Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5254_Библиотеки_им_академика_М_И_Перельмана.pdf
18
Table 2.1 Dermatological classication of psychocutaneous diseases. (Modied, from Ref. [1])
1. Self-inicted cutaneous disorders whose nature is denied or hidden
A.Factitious disorders without external incentives (psychiatric disorders with cutaneous
symptoms)
Dermatitis artefacta
Dermatological pathomimicry (in part)
Gardner-Diamond syndrome
Münchausen syndrome
Münchausen syndrome by proxy
Dermatitis simulata
Dermatitis passivata (“Diogenes syndrome”)
B.Factitious disorders with external incentives (malingering)
Malingering in adolescents
Malingering in soldiers
Occupational dermatitis artefacta
Dermatitis artefacta with patch test artefacts
Witchcraft syndrome
Secrétan syndrome (in part)
Dermatological pathomimicry (in part)
Religious stigmata as malingering artefacts
2. Cutaneous disorders with a non-denied and non-hidden behavior (impulsive/compulsive
disorders)
Psychogenic pruritus
Lichen simplex
Prurigo nodularis
Acne excoriée
Trichotillomania
Trichoteiromania
Trichotemnomania
Onychophagia
Onychotillomania
Onychotemnomania
Cheilitis factitia
Morsicatio buccarum
Pseudo-knuckle pads
Rhinotillexomania
3. Cutaneous diseases precipitated or perpetuated by emotional factors (psychosomatic or
psychophysiological disorders)
Acne
Hemangiomas and vascular malformations
Vitiligo
Albinism
Chronic eczema
G. Angelini et al.
(continued)
2 Psychocutaneous Diseases
Table 2.1 (continued)
Atopic dermatitis
Psoriasis
Seborrheic dermatitis
Vesicular eczema of palms and soles
Alopecia areata
Hyperhidrosis
Urticaria and angioedema
Aphthosis
Flushing reactions and rosacea
4. Psychiatric disorders without signicant dermatological disease
A.Delusional syndromes
Parasitosis
Smell
Impregnations and contamination
Folie à deux
Morgellons syndrome
B.Disorders of body awareness
Body dysmorphic disorders
Psychogenic pruritus
Phobias:
Venereophobia
Parasitophobia
Steroid phobia
Compulsive behaviors:
Hand washing
Pain disorders:
Glossodynia
Vulvodynia
Scrotodynia
Anodynia
Drug-dependence syndromes:
Alcohol-related syndrome
Substance abuse
Psychosis and skin cancer
Cutaneous disorders due to psychopharmacological medicaments
5. Group and mass population reactions
Sick building syndrome
Epidemic hysteria
19
Ideally, these patients should be assessed in a psychodermatology clinic, by an
interdisciplinary team including dermatologists, psychologists, and psychiatrists
[8]. The treatment aims must be not only to reduce or resolve the cutaneous symptoms, eliminate sleep disturbances, boost self-esteem, and cure anxiety and
20
Table 2.2 Interrelation between psychocutaneous disorders and underlying personality disorders
Psychocutaneous disorders Personality disorders
Factitious disorders with a non-denied and non-hidden behavior Obsessive-compulsive
Factitious disorders with a denied and hidden behavior without
external incentives
Body awareness disorders Narcissistic personality
behavior
Borderline personality
disorder
Narcissistic personality
disorder
Borderline personality
disorder
disorder
G. Angelini et al.
depression, but also to improve the patient’s relational life. The various treatments,
both pharmacological and non pharmacological therapy, can be used alone or in
combination, depending on the assessment of the individual patient and his or her
individual needs.
The management of patients with personality disorders is quite challenging.
However, a joint liaison between psychiatry and dermatology has proven very helpful to patients. In a study by Raikhy and Coll., 36.32% of dermatological patients
presented depression, while in 18.61% of patients an anxiety disorder was diagnosed [50]. These gures underline the importance of the liaison among different
specialists. There are ten specic personality disorders; in dermatological clinical
practice, however, the most common are borderline, narcissistic, and obsessivecompulsive personality disorders [36]. Self-inicted cutaneous disorders of a nondenied and non-hidden nature, such as trichotillomania, onychotillomania, face
picking (acne excoriée), and rhinotillexomania, are commonly associated with
compulsive-obsessive behavior although they can also be linked to borderline personality and narcissistic personality disorders [36]. Patients with factitious disorders of a denied or hidden nature and not prompted by external incentives (dermatitis
artefacta), who tend rstly to resort to a visit to the dermatologist, come into the
borderline personality disorder category [51–53]. Subjects who need admiration
and seek grandiosity, who are often among those who request cosmetic procedures,
belong to the narcissistic personality disorder category (Table2.2) [54–59].
