Self-Injury Of The Nails And Hands
1Department of Dermatology, Baylor College of Medicine
Patients who pull out their hair, excoriate, scar, bite, pick and harm their own skin often present to the dermatologist rather than the psychiatrist. It is estimated that up to 30% of all dermatology patients have a neuro-psychiatric disorder that may contribute to their skin disease. Dermatologists should become acquainted with common psychiatric diagnoses such as depression, anxiety, obsessive-compulsive disorder, monosymptomatic hypochondriacal psychosis, Tourette syndrome, etc. Emphasis is on clinical office diagnosis, treatment, both pharmacological and behavioral, and when and how to refer. New treatment modalities, such as SSRI¹s and atypical antidepressants, may allow dermatologists to offer medical intervention without the need to seek the often-unobtainable psychiatric referral.
Self-injury to the fingers and hands is both conscious and sub-conscious. Thumb sucking is nearly ubiquitous in infants but is abandoned by most children by the age of six. When prolonged it can lead to nail and dental deformity. Onychophagia or nail biting is practiced in up to 50% of children, peaking between the ages of 10 and 18 years.[1 ]Other forms of self-injury to the nail include picking at nail plates, cuticles, and nail folds, onychotillomania or tearing the nail plate and pulling it out, and tapping the tops of the fingernail plates with the index fingers. This tapping may cause a midline longitudinal canal in a "Christmas tree" pattern known as median nail dystrophy, dystrophia unguis mediana canaliformis, or solenonychia.
Classification of negative, self-injurious behavior depends on the severity of the damage perpetrated on the body, the underlying psychopathology, and the amount of distress or gain provoked by the action. Categories that can explain self-injury are 1) habit, 2) tic, 3) obsessive-compulsive disorder, 4) masked depression, 5) impulse disorder, 6) psychosis, 7) dementia, 8) autism, 9) attention getting (secondary gain) behavior, etc.
Questions that may be helpful in elucidating the cause of the self-injury are:
Depression And Bipolar Questions
Dementia And Psychosis Questions
For example, a woman who bites her nails to the point of bleeding and is unable to stop inspite of embarrassment and criticism from fellow employees has more that a habit. If she has mid-sleep insomnia, loss of appetite, and finds no fun in life, she probably suffers from depression. If she also has fears of her family dying because she did not turn off the stove or she washes her hands thirty times a day, she has OCD and depression.
Greist et al, have developed a checklist as another helpful way of determining if your patient has OCD. It can be completed by the patient while the doctor steps out of the room or with the doctor present. Score as follows:
Obsessive-Compulsive Checklist0, if you have no problem with the activity, takes no increased time to perform.
1, if the activity takes twice as long as most people, or you have to repeat it twice, or you usually avoid it.
2, if the activity takes you three times as long as most people, or you have to repeat it three or more times, or you usually avoid it.
____ Bathing or showering
____ Washing hands and face
____ Hair care (washing, combing, brushing)
____ Brushing teeth
____ Dressing, undressing
____ Using toilet to urinate
____ Using toilet for bowel movement
____ Touching others or being touched
____ Handling trash, garbage or their containers
____ Washing clothes
____ Washing dishes
____ Handling or cooking food
____ Cleaning house
____ Keeping things tidy
____ Making the bed
____ Cleaning shoes
____ Touching door handles
____ Touching own genitals or sexual activity with another person
____ Throwing things away
____ Visiting a hospital
____ Turning lights or faucets on or off
____ Using electrical appliances
____ Doing arithmetic or accounts
____ Getting to work
____ Doing own work
____ Filling out forms
____ Mailing letters
____ Total Score
A score above 10 suggests the possibility of OCD. A score above 20 supports the diagnosis of OCD more strongly.
Treatment of self-injury of the nails and hands parallels treatment of self-injury in other parts of the body. In a young child ignoring the behavior and allowing time to pass may be all that is necessary for the unwanted habit to disappear. Power struggles should be avoided. Most childhood thumb suckers and nail biters become normal adults inspite of parental anxiety over maligned teeth and unkempt fingernails. If the activity becomes problematic at school or the self-induced trauma is more serious direct intervention may be necessary.Behavior modifications may help with 1) altering the social environment that triggers the behavior and 2) assuaging the behavior's impact on the family.
Medical intervention may be warranted If talk therapy and behavior modifications are not enough. Medications can help reduce the core symptoms of a psychocutaneous disorder.
