Journal Article Annotations
2020, 4th Quarter

Psychodermatology

Annotations by J. Jewel Shim, MD
December, 2020

An evaluation of intensity of delusional belief in patients with delusional infestation pre- and post-treatment in a specialist psychodermatology center
Skin picking treatment with the Rothbaum cognitive behavioral therapy protocol: a randomized clinical trial.

PUBLICATION #1 — Psychodermatology

An evaluation of intensity of delusional belief in patients with delusional infestation pre- and post-treatment in a specialist psychodermatology center

Maria-Angeliki Gkini, Joao Nogueira, Tanyo Tanev, Padma Mohandas, Ruth Taylor, Anthony Bewley

Abstract: J Dermatolog Treat. 2020 Sep;31(6):602-605. doi: 10.1080/09546634.2018.1531106. Epub 2020 Aug 3.

Introduction:
The majority of patients with delusional infestation (DI) seek help from dermatologists as they consider their condition to be of cutaneous origin and deny referral to psychiatrists, with the prevalence of the condition arising. The objectives of our study were: (i) to assess whether there is a fixed delusional ideation in patients with DI, (ii) to assess the efficacy of managing such patients with combined dermatological and psychiatric treatment and (iii) to test any correlation between BABS scores and other variables.

Methods:
All consecutive newly diagnosed patients with DI, from January 2014 to January 2015, seen in our specialist psychodermatology clinic were enrolled in our prospective observational study. Brown Assessment of Beliefs Scale (BABS) was used to assess the intensity of delusion. Correlation between BABS and other variables was also assessed.

Results:
Forty-three patients were enrolled. There was a range of BABS scores pre- and post-treatment, indicative of the presence of a range of delusional ideation. A significant reduction in the BABS scores was noted post-treatment from 16.10 ± 5.53 to 11.66 ± 8.26 (p < .002).

Conclusion:
This is the first study to objectively demonstrate that delusional belief in patients with DI is not a binary phenomenon and to demonstrate an efficacious response to a combined multidisciplinary psychodermatological approach.

Annotation

The finding:
This is a prospective observational study examining 43 consecutive patients with newly diagnosed delusional parasitosis and referred to a specialty psychodermatology clinic. The study authors sought to characterize the severity of delusional beliefs as measured by the Brown Assessment of Beliefs Scale (BABS) and track improvement of these beliefs after multimodal treatment (antipsychotics, CBT based support, dermatological interventions. Results demonstrated significant improvement in BABS scores with treatment.

Strength and weaknesses:
The study offers a novel approach to considering delusional infestation (DI) in a quantitative assessment of the severity of beliefs. However, the sample size was small. There was no information whether the participants all received the same treatment or how their treatment may have differed. There is no information regarding the study interval, ie, length of time between measurements, and whether this was fixed or varied per subject. While claiming that characterizing the severity of delusional beliefs is important clinically, the investigators did not specify how this would impact treatment, though one would logically surmise that the more severe the investment in delusions the more aggressive the treatment.

Relevance:
The study raises the consideration of assessing severity of delusional beliefs and whether to alter treatment approach based on the severity of these symptoms.

Type of study (EBM guide):
case series

PUBLICATION #2 — Psychodermatology

Skin picking treatment with the Rothbaum cognitive behavioral therapy protocol: a randomized clinical trial.

Alice C M Xavier, Camila M B de Souza, Luís H F Flores, Mariane B Bermudez, Renata M F Silva, Ariadne C de Oliveira, Carolina B Dreher

Abstract: Braz J Psychiatry. Sep-Oct 2020;42(5):510-518. doi: 10.1590/1516-4446-2019-0636.

Introduction:
Although behavioral therapies can effectively treat skin picking disorder (SPD), there is no standardized treatment for improving SPD and its comorbidities and there is no group intervention option. This trial aimed to adapt the Rothbaum trichotillomania protocol to SPD (Study 1) and test its efficacy for treating SPD and comorbidities in individual and group formats (Study 2).

Methods:
The adapted protocol was applied to 16 SPD patients, who were allocated to group or individual treatment (Study 1). Afterwards, 54 patients were randomly allocated to treatment in an individual (n=27) or group format (n=27) (Study 2). In both studies, assessments of SPD severity, anxiety, depression, clinical status and skin lesion severity were performed at baseline and the endpoint.

Results:
The adapted protocol was feasible in both treatment modalities (Study 1) and led to high SPD remission rates (individual 63%; group 52%), with no significant difference between intervention types (p = 0.4) (Study 2). SPD, anxiety, and depression symptoms and objective patient lesion measures improved after treatment. There was large effect size for SPD symptom improvement in both treatment types (Cohen’s d: group = 0.88; individual = 1.15) (Study 2).

Conclusion:
The adapted Rothbaum protocol was effective for SPD remission, comorbidities, and skin lesions, both in individual and group formats.

Annotation

The finding:
This study examined the use of a specific treatment method used to treat trichotillomania and found it to be effective in treating skin picking disorder (SPD) in both individual and group formats. In addition, this method also addressed comorbid depression and anxiety symptoms, with individual treatment being somewhat more efficacious in addressing anxiety symptoms.

Strength and weaknesses:
A major weakness is the small sample size and lack of control group and some intergroup differences e.g., no subjects with social anxiety in the group treatment intervention. Strengths include randomization and inclusion of assessment of comorbid depression and anxiety symptoms, which can complicate treatment of SPD.

Relevance:
This study offers an evidence-based treatment for SPD that can be delivered in both individual and group formats.

Type of study (EBM guide):
Randomized trial