Based on the above considerations, and in view of the considerable percentage of
dermopatients with psychiatric disturbances, it is essential that the dermatologist be
familiar with the most common personality disorders, as well as working in close
collaboration with psychiatrists and psychologists in order to ensure the optimal
management of these patients [36, 60].
References
1. Millard LG, Millard J.Psychocutaneous disorders. In: Burns T, Brethnach S, Cox N, etal.,
editors. Rook’s textbook of dermatology. 8th ed. Oxford: Wiley-Backwell; 2010:chap.64.1-55.
2 Psychocutaneous Diseases
2. Rieder E, Tausk FA.Psychocutaneous skin diseases. In: Goldsmith LS, Katz SJ, Gilchrest BA,
etal., editors. Fitzpratick’s dermatology in general medicine. 8th ed. NewYork: McGraw-Hill;
2012. p.1158–66.
3. Linder D, Bassi R.Psyche and skin. In: Giannetti A, Del Forno C, editors. Textbook of dermatology and sexually transmitted diseases. Padova: Piccin Nuova Libreria, S.P.A.; 2013.
p.431–41.
4. Bewley A, Lepping P, Taylor RE. Psychodermatology in clinical practice. Switzerland A6:
Springer Nature; 2021.
5. Jafferany M.Handbook of psychodermatology. Introduction to psychocutaneous disorders.
Switzerland A6: Springer Nature; 2022.
6. O’Sullivan RL, Lipper G, Lerner EA.The neuro-immuno-cutaneous-endocrine network: relationship of mind and skin. Arch Dermatol. 1998;134:1431–5.
7. Jafferany M, Franҫa K. Psychodermatology: basics concepts. Acta Derm Venereol.
2016;96:35–7.
8. Jafferany M, Ferreira BR, Abdelmaksoud A, etal. Management of psychocutaneous disorders:
a practical approach for dermatologists. Dermatol Ther. 2020;33:e13969.
9. Jafferany M, Ferreira BR, Patel A. The essentials of psychodermatology. Cham: Springer
International Publishing; 2020. p.29–34.
10. Kuhn H, Mennella C, Magid M, etal. Psychocutaneous disease: clinical perspectives. J Am
Acad Dermatol. 2017;76:779–91.
11. França K, Chacon A, Ledon J, Savas J, Nouri K.Psychodermatology: a trip through history.
An Bras Dermatol. 2013;88:842–3.
12. Jafferany M.Psychodermatology: a guide to understanding common psychocutaneous disorders. Prim Care Companion J Clin Psychiatry. 2007;9:203–13.
13. Jafferany M, Franҫa K.The interface between geriatrics, psychiatry and dermatology. In:
Jafferany M, Franҫa K, editors. Geriatric psychodermatology: psychocutaneous disorders in
the elderly. NewYork: Nova Science Publishers; 2015. p.3–7.
14. Korabel H, Dudek D, Jaworek A, etal. Psychodermatology: psychological and psychiatrical
aspects of dermatology. Przegl Lek. 2008;65:244–8.
15. Tran A, Desir AK, Okafor LC, etal. Psychodermatology in clinical practice: an examination
of physician attitudes, beliefs, and interventions toward psychocutaneous disease. Dermatol
Ther. 2020;33:e13612.
16. Picari A, Albeni D.Stressful life events and skin diseases: disentangling evidence from myth.
Psychother Psychosom. 2011;70:118–36.
17. Dhabhar FS.Psychological stress and immunoprotection versus immunopathology in the skin.
Clin Dermatol. 2013;31:18–30.
18. Tohid H, Shenefelt PD, Burney WA, etal. Psychodermatology: an association of primary psychiatric disorders with skin. Rev Colomb Psiquiatr. 2019;48:50–7.
19. Lonne-Rahm SB, Rickberg H, El-Nour H, etal. Neuroimmune mechanisms in patients with
atopic dermatitis during chronic stress. J Eur Acad Dermatol Venereol. 2008;22:11–8.
20. American Academy of Dermatology. Managing stress can help people improve their skin conditions. Available from http://www.aad.org/storics- and- news/news- releases/managing- stress-
can- help- people- improve- their- skin- conditions. Accessed 2 Oct 2012.
