Dermatitis artifacta of tongue: A rare case report.

Dermatitis artifacta is a psychiatric disorder in which the patient deliberately produces self-inflicted skin lesions to satisfy an unconscious psychological or emotional need, often a desire to receive medical treatment. We present a case of a 20-year-old female with pain in abdomen, pain during urination, and multiple skin lesions, mostly in the reach of her dominant hand and in tongue. She gave a history of several episodes of similar illnesses with admission in various hospitals. She was improved with selective serotonin reuptake inhibitor, supportive and insight-oriented psychotherapy.

INTRODUCTION

Dermatitis artifacta is a form of factitious disorder which involves self-inflicted lesions that the patient typically denies of self-induced.[1] The skin lesions serve powerful self-expressive nonverbal messages. It may occur as a cry for help when the patient is faced with psychosocial stressors.[2] Dermatitis artifacta is more common in women than in men (4:1), with the highest incidence of onset in late adolescence to early adulthood.[3] It is often associated with childhood psychological disorders or several physical, emotional, and sexual abuses.[45] Wounds are typically found on easily accessible and openly visible areas of the skin including the limbs, face, and less commonly seen in concealed parts of the body such as abdomen and mouth.[6] Dermatitis artifacta has been associated with dissociative disorders, obsessive compulsive disorders, depression and borderline personality disorders.[7] We present a rare case report of a 20-year-old female with dermatitis artifacta in extremities, abdomen and tongue.

CASE REPORT

A 20-year-old female was brought to the Department of Psychiatry, IMS and SUM Hospital, Bhubaneswar, Odisha, India, by her parents with 4-year history of pain in abdomen, pain during urination and multiple skin lesions (scratching marks) distributed symmetrically in her left hand, arm, neck, abdomen and tongue. Her parents reported that initial lesions appeared over her left hand and arm which healed after a few days on its own and repeated in the same skin area [Figure 1]. Later, the same lesions appeared on her neck, abdomen [Figure 2] and tongue [Figure 3]. The lesions were sudden in onset and there was no history of trauma or pain at the sight of the skin lesions. The patient denied of producing lesions by herself. Her parents gave a history of multiple episodes of similar illnesses with admission in various hospitals and going through various tests. Every time, her investigation reports were found normal. The patient was hospitalized for the psychiatric evaluation and management. According to her parents, she left her studies, not doing any work at home, throws a tantrum when her demands are not met and blaming parents for not taking proper care on her. At times, she is urinating and defecating on bed. She is very short-tempered and threatening to commit suicide. On mental status examination (MSE)s, she was guarded, avoided eye contact, denied of self-infliction, and was indifferent to skin lesions. Psychological assessment revealed low mood, low self-esteem, poor concentration, anxiety and depressive features, adjustment problems, severe conflicts in family and interpersonal areas, somatic symptoms, etc. Initially, she denied self-inflicting behavior, but after repeated probing, she admitted and described her stressful events in college, stress related to studies, and her conflicts with family members. She was prescribed 10 mg of escitalopram and 1 mg of risperidone per day with support and insight-oriented therapy. Gradually, her scratching behavior was reduced. After her discharge from the hospital, she was followed up for 2 months and also coming for therapy in 2-weeks interval and doing well.

Figure 1

Parallel multiple scratch marks in the extremities done by the right hand

Figure 2

Parallel scratch marks seen in the abdomen done by the right hand and fingers having sharp nails

Figure 3

Scratch marks in tongue allotted with arrow

DISCUSSION

Psychocutaneous disorders encompass a wide variety of dermatological diseases that may be affected by the presence of psychiatric illness or symptoms and stresses in which the skin is the target of the disordered thinking, behavior, and perception. The self-mutilating behavior often serves as an extreme form of nonverbal communication, an appeal for help and usually occurs in patients with poor coping skills, often represents a maladaptive response to psychological stressors. This disorder is a type of factitious disorder according to the Diagnostic and Statistical Manual of Mental Disorders-IV diagnostic criteria.[8]

The case discussed above denies about the self-inflicted lesions, indifferent to symptoms or how these lesions appeared and presented a hallow history. Most of the lesions are seen in the left hand, arm, and in the same places overlapping, also on the areas of body accessible for the right hand.[9] Though it is very rare to find the lesions in mouth, we found scratch marks in her tongue. The underlying causes may be due to frustration or failure in academics, psychosocial stressors, low self-esteem and confidence, interpersonal conflicts, adjustment difficulties which further induce depression, anxiety and somatic pains. The unconscious desire may to deceive others, to play a sick role to escape from responsibilities, to get support, attention, pity and sympathy from parents, relatives and friends. Whenever she becomes more anxious and depressed, it exacerbates skin lesions by eliciting scratching behavior and the depressive symptoms appear to amplify the itching perception, mother's overprotective behavior may further reinforce the scratching behavior. Patients appear to produce skin lesions as an outlet for tension arising from interpersonal conflicts and unresolved emotional problems, compelling family members to seek medical care. The clinical presentation is characteristically differing from delusional disorders, malingering, and Munchausen's syndrome.[10]

CONCLUSION

Dermatitis artifacta is the intentional production of physical or psychological symptoms with the objective of assuming sick role. As with all factitious disorders, patients with dermatitis artifacta waste their precious time and resources with unnecessary tests and hospital visits. In this regard, knowledge about the disorder, its origin, cause, course, and progression can help patients and their family members to reduce hospital visits. Dermatitis artifacta is a challenging condition, but when patient's life circumstances have changed, improvements can be seen. They can be helped by creating a therapeutic relationship, flexible, nonjudgmental and nonthreatening environment by providing dermatological assessment with psychiatric consultation and most importantly psychosocial support.

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Conflicts of interest

There are no conflicts of interest.