Posttraumatic stress disorder

PTSD-related symptoms tend to be under-recognised in dermatology (Woodruff et al., 1997). The central clinical features of PTSD (American Psychiatric Association, 1994) include the persistent re-experience of extremely traumatic or stressful life experiences or life events, which can manifest as recurrent and intrusive thoughts, dreams, flashbacks or physical symptoms. There is a persistent avoidance of stimuli associated with the trauma and this can manifest as dissociative symptoms.

PTSD secondary to childhood neglect and abuse, especially sexual abuse, is often the underlying psychiatric pathology in dermatological patients who self-induce their lesions. PTSD is often complicated by substance abuse disorders and this often becomes the main focus in treatment. When dissociative symptoms are a prominent feature of the PTSD, the patient may not have recollection of the fact that they self-induced their lesions (Shelley, 1981; Gupta et al., 2000) and may be misdiagnosed as malingerers or attentions seekers and the central role of psychological trauma is often overlooked. PTSD, dissociation and self-injury (Gupta et al., 2000) can be the underlying psychiatric disturbance in some cases of trichotil-lomania and dermatitis artefacta or may complicate the course of other dermato-logical conditions such as acne excoriee or the exacerbation of psoriatic lesions secondary to the Koebner phenomenon.

Tactile nurturance, consisting of secure holding and hugging, is essential for the formation of a healthy body image (Gupta et al., 1995), including cutaneous body image. When there is neglect and/or abuse in early life, the infant does not experience healthy tactile nurturance and may be predisposed to developing body image problems in later life. It has been observed that a perceived lack of adequate tactile nurturance is associated with body image problems (Gupta et al., 1995). A patient with a significant history of trauma or neglect may therefore present with dissatisfaction with their body image including cutaneous body image.

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