21. Slominski A, Mihm MC. Potential mechanism of skin response to stress. Int J Dermatol.
1996;35:849–51.
22. Dave ND, Xiang L, Rehm KE, etal. Stress and allergic diseases. Immunol Allergy Clin North
Am. 2011;31:55–68.
23. Jafferany M, Salimi S, Mkhoyan R, etal. Psychological aspects of aesthetic and cosmetic
surgery: clinical and therapeutic implications. Dermatol Ther. 2020;33:e13727.
24. Ha B, Uvais NA, Jafferany M, etal. Palliative psychodermatology care during COVID-19
pandemic. Dermatol Ther. 2020;3:e13732.
25. Jafferany M, Patel A.Understanding psychocutaneous disease: psychosocial and psychoneuroimmunologic perspectives. Int J Dermatol. 2019;59:8–15.
21
22
26. Engel GL.From biomedical to biopsychosocial. 1. Being scientic in the human domain.
Psychother Psychosom. 1997;66:57–62.
27. White P.Biopsychosocial medicine. Oxford: Oxford University Press; 2005.
28. Koo JYM, Lee CS.General approach to evaluating psychodermatological disorders. In: Koo
JYM, Lee CS, editors. Psychocutaneous medicine. New York: Marcel Dekker, Inc.; 2003.
p.1–29.
29. American Psychiatric Association. Diagnostic and statistical manual of mental disorders.
DSM-V. 5th ed. Arlington: American Psychiatric Association; 2013.
30. International classication of diseases. Tenth revision (ICD-10); 2010. Available from: http://
www.whp.int/classication/icd.Geneva. Cited 2022, Ang 28.
31. Koblenzer CS. Psychosomatic concepts in dermatology. A dermatologist-psychoanalyst’s
viewpoint. Arch Dermatol. 1983;119:501–12.
32. Gupta MA, Gupta AK. Self-induced dermatoses: a great imitator. Clin Dermatol.
2019;37:268–77.
33. Medansky RS, Handler RM.Dermatopsychosomatics: classication, physiology, and therapeutic approaches. J Am Acad Dermatol. 1981;5:125–38.
34. Musalek M, Hable B, Mossabacher U. Diagnostics in psychodermatology. Dermatol
Psychosom. 2011;2:110–5.
35. Gieler U, Consoli SG, Tomás-Aragones L, etal. Self-inicted lesions in dermatology: terminology and classication—a position paper from the European Society for Dermatology and
Psychiatry (ESDaP). Acta Derm Venereol. 2013;93:4–12.
36. Jafferany M, Afrin A, Mkhoyan R, etal. Therapeutic implications of personality disorders in
dermatology. Dermatol Ther. 2020;33:e13910.
37. Patel A, Jafferany M. Multidisciplinary and holistic models of care for patients with dermatologic disease and psychosocial comorbidity: a systematic review. JAMA Dermatol.
2020;156:686–94.
38. Gould WM, Gragg TM. A dermatology-psychiatry liaison clinic. J Am Acad Dermatol.
1983;9:73–7.
39. Woodruff PW, Higgins EM, du Vivier AW, et al. Psychiatric illness in patients referred to a
dermatology-psychiatry clinic. Gen Hosp Psychiatry. 1997;19:29–35.
40. Fritzsche K, Ott J, Zschocke I, etal. Psychosomatic liaison service in dermatology. Need for
psychotherapeutic interventions and their realization. Dermatology. 2001;203:27–31.
41. Misery L, Chastaing M. Joint consultation by psychiatrist and a dermatologist. Dermatol
Psychosom. 2003;4:160–4.
42. Deshponde SS, More Y, Gokhale NR. Identication and management of psychiatric comorbidities in dermatological disorders. Malay J Psychiatry. 2015;24:1–6.
43. Altaf K, Mohandas P, Marshall C, et al. Managing patients with delusional infestations in an
integrated psychodermatology clinic is much more cost-effective than a general dermatology
or primary care setting. Br J Dermatol. 2017;177:544–5.
44. Goulding JMR, Harper N, Kennedy L, etal. Cost-effectiveness in psychodermatology: a case
series. Acta Derm Venereol. 2017;97:663–4.
45. Seale L, Gaulding JV, Porto D, etal. Implementation of a psychodermatology clinic at a major
health system in Detroit. Int J Womens Dermatol. 2018;4:227–9.
