DERMATITIS ARTEFACTA AND SEXUAL ABUSE

Case 1: This 16-year-old woman was referred for psychiatric management of her dermatitis artefacta that presented as superficial linear abrasions on her thighs and arms. During psychotherapy, the patient disclosed that her father had started sexually molesting her when she was about 8 years old. By age 10 years her father was having sexual intercourse with her. Initially, the patient confused her father's sexual advances with affection, but by age 10 years she became acutely aware of the abusive nature of their relationship. At this time, the father threatened to leave the family if the patient disclosed the sexual abuse. This was very threatening for the patient, since it would mean that her mother and her siblings would end up on welfare. The father then blamed the patient for “seducing him” and continued to abuse her sexually; the patient felt guilty and “bad.”

The patient started making superficial linear abrasions on the anterior aspects of her thighs. She described that it helped her “release tension” because the pain helped her to cope with her guilt. The patient was essentially “punishing herself” by inflicting the lesions on herself. The patient also felt “very fat and ugly” and the scars on her body helped to validate this. During the course of therapy, the patient had much difficulty coping with the unresolved anger that began to surface as she acknowledged her feelings regarding the sexual abuse. Initially, she could cope with her anger only by cutting herself, and the symptoms of her dermatitis artefacta became worse. After about 1 year of psychotherapy she was able to acknowledge her feelings more effectively and became much more assertive. This was associated with a marked decrease in the frequency of her self-mutilative behavior.

Case 2: This 29-year-old woman was referred for psychiatric management of her dermatitis artefacta. The patient would typically present to her family doctor with rectangular abrasions on her forearms. The self-inflicted nature of the lesions was obvious on inspection, but the patient denied remembering that she caused the injury. The patient entered psychotherapy once weekly, and after approximately 6 months, she began to have flashbacks about being sexually abused regularly by an older brother when she was between ages 5–8 years. The patient described dissociative experiences when she was being subjected to the abuse. For example, she felt like “she was watching someone else being abused” and remembers “not feeling anything” while her brother was raping her. Over several months she was able to recognize that she would dissociate whenever faced with emotionally disturbing situations, especially those involving anger. During these dissociative states she would inflict the rectangular abrasions on herself. The patient experienced a significant improvement in the frequency of her dissociative experiences and her self-mutilative behavior as she acknowledged her anger toward her brother more directly. Chlorpromazine, 25 mg qid, prn, also proved to be a valuable adjunct in her therapy, as it helped her to cope with her very strong anger, and decreased the frequency of her dissociative reactions.