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Paper text:
lying at the interface between dermatology and psychiatry ; dermatitis artefacta ( da ) is an enigmatic entity , one excellent imitator and , therefore a source of great confusion for unsuspecting physicians as well as for trained specialists . the confusion and consequent misdiagnosis might unnecessarily increase morbidity and mortality of these patients .
we describe here a classic case of da , which closely mimicked deliberate self - harm ( dsh ) in patients with borderline personality disorder ( bpd ) . since bpd , with 6080% dsh rates,1 ) warrants separate and focussed attention ; unscrambling it from da becomes imperative .
an 11 year old third - born rural bengali girl from lower economic strata , with nil - contributory past / family / developmental history ; visited psychiatry outdoors for sudden - onset multiple fine cuts on left forearm and forehead .
she had reportedly been wearing full - sleeved clothes for last 12 weeks in hot summer and had changed her hairdo to cover forehead , both going unnoticed until the mother found blood - stains on her sleeves ; and fearing she had tried to kill herself , consulted us .
however , history did not reveal behavioral disturbances , disruptions in activities of daily living , significant affective or psychotic symptoms .
forearm lesions were linear , horizontal and tailing towards right ( dominant - hand ) .
they were present in closely drawn pairs ; a few having associated hesitation - cuts .
patient denied making any of the cuts , and claimed that they had appeared by themselves over last 7 days .
when told that there was no such skin condition which would manifest like these , she became rigid in her opinion . during the interview ,
she appeared relaxed ; speech was soft / coherent / relevant , and no perceptual / thought abnormalities could be elicited .
her full scale intelligence quotient on malin s intelligence scale for indian children ( misic)2 ) was 88 , which indicated normal intelligence .
assessment on junior temperament and character inventory3 ) failed to reveal significant impairment in any of the scales measuring novelty seeking , harm avoidance , reward dependence or persistence .
scores on hamilton anxiety rating scale ( ham - a)4 ) was 14 indicating mild anxiety ; and on hamilton rating scale for depression5 ) was 6 indicating no depression .
we were unable to find any material gains from the lesions , after thorough clinical and historical evaluations .
the patient was admitted to an open ward along with her mother for the purpose of administering psychotherapy , and supervised initiation of pharmacotherapy .
dermatology consultation maintained a provisional diagnosis of da after due considerations , and advised conservative management of the skin lesions .
she was started on fluoxetine 10 mg , along with supportive psychotherapy and family therapy based on the advises of the treating team .
patient s denial of the origin of the lesions and their unpredictable occurrences proved a major hindrance to abc analysis and behavior - based interventions ; and initial focus was thus maintained on establishing rapport .
she was discharged without development of fresh lesions after 7 days of in - patient stay , and there had been nil fresh crops at 1 month s follow up . at follow up ,
her ham - a score had reduced to 10 , and side - effects to pharmacotherapy were none .
da applies only to conditions in which skin lesions appear in a mysterious ways while the patient denies all responsibilities for them .
these often reflect deeply buried psychological distresses , which need to be sincerely sought after.6 ) linear excoriations , inflicted through fingernails or sharp objects , are the second most common manifestation of da after ulcers.7 ) interestingly , a large number of these patients visit dermatologists , for whom this condition remain a source of great discomfort and a diagnosis of exclusion.7 ) the condition is diagnosed in dermatological practice using gupta and guptas8 ) classificatory system under 
disorders associated with self - inflicted dermatoses  , which is self - explanatory in a sense .
mean age of presentation has been put at around 20 years , with a female preponderance and a greater prevalence in lower socio - economic strata.7 ) the history in these patients is usually 
hollow;9 ) and those with an apparent cause as psychosis or malingering need to be excluded.7 ) diagnosing da requires a high degree of suspicion , a meticulous appraisal of the dermatological signs and a detailed evaluation of psychological faculties . similarly , management requires an eclectic combination of an empathetic patient - doctor relationship , a supportive environment , psychotherapeutic and pharmacological interventions,7 ) thus entailing a proper liaison . from a psychiatrist s perspective ; lesions in our patient closely resembled hesitation cuts and dsh , generally seen in those with bpd .
bpd is characterised by classical presentations of  a pervasive pattern of instability of interpersonal relationships , self - image , and affects , and marked impulsivity10 ) with a central feature of emotional dysregulation.1 ) dsh noted in bpd patients form an important dimension of this disorder and constitutes the chief reason for treatment utilization in this patient population.1 ) though termed
 parasuicidal  , thus signifying a lack of intent , such behaviors could nevertheless be fatal or at least a source of significant morbidity for the patient as well as his / her family .
such behaviors have been attributed to the inherent tendency towards experiential avoidance , escape learning and impulsivity in these patients,1 ) and they require an assertive and active therapist .
the demonstrated success of dialectical behavior therapy in managing bpd cases requires that they be identified at the earliest , before much damage has been incurred.11 ) dsh in da , on other hand , is driven more by the underlying negative affect states , and cognitive - behavioral approach suits these patients more , within a passive yet empathetic psychiatrist - patient relationship .
differences also exist in the way these patients are managed pharmacologically . while stress and anxiety in da would respond to ssris most of the time ; they require extreme caution in bpd to avoid mood dysregulation and induced switch.12 ) in our patient we had carefully ruled out malingering and other major psychiatric conditions through detailed clinical and psychometric evaluations to arrive at a diagnosis of da .
our case reiterates the utility of detailed evaluation of dsh in practise , a need for liaison with dermatology , for the psychiatrist to be open to possibilities and be ready to go beyond what is seen .
dermatitis artefacta lies in a gray zone , between the specialities of psychiatry and dermatology . 
 the condition could mimic a number of other lesions and therefore is a source of much confusion in clinical practice . here , we describe a case of dermatitis artefacta in an 11-years old girl , which resembled self - harming behavior in borderline personality disorder . 
 we then discuss how the two could be differentiated and why this becomes imperative while dealing with such cases .