46. Franger K, Mahmud M. Doctor-patient relationship in geriatric psychodermatology. In:
Jafferany M, Franҫa K, editors. Geriatric psychodermatology: psychocutaneous disorders in
the elderly. NewYork: Nova Science Publishers; 2015. p.9–13.
47. Kuhn H, Mennella C, Magid M, etal. Psychocutaneous disease: Pharmacotherapy and psychotherapy. J Am Acad Dermatol. 2017;76:795–808.
48. Reichenberg JS, Kroumpouzos G, Magid M.Approach to a psychodermatology patient. G Ital
Dermatol Venereol. 2018;153:494–6.
49. Shah RB.Psychological assessment and interventions for people with skin disease. In: Bewley
A, Taylor RE, Reichenberg JS, et al., editors. Practical psychodermatology. Oxford, UK:
Wiley-Blackwell; 2014. p.40–9.
G. Angelini et al.
2 Psychocutaneous Diseases
50. Raikhy S, Gautam S, Kanodia S. Pattern and prevalence of psychiatric disorders among
patients attending dermatology OPD.Asian J Psychiatr. 2017;29:85–8.
51. Briere J, Gil E.Self-mutilation in clinical and general population samples: prevalence, correlates, and functions. Am J Orthopsychiatry. 1998;68:609–20.
52. Chatterjee SS, Mitra S.Dermatitis artefacta mimicking borderline personality disorder: sometimes, skin could be misleading. Clin Psychopharmacol Neurosci. 2016;14:311–3.
53. Harth W, Mayer K, Linse R. The borderline syndrome in psychosomatic dermatology.
Overview and case report. J Eur Acad Dermatol Venereol. 2004;18:503–7.
54. Loron AM, Ghaffari A, Poursafargholi N. Personality disorders among individuals seeking
cosmetic botulinum toxin type A (BoNTA) injection, a cross-sectional study. Eurasian J Med.
2018;50:164–7.
55. Koblenzer CS. Body dysmorphic disorder in the dermatology patient. Clin Dermatol.
2017;35:298–301.
56. Phillips KA, Dufresne RG Jr, Wilkel CS, etal. Rate of body dysmorphic disorder in dermatology patients. J Am Acad Dermatol. 2000;42:436–41.
57. Bowe WP, Leyden JJ, Crerand CE, etal. Body dysmorphic disorder symptoms among patients
with acne vulgaris. J Am Acad Dermatol. 2007;57:222–30.
58. Bjornsson AS, Didie ER, Grant JE, etal. Age at onset and clinical correlates in body dysmorphic disorder. Compr Psychiatry. 2013;54:893–903.
59. Afeck A, Stewart M.Body dysmorphic disorder in dermatology: beware of diagnostic overlabelling. Clin Exp Dermatol. 2016;41:214–5.
60. Azambuja RD.The need of dermatologists, psychiatrists and psychologists joint care in psychodermatology. An Bras Dermatol. 2017;92:63–71.
23
Chapter 3
Self-Inicted Skin Disorders: Diagnosis
andManagement
GianniAngelini, AuroraDe Marco, andDomenicoBonamonte
Self-inicted skin disorders (SISD) belong to the vast group of self-inicted disorders (SID) that can be observed in all branches of specialist medicine.
SID, or factitious (from the Latin factitious: articial, not natural, artful, selfinduced) [1] diseases, are dened as a “falsication of physical or psychological
signs or symptoms, or induction of injury or disease, associated with identied
deception” [2]. Factitious disorders are, therefore, psychiatric disorders in which
patients intentionally fabricate psychological or physical symptoms in order to
acquire the role of patient affected by a disease [3–5].
3.1 General Clinical Remarks
In accordance with the DSM-5 and the eleventh revision of the International
Classication of Diseases, most patients with SID are not, in fact, actuated by
motives of external gain [2, 6]. On the contrary, in cases of malingering the selfinicted disorder is motivated by clear external rewards or incentives, in order to
avoid various duties (e.g. military service) or a prison sentence, or else to gain some
advantage, usually of an occupational nature [6–13].
