small of the back. In addition, somatisation disorders such as increased sweating, inner restlessness, tachycardias, difficulty falling asleep and insomnias, heartburn and lump in the throat may also occur.

Differential-diagnostics must exclude prostate inflammation [34]. Persistent penis pains may have a chronic inflammatory process (penis erysipelas, balanoposthitis, cavernitis, urethritis) as the cause or rarely also an Induratio penis plastica, penis deviation or “penis fracture”. If one-sided testicle pain occurs as the only symptom, affections of the nerve roots L1 and L2 must be considered.

After exclusion of organic illnesses, etiological components like impaired sexuality, incorrect physical posture, neuroticism and exhaustion symptoms may be assumed, which may in turn be based on a compulsive personality structure, sexual problems or partnership conflicts [33]. The anogenital area is a preferred part of the body for symbolic pain (conversion). Psychodynamically, conflicts are related to ambition, striving for demarcation and autonomy, as well as desire for submission.

The term Vulvodynia denotes a chronic state of pain in the external female genitals. Chronic pain syndromes like chronic pelvic pain (Chronic Pelvic Pain Syndrome) and chronic vulvodynia account for about 15-20% of all consultations in outpatient gynaecological treatment [35]. Patients with vulvodynia show greater psychosocial abnormalities and tendency to somatisation in test-psychological questionnaires of self-rating than a control group [36]. Characteristically, there are more anxiety disorders, hypochondriacal disorders and sexual disorders. In 10%, sexual abuse is reported in the history and attention should be paid to this.
Table 4 Dysesthesias in dermatology

Other undifferentiated somatoform disorders (cutaneous sensory disorders)

The symptom itching is the complaint most often voiced by patients in dermatology. Itching can be provoked not only by mechanical, electrical or chemical stimuli, but may also be emotionally provoked [37]. It occurs conspicuously often in emotional excitement (rage, annoyance, excitation, more rarely joy).

The diagnosis of somatoform itching is possible according to the following additional criteria:

• 1. Psychological factors play an important role in the onset, severity, elicitation or maintenance of the itching,
• 2. Greater suffering or marked impairments in social or professional life,
• 3. Preoccupation (in thought and actions) with the itching or state of the skin,
• 4. Search for medical clarification (e.g. allergy testing).

Two groups can be differentiated: generalized somatoform itching (e.g. Pruritus sine materia) and localized somatoform itching.

Generalized Pruritus sine materia (ICD-10: F45.8) is the chronic occurrence of a usually subliminal psychogenic itching. The clinical picture of Prurigo has additional excoriations ( (figure 2) ). The diagnosis of a somatoform pruritus (sine materia) should only be made after careful exclusion of internal diseases (e.g. diabetes, lymphoma, hepatogenic itching etc.). In particular, unclear itching in young men is atypical and may reveal itself as an initial precursor symptom of lymphoma in the sense of a paraneoplastic pruritus.

Characteristically, a tormenting itching of unclear genesis is in the foreground of localized somatoform pruritus, whereby especially the genital or anal area is affected. Genital forms of itching in women used also to be called “widow’s pruritus” (ICD-10: L29.2, F52.9) and thus pointed to the libidinous significance of the syndrome and a (not necessarily unconscious) sexual conflict [38].

Itching can be elicited mentally [39, 40]. The emotional and cognitive perception of itching presents in the following aspects:

• 1. The intensity of itching depends on the attention paid to it and its subjective controllability [41].
• 2. A close relationship between depressivity and itching could be demonstrated in both laboratory studies [39] and in clinical studies on dermatological patients [42].
• 3. Animal-experimental studies confirm that the excretion of histamine, one of the most important itch-eliciting mediator substances, can be classically conditioned [43]. In skin diseases accompanied by the symptom pruritus, questions about elicitors of itching should be raised (stress, burdens, changes in life events).

