doi: 10.1111/j.1365-4632.2005.02451.x
Case report Oxford, UK International IJD Blackwell 1365-4632 45 Publishing, Publishing Journal Ltd, of Ltd. Dermatology 2004
Dissociative identity disorder presenting as dermatitis artefacta Dissociative Ozmen CAMEO et al.identity disorder presenting as dermatitis artefacta
Mine Ozmen, MD, Ayten Erdogan, MD, Ertugrul H. Aydemir, MD, and Oya Oguz, MD
From the Department of Psychiatry, Consultation-Liaison Division, and the Department of Dermatology, Istanbul University, Cerrahpasa Medical Faculty, Istanbul, Turkey Correspondence Mine Ozmen, MD Istanbul University Cerrahpasa Medical Faculty Department of Psychiatry Consultation-Liaison Division Cerrahpasa Cad, Kocamustafapasa, 34230 Istanbul, Turkey E-mail:
[email protected]
Dermatitis artefacta is a rare psychiatric condition characterized by rubbing of skin blisters and denial of self-infliction. Dissociation may be comorbid with self-injurious behavior. A background of emotional disturbances during formative years and in later life often results in feelings of isolation and insecurity, which can lead to dissociation as a primary defense mechanism used to overcome traumatic events. In this case report, we describe a female patient with dermatitis artefacta associated with dissociative identity disorder. The patient was a 14-year-old girl. Multiple large, deep ulcerations with unnatural shapes were seen on her left forearm. The ulcerations were thought to be self-inflicted. Psychiatric examination revealed that she had a different identity, and inflicted the lesions when this was assumed. This case leads us to suggest that patients with dermatitis artefacta might have comorbid dissociative experiences, which cannot be identified easily.
Introduction Dermatitis artefacta is a very varied group of self-inflicted dermatoses. Patients cannot provide descriptive details of the evolutionary stages of the lesions but deny self-infliction. Early diagnosis is important to prevent unnecessary drug therapy, repeated surgical procedures and chronic morbidity.1–4 Dissociative identity disorder (DID) is characterized by the presence of two or more distinct identities that recurrently take control of the person’s behavior.5 DID is thought to develop when a child cannot flee from overwhelming violence or trauma.7 In these situations, children may develop alternate identities to allow them to adapt to the traumatic circumstances and live with otherwise intolerable affects. In other words, dissociation is a way of emotional survival, which accompanies a range of psychiatric disorders and is highly comorbid with suicidal and self-mutilative behaviors.6–11 In this report, we present the case of a female patient with “dermatitis artefacta” associated with DID.
In the initial psychiatric interview, the patient strongly denied that she had ever touched the ulcerations. Since she was not thought to have DID, no questions about dissociative experiences were asked. During the third interview, an alter personality appeared spontaneously and admitted scratching her scar. She loved to feel pain, and described it as a “tremendous feeling”. When she was confronted with the possibility of loosing her arm, she answered that she would love it. It gradually became clear that she had an unconscious wish to punish herself and, whenever the alter personality took control, she would force others to attack her or would order herself to mutilate her body.
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A 14-year-old female patient was found to have multiple bizarreshaped ulcerations on her left forearm (Fig. 1). The lesions appeared after a superficial burn during cooking 9 months ago. By keeping closed, the ulcers had become smaller, but never resolved entirely, and then enlarged again into lesions of different shapes and sizes. Since the ulcerations were thought to be self-inflicted, a psychiatric consultation was recommended. International Journal of Dermatology 2006, 45, 770 – 771
Figure 1 Multiple bizarre-shaped ulcerations on the left forearm
found during the first examination © 2005 The International Society of Dermatology
Ozmen et al.
She had lost her mother 2 years ago, and had felt lonely and guilty afterwards. She was sexually abused by a neighbor 1 year ago, and felt shame and guilt, and was unable to tell anybody. Around the same time, against her wishes, her family decided to stop her education, as a consequence of cultural attitudes towards girls in some rural areas of Turkey. Thereafter, the furious alter personality emerged. During the psychiatric examination she was silent and avoidant, and gave short answers to questions. Her mood was depressive. She did not have delusions, hallucinations, or disorganized patterns of associations, speech or behavior. According to school records she was thought to have a moderate intellectual capacity. There was no history of drug or alcohol use. After 10 weekly sessions of psychotherapy and sertaline treatment, the alter personality agreed not to mutilate herself but to talk about her feelings instead. The ulcers started to improve. Inpatient treatment was planned but could not be arranged since the family had to return to their home town. Discussion To our knowledge there is only one previous case report of underlying dissociative pathology and dermatitis artefacta.12 Dermatitis artefacta may masquerade as numerous clinical entities and should be included in the differential diagnosis of skin lesions. The presence of dermatological nondisease, exacerbation of pre-existing chronic skin disease and lesions out of proportion to the skin disease should particularly alert the physician to the possibility of underlying psychological problems.13 This patient’s amnesia about her past, and the emergence of an alter personality with different ways of thinking about the self and environment led to the diagnosis of DID. This case suggests that patients with dermatitis artefacta might have comorbid dissociative experiences that are responsible for the skin lesions, and which cannot be identified easily.
© 2005 The International Society of Dermatology
Dissociative identity disorder presenting as dermatitis artefacta Case report
References 1 Van Moffaert M, Vermander F, Kint A. Dermatitis artefacta. Int J Dermatol 1985; 24: 236 –238. 2 Gupta MA, Gupta AK. Dermatitis artefacta and sexual abuse. Int J Dermatol 1993; 32: 825 – 826. 3 Doran AR, Roy A, Wolkowitz OM. Self-destructive dermatoses. Psychiatr Clin North Am 1985; 8: 291–298. 4 Koblenzer CS. Dermatitis artefacta. Clinical features and approaches to treatment. Am J Clin Dermatol 2000; 1: 47–55. 5 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 4th edn. Washington, DC: American Psychiatric Association Publications Division, 1994; 484–487. 6 Kisiel CL, Lyons JS. Dissociation as a mediator of psychopathology among sexually abused children and adolescents. Am J Psychiatry 2001; 158: 1034–1039. 7 Putnam F. Dissociative disorders in children and adolescents. A developmental perspective. Psychiatr Clin North Am 1991; 14: 519 –531. 8 Tutkun H, Yargic LI, Sar V. Dissociative identity disorder. Clinical investigation of 20 cases from Turkey. Dissociation 1995; 8: 3– 9. 9 Pfeffer CR, Martins P, Mann J, et al. Child survivors of suicide: psychological characteristics. J Am Acad Child Adolesc Psychiatry 1997; 36: 65– 74. 10 Simpson CA, Porter GL. Self-mutilation in children and adolescents. Bull Menninger Clin 1981; 45: 428–438. 11 Van der Kolk BA, Perry JC, Herman JL. Childhood origins of self-destructive behavior. Am J Psychiatry 1991; 148: 1665–1671. 12 Shelley WB. Dermatitis artefacta induced in a patient by one of her multiple personalities. Br J Dermatol 1981; 105: 587–589. 13 Koblenzer CS. Neurotic excoriations and dermatitis artefacta. Dermatol Clin 1996; 14: 447–455.
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