The motivations of patients with SID are often complex and not always entirely
intelligible. In general, such subjects are driven by a more or less conscious need for
G. Angelini
Dermatology, University of Bari “Aldo Moro”, Bari, Italy
e-mail: gianniang@alice.it
A. De Marco · D. Bonamonte (
Department of Precision and Regenerative Medicine and Ionian Area, University of Bari
“Aldo Moro”, Bari, Italy
e-mail: a.demarco24@studenti.uniba.it; domenico.bonamonte@uniba.it
Switzerland AG 2024
G. Angelini et al. (eds.), Psychocutaneous Diseases,
https://doi.org/10.1007/978-3-031-70296-9_3
*)
25© The Author(s), under exclusive license to Springer Nature
26
G. Angelini et al.
affection and care, and so for this purpose they often have recourse to medical treatments and surgical procedures [14]. In this sense, an emblematic case is that of a
patient who underwent 42 surgical procedures in the course of 850 admissions to
650 different hospitals [15]. Inevitably, such behaviour exposes them to a considerable risk of iatrogenic harm [16] and even, in rare cases, of a possible fatality
[17–19]. And of course, the impact of such behaviour on health care costs is quite
heavy [3, 20, 21]. Another problem is that patients with SID can have a heavy psychological impact on the hospital staff, that may feel they are being deceived in
some way [22], or else that the patient is manipulating their emotions and making
them feel guilty [23]. Sometimes, the patient with SID can also feel some satisfaction when observing the doctor’s evident difculties in making a diagnosis and prescribing treatment [24].
Although they have been known for centuries, the rst extensive study of SID
was made by Asher in the context of the Münchausen syndrome, named after the
eighteenth century European aristocrat Hieronymus Karl Friedrich, Baron von
Münchausen (1720–1797) [25]. Since then, the term Münchausen syndrome, that
refers to a particular picture of severe, chronic SID, is often used interchangeably
with factitious. Other names for SID in the literature, often mocking or derisive, are
“hospital hopper syndrome”, “hospital hobo syndrome”, “thick chart syndrome”,
and “black hole syndrome” [3].
The precise prevalence of SID is not known but ranges from 0.02% to 3% in the
general clinical population [26–31]. A recent study of factitious disorders, conducted in Germany and Norway in somatic hospitals from 2008 to 2016, reported a
comparable incidence, of 3.71% and 3.18% per 100,000 patients, respectively [32].
Subjects with SID have been reported all over the world, but in particular in the
United States and Europe [3]. Various studies show a prevalence in the female gender, with percentages ranging from 65.4%, 66.2% [3], to 73.5% [5]. Subjects with
SID tend to come to medical attention already as young adults. The mean age ranges
from 32 [3], 33.5 [33], to 38.4 [5] years, excluding young subjects and minors under
the age of 18years. The mean age is generally lower in females.
A number of studies show a preponderance of patients employed in the health
care sector; this suggests that health care work may be a risk factor when associated
with stressful life events [33–35]. Such health care work includes nursing, but also
medical assistants, pharmacists, administrators, and nutritionists [4].
From the literature, a preponderance of comorbidities with personality disorders,
in particular borderline personality disorders and depression, also emerges [3–5, 33,
36, 37]. Overall, these epidemiological data describe the SID phenotype: young
women with health care experience and psychopathology [4, 38, 39].
In an analysis of a wide sample of patients, Yates and Feldman found that 58.7%
of subjects with factitious disorders prefer to induce the illness or injury rather than
simulating it (19.1%) or falsely referring (22.2%) a medical problem [3]. Therefore,
these patients are at high risk of self-injury, and this risk must be taken into account
in the patient management plan: family members, partners, and friends must be
informed and involved in the management, so as to control the patient’s access to
various harmful tools and substances (drugs, poisons) that can be employed for
3 Self-Inicted Skin Disorders: Diagnosis andManagement
27
self-injury. However, these patients sometimes use methods of self-injury that are
difcult to control, such as abuse of insulin to induce hypoglycaemia, or selfvenesection to provoke anaemia [3]. Once again, therefore, early detection of SID is
very important to limit self-harm and promote improved outcomes. In this regard,
special guidelines are needed to show how a self-inicted injury can be diagnosed
by the clinician and how such injuries can be detected early on, in the relative medical specialty eld [3].
Patients with SID can induce diseases in various ways, depending on their level
of imagination, medical knowledge, and on the nature of the problem they wish to
produce [40]. The same patient can actually use various different methods at once
to create different diseases, for example, an ulcerative dermatological lesion using
metal tools or caustic substances as well as haematuria by adding blood to urine
samples. In all cases, however, a certain diagnosis of a simulated disease is difcult
to make and must always follow a complete series of clinical examinations and
laboratory tests.