In addition burning, tingling and stabbing are counted among the other, undifferentiated somatoform disorders. Most often, the patients complain of burning in vague terms (quote: “as if a needle were being stuck in the skin”). The complaints may be localized or generalized and greatly impair the quality of life. In some cases, the patient reacts to tingling or stabbing with autoaggressive manipulation of his own skin with tools or instruments. Secondarily there are then artificial lesions or irritative eczemas due to self-manipulation. A transition to tactile hallucinoses must be watched for and paranoias differential-diagnostically clarified in such cases. Stress, changes in life and current conflicts as well as inhibited rage may be thematized as the elicitor and potentiater of the complaints. Frequently there are comorbidities with affective disorders/ depressivity or anxiety disorders. Additional data are not yet available for this group.

Therapy

In general, a psychosomatic approach can be achieved in part in all somatoform disorders via thematization of the overall current psychosocial situation, coping with the disease, earlier experience with disease and possible serious eliciting situations. In practice, the initial goal is taking the complaints seriously and understanding them as part of psychosomatic primary care. Consultations are directed away from the symptoms toward the psychosocial aspects. ( )

The establishment of a viable doctor/patient relationship under expanded biopsychosocial aspects with structured psychoeducation has also proven valuable for patients. The basis of psychoeducation is imparting psychosomatic concepts as part of information and knowledge about the disease and thus imparting a biopsychosocial model of illness.

Basically, the principles of patient management set forth by Rief and Hiller [44] for medical and psychosomatic treatment can be applied to somatoform disorders/body dysmorphic disorders in dermatological disease. Initial patient management consists of:

• – Creation of a doctor/patient relationship characterized by acceptance and understanding;
• – Imparting of an adequate (preferably multifactorial) explanatory model;
• – Working out of relationships between skin disorders and eliciting emotional and cognitive behavioural therapy as well as unconscious reaction patterns;
• – Preparation for more intensive psychotherapy taking the patient’s motivation into account.

In particular for pain syndromes, the foundation is initially keeping a complaint diary and definition of the complaint intensity by means of the scores of a visual analogue scale (VAS). At the next appointment, the entries can then be discussed with the patient and structured. When and under what conditions the complaints occurred can be recorded in the pain diary. The visual analogue scale helps to record the extent of pain or complaints from the patient’s point of view. With the score, one also has a course control of the success of treatment. Relaxation techniques can provide supportive help [45]. The question of when psychotherapy is indicated in pain syndromes arises from the co-morbidities and existing conflicts as well as from the patient’s motivation.

Using a complaint diary and the visual analogue scale have also proven helpful in somatoform pruritus. Frequently, the patients can recognize the relationships between emotional stress and itching within the framework of psychosomatic primary care. The trigger for somatoform pruritus may arise as a result of emotional conflict situations. Pruritus patients are more than usually open to a biopsychosocial understanding of illness. Even a psychoeducation can contribute to better coping with the symptoms.

In somatising disorders and cutaneous hypochondrias, there are often depressive disorders, anxiety disorders which require supportive, behaviour-therapeutic measures with cognitive restructuring, psychodynamic therapies or pharmacological modes of treatment.

In environment-related physical complaints, the general recommendation to completely avoid the agent considered harmful, or to remove the agent by renovating the apartment, or to remove all amalgam fillings is contraindicated as a sole treatment. It is possible that iatrogenic phobias or hypochondrias arise from correspondingly explicit recommendations or carrying out detoxification cures, for example, including drawing all teeth, and this must be avoided from the start. Interdisciplinary cooperation between medical environmentalists, psychosomatic specialists, allergologists and dermatologists is the key to successful treatment [9].

In BDD, it is important to reach the suspected diagnosis early on. We warn against cosmetic procedures in patients with body dysmorphic disorders, who attempt an apparent cure of the emotional disorders by means of the scalpel. This procedure is attended by the danger of fixation of the patient on a purely somatic understanding of illness and may contribute to the reinforcement and chronification of the emotional disorder.