Obsessive-compulsive self-mutilating behavior will often require treatment with a seratonin reuptake inhibitor (SSRI), such as paroxetine (Paxil), sertraline [SAS1] (Zoloft), fluvoxamine (Luvox), fluoxetine, or citalopram (Celexa). The second-generation tricyclic, clomipramine (Anafranil), also has serotonin uptake blocking ability and has a beneficial effect on OCD symptoms. Paroxetine and venlafaxine (Effexor) not only raise the serotonin levels but also have been found to raise norepinepherine levels.
Depressed patients often respond within 1 to 3 weeks to the newer somewhat safer SSRIs. They have less anticholinergic effects than tricyclics but can cause weakness, nausea, diarrhea, somnolence, and abnormal ejaculation. Nonresponders may benefit from the atypical non-tricyclic, non-monoamine oxidase inhibitor antidepressants such as trazodone (Desyrel) which has caused priapism, bupropion (Wellbutrin) which lowers seizure threshold, or nefazodone (Serzone) which has some anticholinergic and gastrointestinal side effects. The older tricyclics theoretically work by potentiating central adrenergic tone by blocking uptake of norepinepherine at the nerve terminal. Nortriptyline (Pamelor), amitriptyline (Elavil), imipramine (Tofranil), are useful but have more anticholinergic effects, may cause cardiac arrhythmias and conduction delays, so a pre and post-treatment ECG may be useful. Overdose may cause death and is a sobering concern.
Monoamine oxidase inhibitors (Nardil and Parnate) can cause hypertensive crisis, interact with numerous other drugs, aged cheeses, preserved foods, and wines. They are rarely used.
Anxiety disorders may respond to anxiolytics such as buspirone (Buspar) or small doses of benzodiazepines such as, clonazepam (Klonopin), alprazolam (Xanax) or lorazepam (Ativan). Long term use of benzodiazepines has been associated with withdrawal symptoms such as dysphoria, insomnia, muscle cramps, sweats, and seizures.
Tic disorders, such as Tourette syndrome, may respond to alpha-adrenergic stimulants that have the effect of lowering adrenergic tone centrally. They are marketed as antihypertensives. Both clonidine (Catapres) and guanfacine (Tenex) have proven beneficial in treating poor impulse control associated with Tourette syndrome, as well as ADHD and other conditions.[5,6] Clonidine, short acting and dosed three to four times a day or by way of the transdermal patch, is better for hyperactivity while guanfacine, less potent but longer acting and dosed two times a day, is better for the attention deficit.
Nonresponders, especially those with severe symptomatology and features of psychosis, may require small doses of neuroleptics, such as haloperidol (Haldol), pimozide (Orap). The newer antipsychotics, risperidone (Risperdal) and olanzapine (Zyprexa), produce improvement in positive symptoms -hallucinations, delusions, incoherence, and catatonia; as well as the traditionally more difficult to treat negative symptoms-lack of emotion, paucity of speech, impoverished thought, apathy, and anhedonia. These drugs appear to block dopamine (D2) and serotonin (5HT2) receptors. Olanzapine also blocks histamine receptors and may directly reduce itch. They produce less pseudoparkinsonism than older antipsychotics and may carry less risk of tardive dyskinesia. Neuroleptic malignant syndrome, prolonged QT interval with potential for torsades de pointes, and an asymptomatic increase in prolactin are features shared with older neuroleptics. Clozapine (Clozaril) another new antipsychotic blocks D1-5 receptors as well as adrenergic, cholinergic, histaminergic, and serotonergic receptors. Laboratory evidence suggests that clozapine is more active in the limbic system than in the striatal dopamine which may explain its relative freedom from extrapyramidal side effects. Nevertheless, clozapine is reserved for refractory situations because it has been associated with a .004% rate of agranulocytosis, many of which are fatal, orthostatic hypotension, and 5% yearly incidence of seizures.
As the primary care specialists of the skin dermatologists should be able to diagnosis and treat self-injury to the skin in its simpler forms. This can be made easier by utilizing simple questionnaires and a short mental status exam examination. Since referral to a psychiatrist has become more difficult in the age of managed care it behooves the dermatologist to learn one or two drugs from each class of psychotropic medication and to utilize them appropriately. The new SSRIs have less risk of anticholinergic, convulsive, and cardiac side effects, as well as less danger of overdose. The new antipsychotics also appear to be easier to use safely. With a little effort dermatologists can familiarize themselves with these useful medications thereby assisting their patients in stopping undesired behaviors.
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