Thousands of scientific papers have been written about bulimia, but not all patients receive effective treatments that produce remission.

To set the record straight and help psychiatrists avoid undertreating bulimia, this article discusses:

• evidence for using antidepressants, even when patients are not “depressed”
• merits of psychotherapies, including those shown to work and those that can harm
• augmentation therapies that can help increase response from partial to full remission.

Initial evaluation

Diagnosis. Bulimia nervosa is characterized by eating binges, followed by purging behaviors such as self-induced vomiting or laxative abuse^1,2 (Table 1). It affects 1% to 3% of adolescent girls and young women and occurs in women 5 to 10 times more often than in men.

Bulimia is often persistent. About one-half of bulimic patients—including those who have been treated—continue to show eating disorder features on long-term follow-up.^3,4

Psychiatric comorbidity. Most bulimic patients report a history of other psychiatric disorders, especially major depressive and bipolar disorders and anxiety disorders such as panic disorder, social phobia, and obsessive-compulsive disorder (OCD).⁵ Because these psychiatric comorbidities may occur before, during, or after bulimia nervosa, one cannot assume that mood or anxiety disorders are a cause or consequence of bulimia. Instead, bulimia nervosa, mood disorders, and anxiety disorders may be different expressions of a shared etiologic abnormality.

Table 1

DSM-IV-TR diagnostic criteria for bulimia nervosa

Evidence supporting this hypothesis comes from studies showing that these disorders:

• respond to several chemically unrelated families of antidepressants^6,7
• frequently co-occur in individual patients^5,7
• frequently co-aggregate in families.^7-9

We have published this evidence^6,7 and proposed that bulimia nervosa may be one form of a larger underlying disorder, which we termed “affective spectrum disorder.”

Antidepressants are often rapidly effective in treating bulimic symptoms,¹⁰ regardless of whether patients exhibit depressive symptoms. Thus, there is no reason to withhold antidepressant therapy simply because a bulimic patient is not depressed. The term “antidepressant” may be a misnomer; these drugs are effective for numerous conditions, of which depression is only one.

Anorexic symptoms. Co-occurring depressive or anxiety disorders in a bulimic patient will not greatly alter treatment. The antidepressants and psychotherapies typically used to treat bulimia are often equally effective for affective disorders. Co-occurring anorexia nervosa, however, is a more serious concern.

Bulimic patients often display a history of anorexia nervosa; in many cases, the patient develops anorexia nervosa as a teenager and then progresses to bulimia nervosa across several years. Her prognosis is much better if her weight normalizes with the shift to bulimia nervosa, than if her weight remains well below normal for her height. It is unclear why medications and psychotherapy are much less effective in bulimic patients with anorexic symptoms than in those with bulimia alone. Watch for further details on anorexia nervosa as this series continues in future issues of.

Medical considerations. Potential medical complications—mostly consequences of vomiting or laxative use—are important to consider when you assess a bulimic patient:¹

• The acid in vomitus may gradually erode tooth enamel, requiring dental consultation.
• Vomitus may inflame salivary gland ducts, though the swelling is usually benign.
• Frequent vomiting may result in hypokalemia and alkalosis, although aggressive medical treatment usually is not needed.

Ask about ipecac use. To induce vomiting, some patients may abuse ipecac syrup, which can cause cardiomyopathy.¹¹

Inpatient or outpatient? Unless the bulimic patient displays severe and medically dangerous anorexic symptoms, she can usually be treated as an outpatient. However, evaluate her carefully for suicidal ideation—which is not uncommon in bulimia nervosa—and consider inpatient treatment if necessary.

Medication vs. psychotherapy

The relative merits of medication versus psychotherapy in treating bulimia nervosa continue to be debated. The Cochrane Database of Systematic Reviews includes meta-analyses of both drug therapy¹² and psychotherapy¹³ for bulimia nervosa. The 2001 drug therapy review found that “the use of a single antidepressant agent was clinically effective,” with no one drug clearly superior to another. Notably, this review was published before recent findings on topiramate.

The corresponding 2002 review of psychotherapy concludes—somewhat more cautiously—that “there is a small body of evidence for the efficacy of cognitive-behavior therapy in bulimia nervosa and similar syndromes, but the quality of trials is very variable and sample sizes are often small.”

In bulimia nervosa and other psychiatric disorders, comparing psychotherapy with drug therapy is hazardous because several factors bias the comparison in favor of psychotherapy. These factors include an expectational effect, a responsibility effect, and differential generalizability of study results.

Expectational effect. Patients in clinical trials are aware that they are receiving psychotherapy and, presumably, that study investigators hope to demonstrate its efficacy. This might account for much of psychotherapy’s apparent effect, as even placebos can produce 30% to 50% improvement in bulimia.¹⁴

Responsibility effect. If a patient fails to improve in a drug study, she will conclude that the drug has failed. But if she fails to improve in a psychotherapy study, she may conclude that she has failed. Because psychological treatments generally require patients to work in therapy, the patient may feel partially responsible for the outcome. Thus, to avoid cognitive dissonance, she may consciously or unconsciously exaggerate her improvement, both in her own mind and when reporting to treaters.

Differential generalizability. Psychological study protocols, such as administering several months of a behavioral treatment, usually mimic clinical practice fairly well. This is not the case with drug study protocols.

No responsible clinician would inflexibly administer a single dosage of a single drug for a fixed period to every bulimic patient and then declare failure for all nonresponders, as is done in study protocols. In practice, the clinician can offer nonresponders augmentation strategies and additional drug trials. Thus, calculations of bulimia response rates in drug studies substantially understate response to drug therapy in clinical practice.

Table 2

How effective are medications in treating bulimia nervosa?

One also might note that psychological study findings have not “sold” well in the clinical practice marketplace. For example, in a recent survey of more than 220 bulimic women treated with psychotherapy, only 6.9% said they received a full course of cognitive behavioral therapy (CBT)¹⁴ —despite two decades of evidence of its efficacy. By contrast, untested, inefficacious, and possibly harmful psychotherapies for bulimia—including recovered-memory therapy—appear to be thriving.

Recommendation. Interpret with caution any head-to-head comparisons of psychological versus drug therapies—especially when clinical practice recommendations are made. Certain psychological therapies provided by specifically-trained individuals likely do help patients with bulimia nervosa. However, biases inherent to the studies may inflate psychological therapies’ efficacy when compared with that of drug therapy.

Therefore, for a psychiatrist who does not specialize in eating disorders to offer exclusively psychological therapy to a bulimic patient—while withholding or postponing drug therapy—may now be a questionable practice.

Choosing drug therapies

Although consensus is lacking on an optimal treatment trial sequence for bulimia nervosa, we suggest a rational approach based on the evidence and our experience (Algorithm).

First-line antidepressants. A selective serotonin reuptake inhibitor (SSRI) trial is usually the first choice (Table 2), and some data suggest that higher-than-usual dosages may be required. For example, in a large multicenter trial of fluoxetine in bulimia nervosa, 60 mg/d was considerably more effective than 20 mg/d for reducing binge eating behavior and vomiting frequency.¹⁵

Based on our observations, however, we believe that noncompliance or irregular compliance may account for this difference in response. Bulimic patients’ impulsive and obsessional behavior may keep them from taking their medications as prescribed. The higher fluoxetine dosage may therefore have been more effective simply because it ensured adequate plasma levels, even when patients missed or forgot multiple doses.

Augmenting agents. A first antidepressant trial rarely leads to complete remission of bulimic symptoms. This is not a serious concern, however, because many other options are available.

Liothyronine. Partial responders to SSRIs often become complete responders when we add a 10-day trial of liothyronine (T3), 25 μg/d. If this fails, we may try augmenting with lithium carbonate, although bulimic patients are often afraid of weight gain or lithium’s other side effects.

Topiramate. A newer augmentation strategy is to add the anticonvulsant topiramate. Used alone, topiramate demonstrated effectiveness for bulimia nervosa in one placebo-controlled, double-blind trial.¹⁶

Adding topiramate to an antidepressant regimen will likely reduce any remaining bulimic symptoms. In addition, topiramate often produces weight loss—a side effect that bulimic patients usually welcome. It remains unclear whether topiramate’s weight-loss effects might pose a hazard in patients with simultaneous bulimic and anorexic symptoms.

Other antidepressants. If the above strategies fail, other antidepressant options include venlafaxine, tricyclics, and monoamine oxidase inhibitors. Bupropion is not recommended in bulimia nervosa; one trial¹⁷ of this agent resulted in a much higher rate of grand mal seizures in bulimic patients than in patients taking bupropion for depression.

In bulimic patients with concomitant bipolar disorder, the anticonvulsants carbamazepine and valproate often reduce affective and bulimic symptoms. By contrast, the anticonvulsant phenytoin—once thought to be useful in bulimia nervosa¹⁰ —offers little benefit for either bulimic or affective symptoms.

Persistence is important when initial medication trials fail. One unblinded study followed 36 bulimic patients 9 to 19 months after they completed a controlled study with trazodone.¹⁸ Of the 26 patients who tried a second or third antidepressant, 17 (65%) achieved remission of bulimia on follow-up. Of the 10 patients who declined a second or third trial, only 1 (10%) attained remission.

Notably, these study results were obtained before the SSRIs and other newer antidepressants or topiramate became available. Cooperative patients using present-day medications might be able to achieve remission rates that exceed 65%.

Algorithm Proposed treatment approach to bulimia nervosa

How effective are psychotherapies in treating bulimia nervosa?

Psychotherapy

Cognitive-behavioral therapy. CBT—given either individually or in groups—is the most effective psychotherapy for bulimia (Table 3).¹⁹ CBT typically involves 3 to 6 months of helping the patient focus on her bulimic behaviors and on specific attitudes—such as unrealistic preoccupations with being “too fat”—that perpetuate the behaviors.

In practice, unfortunately, few bulimic patients are offered CBT, perhaps because few clinicians are trained in the specific approach used for bulimia nervosa.¹⁹ If you are not trained in using CBT for bulimia and do not have access to colleagues who offer this treatment, you may begin with medication plus simple behavioral treatments, such as:

• offering supportive therapy in the office
• referring patients to self-help groups for persons with eating disorders.

If this strategy fails, encourage patients to consider CBT—even if they must travel some distance to obtain it.

Other specialized psychotherapies. Dialectical behavior therapy and interpersonal psychotherapy appear to be effective in bulimia. Again, however, clinicians who lack training in these techniques or access to local experts may be unable to offer them. Psychodynamic therapy does not appear to offer greater benefit in bulimia nervosa than ordinary supportive counseling.

Dubious therapies. One psychodynamic approach—regrettably still practiced—is “recovered memory therapy.” Therapists who use it claim that childhood sexual abuse or other trauma can cause bulimic symptoms but patients have repressed the memory of these events.²⁰

No methodologically sound evidence has shown that childhood sexual abuse can cause bulimia nervosa years or decades later.²¹ Nor is there acceptable evidence that people can repress the memory of a traumatic experience.²² Therapists administering recovered memory therapy have been subjected to malpractice judgments totaling tens of millions of dollars from suits filed by patients who eventually realized that so-called “recovered” memories were false.²³

Another dubious therapy—eye movement desensitization and reprocessing (EMDR)—also may involve attempts to “recover” memories of putative traumatic events.²⁴ No methodologically sound evidence has shown that EMDR is effective in bulimic patients, and the technique’s theoretical basis is questionable.^24,25

Related resources

• Mental Health Net/Eating disorders. http://eatingdisorders.mentalhelp.net
• National Association of Anorexia Nervosa and Associated Disorders (ANAD). www.altrue.net/site/anadweb/
• Association for Advancement of Behavior Therapy. www.aabt.org

Drug brand names

• Bupropion • Wellbutrin
• Citalopram • Celexa
• Desipramine • Norpramin
• Fluoxetine • Prozac
• Lithium • Lithobid, Eskalith
• Nortriptyline • Pamelor, Aventyl
• Sertraline • Zoloft
• Topiramate • Topamax
• Trazodone • Desyrel
• Liothyronine • Cytomel
• Venlafaxine • Effexor

Disclosure

Dr. Pope receives research support from Ortho-McNeil Pharmaceuticals and is a consultant to Solvay Pharmaceuticals and Auxilium Pharmaceuticals.

Dr. Hudson receives research support from and is a consultant to Eli Lilly & Co. and Ortho-McNeil Pharmaceuticals.

Thousands of scientific papers have been written about bulimia, but not all patients receive effective treatments that produce remission.

To set the record straight and help psychiatrists avoid undertreating bulimia, this article discusses:

• evidence for using antidepressants, even when patients are not “depressed”
• merits of psychotherapies, including those shown to work and those that can harm
• augmentation therapies that can help increase response from partial to full remission.

Initial evaluation

Diagnosis. Bulimia nervosa is characterized by eating binges, followed by purging behaviors such as self-induced vomiting or laxative abuse^1,2 (Table 1). It affects 1% to 3% of adolescent girls and young women and occurs in women 5 to 10 times more often than in men.

Bulimia is often persistent. About one-half of bulimic patients—including those who have been treated—continue to show eating disorder features on long-term follow-up.^3,4

Psychiatric comorbidity. Most bulimic patients report a history of other psychiatric disorders, especially major depressive and bipolar disorders and anxiety disorders such as panic disorder, social phobia, and obsessive-compulsive disorder (OCD).⁵ Because these psychiatric comorbidities may occur before, during, or after bulimia nervosa, one cannot assume that mood or anxiety disorders are a cause or consequence of bulimia. Instead, bulimia nervosa, mood disorders, and anxiety disorders may be different expressions of a shared etiologic abnormality.

