Integrating psychological intervention in Gardner-Diamond Syndrome

Dear Editor,

We wish to emphasize the critical role of psychotherapeutic interventions and specific diagnostic tests in managing Gardner-Diamond Syndrome (GDS), a rare psychodermatological disorder characterized by spontaneous, painful bruising often linked to emotional distress.[1] The course involves relapses and remissions, with varying intervals between episodes.

A 32-year-old woman presented with recurrent episodes of ecchymosis on her arms, legs, abdomen, and face [Figures 1 and 2]. Despite thorough laboratory investigations showing normal results—including hemoglobin levels (9.9 g/dL), platelet count (152,000), and coagulation profile (PTI: 11.8/INR: 1.08)—no identifiable causes for her bruising were found. Skin biopsy demonstrated perivascular inflammatory infiltrate with red blood cell extravasation without evidence of fibrinoid necrosis or leukocytoclastic. The absence of a personal or family history of bleeding disorders further complicated the diagnosis.

Figure 1.

Ecchymotic lesion on anterior aspect of left arm

Figure 2.

Ecchymotic lesion on posterior aspect of right arm

An intradermal autoerythrocyte sensitization test (AEST) was conducted to confirm GDS. A 0.1 mL sample of the patient’s blood was injected, resulting in an ecchymotic reaction after 24 hours, while no reaction occurred at the saline control site. This positive response supported the diagnosis of GDS.

A psychiatric evaluation using the Structured Clinical Interview for DSM-5 (SCID-5-CV) and Rorschach Inkblot Test revealed significant emotional distress, adjustment disorder, and histrionic personality traits. The patient’s personal history included early marriage, family losses, and multiple miscarriages, culminating in surgeries that further exacerbated her emotional state. There was no significant family psychiatric illness history or past psychiatric history. Premorbidly, she was flexible, had good interpersonal and social relations and was overall well- adjusted.

She was prescribed oral corticosteroids and SSRIs (escitalopram oxalate and clonazepam).[2] Dialectical behavior therapy was implemented to address her psychological symptoms. Techniques such as mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness skills were taught.

Over 5 months, the patient experienced a significant reduction in episodes of bruising and associated pain as her psychological symptoms improved. This case supports the notion that psychotherapy plays a crucial role in managing medically unexplained physical symptoms like those seen in GDS, particularly in individuals with underlying psychiatric conditions.[3]

Psychological stressors and comorbidities like depression, anxiety, and personality disorders are frequently implicated in triggering or exacerbating painful bruising episodes. The integration of psychotherapy in GDS treatment is vital as psychotherapy addresses these factors by helping patients manage emotional distress, develop coping strategies, and resolve underlying psychological conflicts, which can reduce lesion recurrence and improve quality of life.[4]

Author’s contribution

Concept, design, Manuscript Review: GK, NK. Manuscript preparation and editing: AT, DK. Guarantor: NK.

Ethical statement

Ethical approval was not sought since it was a single case report.

Conflicts of interest

There are no conflicts of interest.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient consented to her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Funding Statement

Nil.