The efficacy of behavioural cognitive therapy with cognitive restructuring in body dysmorphic disorder has been proven. The success of behavioural programs are presented in some studies with 2-year follow-up [46, 47].

An approach termed integrative psychodynamic psychotherapy was described by Kholmogorova & Garanjan [48], as a combination of cognitive and psychodynamic components especially for somatoform disorders. The psychodynamic therapy approach comprises not only learned behaviour patterns, but also contemplation of a conflict model which is behind the symptoms.

Psychopharmaceuticals

• 1. Unequivocal diagnosis of the emotional main and secondary symptoms;
• 2. Definition of primary target symptoms (clear indication definition);
• 3. Selection of the substance by primary mode of action (desired effect);
• 4. Taking into account undesired side effects and;
• 5. Clear strategy for performance and long-term control (Prior information about side effects, delayed onset of action, dose titration).

In somatoform disorders, there may be a heterogeneous pattern of different emotional disorders ranging up to a transition to psychotic disorders, such as the psychotic form of the body dysmorphic disorder. The target symptoms of psychopharmaceuticals must be selected accordingly. A single, uniform group of medications is hardly indicated.

Drug therapy is in the foreground of the psychotic form of somatoform disorders.

In the non-psychotic type adequate psychotherapy or drug combination therapy, usually with selective serotonin-reuptake-inhibitors (SSRI) is in the forefront of treatment strategy.

One randomized placebo-controlled study with DSM-IV BDD patients evaluated the efficacy and safety of fluoxetine hydrochloride [49]. Also Clomipramine is more effective than desipramine in the treatment of body dysmorphic disorder and is effective even among those patients who are delusional [50].

As a local therapy of a cutaneous pain syndrome, the use of Capsaicin or EMLA- Creme is recommended. Neither has any significant clinical relevance. Treatment with classical analgesics often is without noticeable pain relief in urogenital and rectal pain syndromes. Empirical reports identify antidepressives and relaxation procedures as the therapy of choice [51]. The therapy of cutaneous pain syndromes is currently made taking co-morbidities into account (depressive disorders, anxiety disorders) primarily with SSRI, Doxepin or Amitriptylin. Newer antidepressives like Mitrazapin should possibly be preferred, but no corresponding studies have yet been reported. Among the particular side effects, attention must be paid to anticholinergic side effects with dry mouth, which may potentiate complaints in the mouth, like glossodynia.

Gabapentin appears to be successful in individual cases and offers an alternative to the use of antidepressives in somatoform pain symptoms [52]. Individual reports show good efficacy of Gabapentin in the treatment of glossodynia, which is supposed to be superior to antidepressives without the anticholinergic side effects. The mean dose is 900-1200 mg/d and can be slowly increased to 2400 mg/d.

Individual case reports of Scalp Dyesthesia show depressive and anxiety disorders as comorbidities, whereby antidepressives like SSRI, Doxepin or Alprazolam are preferred as therapy options [53].

Antihistamines are used in somatoform pruritus, whereby non-sedating preparations often do not show sufficient efficacy. Some of the pharmacological properties of the antidepressant agents that are not related to their antidepressant activity, such as the histamine H1 blocking effect of tricyclic antidepressives are of benefit in dermatological conditions such as somatoform pruritus [54]. Sedating antihistaminic-effect drugs (Hydroxyzin) and antidepressives (Doxepin) may be effective in breaking through the vicious circle of itching and depression or itching and scratching. The use of tricyclic antidepressives is also recommended in sensory complaints such as burning, stabbing, gnawing or tingling.

In summary, somatoform disorders in dermatology are a great challenge for the dermatologist. Due to the often clear expectation of somatic treatment on the part of the patient, the dermatologist is often the first person consulted, and it is up to him to reach the suspected diagnosis of a somatoform disorder early on and to initiate an expanded combination therapy. The therapy of somatoform disorders can only be successful when biopsychosocial aspects are taken into account in causality, diagnostics and in therapy.

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