Table 1

DSM-IV-TR diagnostic criteria for bulimia nervosa

Evidence supporting this hypothesis comes from studies showing that these disorders:

• respond to several chemically unrelated families of antidepressants^6,7
• frequently co-occur in individual patients^5,7
• frequently co-aggregate in families.^7-9

We have published this evidence^6,7 and proposed that bulimia nervosa may be one form of a larger underlying disorder, which we termed “affective spectrum disorder.”

Antidepressants are often rapidly effective in treating bulimic symptoms,¹⁰ regardless of whether patients exhibit depressive symptoms. Thus, there is no reason to withhold antidepressant therapy simply because a bulimic patient is not depressed. The term “antidepressant” may be a misnomer; these drugs are effective for numerous conditions, of which depression is only one.

Anorexic symptoms. Co-occurring depressive or anxiety disorders in a bulimic patient will not greatly alter treatment. The antidepressants and psychotherapies typically used to treat bulimia are often equally effective for affective disorders. Co-occurring anorexia nervosa, however, is a more serious concern.

Bulimic patients often display a history of anorexia nervosa; in many cases, the patient develops anorexia nervosa as a teenager and then progresses to bulimia nervosa across several years. Her prognosis is much better if her weight normalizes with the shift to bulimia nervosa, than if her weight remains well below normal for her height. It is unclear why medications and psychotherapy are much less effective in bulimic patients with anorexic symptoms than in those with bulimia alone. Watch for further details on anorexia nervosa as this series continues in future issues of.

Medical considerations. Potential medical complications—mostly consequences of vomiting or laxative use—are important to consider when you assess a bulimic patient:¹

• The acid in vomitus may gradually erode tooth enamel, requiring dental consultation.
• Vomitus may inflame salivary gland ducts, though the swelling is usually benign.
• Frequent vomiting may result in hypokalemia and alkalosis, although aggressive medical treatment usually is not needed.

Ask about ipecac use. To induce vomiting, some patients may abuse ipecac syrup, which can cause cardiomyopathy.¹¹

Inpatient or outpatient? Unless the bulimic patient displays severe and medically dangerous anorexic symptoms, she can usually be treated as an outpatient. However, evaluate her carefully for suicidal ideation—which is not uncommon in bulimia nervosa—and consider inpatient treatment if necessary.

Medication vs. psychotherapy

The relative merits of medication versus psychotherapy in treating bulimia nervosa continue to be debated. The Cochrane Database of Systematic Reviews includes meta-analyses of both drug therapy¹² and psychotherapy¹³ for bulimia nervosa. The 2001 drug therapy review found that “the use of a single antidepressant agent was clinically effective,” with no one drug clearly superior to another. Notably, this review was published before recent findings on topiramate.

The corresponding 2002 review of psychotherapy concludes—somewhat more cautiously—that “there is a small body of evidence for the efficacy of cognitive-behavior therapy in bulimia nervosa and similar syndromes, but the quality of trials is very variable and sample sizes are often small.”

In bulimia nervosa and other psychiatric disorders, comparing psychotherapy with drug therapy is hazardous because several factors bias the comparison in favor of psychotherapy. These factors include an expectational effect, a responsibility effect, and differential generalizability of study results.

Expectational effect. Patients in clinical trials are aware that they are receiving psychotherapy and, presumably, that study investigators hope to demonstrate its efficacy. This might account for much of psychotherapy’s apparent effect, as even placebos can produce 30% to 50% improvement in bulimia.¹⁴

Responsibility effect. If a patient fails to improve in a drug study, she will conclude that the drug has failed. But if she fails to improve in a psychotherapy study, she may conclude that she has failed. Because psychological treatments generally require patients to work in therapy, the patient may feel partially responsible for the outcome. Thus, to avoid cognitive dissonance, she may consciously or unconsciously exaggerate her improvement, both in her own mind and when reporting to treaters.

Differential generalizability. Psychological study protocols, such as administering several months of a behavioral treatment, usually mimic clinical practice fairly well. This is not the case with drug study protocols.

No responsible clinician would inflexibly administer a single dosage of a single drug for a fixed period to every bulimic patient and then declare failure for all nonresponders, as is done in study protocols. In practice, the clinician can offer nonresponders augmentation strategies and additional drug trials. Thus, calculations of bulimia response rates in drug studies substantially understate response to drug therapy in clinical practice.

Table 2

How effective are medications in treating bulimia nervosa?

One also might note that psychological study findings have not “sold” well in the clinical practice marketplace. For example, in a recent survey of more than 220 bulimic women treated with psychotherapy, only 6.9% said they received a full course of cognitive behavioral therapy (CBT)¹⁴ —despite two decades of evidence of its efficacy. By contrast, untested, inefficacious, and possibly harmful psychotherapies for bulimia—including recovered-memory therapy—appear to be thriving.

Recommendation. Interpret with caution any head-to-head comparisons of psychological versus drug therapies—especially when clinical practice recommendations are made. Certain psychological therapies provided by specifically-trained individuals likely do help patients with bulimia nervosa. However, biases inherent to the studies may inflate psychological therapies’ efficacy when compared with that of drug therapy.

Therefore, for a psychiatrist who does not specialize in eating disorders to offer exclusively psychological therapy to a bulimic patient—while withholding or postponing drug therapy—may now be a questionable practice.

Choosing drug therapies

Although consensus is lacking on an optimal treatment trial sequence for bulimia nervosa, we suggest a rational approach based on the evidence and our experience (Algorithm).

First-line antidepressants. A selective serotonin reuptake inhibitor (SSRI) trial is usually the first choice (Table 2), and some data suggest that higher-than-usual dosages may be required. For example, in a large multicenter trial of fluoxetine in bulimia nervosa, 60 mg/d was considerably more effective than 20 mg/d for reducing binge eating behavior and vomiting frequency.¹⁵

Based on our observations, however, we believe that noncompliance or irregular compliance may account for this difference in response. Bulimic patients’ impulsive and obsessional behavior may keep them from taking their medications as prescribed. The higher fluoxetine dosage may therefore have been more effective simply because it ensured adequate plasma levels, even when patients missed or forgot multiple doses.

Augmenting agents. A first antidepressant trial rarely leads to complete remission of bulimic symptoms. This is not a serious concern, however, because many other options are available.

Liothyronine. Partial responders to SSRIs often become complete responders when we add a 10-day trial of liothyronine (T3), 25 μg/d. If this fails, we may try augmenting with lithium carbonate, although bulimic patients are often afraid of weight gain or lithium’s other side effects.

Topiramate. A newer augmentation strategy is to add the anticonvulsant topiramate. Used alone, topiramate demonstrated effectiveness for bulimia nervosa in one placebo-controlled, double-blind trial.¹⁶

Adding topiramate to an antidepressant regimen will likely reduce any remaining bulimic symptoms. In addition, topiramate often produces weight loss—a side effect that bulimic patients usually welcome. It remains unclear whether topiramate’s weight-loss effects might pose a hazard in patients with simultaneous bulimic and anorexic symptoms.

Other antidepressants. If the above strategies fail, other antidepressant options include venlafaxine, tricyclics, and monoamine oxidase inhibitors. Bupropion is not recommended in bulimia nervosa; one trial¹⁷ of this agent resulted in a much higher rate of grand mal seizures in bulimic patients than in patients taking bupropion for depression.

In bulimic patients with concomitant bipolar disorder, the anticonvulsants carbamazepine and valproate often reduce affective and bulimic symptoms. By contrast, the anticonvulsant phenytoin—once thought to be useful in bulimia nervosa¹⁰ —offers little benefit for either bulimic or affective symptoms.

Persistence is important when initial medication trials fail. One unblinded study followed 36 bulimic patients 9 to 19 months after they completed a controlled study with trazodone.¹⁸ Of the 26 patients who tried a second or third antidepressant, 17 (65%) achieved remission of bulimia on follow-up. Of the 10 patients who declined a second or third trial, only 1 (10%) attained remission.

Notably, these study results were obtained before the SSRIs and other newer antidepressants or topiramate became available. Cooperative patients using present-day medications might be able to achieve remission rates that exceed 65%.

Algorithm Proposed treatment approach to bulimia nervosa

How effective are psychotherapies in treating bulimia nervosa?

Psychotherapy

Cognitive-behavioral therapy. CBT—given either individually or in groups—is the most effective psychotherapy for bulimia (Table 3).¹⁹ CBT typically involves 3 to 6 months of helping the patient focus on her bulimic behaviors and on specific attitudes—such as unrealistic preoccupations with being “too fat”—that perpetuate the behaviors.

In practice, unfortunately, few bulimic patients are offered CBT, perhaps because few clinicians are trained in the specific approach used for bulimia nervosa.¹⁹ If you are not trained in using CBT for bulimia and do not have access to colleagues who offer this treatment, you may begin with medication plus simple behavioral treatments, such as:

• offering supportive therapy in the office
• referring patients to self-help groups for persons with eating disorders.

If this strategy fails, encourage patients to consider CBT—even if they must travel some distance to obtain it.

Other specialized psychotherapies. Dialectical behavior therapy and interpersonal psychotherapy appear to be effective in bulimia. Again, however, clinicians who lack training in these techniques or access to local experts may be unable to offer them. Psychodynamic therapy does not appear to offer greater benefit in bulimia nervosa than ordinary supportive counseling.

Dubious therapies. One psychodynamic approach—regrettably still practiced—is “recovered memory therapy.” Therapists who use it claim that childhood sexual abuse or other trauma can cause bulimic symptoms but patients have repressed the memory of these events.²⁰

No methodologically sound evidence has shown that childhood sexual abuse can cause bulimia nervosa years or decades later.²¹ Nor is there acceptable evidence that people can repress the memory of a traumatic experience.²² Therapists administering recovered memory therapy have been subjected to malpractice judgments totaling tens of millions of dollars from suits filed by patients who eventually realized that so-called “recovered” memories were false.²³

Another dubious therapy—eye movement desensitization and reprocessing (EMDR)—also may involve attempts to “recover” memories of putative traumatic events.²⁴ No methodologically sound evidence has shown that EMDR is effective in bulimic patients, and the technique’s theoretical basis is questionable.^24,25

Related resources

• Mental Health Net/Eating disorders. http://eatingdisorders.mentalhelp.net
• National Association of Anorexia Nervosa and Associated Disorders (ANAD). www.altrue.net/site/anadweb/
• Association for Advancement of Behavior Therapy. www.aabt.org

Drug brand names

• Bupropion • Wellbutrin
• Citalopram • Celexa
• Desipramine • Norpramin
• Fluoxetine • Prozac
• Lithium • Lithobid, Eskalith
• Nortriptyline • Pamelor, Aventyl
• Sertraline • Zoloft
• Topiramate • Topamax
• Trazodone • Desyrel
• Liothyronine • Cytomel
• Venlafaxine • Effexor

Disclosure

Dr. Pope receives research support from Ortho-McNeil Pharmaceuticals and is a consultant to Solvay Pharmaceuticals and Auxilium Pharmaceuticals.

Dr. Hudson receives research support from and is a consultant to Eli Lilly & Co. and Ortho-McNeil Pharmaceuticals.

Thousands of scientific papers have been written about bulimia, but not all patients receive effective treatments that produce remission.

To set the record straight and help psychiatrists avoid undertreating bulimia, this article discusses:

• evidence for using antidepressants, even when patients are not “depressed”
• merits of psychotherapies, including those shown to work and those that can harm
• augmentation therapies that can help increase response from partial to full remission.

Initial evaluation

Diagnosis. Bulimia nervosa is characterized by eating binges, followed by purging behaviors such as self-induced vomiting or laxative abuse^1,2 (Table 1). It affects 1% to 3% of adolescent girls and young women and occurs in women 5 to 10 times more often than in men.

Bulimia is often persistent. About one-half of bulimic patients—including those who have been treated—continue to show eating disorder features on long-term follow-up.^3,4

Psychiatric comorbidity. Most bulimic patients report a history of other psychiatric disorders, especially major depressive and bipolar disorders and anxiety disorders such as panic disorder, social phobia, and obsessive-compulsive disorder (OCD).⁵ Because these psychiatric comorbidities may occur before, during, or after bulimia nervosa, one cannot assume that mood or anxiety disorders are a cause or consequence of bulimia. Instead, bulimia nervosa, mood disorders, and anxiety disorders may be different expressions of a shared etiologic abnormality.

Table 1

DSM-IV-TR diagnostic criteria for bulimia nervosa

Evidence supporting this hypothesis comes from studies showing that these disorders:

• respond to several chemically unrelated families of antidepressants^6,7
• frequently co-occur in individual patients^5,7
• frequently co-aggregate in families.^7-9

We have published this evidence^6,7 and proposed that bulimia nervosa may be one form of a larger underlying disorder, which we termed “affective spectrum disorder.”

Antidepressants are often rapidly effective in treating bulimic symptoms,¹⁰ regardless of whether patients exhibit depressive symptoms. Thus, there is no reason to withhold antidepressant therapy simply because a bulimic patient is not depressed. The term “antidepressant” may be a misnomer; these drugs are effective for numerous conditions, of which depression is only one.

Anorexic symptoms. Co-occurring depressive or anxiety disorders in a bulimic patient will not greatly alter treatment. The antidepressants and psychotherapies typically used to treat bulimia are often equally effective for affective disorders. Co-occurring anorexia nervosa, however, is a more serious concern.

Bulimic patients often display a history of anorexia nervosa; in many cases, the patient develops anorexia nervosa as a teenager and then progresses to bulimia nervosa across several years. Her prognosis is much better if her weight normalizes with the shift to bulimia nervosa, than if her weight remains well below normal for her height. It is unclear why medications and psychotherapy are much less effective in bulimic patients with anorexic symptoms than in those with bulimia alone. Watch for further details on anorexia nervosa as this series continues in future issues of.

