Neurotic Excoriations Secondary to Underlying Major Depression

Mr. Adams is 27 year-old Caucasian new patient, who presented to the dermatology clinic with several excoriations on the face, arms, and legs. The lesions were all located on easily reachable areas of his anatomy such as the extensor arms but not the medial arms, the anterior legs but not the posterior legs, etc. No primary skin lesions were seen. The patient was visibly depressed. However, when asked what was causing him to be distressed, he answered: “nothing other than having these spots on my [his] skin.” The practitioner, sensing that forward questions might not be useful, decided to change the questioning approach and asked about his general wellbeing. The patient then reported severe early insomnia (i.e., he cannot fall asleep), middle insomnia (i.e., he wakes up frequently in the middle of the night), and terminal insomnia (i.e., he wakes up early in the morning and cannot go back to sleep even despite being extremely tired).