All medical specialists may nd themselves in the position of needing to manage
patients with an SID.In literature, the data on the predominance of cases in one
specialty rather than another are conicting. This variability may be due to a different interest in diagnosing SID in the various medical branches. Alternatively, it may
be explained by the difculties related to making a diagnosis of SID in the various
specialist sectors. A simulated disease can be diagnosed more easily in dermatology, owing to the particular morphological features of self-inicted lesions, or in
endocrinology because a factitious hypoglycaemia can be revealed by laboratory
tests of insulin abuse [7, 10–12, 41–47]. Clearly, the greater frequency of one type
of simulation than another also depends on the fact that it is easier for the patient to
induce skin damage or an endocrinological problem than to act on other organs or
systems.
Whatever the true distribution of SID cases in the various specialist elds, bearing in mind the ample volume of literature on this subject it is important that all
specialists be aware of this problem, and especially dermatologists, neuropsychiatrists, and endocrinologists.
In any case, it is clear from the literature that dermatology is the specialty with
the highest number of cases of SID [5, 48], or at least one of the specialties with the
highest incidence [3]. The lower dermatological incidence reported in some studies
could depend on the patients sample enrolled: it should be remembered that patients
presenting with SID in dermatology are more often under ambulatorial management. Thus, such patients would not be included in studies of only hospital patients
[5]. The medical branches with the lowest incidence of SID seem to be obstetrics
and gynaecology [3], as well as oncology [3, 49–51]: it is difcult to achieve simulation in the former elds, and not easy to convince the physician of the existence of
a cancer unless specic imaging tests show some signs.
It is also likely that the incidence of SID is underestimated in the general population. Clinicians are led to believe the clinical history referred by the patient and, in
any case, have little familiarity with SID.And even in cases of suspected SID, it
remains difcult to make a denitive diagnosis of simulation, also in view of the
28
G. Angelini et al.
medico-legal problems that such a diagnosis can provoke, when needing to differentiate between true simulating (malingering) and psychosomatic disease [52]. It
can also be difcult to differentiate SID from a simple exaggeration or amplication
of the symptoms [5]. A certain reluctance to make a diagnosis of an SID has also
been reported, even in cases with strong evidence of simulation [39]. It must be
remembered, however, that failure to diagnose an SID can lead to the prescription
of unnecessary tests that may also be potentially harmful [5].
Other important characteristics among patients with SID are the denial of selfharm, refusal to accept a diagnosis of self-inicted pathology, and refusal in most
cases to undergo psychiatric consultation or treatment. This anomalous behaviour is
inevitably accompanied by failure of all treatments and a high disease recurrence.
In conclusion, SID are one of the most challenging problems in clinical medicine
and warrant further in-depth study. It is important that general practitioners and the
various specialists be fully aware of this major medical problem.
3.2 Self-Inicted Disorders inDermatology
SISD are due to excessive manipulation of the skin and appendages, hair, and nails.
This anomalous behaviour is typically repetitive, and it is this reiteration that generally leads to chronic damage. Manipulation of the skin can cause a de novo disease,
or else complicate the course of a primary dermatological condition, as in the cases
of pre-existing acne, psoriasis, and other itchy skin conditions [53–55].
In cases of trichotillomania and skin picking, as well as being repetitive, the
nature of the behaviour is “automatic”, in the sense that the patient is often unaware
of doing it. These disorders are described as “stereotypic”: the motor behaviour
interferes with the patient’s normal activity and nally results in self-inicted injury,
that is often severe enough to require medical treatment [53].
Another important aspect of the problem is the observation of several SISD
together: in more than 38% of adults, skin picking is associated with trichotillomania, and in more than 20% of cases, hair pulling, or skin picking are associated with
compulsive nail biting [56–58].
Self-induced dermatoses are inicted using multiple different means, for different purposes [59–71]. They are among the most frequent self-inicted disorders in
medicine, in particular because the use of an exogenous mechanism to induce an
artefact is not only easier than an endogenous mechanism, but also allows the disease to become “manifest” to all; this is the true reason motivating the whole artefactual procedure. The adoption of an exogenous mechanism, moreover, allows the
patient to choose the cutaneous site very carefully, to avoid affecting the whole
organism (as may occur in the case of a self-inicted systemic disease), and to stop
the harmful action when he/she wishes [7, 10, 43–45, 72–75].
In the great majority of cases, the simulation of a cutaneous disorder is dictated
by psychiatric problems: in such an event, the subject desires to attract the attention
of those around him, in particular the general practitioner, or else is reacting to a