Medical considerations. Potential medical complications—mostly consequences of vomiting or laxative use—are important to consider when you assess a bulimic patient:¹

• The acid in vomitus may gradually erode tooth enamel, requiring dental consultation.
• Vomitus may inflame salivary gland ducts, though the swelling is usually benign.
• Frequent vomiting may result in hypokalemia and alkalosis, although aggressive medical treatment usually is not needed.

Ask about ipecac use. To induce vomiting, some patients may abuse ipecac syrup, which can cause cardiomyopathy.¹¹

Inpatient or outpatient? Unless the bulimic patient displays severe and medically dangerous anorexic symptoms, she can usually be treated as an outpatient. However, evaluate her carefully for suicidal ideation—which is not uncommon in bulimia nervosa—and consider inpatient treatment if necessary.

Medication vs. psychotherapy

The relative merits of medication versus psychotherapy in treating bulimia nervosa continue to be debated. The Cochrane Database of Systematic Reviews includes meta-analyses of both drug therapy¹² and psychotherapy¹³ for bulimia nervosa. The 2001 drug therapy review found that “the use of a single antidepressant agent was clinically effective,” with no one drug clearly superior to another. Notably, this review was published before recent findings on topiramate.

The corresponding 2002 review of psychotherapy concludes—somewhat more cautiously—that “there is a small body of evidence for the efficacy of cognitive-behavior therapy in bulimia nervosa and similar syndromes, but the quality of trials is very variable and sample sizes are often small.”

In bulimia nervosa and other psychiatric disorders, comparing psychotherapy with drug therapy is hazardous because several factors bias the comparison in favor of psychotherapy. These factors include an expectational effect, a responsibility effect, and differential generalizability of study results.

Expectational effect. Patients in clinical trials are aware that they are receiving psychotherapy and, presumably, that study investigators hope to demonstrate its efficacy. This might account for much of psychotherapy’s apparent effect, as even placebos can produce 30% to 50% improvement in bulimia.¹⁴

Responsibility effect. If a patient fails to improve in a drug study, she will conclude that the drug has failed. But if she fails to improve in a psychotherapy study, she may conclude that she has failed. Because psychological treatments generally require patients to work in therapy, the patient may feel partially responsible for the outcome. Thus, to avoid cognitive dissonance, she may consciously or unconsciously exaggerate her improvement, both in her own mind and when reporting to treaters.

Differential generalizability. Psychological study protocols, such as administering several months of a behavioral treatment, usually mimic clinical practice fairly well. This is not the case with drug study protocols.

No responsible clinician would inflexibly administer a single dosage of a single drug for a fixed period to every bulimic patient and then declare failure for all nonresponders, as is done in study protocols. In practice, the clinician can offer nonresponders augmentation strategies and additional drug trials. Thus, calculations of bulimia response rates in drug studies substantially understate response to drug therapy in clinical practice.

Table 2

How effective are medications in treating bulimia nervosa?

One also might note that psychological study findings have not “sold” well in the clinical practice marketplace. For example, in a recent survey of more than 220 bulimic women treated with psychotherapy, only 6.9% said they received a full course of cognitive behavioral therapy (CBT)¹⁴ —despite two decades of evidence of its efficacy. By contrast, untested, inefficacious, and possibly harmful psychotherapies for bulimia—including recovered-memory therapy—appear to be thriving.

Recommendation. Interpret with caution any head-to-head comparisons of psychological versus drug therapies—especially when clinical practice recommendations are made. Certain psychological therapies provided by specifically-trained individuals likely do help patients with bulimia nervosa. However, biases inherent to the studies may inflate psychological therapies’ efficacy when compared with that of drug therapy.

Therefore, for a psychiatrist who does not specialize in eating disorders to offer exclusively psychological therapy to a bulimic patient—while withholding or postponing drug therapy—may now be a questionable practice.

Choosing drug therapies

Although consensus is lacking on an optimal treatment trial sequence for bulimia nervosa, we suggest a rational approach based on the evidence and our experience (Algorithm).

First-line antidepressants. A selective serotonin reuptake inhibitor (SSRI) trial is usually the first choice (Table 2), and some data suggest that higher-than-usual dosages may be required. For example, in a large multicenter trial of fluoxetine in bulimia nervosa, 60 mg/d was considerably more effective than 20 mg/d for reducing binge eating behavior and vomiting frequency.¹⁵

Based on our observations, however, we believe that noncompliance or irregular compliance may account for this difference in response. Bulimic patients’ impulsive and obsessional behavior may keep them from taking their medications as prescribed. The higher fluoxetine dosage may therefore have been more effective simply because it ensured adequate plasma levels, even when patients missed or forgot multiple doses.

Augmenting agents. A first antidepressant trial rarely leads to complete remission of bulimic symptoms. This is not a serious concern, however, because many other options are available.

Liothyronine. Partial responders to SSRIs often become complete responders when we add a 10-day trial of liothyronine (T3), 25 μg/d. If this fails, we may try augmenting with lithium carbonate, although bulimic patients are often afraid of weight gain or lithium’s other side effects.

Topiramate. A newer augmentation strategy is to add the anticonvulsant topiramate. Used alone, topiramate demonstrated effectiveness for bulimia nervosa in one placebo-controlled, double-blind trial.¹⁶

Adding topiramate to an antidepressant regimen will likely reduce any remaining bulimic symptoms. In addition, topiramate often produces weight loss—a side effect that bulimic patients usually welcome. It remains unclear whether topiramate’s weight-loss effects might pose a hazard in patients with simultaneous bulimic and anorexic symptoms.

Other antidepressants. If the above strategies fail, other antidepressant options include venlafaxine, tricyclics, and monoamine oxidase inhibitors. Bupropion is not recommended in bulimia nervosa; one trial¹⁷ of this agent resulted in a much higher rate of grand mal seizures in bulimic patients than in patients taking bupropion for depression.

In bulimic patients with concomitant bipolar disorder, the anticonvulsants carbamazepine and valproate often reduce affective and bulimic symptoms. By contrast, the anticonvulsant phenytoin—once thought to be useful in bulimia nervosa¹⁰ —offers little benefit for either bulimic or affective symptoms.

Persistence is important when initial medication trials fail. One unblinded study followed 36 bulimic patients 9 to 19 months after they completed a controlled study with trazodone.¹⁸ Of the 26 patients who tried a second or third antidepressant, 17 (65%) achieved remission of bulimia on follow-up. Of the 10 patients who declined a second or third trial, only 1 (10%) attained remission.

Notably, these study results were obtained before the SSRIs and other newer antidepressants or topiramate became available. Cooperative patients using present-day medications might be able to achieve remission rates that exceed 65%.

Algorithm Proposed treatment approach to bulimia nervosa

How effective are psychotherapies in treating bulimia nervosa?

Psychotherapy

Cognitive-behavioral therapy. CBT—given either individually or in groups—is the most effective psychotherapy for bulimia (Table 3).¹⁹ CBT typically involves 3 to 6 months of helping the patient focus on her bulimic behaviors and on specific attitudes—such as unrealistic preoccupations with being “too fat”—that perpetuate the behaviors.

In practice, unfortunately, few bulimic patients are offered CBT, perhaps because few clinicians are trained in the specific approach used for bulimia nervosa.¹⁹ If you are not trained in using CBT for bulimia and do not have access to colleagues who offer this treatment, you may begin with medication plus simple behavioral treatments, such as:

• offering supportive therapy in the office
• referring patients to self-help groups for persons with eating disorders.

If this strategy fails, encourage patients to consider CBT—even if they must travel some distance to obtain it.

Other specialized psychotherapies. Dialectical behavior therapy and interpersonal psychotherapy appear to be effective in bulimia. Again, however, clinicians who lack training in these techniques or access to local experts may be unable to offer them. Psychodynamic therapy does not appear to offer greater benefit in bulimia nervosa than ordinary supportive counseling.

Dubious therapies. One psychodynamic approach—regrettably still practiced—is “recovered memory therapy.” Therapists who use it claim that childhood sexual abuse or other trauma can cause bulimic symptoms but patients have repressed the memory of these events.²⁰

No methodologically sound evidence has shown that childhood sexual abuse can cause bulimia nervosa years or decades later.²¹ Nor is there acceptable evidence that people can repress the memory of a traumatic experience.²² Therapists administering recovered memory therapy have been subjected to malpractice judgments totaling tens of millions of dollars from suits filed by patients who eventually realized that so-called “recovered” memories were false.²³

Another dubious therapy—eye movement desensitization and reprocessing (EMDR)—also may involve attempts to “recover” memories of putative traumatic events.²⁴ No methodologically sound evidence has shown that EMDR is effective in bulimic patients, and the technique’s theoretical basis is questionable.^24,25

Related resources

• Mental Health Net/Eating disorders. http://eatingdisorders.mentalhelp.net
• National Association of Anorexia Nervosa and Associated Disorders (ANAD). www.altrue.net/site/anadweb/
• Association for Advancement of Behavior Therapy. www.aabt.org

Drug brand names

• Bupropion • Wellbutrin
• Citalopram • Celexa
• Desipramine • Norpramin
• Fluoxetine • Prozac
• Lithium • Lithobid, Eskalith
• Nortriptyline • Pamelor, Aventyl
• Sertraline • Zoloft
• Topiramate • Topamax
• Trazodone • Desyrel
• Liothyronine • Cytomel
• Venlafaxine • Effexor

Disclosure

Dr. Pope receives research support from Ortho-McNeil Pharmaceuticals and is a consultant to Solvay Pharmaceuticals and Auxilium Pharmaceuticals.

Dr. Hudson receives research support from and is a consultant to Eli Lilly & Co. and Ortho-McNeil Pharmaceuticals.

Lying in the hospital bed, her face covered in bandages, Ms. S talked of suicide while awaiting reconstructive surgery on her nose: “If the only way to stop is by killing myself, I will.” When asked what she wanted to stop, she replied, “The picking. I pick at my face all day, every day.”

Ms. S, age 22, had picked a hole through the bridge of her nose, and her face was scarred and covered with scabs. Every morning for 5 years, she had gotten up, dressed, and then—after washing her face—felt intense, uncontrollable urges to pick at her face. Hours would go by and she was still picking, even as her face started to bleed: “I try to resist, but I can’t.”

Ms. S started picking her face when she was 17. She missed so much of high school because of time spent picking that she did not graduate. She now lives alone on medical disability. Conscious of her facial scarring, she rarely goes out in public. “People stare at me as if I’m a zoo animal; it’s so painful,” she says.

After her plastic surgery, she told the staff psychiatrist she had never sought help because she thought no one would understand her behavior. “It doesn’t make sense to me, and I’ve lived with it for years.”

Patients such as Ms. S often suffer in isolation for years, unaware that skin picking is a psychiatric disorder that can be treated successfully. Some are referred to psychiatrists through hospital emergency rooms or by dermatologists; others commit suicide, as Ms. S threatened to do.

In our practice, we recognize skin picking in patients with comorbid mood and anxiety disorders, body dysmorphic disorder (BDD), substance use disorders, impulse control disorders such as trichotillomania or kleptomania, and personality disorders.

Based on recent evidence and our experience, we discuss three steps to help you diagnose pathologic skin picking. We then examine treatment options that have shown benefit for skinpicking patients, including habit reversal psychotherapy and medications.

WHAT IS SKIN PICKING?

Pathologic skin picking is repetitive, ritualistic, or impulsive picking of normal skin, leading to tissue damage, personal distress, and impaired functioning.¹ The behavior has been described for more than 100 years but remains poorly understood, under-diagnosed, and under-treated.^2,3

Most people pick at their hands or face to a limited extent,⁴ and picking does not by itself suggest a psychiatric disorder. Pathology exists in the focus, duration, and extent of the behavior, as well as reasons for picking, associated emotions, and resulting problems. Persons with pathologic skin picking report irresistible, intrusive, and/or senseless thoughts of picking or impulses to pick, accompanied by marked distress.¹ Pathologic skin picking is recurrent and usually results in noticeable skin damage, although many patients try to camouflage the lesions or scarring with makeup.

Pathologic skin picking’s prevalence is unknown. One early study estimated that 2% of dermatology patients suffer from skin picking.¹ Two clinical studies found that 3.8% of college students⁴ and 28% of patients with BDD meet diagnostic criteria.^5,6

TWEEZERS, RAZOR BLADES, KNIVES…

Persons who engage in pathologic skin picking typically spend substantial time picking. Most often they pick the face, but any body part—lips, arms, hands, or legs—may be the focus. They may pick at blemishes, pimples, scars, or healthy skin. Some use their hands and fingernails to pick, and others use pins, tweezers, razor blades, or knives. Picking may worsen in the evening.^2,7

Although picking episodes may last only a few minutes, many patients have multiple episodes each day. Some pick for as long as 12 hours every day,^2,5 which often leads to scarring and disfigurement. In one study, 90% of patients had at least minor tissue damage, 61% suffered infections, and 45% had “deep craters” because of picking.²

Reasons for picking. Many patients pick to relieve discomfort or tension.¹ Others pick to improve their appearance, as in BDD, or to remove perceived dirt or contaminants, as in obsessive-compulsive disorder (OCD).^1,5 Still others say they pick as a habit, with minimal awareness.¹ Itching or uneven skin may also cause the behavior.^1,3 We have found that a patient may pick for several of these reasons. Most report:

• tension before picking
• satisfaction during picking
• guilt, shame, and dysphoria after picking.¹

Social impairment. Shame after picking episodes often leads patients to cover lesions with clothing or makeup and to avoid social contact.⁷ Substantial social and occupational impairment have been reported^3,5,7 because of the hours spent picking and from avoiding people because of disfigurement.

