(146) Excoriation Disorder, Self-Induced Craniectomy, and the Limitations of Telepsychiatry

Abstract: Objective: We present a severe case of excoriation disorder complicated by stimulant use and discuss inpatient and outpatient management, highlighting the limitations of telepsychiatry in diagnosing excoriation disorder and other disorders associated with self-injurious behavior.

Case: A 39-year-old female with a psychiatric history of MDD, GAD, ADD on stimulants, and OCD with skin-picking behaviors and a medical history of chronic Lyme disease presented to the hospital with a bleeding skull wound. Physical examination revealed a 5cm wound extending through the skull, with the superior sagittal sinus visible on the surface of the brain. CT Head showed herniation of the right frontal lobe through the skull, as well as a 2.1 x 2.2 cm hypodensity concerning for subacute infarct. MRI Brain showed three areas of restricted diffusion with peripheral enhancement concerning for developing abscesses. History revealed that she was using cuticle nippers to remove pieces of her skull during episodes of picking. She was co-managed by a local psychiatric practice and an out-of-state psychiatrist specializing in chronic Lyme disease. During outpatient telepsychiatry appointments, she wore a knit cap to hide her skull wound. She was subsequently admitted to the neurosurgical service where she underwent serial debridement of necrotic brain matter, followed by closure of the skull defect with mesh cranioplasty and thigh flap. Her dextroamphetamine-amphetamine was discontinued and she was initiated on escitalopram and quetiapine for skin-picking and propranolol for anxiety and restlessness. Neither outpatient provider was aware of the extent of the patient’s skin-picking behaviors. We recommended indefinite discontinuation of stimulants and in-person evaluations moving forward.

Discussion: The COVID-19 pandemic has precipitated transformative changes to the way that psychiatry is practiced.¹ Telepsychiatry has risen to the forefront as a way to expand access to psychiatric care nationally while minimizing infectious risk. One of the most obvious limitations of telepsychiatry is the risk of an incomplete physical exam.² Specific conditions associated with self-injury such as excoriation disorder may be less appropriate for treatment using telepsychiatry given the risk of worsening self-injury that goes unnoticed.

Conclusion: This case highlights the limitations of telepsychiatry in evaluating for potentially life-threatening complications of excoriation disorder and other disorders associated with self-injurious behavior. It is important for psychiatrists practicing in the outpatient setting to thoroughly screen for these diagnoses. Further work needs to be done to develop a standardized physical exam for use in the telepsychiatry setting.

References

1. Shore JH, Schneck CD and Mishkind MC. Telepsychiatry and the Coronavirus Disease 2019 Pandemic—Current and Future Outcomes of the Rapid Virtualization of Psychiatric Care. JAMA Psychiatry. 2020; 77: 1211-2.

2. Reeves JJ, Ayers JW and Longhurst CA. Telehealth in the COVID-19 era: a balancing act to avoid harm. Journal of Medical Internet Research. 2021; 23: e24785.

Presenting Author(s)

Brooke E. Lifland, MD

Resident Physician
Yale University
New Haven, Connecticut, United States

Co-Author(s)

Onyi Okeke, MD

Consultation- Liaison Psychiatry Fellow
Yale University
New Haven, Connecticut, United States

PZ

Paula Zimbrean, MD, FACLP, FAPA

Associate Professor of Psychiatry and Surgery (Transplantation)
Yale University
New Haven, Connecticut, United States