Physical injury. Skin picking may cause serious injuries. Some of our patients have required emergency medical intervention and sutures after picking through a major blood vessel (such as the facial artery). One woman—who picked at a pimple on her neck with tweezers—lacerated her carotid artery, causing a near-fatal hemorrhage that required emergency surgery.⁸

Suicide risk. In a series of 123 patients with BDD, 33 (27%) excessively picked their skin and 10 of those who picked their skin (33%) had attempted suicide.5 In a case series of 31 patients with skin picking, 10% had attempted suicide.² We know of several young women whose chief complaint was skin picking and who committed suicide.⁵

Gender. The gender ratio of patients with skin picking remains unclear. In two case series that totaled 65 patients, 87% to 92% of those with pathologic skin picking were female.^2,7 In the series of patients with BDD, 58% of the 33 who compulsively picked their skin were female.⁵ On the other hand, most of 28 patients seen in a dermatology clinic for neurotic excoriations were male.⁹

Onset and chronicity. Pathologic skin picking may develop at any age, but it usually manifests in late adolescence or early adulthood, often after onset of a dermatologic illness such as acne² or in response to itching.³ Although long-term studies have not been done, the disorder appears to often be chronic, with waxing and waning of picking intensity and frequency.^1,2

Table 1

Skin picking: 3 steps to diagnosis and treatment

Comorbid psychopathology. In clinical settings, common comorbid psychopathologies include mood disorders (in 48% to 68% of patients with skin picking), anxiety disorders (41% to 64%), and alcohol use disorders (39%).²

In one patient sample, 71% of skin pickers met criteria for at least one personality disorder (48% had obsessive-compulsive personality disorder, and 26% met criteria for borderline personality disorder).²

Table 2

Medications with evidence of benefit for skin picking*

PRIMARY VS. SECONDARY DISORDER

Is skin picking an independent disorder or a symptom of other psychiatric disorders? Although skin picking is not included in DSM-IV and has no formal diagnostic criteria, some forms of this behavior may belong among the impulse control disorders.

Patients often report an urge to pick their skin in response to increasing tension,^1,3 and picking results in transient relief or pleasure.^1,2 This description mirrors that of other impulse control disorders, such as trichotillomania and kleptomania. In fact, one study found that trichotillomania and kleptomania were common comorbidities among patients with skin picking (23% and 16%, respectively).² In 34 patients with psychogenic excoriation, only 7 (21%) appeared to have skin picking as a primary complaint, unaccounted for by another psychiatric disorder.⁷

Skin picking may also be a symptom of other psychiatric disorders. To determine whether another disorder is present, we ask patients why they pick their skin. Patients may be reluctant to reveal either the picking or the underlying disorder because of embarrassment and shame. The diagnosis can often be clarified by asking about the following conditions:

Body dysmorphic disorder. Nearly 30% of patients with BDD pick their skin to a pathologic extent.^5,6 The purpose of picking in BDD is to remove or minimize a nonexistent or slight imperfection in appearance (such as scars, pimples, bumps).^5,6

Obsessive-compulsive disorder. Patients with OCD may pick their skin in response to contamination obsessions.¹ Picking is often repetitive and ritualistic, and—as with compulsions—the behavior may reduce tension.¹⁰

Genetic disorders. Skin picking may be a symptom of Prader-Willi syndrome, a genetic disorder characterized by muscular hypotonia, short stature, characteristic facial features, intellectual disabilities, hypogonadism, hyperphagia, and an increased obesity risk. In one study, 97% of patients with Prader-Willi syndrome engaged in skin picking.¹¹

Delusional disorder. Delusions of parasitosis may result in skin picking, as patients attempt to remove imagined parasites or other vermin from on or under their skin.¹²

Dermatitis artefacta. Patients may consciously create skin lesions to assume the sick role. Onethird of patients presenting to dermatologists with a disease that is primarily psychiatric may be suffering from dermatitis artefacta.¹³

TREATMENT RECOMMENDATIONS

Successful clinical care of pathologic skin picking requires perseverance and patience from both patient and clinician.

Treatment begins with a thorough dermatologic examination for medical causes of skin picking (such as atopic dermatitis or scabies) and to treat excoriations (such as with antibiotics for infection). After the dermatologist has ruled out a medical cause, carefully assess the patient’s picking behavior and related psychiatric problems (Table 1).

• If picking is secondary to a psychiatric disorder, begin by providing appropriate treatment for that disorder.
• If picking results from BDD or OCD, we recommend habit reversal therapy combined with medication.
• If picking appears to be an independent impulse control disorder, simultaneous habit reversal therapy and medication is usually necessary to reduce symptoms.

SSRIs are a reasonable first medication because of evidence for their efficacy in reducing skin picking. Higher dosages—comparable to those used in treating OCD—are usually required to improve skin-picking behavior. You may need to try another SSRI if the first trial results in partial or no response.

In our experience, augmenting an SSRI with naltrexone, 50 mg/d, helps reduce intrusive urges to pick and is worth considering if SSRI therapy results in only partial response.

Children or adolescents. Depending upon symptom severity, a trial of habit reversal therapy may be appropriate before you recommend using medication.

EVIDENCE FOR DRUG THERAPY

Although few treatment studies have been done, skin picking does appear to respond to medication (Table 2).

Because no medications are approved to treat skin-picking behavior, inform patients of any “off-label” uses and the scientific or clinical evidence for considering medication treatment.

Case reports and case series. Selective serotonin reuptake inhibitors (SSRIs) appear most effective in patients with picking behavior, including:

• fluvoxamine, 300 mg/d, in one case report⁸
• fluoxetine, 20 to 80 mg/d, in several case reports.^5,14-15

In a series of 33 patients with BDD and compulsive skin picking, one-half (49%) of a variety of SSRI treatment trials improved BDD symptoms and skin picking behavior. The percentage of patients who improved was not examined. Dermatologic treatment alone was effective for only 15% of patients.⁵

Medications other than SSRIs have also been studied. One patient improved within 3 weeks of taking the tricyclic antidepressant clomipramine, 50 mg/d.³ Another patient picked her skin less often 4 weeks after inositol, 18 grams/d, was added to citalopram, 40 mg/d. Inositol, a nonprescription isomer of glucose, is a precursor in the phosphatidylinositol second-messenger cycle, which may play a role at certain serotonin receptors.¹⁶ The patient was given 6 grams dissolved in water three times daily.

Case reports have also suggested that olanzapine, pimozide, doxepin, and naltrexone may be beneficial in reducing skin excoriations. These reports often involved patients with psychiatric and medical comorbidities.^17-20

Table 3

Habit reversal: 5 components in patient learning

Open-label studies. In an open-label study of 28 patients with neurotic excoriation treated in a dermatology clinic, 68% improved within 1 month with sertraline, mean dosage 95 mg/d.⁹ Similarly, open-label fluvoxamine, mean dosage 112.5 mg/d, was effective in reducing skin excoriation in 7 of 14 patients treated for 12 weeks in a psychiatric setting.²¹

Double-blind studies. In a double-blind study using fluvoxamine with supportive psychotherapy in patients with psychocutaneous disorders, all five patients with acne excoriee improved after 4 weeks of medication treatment (none was randomized to placebo).²²

In a 10-week, double-blind study, 10 patients were assigned to fluoxetine, mean dosage 53.0 ± 16.4 mg/d, and 11 to placebo. A patient self-report visual analog scale showed that fluoxetine was significantly more effective than placebo in reducing picking behavior. Two other measures did not show significant improvement, however, perhaps because of the small sample size.²³

In a third study, 8 of 15 patients responded to open-label fluoxetine, 20 to 60 mg/d after 6 weeks. The responders were then randomized to 6 additional weeks of fluoxetine or placebo. All four patients assigned to continue active medication maintained their improvement. Symptoms returned to baseline by week 12 in the four assigned to placebo.²⁴

EVIDENCE FOR HABIT REVERSAL THERAPY

No controlled trials have examined psychosocial treatments for skin picking, but several psychotherapeutic interventions appear promising. Habit reversal has shown promise in three case reports totaling seven patients and appears to reduce picking behavior within a few weeks.^25-27

In a case series, three patients were successfully treated with habit reversal (Table 3) and cognitive-behavioral techniques, consisting of:

• awareness training (using a skin-picking diary)
• competing response techniques (such as making a fist or squeezing a ball)
• emotion regulation skills
• psychoeducation
• cognitive restructuring (such as using Socratic questioning to produce rational alternatives) in situations that elicit the urge to pick.²⁸

In another case series, 22 dermatology patients with skin picking received psychotherapy with insight-oriented and behavioral components. Therapy included attention to developmental issues and active conflicts, cognitive restructuring, and tools to manage aggression and social relations. Although treatment duration varied— the mean was weekly for 14 months—skin lesions healed in 17 patients (77%).²⁹

Related resources

• Obsessive-Compulsive Foundation http://www.ocfoundation.org
• Koran LM. Obsessive-compulsive and related disorders in adults: A comprehensive clinical guide. Cambridge, UK: Cambridge University Press, 1999.
• Phillips KA. The broken mirror: Recognizing and treating body dysmorphic disorder. New York: Oxford University Press, 1996.

Drug brand names

• Citalopram • Celexa
• Clomipramine • Anafranil
• Doxepin • Sinequan
• Fluoxetine • Prozac
• Fluvoxamine • Luvox
• Naltrexone • ReVia
• Olanzapine • Zyprexa
• Pimozide • Orap
• Sertraline • Zoloft

Disclosure

Dr. Grant reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Phillips receives research support from Eli Lilly and Co., Forest Pharmaceuticals, and Gate Pharmaceuticals; she is a speaker for or consultant to Eli Lilly and Co., Forest Pharmaceuticals, and UCB Pharma.

Lying in the hospital bed, her face covered in bandages, Ms. S talked of suicide while awaiting reconstructive surgery on her nose: “If the only way to stop is by killing myself, I will.” When asked what she wanted to stop, she replied, “The picking. I pick at my face all day, every day.”

Ms. S, age 22, had picked a hole through the bridge of her nose, and her face was scarred and covered with scabs. Every morning for 5 years, she had gotten up, dressed, and then—after washing her face—felt intense, uncontrollable urges to pick at her face. Hours would go by and she was still picking, even as her face started to bleed: “I try to resist, but I can’t.”

Ms. S started picking her face when she was 17. She missed so much of high school because of time spent picking that she did not graduate. She now lives alone on medical disability. Conscious of her facial scarring, she rarely goes out in public. “People stare at me as if I’m a zoo animal; it’s so painful,” she says.

After her plastic surgery, she told the staff psychiatrist she had never sought help because she thought no one would understand her behavior. “It doesn’t make sense to me, and I’ve lived with it for years.”

Patients such as Ms. S often suffer in isolation for years, unaware that skin picking is a psychiatric disorder that can be treated successfully. Some are referred to psychiatrists through hospital emergency rooms or by dermatologists; others commit suicide, as Ms. S threatened to do.

In our practice, we recognize skin picking in patients with comorbid mood and anxiety disorders, body dysmorphic disorder (BDD), substance use disorders, impulse control disorders such as trichotillomania or kleptomania, and personality disorders.

Based on recent evidence and our experience, we discuss three steps to help you diagnose pathologic skin picking. We then examine treatment options that have shown benefit for skinpicking patients, including habit reversal psychotherapy and medications.

WHAT IS SKIN PICKING?

Pathologic skin picking is repetitive, ritualistic, or impulsive picking of normal skin, leading to tissue damage, personal distress, and impaired functioning.¹ The behavior has been described for more than 100 years but remains poorly understood, under-diagnosed, and under-treated.^2,3

Most people pick at their hands or face to a limited extent,⁴ and picking does not by itself suggest a psychiatric disorder. Pathology exists in the focus, duration, and extent of the behavior, as well as reasons for picking, associated emotions, and resulting problems. Persons with pathologic skin picking report irresistible, intrusive, and/or senseless thoughts of picking or impulses to pick, accompanied by marked distress.¹ Pathologic skin picking is recurrent and usually results in noticeable skin damage, although many patients try to camouflage the lesions or scarring with makeup.

Pathologic skin picking’s prevalence is unknown. One early study estimated that 2% of dermatology patients suffer from skin picking.¹ Two clinical studies found that 3.8% of college students⁴ and 28% of patients with BDD meet diagnostic criteria.^5,6

TWEEZERS, RAZOR BLADES, KNIVES…

Persons who engage in pathologic skin picking typically spend substantial time picking. Most often they pick the face, but any body part—lips, arms, hands, or legs—may be the focus. They may pick at blemishes, pimples, scars, or healthy skin. Some use their hands and fingernails to pick, and others use pins, tweezers, razor blades, or knives. Picking may worsen in the evening.^2,7

Although picking episodes may last only a few minutes, many patients have multiple episodes each day. Some pick for as long as 12 hours every day,^2,5 which often leads to scarring and disfigurement. In one study, 90% of patients had at least minor tissue damage, 61% suffered infections, and 45% had “deep craters” because of picking.²

Reasons for picking. Many patients pick to relieve discomfort or tension.¹ Others pick to improve their appearance, as in BDD, or to remove perceived dirt or contaminants, as in obsessive-compulsive disorder (OCD).^1,5 Still others say they pick as a habit, with minimal awareness.¹ Itching or uneven skin may also cause the behavior.^1,3 We have found that a patient may pick for several of these reasons. Most report:

• tension before picking
• satisfaction during picking
• guilt, shame, and dysphoria after picking.¹

Social impairment. Shame after picking episodes often leads patients to cover lesions with clothing or makeup and to avoid social contact.⁷ Substantial social and occupational impairment have been reported^3,5,7 because of the hours spent picking and from avoiding people because of disfigurement.

Physical injury. Skin picking may cause serious injuries. Some of our patients have required emergency medical intervention and sutures after picking through a major blood vessel (such as the facial artery). One woman—who picked at a pimple on her neck with tweezers—lacerated her carotid artery, causing a near-fatal hemorrhage that required emergency surgery.⁸

Suicide risk. In a series of 123 patients with BDD, 33 (27%) excessively picked their skin and 10 of those who picked their skin (33%) had attempted suicide.5 In a case series of 31 patients with skin picking, 10% had attempted suicide.² We know of several young women whose chief complaint was skin picking and who committed suicide.⁵

Gender. The gender ratio of patients with skin picking remains unclear. In two case series that totaled 65 patients, 87% to 92% of those with pathologic skin picking were female.^2,7 In the series of patients with BDD, 58% of the 33 who compulsively picked their skin were female.⁵ On the other hand, most of 28 patients seen in a dermatology clinic for neurotic excoriations were male.⁹

Onset and chronicity. Pathologic skin picking may develop at any age, but it usually manifests in late adolescence or early adulthood, often after onset of a dermatologic illness such as acne² or in response to itching.³ Although long-term studies have not been done, the disorder appears to often be chronic, with waxing and waning of picking intensity and frequency.^1,2

Table 1

Skin picking: 3 steps to diagnosis and treatment

Comorbid psychopathology. In clinical settings, common comorbid psychopathologies include mood disorders (in 48% to 68% of patients with skin picking), anxiety disorders (41% to 64%), and alcohol use disorders (39%).²

In one patient sample, 71% of skin pickers met criteria for at least one personality disorder (48% had obsessive-compulsive personality disorder, and 26% met criteria for borderline personality disorder).²

Table 2

Medications with evidence of benefit for skin picking*

PRIMARY VS. SECONDARY DISORDER

Is skin picking an independent disorder or a symptom of other psychiatric disorders? Although skin picking is not included in DSM-IV and has no formal diagnostic criteria, some forms of this behavior may belong among the impulse control disorders.

Patients often report an urge to pick their skin in response to increasing tension,^1,3 and picking results in transient relief or pleasure.^1,2 This description mirrors that of other impulse control disorders, such as trichotillomania and kleptomania. In fact, one study found that trichotillomania and kleptomania were common comorbidities among patients with skin picking (23% and 16%, respectively).² In 34 patients with psychogenic excoriation, only 7 (21%) appeared to have skin picking as a primary complaint, unaccounted for by another psychiatric disorder.⁷

Skin picking may also be a symptom of other psychiatric disorders. To determine whether another disorder is present, we ask patients why they pick their skin. Patients may be reluctant to reveal either the picking or the underlying disorder because of embarrassment and shame. The diagnosis can often be clarified by asking about the following conditions:

Body dysmorphic disorder. Nearly 30% of patients with BDD pick their skin to a pathologic extent.^5,6 The purpose of picking in BDD is to remove or minimize a nonexistent or slight imperfection in appearance (such as scars, pimples, bumps).^5,6

Obsessive-compulsive disorder. Patients with OCD may pick their skin in response to contamination obsessions.¹ Picking is often repetitive and ritualistic, and—as with compulsions—the behavior may reduce tension.¹⁰

Genetic disorders. Skin picking may be a symptom of Prader-Willi syndrome, a genetic disorder characterized by muscular hypotonia, short stature, characteristic facial features, intellectual disabilities, hypogonadism, hyperphagia, and an increased obesity risk. In one study, 97% of patients with Prader-Willi syndrome engaged in skin picking.¹¹

Delusional disorder. Delusions of parasitosis may result in skin picking, as patients attempt to remove imagined parasites or other vermin from on or under their skin.¹²

Dermatitis artefacta. Patients may consciously create skin lesions to assume the sick role. Onethird of patients presenting to dermatologists with a disease that is primarily psychiatric may be suffering from dermatitis artefacta.¹³

TREATMENT RECOMMENDATIONS

Successful clinical care of pathologic skin picking requires perseverance and patience from both patient and clinician.

Treatment begins with a thorough dermatologic examination for medical causes of skin picking (such as atopic dermatitis or scabies) and to treat excoriations (such as with antibiotics for infection). After the dermatologist has ruled out a medical cause, carefully assess the patient’s picking behavior and related psychiatric problems (Table 1).

• If picking is secondary to a psychiatric disorder, begin by providing appropriate treatment for that disorder.
• If picking results from BDD or OCD, we recommend habit reversal therapy combined with medication.
• If picking appears to be an independent impulse control disorder, simultaneous habit reversal therapy and medication is usually necessary to reduce symptoms.

SSRIs are a reasonable first medication because of evidence for their efficacy in reducing skin picking. Higher dosages—comparable to those used in treating OCD—are usually required to improve skin-picking behavior. You may need to try another SSRI if the first trial results in partial or no response.

In our experience, augmenting an SSRI with naltrexone, 50 mg/d, helps reduce intrusive urges to pick and is worth considering if SSRI therapy results in only partial response.

Children or adolescents. Depending upon symptom severity, a trial of habit reversal therapy may be appropriate before you recommend using medication.

EVIDENCE FOR DRUG THERAPY

Although few treatment studies have been done, skin picking does appear to respond to medication (Table 2).

Because no medications are approved to treat skin-picking behavior, inform patients of any “off-label” uses and the scientific or clinical evidence for considering medication treatment.

Case reports and case series. Selective serotonin reuptake inhibitors (SSRIs) appear most effective in patients with picking behavior, including:

• fluvoxamine, 300 mg/d, in one case report⁸
• fluoxetine, 20 to 80 mg/d, in several case reports.^5,14-15

In a series of 33 patients with BDD and compulsive skin picking, one-half (49%) of a variety of SSRI treatment trials improved BDD symptoms and skin picking behavior. The percentage of patients who improved was not examined. Dermatologic treatment alone was effective for only 15% of patients.⁵

Medications other than SSRIs have also been studied. One patient improved within 3 weeks of taking the tricyclic antidepressant clomipramine, 50 mg/d.³ Another patient picked her skin less often 4 weeks after inositol, 18 grams/d, was added to citalopram, 40 mg/d. Inositol, a nonprescription isomer of glucose, is a precursor in the phosphatidylinositol second-messenger cycle, which may play a role at certain serotonin receptors.¹⁶ The patient was given 6 grams dissolved in water three times daily.

Case reports have also suggested that olanzapine, pimozide, doxepin, and naltrexone may be beneficial in reducing skin excoriations. These reports often involved patients with psychiatric and medical comorbidities.^17-20

Table 3

Habit reversal: 5 components in patient learning

Open-label studies. In an open-label study of 28 patients with neurotic excoriation treated in a dermatology clinic, 68% improved within 1 month with sertraline, mean dosage 95 mg/d.⁹ Similarly, open-label fluvoxamine, mean dosage 112.5 mg/d, was effective in reducing skin excoriation in 7 of 14 patients treated for 12 weeks in a psychiatric setting.²¹

Double-blind studies. In a double-blind study using fluvoxamine with supportive psychotherapy in patients with psychocutaneous disorders, all five patients with acne excoriee improved after 4 weeks of medication treatment (none was randomized to placebo).²²

In a 10-week, double-blind study, 10 patients were assigned to fluoxetine, mean dosage 53.0 ± 16.4 mg/d, and 11 to placebo. A patient self-report visual analog scale showed that fluoxetine was significantly more effective than placebo in reducing picking behavior. Two other measures did not show significant improvement, however, perhaps because of the small sample size.²³

In a third study, 8 of 15 patients responded to open-label fluoxetine, 20 to 60 mg/d after 6 weeks. The responders were then randomized to 6 additional weeks of fluoxetine or placebo. All four patients assigned to continue active medication maintained their improvement. Symptoms returned to baseline by week 12 in the four assigned to placebo.²⁴

EVIDENCE FOR HABIT REVERSAL THERAPY

No controlled trials have examined psychosocial treatments for skin picking, but several psychotherapeutic interventions appear promising. Habit reversal has shown promise in three case reports totaling seven patients and appears to reduce picking behavior within a few weeks.^25-27

In a case series, three patients were successfully treated with habit reversal (Table 3) and cognitive-behavioral techniques, consisting of:

• awareness training (using a skin-picking diary)
• competing response techniques (such as making a fist or squeezing a ball)
• emotion regulation skills
• psychoeducation
• cognitive restructuring (such as using Socratic questioning to produce rational alternatives) in situations that elicit the urge to pick.²⁸

In another case series, 22 dermatology patients with skin picking received psychotherapy with insight-oriented and behavioral components. Therapy included attention to developmental issues and active conflicts, cognitive restructuring, and tools to manage aggression and social relations. Although treatment duration varied— the mean was weekly for 14 months—skin lesions healed in 17 patients (77%).²⁹

Related resources

• Obsessive-Compulsive Foundation http://www.ocfoundation.org
• Koran LM. Obsessive-compulsive and related disorders in adults: A comprehensive clinical guide. Cambridge, UK: Cambridge University Press, 1999.
• Phillips KA. The broken mirror: Recognizing and treating body dysmorphic disorder. New York: Oxford University Press, 1996.

Drug brand names

• Citalopram • Celexa
• Clomipramine • Anafranil
• Doxepin • Sinequan
• Fluoxetine • Prozac
• Fluvoxamine • Luvox
• Naltrexone • ReVia
• Olanzapine • Zyprexa
• Pimozide • Orap
• Sertraline • Zoloft

Disclosure

Dr. Grant reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Phillips receives research support from Eli Lilly and Co., Forest Pharmaceuticals, and Gate Pharmaceuticals; she is a speaker for or consultant to Eli Lilly and Co., Forest Pharmaceuticals, and UCB Pharma.

Lying in the hospital bed, her face covered in bandages, Ms. S talked of suicide while awaiting reconstructive surgery on her nose: “If the only way to stop is by killing myself, I will.” When asked what she wanted to stop, she replied, “The picking. I pick at my face all day, every day.”

Ms. S, age 22, had picked a hole through the bridge of her nose, and her face was scarred and covered with scabs. Every morning for 5 years, she had gotten up, dressed, and then—after washing her face—felt intense, uncontrollable urges to pick at her face. Hours would go by and she was still picking, even as her face started to bleed: “I try to resist, but I can’t.”

Ms. S started picking her face when she was 17. She missed so much of high school because of time spent picking that she did not graduate. She now lives alone on medical disability. Conscious of her facial scarring, she rarely goes out in public. “People stare at me as if I’m a zoo animal; it’s so painful,” she says.

After her plastic surgery, she told the staff psychiatrist she had never sought help because she thought no one would understand her behavior. “It doesn’t make sense to me, and I’ve lived with it for years.”

Patients such as Ms. S often suffer in isolation for years, unaware that skin picking is a psychiatric disorder that can be treated successfully. Some are referred to psychiatrists through hospital emergency rooms or by dermatologists; others commit suicide, as Ms. S threatened to do.

In our practice, we recognize skin picking in patients with comorbid mood and anxiety disorders, body dysmorphic disorder (BDD), substance use disorders, impulse control disorders such as trichotillomania or kleptomania, and personality disorders.

Based on recent evidence and our experience, we discuss three steps to help you diagnose pathologic skin picking. We then examine treatment options that have shown benefit for skinpicking patients, including habit reversal psychotherapy and medications.

WHAT IS SKIN PICKING?

Pathologic skin picking is repetitive, ritualistic, or impulsive picking of normal skin, leading to tissue damage, personal distress, and impaired functioning.¹ The behavior has been described for more than 100 years but remains poorly understood, under-diagnosed, and under-treated.^2,3

Most people pick at their hands or face to a limited extent,⁴ and picking does not by itself suggest a psychiatric disorder. Pathology exists in the focus, duration, and extent of the behavior, as well as reasons for picking, associated emotions, and resulting problems. Persons with pathologic skin picking report irresistible, intrusive, and/or senseless thoughts of picking or impulses to pick, accompanied by marked distress.¹ Pathologic skin picking is recurrent and usually results in noticeable skin damage, although many patients try to camouflage the lesions or scarring with makeup.

Pathologic skin picking’s prevalence is unknown. One early study estimated that 2% of dermatology patients suffer from skin picking.¹ Two clinical studies found that 3.8% of college students⁴ and 28% of patients with BDD meet diagnostic criteria.^5,6

TWEEZERS, RAZOR BLADES, KNIVES…

Persons who engage in pathologic skin picking typically spend substantial time picking. Most often they pick the face, but any body part—lips, arms, hands, or legs—may be the focus. They may pick at blemishes, pimples, scars, or healthy skin. Some use their hands and fingernails to pick, and others use pins, tweezers, razor blades, or knives. Picking may worsen in the evening.^2,7

Although picking episodes may last only a few minutes, many patients have multiple episodes each day. Some pick for as long as 12 hours every day,^2,5 which often leads to scarring and disfigurement. In one study, 90% of patients had at least minor tissue damage, 61% suffered infections, and 45% had “deep craters” because of picking.²

Reasons for picking. Many patients pick to relieve discomfort or tension.¹ Others pick to improve their appearance, as in BDD, or to remove perceived dirt or contaminants, as in obsessive-compulsive disorder (OCD).^1,5 Still others say they pick as a habit, with minimal awareness.¹ Itching or uneven skin may also cause the behavior.^1,3 We have found that a patient may pick for several of these reasons. Most report:

• tension before picking
• satisfaction during picking
• guilt, shame, and dysphoria after picking.¹

Social impairment. Shame after picking episodes often leads patients to cover lesions with clothing or makeup and to avoid social contact.⁷ Substantial social and occupational impairment have been reported^3,5,7 because of the hours spent picking and from avoiding people because of disfigurement.

Physical injury. Skin picking may cause serious injuries. Some of our patients have required emergency medical intervention and sutures after picking through a major blood vessel (such as the facial artery). One woman—who picked at a pimple on her neck with tweezers—lacerated her carotid artery, causing a near-fatal hemorrhage that required emergency surgery.⁸

Suicide risk. In a series of 123 patients with BDD, 33 (27%) excessively picked their skin and 10 of those who picked their skin (33%) had attempted suicide.5 In a case series of 31 patients with skin picking, 10% had attempted suicide.² We know of several young women whose chief complaint was skin picking and who committed suicide.⁵

Gender. The gender ratio of patients with skin picking remains unclear. In two case series that totaled 65 patients, 87% to 92% of those with pathologic skin picking were female.^2,7 In the series of patients with BDD, 58% of the 33 who compulsively picked their skin were female.⁵ On the other hand, most of 28 patients seen in a dermatology clinic for neurotic excoriations were male.⁹

Onset and chronicity. Pathologic skin picking may develop at any age, but it usually manifests in late adolescence or early adulthood, often after onset of a dermatologic illness such as acne² or in response to itching.³ Although long-term studies have not been done, the disorder appears to often be chronic, with waxing and waning of picking intensity and frequency.^1,2

Table 1

Skin picking: 3 steps to diagnosis and treatment

Comorbid psychopathology. In clinical settings, common comorbid psychopathologies include mood disorders (in 48% to 68% of patients with skin picking), anxiety disorders (41% to 64%), and alcohol use disorders (39%).²

In one patient sample, 71% of skin pickers met criteria for at least one personality disorder (48% had obsessive-compulsive personality disorder, and 26% met criteria for borderline personality disorder).²

Table 2

Medications with evidence of benefit for skin picking*

PRIMARY VS. SECONDARY DISORDER

Is skin picking an independent disorder or a symptom of other psychiatric disorders? Although skin picking is not included in DSM-IV and has no formal diagnostic criteria, some forms of this behavior may belong among the impulse control disorders.

Patients often report an urge to pick their skin in response to increasing tension,^1,3 and picking results in transient relief or pleasure.^1,2 This description mirrors that of other impulse control disorders, such as trichotillomania and kleptomania. In fact, one study found that trichotillomania and kleptomania were common comorbidities among patients with skin picking (23% and 16%, respectively).² In 34 patients with psychogenic excoriation, only 7 (21%) appeared to have skin picking as a primary complaint, unaccounted for by another psychiatric disorder.⁷

Skin picking may also be a symptom of other psychiatric disorders. To determine whether another disorder is present, we ask patients why they pick their skin. Patients may be reluctant to reveal either the picking or the underlying disorder because of embarrassment and shame. The diagnosis can often be clarified by asking about the following conditions:

Body dysmorphic disorder. Nearly 30% of patients with BDD pick their skin to a pathologic extent.^5,6 The purpose of picking in BDD is to remove or minimize a nonexistent or slight imperfection in appearance (such as scars, pimples, bumps).^5,6

Obsessive-compulsive disorder. Patients with OCD may pick their skin in response to contamination obsessions.¹ Picking is often repetitive and ritualistic, and—as with compulsions—the behavior may reduce tension.¹⁰

Genetic disorders. Skin picking may be a symptom of Prader-Willi syndrome, a genetic disorder characterized by muscular hypotonia, short stature, characteristic facial features, intellectual disabilities, hypogonadism, hyperphagia, and an increased obesity risk. In one study, 97% of patients with Prader-Willi syndrome engaged in skin picking.¹¹

Delusional disorder. Delusions of parasitosis may result in skin picking, as patients attempt to remove imagined parasites or other vermin from on or under their skin.¹²

Dermatitis artefacta. Patients may consciously create skin lesions to assume the sick role. Onethird of patients presenting to dermatologists with a disease that is primarily psychiatric may be suffering from dermatitis artefacta.¹³

TREATMENT RECOMMENDATIONS

Successful clinical care of pathologic skin picking requires perseverance and patience from both patient and clinician.

Treatment begins with a thorough dermatologic examination for medical causes of skin picking (such as atopic dermatitis or scabies) and to treat excoriations (such as with antibiotics for infection). After the dermatologist has ruled out a medical cause, carefully assess the patient’s picking behavior and related psychiatric problems (Table 1).

• If picking is secondary to a psychiatric disorder, begin by providing appropriate treatment for that disorder.
• If picking results from BDD or OCD, we recommend habit reversal therapy combined with medication.
• If picking appears to be an independent impulse control disorder, simultaneous habit reversal therapy and medication is usually necessary to reduce symptoms.

SSRIs are a reasonable first medication because of evidence for their efficacy in reducing skin picking. Higher dosages—comparable to those used in treating OCD—are usually required to improve skin-picking behavior. You may need to try another SSRI if the first trial results in partial or no response.

In our experience, augmenting an SSRI with naltrexone, 50 mg/d, helps reduce intrusive urges to pick and is worth considering if SSRI therapy results in only partial response.

Children or adolescents. Depending upon symptom severity, a trial of habit reversal therapy may be appropriate before you recommend using medication.

EVIDENCE FOR DRUG THERAPY

Although few treatment studies have been done, skin picking does appear to respond to medication (Table 2).

Because no medications are approved to treat skin-picking behavior, inform patients of any “off-label” uses and the scientific or clinical evidence for considering medication treatment.

Case reports and case series. Selective serotonin reuptake inhibitors (SSRIs) appear most effective in patients with picking behavior, including:

• fluvoxamine, 300 mg/d, in one case report⁸
• fluoxetine, 20 to 80 mg/d, in several case reports.^5,14-15

In a series of 33 patients with BDD and compulsive skin picking, one-half (49%) of a variety of SSRI treatment trials improved BDD symptoms and skin picking behavior. The percentage of patients who improved was not examined. Dermatologic treatment alone was effective for only 15% of patients.⁵

Medications other than SSRIs have also been studied. One patient improved within 3 weeks of taking the tricyclic antidepressant clomipramine, 50 mg/d.³ Another patient picked her skin less often 4 weeks after inositol, 18 grams/d, was added to citalopram, 40 mg/d. Inositol, a nonprescription isomer of glucose, is a precursor in the phosphatidylinositol second-messenger cycle, which may play a role at certain serotonin receptors.¹⁶ The patient was given 6 grams dissolved in water three times daily.

Case reports have also suggested that olanzapine, pimozide, doxepin, and naltrexone may be beneficial in reducing skin excoriations. These reports often involved patients with psychiatric and medical comorbidities.^17-20

Table 3

Habit reversal: 5 components in patient learning

Open-label studies. In an open-label study of 28 patients with neurotic excoriation treated in a dermatology clinic, 68% improved within 1 month with sertraline, mean dosage 95 mg/d.⁹ Similarly, open-label fluvoxamine, mean dosage 112.5 mg/d, was effective in reducing skin excoriation in 7 of 14 patients treated for 12 weeks in a psychiatric setting.²¹

Double-blind studies. In a double-blind study using fluvoxamine with supportive psychotherapy in patients with psychocutaneous disorders, all five patients with acne excoriee improved after 4 weeks of medication treatment (none was randomized to placebo).²²

In a 10-week, double-blind study, 10 patients were assigned to fluoxetine, mean dosage 53.0 ± 16.4 mg/d, and 11 to placebo. A patient self-report visual analog scale showed that fluoxetine was significantly more effective than placebo in reducing picking behavior. Two other measures did not show significant improvement, however, perhaps because of the small sample size.²³

In a third study, 8 of 15 patients responded to open-label fluoxetine, 20 to 60 mg/d after 6 weeks. The responders were then randomized to 6 additional weeks of fluoxetine or placebo. All four patients assigned to continue active medication maintained their improvement. Symptoms returned to baseline by week 12 in the four assigned to placebo.²⁴

EVIDENCE FOR HABIT REVERSAL THERAPY

No controlled trials have examined psychosocial treatments for skin picking, but several psychotherapeutic interventions appear promising. Habit reversal has shown promise in three case reports totaling seven patients and appears to reduce picking behavior within a few weeks.^25-27

In a case series, three patients were successfully treated with habit reversal (Table 3) and cognitive-behavioral techniques, consisting of:

• awareness training (using a skin-picking diary)
• competing response techniques (such as making a fist or squeezing a ball)
• emotion regulation skills
• psychoeducation
• cognitive restructuring (such as using Socratic questioning to produce rational alternatives) in situations that elicit the urge to pick.²⁸

In another case series, 22 dermatology patients with skin picking received psychotherapy with insight-oriented and behavioral components. Therapy included attention to developmental issues and active conflicts, cognitive restructuring, and tools to manage aggression and social relations. Although treatment duration varied— the mean was weekly for 14 months—skin lesions healed in 17 patients (77%).²⁹

Related resources

• Obsessive-Compulsive Foundation http://www.ocfoundation.org
• Koran LM. Obsessive-compulsive and related disorders in adults: A comprehensive clinical guide. Cambridge, UK: Cambridge University Press, 1999.
• Phillips KA. The broken mirror: Recognizing and treating body dysmorphic disorder. New York: Oxford University Press, 1996.

Drug brand names

• Citalopram • Celexa
• Clomipramine • Anafranil
• Doxepin • Sinequan
• Fluoxetine • Prozac
• Fluvoxamine • Luvox
• Naltrexone • ReVia
• Olanzapine • Zyprexa
• Pimozide • Orap
• Sertraline • Zoloft

Disclosure

Dr. Grant reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Phillips receives research support from Eli Lilly and Co., Forest Pharmaceuticals, and Gate Pharmaceuticals; she is a speaker for or consultant to Eli Lilly and Co., Forest Pharmaceuticals, and UCB Pharma.

HISTORY: New school, old problems

Mr. E, age 13, was diagnosed with Down syndrome at birth and has mild mental retardation and bilateral sensorineural hearing loss. His pediatrician referred him to our child and adolescent psychiatry clinic for regressed behavior, depression, and apparent psychotic symptoms. He was also having problems sleeping and had begun puberty 8 months earlier.

Five months before referral, Mr. E had graduated from a small elementary school, where he was fully mainstreamed, to a large junior high school, where he spent most of the school day in a functional skills class. About that time, Mr. E began exhibiting nocturnal and daytime enuresis, loss of previously mastered skills, intolerance of novelty and change, and separation difficulty. Although toilet trained at age 7, he started having “accidents” at home, school, and elsewhere. He was reluctant to dress himself, and he resisted going to school.

The youth also talked to himself often and appeared to respond to internal stimuli. He “relived” conversations aloud, described imaginary friends to family and teachers, and spoke to a stuffed dog called Goofy. He would sit and stare into space for up to a half-hour, appearing preoccupied. Family members said he had exhibited these behaviors in grade school but until now appeared to have “outgrown” them.

Once sociable, Mr. E had become increasingly moody, negativistic, and isolative. He spent hours alone in his room. His mother, with whom he was close, reported that he was often angry with her for no apparent reason.

With puberty, his mother noted, Mr. E had begun kissing other developmentally disabled children. He also masturbated, but at his parents’ urging he restricted this activity to his room.

On evaluation, Mr. E was pleasant and outgoing. He had the facial dysmorphia and stature typical of Down syndrome. He smiled often and interacted well, and he attended and adapted to transitions in conversation and activities. His speech was dysarthric (with hyperglossia) and telegraphic; he could speak only four- to five-word sentences.

Was Mr. E exhibiting an adjustment reaction, depression, or a normal developmental response to puberty? Do his psychotic symptoms signal onset of schizophrenia?

Dr. Krassner’s and Kraus’ observations

Because Down syndrome is the most common genetic cause of mental retardation—seen in approximately 1 in 1,000 live births¹—pediatricians and child psychiatrists see this disorder fairly frequently.

Regression, a form of coping exhibited by many children, is extremely common in youths with Down syndrome² and often has a definite—though sometimes unclear—precipitant. We felt Mr. E’s move from a highly responsive, familiar school environment to a far less responsive one that accentuated his differences contributed to many of his symptoms.

Psychosis is less common in Down syndrome than in other developmental disabilities.² Schizophrenia may occur, but diagnosis is complicated by cognition impairments, test-taking skills, and—in Mr. E’s case—inability to describe disordered thoughts or hallucinations due to poor language skills.³

Self-talk is common in Down syndrome and might be mistaken for psychosis. Note that despite his chronologic age, Mr. E is developmentally a 6-year-old, and self-talk and imaginary friends are considered normal behaviors for a child that age. What’s more, the stress of changing schools may have further compromised his developmental skills.

Box 1

By contrast, depression is fairly common in Down syndrome, although it is much less prevalent in children than in adults with the developmental disorder.²

Finally, children with Down syndrome often enter puberty early, but without the cognitive or emotional maturity or knowledge to deal with the physiologic changes of adolescence.³ Parents often are reluctant to recognize their developmentally disabled child’s sexuality or are uncomfortable providing sexuality education.⁴ Mr. E’s parents clearly were unconvinced that his sexual behavior was normal for an adolescent.

TREATMENT Antidepressants lead to improvement

We felt Mr. E regressed secondary to emotional stress caused by switching schools. We viewed his psychotic symptoms as part of an adjustment disorder and attributed most of his other symptoms to depression. We anticipated Mr. E’s psychotic symptoms would remit spontaneously and focused on treating his mood and sleep disturbances.

We prescribed sertraline liquid suspension, 10 mg/d titrated across 3 weeks to 40 mg/d. We based our medication choice on clinical experience, mindful of a recent FDA advisory about the use of antidepressants in pediatric patients (Box 1). Also, the liquid suspension is easier to titrate than the tablet form, and we feared Mr. E might have trouble swallowing a tablet.

Mr. E’s mood and sociability improved after 3 to 4 weeks. Within 6 weeks, he regained some of his previously mastered daily activities. We added zolpidem, 10 mg nightly, to address his sleeping difficulties but discontinued the agent after 2 weeks, when his sleep patterns normalized.

At 2, 4, and 6 weeks, Mr. E was pleasant and cooperative, his thinking less concrete, and his speech more intelligible. His parents reported he was happier and more involved with family activities. At his mother’s request, sertraline was changed to 37.5 mg/d in tablet form. The patient remained stable for another month, during which his self-talk, though decreased, continued.

Two weeks later, Mr. E’s mother reported that, during a routine dermatologic examination for a chronic, presacral rash, the dermatologist noticed strategic shaving on the boy’s thighs, calves, and scrotum. Strategic shaving has been reported among sexually active youths as a means of purportedly increasing their sexual pleasure.

The dermatologist then told Mr. E’s mother that her son likely was sexually molested. Based on the boy’s differential rates of pubic hair growth, the doctor suspected that the molestation was chronic, dating back at least 3 months and probably continuing until the week before the examination. Upon hearing this, Mr. E’s parents were stunned and angry.

What behavioral signs might have suggested sexual abuse? How do the dermatologist’s findings alter diagnosis and treatment?

Dr. Krassner’s and Kraus’ observations

Given the dermatologist’s findings, Mr. E’s parents asked us whether their son’s presenting psychiatric symptoms were manifestations of posttraumatic stress disorder (PTSD).

Until now, explaining Mr. E’s symptoms as a reaction to changing schools seemed plausible. His symptoms were improving with treatment, and his sexual behaviors and interest in sexual topics were physiologically normal for his chronologic age. Despite his earlier pubertal experimentations, nothing in his psychosocial history indicated risk for sexual abuse or exploitation.

Still, children with Down syndrome are at higher risk for sexual exploitation than other children,⁴ so the possibility should have been explored with the parents. Psychiatrists should watch for physical signs of sexual abuse in these patients during the first examination (Box 2).⁴

But how is sexual abuse defined in this case? Deficient language skills prevented Mr. E from describing what happened to him, so determining whether he initiated sexual relations and with whom is nearly impossible. The act clearly could be considered abuse if Mr. E had been with an adult or older child—even if Mr. E consented. However, if Mr. E had initiated contact with another mentally retarded child, then cause, blame, and semantics become unclear. Either way, the incident could have caused PTSD.⁵

Diagnosing PTSD in non- or semi-verbal or retarded children is extremely difficult.^6,7 Unlike adults with PTSD, pre-verbal children might not have recurrent, distressing recollections of the trauma, but symbolic displacement may characterize repetitive play, during which themes are expressed.⁸

Scheeringa et al have recommended PTSD criteria for preschool children, including:

• social withdrawal
• extreme temper tantrums
• loss of developmental skills
• new separation anxiety
• new onset of aggression
• new fears without obvious links to the trauma.^5,6

Treating PTSD in children with developmental disabilities is also difficult. Modalities applicable to adults or mainstream children—such as psychodynamic psychotherapy, cognitive-behavioral therapy (CBT), exposure therapy, and medications—often do not help developmentally disabled children. For example, Mr. E lacks the cognitive apparatus to respond to CBT.

On the other hand, behavioral therapy, reducing risk factors, minimizing dissociative triggers, and educating patients, parents, friends, and teachers about PTSD can help patients such as Mr. E.⁵ Attempting to provide structure and maintain routines is a cornerstone of any intervention.

Box 2

FURTHER TREATMENT A family in turmoil

We addressed Mr. E’s symptoms as PTSD-related, though his poor language skills kept us from identifying a trauma. Based on data regarding pediatric PTSD treatment,⁹ we increased sertraline to 50 mg/d and then to 75 mg/d across 2 weeks.

However, an intense legal investigation brought on by the parents, combined with ensuing tumult within the family, worsened Mr. E’s symptoms. His self-talk became more pronounced and his isolative behavior reappeared, suggesting that the intrusive, repetitive questioning caused him to re-experience the trauma.

We again increased sertraline, to 100 mg/d, and offered supportive therapy to Mr. E. We tried to educate his parents about understanding his symptoms and managing his behavior and strongly recommended that they undergo crisis therapy to keep their reactions and emotions from hurting Mr. E. The parents declined, however, and alleged that we did not adequately support their pursuit of a diagnosis or legal action, which for them had become synonymous with treatment.

Mr. E’s mother brought her son to a psychologist, who engaged him in play therapy. She followed her son around, noting everything he said. All the while, she failed to resolve her guilt and anger. When we explained to her that these actions were hurting Mr. E’s progress, she terminated therapy.

How would you have tried to keep Mr. E’s family in therapy?

Dr. Krassner’s and Kraus’ observations

Treating psychopathology in children carries the risk of strained relations with the patient’s family. The risk increases exponentially for developmentally disabled children, as they have little or no input and their parents are exquisitely sensitive to their needs. Further, the revelation that the parents might have somehow failed to avert or anticipate danger to the child complicates their emotional response.

Although the child is the patient, the parent is the consumer. Failure to gain or keep the parents’ confidence will hinder or destroy therapy.

We might have protected our working relationship with Mr. E’s parents by recognizing how fragile they were and how intensely they would react to any constructive criticism. Paradoxically, for the short-term we could have tolerated their detrimental behaviors toward Mr. E (such as repeated questioning) in the hopes of protecting a long-term relationship. Spending more time exploring the guilt, anger, and confusion that tormented Mr. E’s parents—particularly his mother—also might have helped.

Related resources

• Ryan RM. Recognition of psychosis in persons who do not use spoken communication. In: Ancill RJ, Holliday S, Higenbottam J (eds). Schizophrenia: exploring the spectrum of psychosis. New York: John Wiley & Sons, 1994.

Drug brand names

• Bupropion • Wellbutrin
• Citalopram • Celexa
• Escitalopram • Lexapro
• Fluoxetine • Prozac
• Mirtazapine • Remeron
• Nefazodone • Serzone
• Paroxetine • Paxil
• Sertraline • Zoloft
• Trazodone • Desyrel
• Venlafaxine • Effexor
• Zolpidem • Ambien

HISTORY: New school, old problems

Mr. E, age 13, was diagnosed with Down syndrome at birth and has mild mental retardation and bilateral sensorineural hearing loss. His pediatrician referred him to our child and adolescent psychiatry clinic for regressed behavior, depression, and apparent psychotic symptoms. He was also having problems sleeping and had begun puberty 8 months earlier.

Five months before referral, Mr. E had graduated from a small elementary school, where he was fully mainstreamed, to a large junior high school, where he spent most of the school day in a functional skills class. About that time, Mr. E began exhibiting nocturnal and daytime enuresis, loss of previously mastered skills, intolerance of novelty and change, and separation difficulty. Although toilet trained at age 7, he started having “accidents” at home, school, and elsewhere. He was reluctant to dress himself, and he resisted going to school.

The youth also talked to himself often and appeared to respond to internal stimuli. He “relived” conversations aloud, described imaginary friends to family and teachers, and spoke to a stuffed dog called Goofy. He would sit and stare into space for up to a half-hour, appearing preoccupied. Family members said he had exhibited these behaviors in grade school but until now appeared to have “outgrown” them.

Once sociable, Mr. E had become increasingly moody, negativistic, and isolative. He spent hours alone in his room. His mother, with whom he was close, reported that he was often angry with her for no apparent reason.

With puberty, his mother noted, Mr. E had begun kissing other developmentally disabled children. He also masturbated, but at his parents’ urging he restricted this activity to his room.

On evaluation, Mr. E was pleasant and outgoing. He had the facial dysmorphia and stature typical of Down syndrome. He smiled often and interacted well, and he attended and adapted to transitions in conversation and activities. His speech was dysarthric (with hyperglossia) and telegraphic; he could speak only four- to five-word sentences.

Was Mr. E exhibiting an adjustment reaction, depression, or a normal developmental response to puberty? Do his psychotic symptoms signal onset of schizophrenia?

Dr. Krassner’s and Kraus’ observations

Because Down syndrome is the most common genetic cause of mental retardation—seen in approximately 1 in 1,000 live births¹—pediatricians and child psychiatrists see this disorder fairly frequently.

Regression, a form of coping exhibited by many children, is extremely common in youths with Down syndrome² and often has a definite—though sometimes unclear—precipitant. We felt Mr. E’s move from a highly responsive, familiar school environment to a far less responsive one that accentuated his differences contributed to many of his symptoms.

Psychosis is less common in Down syndrome than in other developmental disabilities.² Schizophrenia may occur, but diagnosis is complicated by cognition impairments, test-taking skills, and—in Mr. E’s case—inability to describe disordered thoughts or hallucinations due to poor language skills.³

Self-talk is common in Down syndrome and might be mistaken for psychosis. Note that despite his chronologic age, Mr. E is developmentally a 6-year-old, and self-talk and imaginary friends are considered normal behaviors for a child that age. What’s more, the stress of changing schools may have further compromised his developmental skills.

Box 1

By contrast, depression is fairly common in Down syndrome, although it is much less prevalent in children than in adults with the developmental disorder.²

Finally, children with Down syndrome often enter puberty early, but without the cognitive or emotional maturity or knowledge to deal with the physiologic changes of adolescence.³ Parents often are reluctant to recognize their developmentally disabled child’s sexuality or are uncomfortable providing sexuality education.⁴ Mr. E’s parents clearly were unconvinced that his sexual behavior was normal for an adolescent.

TREATMENT Antidepressants lead to improvement

We felt Mr. E regressed secondary to emotional stress caused by switching schools. We viewed his psychotic symptoms as part of an adjustment disorder and attributed most of his other symptoms to depression. We anticipated Mr. E’s psychotic symptoms would remit spontaneously and focused on treating his mood and sleep disturbances.

We prescribed sertraline liquid suspension, 10 mg/d titrated across 3 weeks to 40 mg/d. We based our medication choice on clinical experience, mindful of a recent FDA advisory about the use of antidepressants in pediatric patients (Box 1). Also, the liquid suspension is easier to titrate than the tablet form, and we feared Mr. E might have trouble swallowing a tablet.

Mr. E’s mood and sociability improved after 3 to 4 weeks. Within 6 weeks, he regained some of his previously mastered daily activities. We added zolpidem, 10 mg nightly, to address his sleeping difficulties but discontinued the agent after 2 weeks, when his sleep patterns normalized.

At 2, 4, and 6 weeks, Mr. E was pleasant and cooperative, his thinking less concrete, and his speech more intelligible. His parents reported he was happier and more involved with family activities. At his mother’s request, sertraline was changed to 37.5 mg/d in tablet form. The patient remained stable for another month, during which his self-talk, though decreased, continued.

Two weeks later, Mr. E’s mother reported that, during a routine dermatologic examination for a chronic, presacral rash, the dermatologist noticed strategic shaving on the boy’s thighs, calves, and scrotum. Strategic shaving has been reported among sexually active youths as a means of purportedly increasing their sexual pleasure.

The dermatologist then told Mr. E’s mother that her son likely was sexually molested. Based on the boy’s differential rates of pubic hair growth, the doctor suspected that the molestation was chronic, dating back at least 3 months and probably continuing until the week before the examination. Upon hearing this, Mr. E’s parents were stunned and angry.

What behavioral signs might have suggested sexual abuse? How do the dermatologist’s findings alter diagnosis and treatment?

Dr. Krassner’s and Kraus’ observations

Given the dermatologist’s findings, Mr. E’s parents asked us whether their son’s presenting psychiatric symptoms were manifestations of posttraumatic stress disorder (PTSD).

Until now, explaining Mr. E’s symptoms as a reaction to changing schools seemed plausible. His symptoms were improving with treatment, and his sexual behaviors and interest in sexual topics were physiologically normal for his chronologic age. Despite his earlier pubertal experimentations, nothing in his psychosocial history indicated risk for sexual abuse or exploitation.

Still, children with Down syndrome are at higher risk for sexual exploitation than other children,⁴ so the possibility should have been explored with the parents. Psychiatrists should watch for physical signs of sexual abuse in these patients during the first examination (Box 2).⁴

But how is sexual abuse defined in this case? Deficient language skills prevented Mr. E from describing what happened to him, so determining whether he initiated sexual relations and with whom is nearly impossible. The act clearly could be considered abuse if Mr. E had been with an adult or older child—even if Mr. E consented. However, if Mr. E had initiated contact with another mentally retarded child, then cause, blame, and semantics become unclear. Either way, the incident could have caused PTSD.⁵

Diagnosing PTSD in non- or semi-verbal or retarded children is extremely difficult.^6,7 Unlike adults with PTSD, pre-verbal children might not have recurrent, distressing recollections of the trauma, but symbolic displacement may characterize repetitive play, during which themes are expressed.⁸

Scheeringa et al have recommended PTSD criteria for preschool children, including:

• social withdrawal
• extreme temper tantrums
• loss of developmental skills
• new separation anxiety
• new onset of aggression
• new fears without obvious links to the trauma.^5,6

Treating PTSD in children with developmental disabilities is also difficult. Modalities applicable to adults or mainstream children—such as psychodynamic psychotherapy, cognitive-behavioral therapy (CBT), exposure therapy, and medications—often do not help developmentally disabled children. For example, Mr. E lacks the cognitive apparatus to respond to CBT.

On the other hand, behavioral therapy, reducing risk factors, minimizing dissociative triggers, and educating patients, parents, friends, and teachers about PTSD can help patients such as Mr. E.⁵ Attempting to provide structure and maintain routines is a cornerstone of any intervention.

Box 2

FURTHER TREATMENT A family in turmoil

We addressed Mr. E’s symptoms as PTSD-related, though his poor language skills kept us from identifying a trauma. Based on data regarding pediatric PTSD treatment,⁹ we increased sertraline to 50 mg/d and then to 75 mg/d across 2 weeks.

However, an intense legal investigation brought on by the parents, combined with ensuing tumult within the family, worsened Mr. E’s symptoms. His self-talk became more pronounced and his isolative behavior reappeared, suggesting that the intrusive, repetitive questioning caused him to re-experience the trauma.

We again increased sertraline, to 100 mg/d, and offered supportive therapy to Mr. E. We tried to educate his parents about understanding his symptoms and managing his behavior and strongly recommended that they undergo crisis therapy to keep their reactions and emotions from hurting Mr. E. The parents declined, however, and alleged that we did not adequately support their pursuit of a diagnosis or legal action, which for them had become synonymous with treatment.

Mr. E’s mother brought her son to a psychologist, who engaged him in play therapy. She followed her son around, noting everything he said. All the while, she failed to resolve her guilt and anger. When we explained to her that these actions were hurting Mr. E’s progress, she terminated therapy.

How would you have tried to keep Mr. E’s family in therapy?

Dr. Krassner’s and Kraus’ observations

Treating psychopathology in children carries the risk of strained relations with the patient’s family. The risk increases exponentially for developmentally disabled children, as they have little or no input and their parents are exquisitely sensitive to their needs. Further, the revelation that the parents might have somehow failed to avert or anticipate danger to the child complicates their emotional response.

Although the child is the patient, the parent is the consumer. Failure to gain or keep the parents’ confidence will hinder or destroy therapy.

We might have protected our working relationship with Mr. E’s parents by recognizing how fragile they were and how intensely they would react to any constructive criticism. Paradoxically, for the short-term we could have tolerated their detrimental behaviors toward Mr. E (such as repeated questioning) in the hopes of protecting a long-term relationship. Spending more time exploring the guilt, anger, and confusion that tormented Mr. E’s parents—particularly his mother—also might have helped.

Related resources

• Ryan RM. Recognition of psychosis in persons who do not use spoken communication. In: Ancill RJ, Holliday S, Higenbottam J (eds). Schizophrenia: exploring the spectrum of psychosis. New York: John Wiley & Sons, 1994.

Drug brand names

• Bupropion • Wellbutrin
• Citalopram • Celexa
• Escitalopram • Lexapro
• Fluoxetine • Prozac
• Mirtazapine • Remeron
• Nefazodone • Serzone
• Paroxetine • Paxil
• Sertraline • Zoloft
• Trazodone • Desyrel
• Venlafaxine • Effexor
• Zolpidem • Ambien

HISTORY: New school, old problems

Mr. E, age 13, was diagnosed with Down syndrome at birth and has mild mental retardation and bilateral sensorineural hearing loss. His pediatrician referred him to our child and adolescent psychiatry clinic for regressed behavior, depression, and apparent psychotic symptoms. He was also having problems sleeping and had begun puberty 8 months earlier.

Five months before referral, Mr. E had graduated from a small elementary school, where he was fully mainstreamed, to a large junior high school, where he spent most of the school day in a functional skills class. About that time, Mr. E began exhibiting nocturnal and daytime enuresis, loss of previously mastered skills, intolerance of novelty and change, and separation difficulty. Although toilet trained at age 7, he started having “accidents” at home, school, and elsewhere. He was reluctant to dress himself, and he resisted going to school.

The youth also talked to himself often and appeared to respond to internal stimuli. He “relived” conversations aloud, described imaginary friends to family and teachers, and spoke to a stuffed dog called Goofy. He would sit and stare into space for up to a half-hour, appearing preoccupied. Family members said he had exhibited these behaviors in grade school but until now appeared to have “outgrown” them.

Once sociable, Mr. E had become increasingly moody, negativistic, and isolative. He spent hours alone in his room. His mother, with whom he was close, reported that he was often angry with her for no apparent reason.

With puberty, his mother noted, Mr. E had begun kissing other developmentally disabled children. He also masturbated, but at his parents’ urging he restricted this activity to his room.

On evaluation, Mr. E was pleasant and outgoing. He had the facial dysmorphia and stature typical of Down syndrome. He smiled often and interacted well, and he attended and adapted to transitions in conversation and activities. His speech was dysarthric (with hyperglossia) and telegraphic; he could speak only four- to five-word sentences.

Was Mr. E exhibiting an adjustment reaction, depression, or a normal developmental response to puberty? Do his psychotic symptoms signal onset of schizophrenia?

Dr. Krassner’s and Kraus’ observations

Because Down syndrome is the most common genetic cause of mental retardation—seen in approximately 1 in 1,000 live births¹—pediatricians and child psychiatrists see this disorder fairly frequently.

Regression, a form of coping exhibited by many children, is extremely common in youths with Down syndrome² and often has a definite—though sometimes unclear—precipitant. We felt Mr. E’s move from a highly responsive, familiar school environment to a far less responsive one that accentuated his differences contributed to many of his symptoms.

Psychosis is less common in Down syndrome than in other developmental disabilities.² Schizophrenia may occur, but diagnosis is complicated by cognition impairments, test-taking skills, and—in Mr. E’s case—inability to describe disordered thoughts or hallucinations due to poor language skills.³

Self-talk is common in Down syndrome and might be mistaken for psychosis. Note that despite his chronologic age, Mr. E is developmentally a 6-year-old, and self-talk and imaginary friends are considered normal behaviors for a child that age. What’s more, the stress of changing schools may have further compromised his developmental skills.

Box 1

By contrast, depression is fairly common in Down syndrome, although it is much less prevalent in children than in adults with the developmental disorder.²

Finally, children with Down syndrome often enter puberty early, but without the cognitive or emotional maturity or knowledge to deal with the physiologic changes of adolescence.³ Parents often are reluctant to recognize their developmentally disabled child’s sexuality or are uncomfortable providing sexuality education.⁴ Mr. E’s parents clearly were unconvinced that his sexual behavior was normal for an adolescent.

TREATMENT Antidepressants lead to improvement

We felt Mr. E regressed secondary to emotional stress caused by switching schools. We viewed his psychotic symptoms as part of an adjustment disorder and attributed most of his other symptoms to depression. We anticipated Mr. E’s psychotic symptoms would remit spontaneously and focused on treating his mood and sleep disturbances.

We prescribed sertraline liquid suspension, 10 mg/d titrated across 3 weeks to 40 mg/d. We based our medication choice on clinical experience, mindful of a recent FDA advisory about the use of antidepressants in pediatric patients (Box 1). Also, the liquid suspension is easier to titrate than the tablet form, and we feared Mr. E might have trouble swallowing a tablet.

Mr. E’s mood and sociability improved after 3 to 4 weeks. Within 6 weeks, he regained some of his previously mastered daily activities. We added zolpidem, 10 mg nightly, to address his sleeping difficulties but discontinued the agent after 2 weeks, when his sleep patterns normalized.

At 2, 4, and 6 weeks, Mr. E was pleasant and cooperative, his thinking less concrete, and his speech more intelligible. His parents reported he was happier and more involved with family activities. At his mother’s request, sertraline was changed to 37.5 mg/d in tablet form. The patient remained stable for another month, during which his self-talk, though decreased, continued.

Two weeks later, Mr. E’s mother reported that, during a routine dermatologic examination for a chronic, presacral rash, the dermatologist noticed strategic shaving on the boy’s thighs, calves, and scrotum. Strategic shaving has been reported among sexually active youths as a means of purportedly increasing their sexual pleasure.

The dermatologist then told Mr. E’s mother that her son likely was sexually molested. Based on the boy’s differential rates of pubic hair growth, the doctor suspected that the molestation was chronic, dating back at least 3 months and probably continuing until the week before the examination. Upon hearing this, Mr. E’s parents were stunned and angry.

What behavioral signs might have suggested sexual abuse? How do the dermatologist’s findings alter diagnosis and treatment?

Dr. Krassner’s and Kraus’ observations

Given the dermatologist’s findings, Mr. E’s parents asked us whether their son’s presenting psychiatric symptoms were manifestations of posttraumatic stress disorder (PTSD).

Until now, explaining Mr. E’s symptoms as a reaction to changing schools seemed plausible. His symptoms were improving with treatment, and his sexual behaviors and interest in sexual topics were physiologically normal for his chronologic age. Despite his earlier pubertal experimentations, nothing in his psychosocial history indicated risk for sexual abuse or exploitation.

Still, children with Down syndrome are at higher risk for sexual exploitation than other children,⁴ so the possibility should have been explored with the parents. Psychiatrists should watch for physical signs of sexual abuse in these patients during the first examination (Box 2).⁴

But how is sexual abuse defined in this case? Deficient language skills prevented Mr. E from describing what happened to him, so determining whether he initiated sexual relations and with whom is nearly impossible. The act clearly could be considered abuse if Mr. E had been with an adult or older child—even if Mr. E consented. However, if Mr. E had initiated contact with another mentally retarded child, then cause, blame, and semantics become unclear. Either way, the incident could have caused PTSD.⁵

Diagnosing PTSD in non- or semi-verbal or retarded children is extremely difficult.^6,7 Unlike adults with PTSD, pre-verbal children might not have recurrent, distressing recollections of the trauma, but symbolic displacement may characterize repetitive play, during which themes are expressed.⁸

Scheeringa et al have recommended PTSD criteria for preschool children, including:

• social withdrawal
• extreme temper tantrums
• loss of developmental skills
• new separation anxiety
• new onset of aggression
• new fears without obvious links to the trauma.^5,6

Treating PTSD in children with developmental disabilities is also difficult. Modalities applicable to adults or mainstream children—such as psychodynamic psychotherapy, cognitive-behavioral therapy (CBT), exposure therapy, and medications—often do not help developmentally disabled children. For example, Mr. E lacks the cognitive apparatus to respond to CBT.

On the other hand, behavioral therapy, reducing risk factors, minimizing dissociative triggers, and educating patients, parents, friends, and teachers about PTSD can help patients such as Mr. E.⁵ Attempting to provide structure and maintain routines is a cornerstone of any intervention.

Box 2

FURTHER TREATMENT A family in turmoil

We addressed Mr. E’s symptoms as PTSD-related, though his poor language skills kept us from identifying a trauma. Based on data regarding pediatric PTSD treatment,⁹ we increased sertraline to 50 mg/d and then to 75 mg/d across 2 weeks.

However, an intense legal investigation brought on by the parents, combined with ensuing tumult within the family, worsened Mr. E’s symptoms. His self-talk became more pronounced and his isolative behavior reappeared, suggesting that the intrusive, repetitive questioning caused him to re-experience the trauma.

We again increased sertraline, to 100 mg/d, and offered supportive therapy to Mr. E. We tried to educate his parents about understanding his symptoms and managing his behavior and strongly recommended that they undergo crisis therapy to keep their reactions and emotions from hurting Mr. E. The parents declined, however, and alleged that we did not adequately support their pursuit of a diagnosis or legal action, which for them had become synonymous with treatment.

Mr. E’s mother brought her son to a psychologist, who engaged him in play therapy. She followed her son around, noting everything he said. All the while, she failed to resolve her guilt and anger. When we explained to her that these actions were hurting Mr. E’s progress, she terminated therapy.

How would you have tried to keep Mr. E’s family in therapy?

Dr. Krassner’s and Kraus’ observations

Treating psychopathology in children carries the risk of strained relations with the patient’s family. The risk increases exponentially for developmentally disabled children, as they have little or no input and their parents are exquisitely sensitive to their needs. Further, the revelation that the parents might have somehow failed to avert or anticipate danger to the child complicates their emotional response.

Although the child is the patient, the parent is the consumer. Failure to gain or keep the parents’ confidence will hinder or destroy therapy.

We might have protected our working relationship with Mr. E’s parents by recognizing how fragile they were and how intensely they would react to any constructive criticism. Paradoxically, for the short-term we could have tolerated their detrimental behaviors toward Mr. E (such as repeated questioning) in the hopes of protecting a long-term relationship. Spending more time exploring the guilt, anger, and confusion that tormented Mr. E’s parents—particularly his mother—also might have helped.

Related resources

• Ryan RM. Recognition of psychosis in persons who do not use spoken communication. In: Ancill RJ, Holliday S, Higenbottam J (eds). Schizophrenia: exploring the spectrum of psychosis. New York: John Wiley & Sons, 1994.

Drug brand names

• Bupropion • Wellbutrin
• Citalopram • Celexa
• Escitalopram • Lexapro
• Fluoxetine • Prozac
• Mirtazapine • Remeron
• Nefazodone • Serzone
• Paroxetine • Paxil
• Sertraline • Zoloft
• Trazodone • Desyrel
• Venlafaxine • Effexor
• Zolpidem • Ambien

Supplement Editor:
Joel E. Richter, MD

Contents

GERD pathogenesis, pathophysiology, and clinical manifestations
Peter J. Kahrilas, MD

Extraesophageal symptoms of GERD
Kenneth R. DeVault, MD

The continuum of GERD complications
M. Brian Fennerty, MD

Profile and assessment of GERD pharmacotherapy
Paul N. Maton, MD

Supplement Editor:
Joel E. Richter, MD

Contents

GERD pathogenesis, pathophysiology, and clinical manifestations
Peter J. Kahrilas, MD

Extraesophageal symptoms of GERD
Kenneth R. DeVault, MD

The continuum of GERD complications
M. Brian Fennerty, MD

Profile and assessment of GERD pharmacotherapy
Paul N. Maton, MD

Supplement Editor:
Joel E. Richter, MD

Contents

GERD pathogenesis, pathophysiology, and clinical manifestations
Peter J. Kahrilas, MD

Extraesophageal symptoms of GERD
Kenneth R. DeVault, MD

The continuum of GERD complications
M. Brian Fennerty, MD

Profile and assessment of GERD pharmacotherapy
Paul N. Maton, MD