What is Excoriation (Skin Picking) Disorder?

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Excoriation (Skin Picking) Disorder is a psychiatric disorder which involves the repetitive picking of one's own skin. Excoriation belongs to a collection of behaviors known as Body-Focused Repetitive Behaviors (BFRBs), self-grooming behaviors in which individuals pull, pick, scrape, or bite their own hair, skin, or nails, resulting in damage to the body, including trichotillomania and onychophagia.

Classified among the "Obsessive Compulsive and Related Disorders" in the Diagnostic and Statistical Manual of Metal Disorders, Fifth Edition (DSM-5), Excoriation Disorder is not uncommon. Studies suggest that pathological skin picking affects 1.4% - 5.4% of the U.S. adult population, 75% of whom are female.  

The DSM-5 diagnostic criteria include:

  1. Recurrent skin picking that results in skin lesions
  2. Repeated attempts to stop the behavior
  3. The symptoms cause clinically significant distress or impairment
  4. The symptoms are not caused by a substance or medical, or dermatological condition
  5. The symptoms are not better explained by another psychiatric disorder

Skin picking behavior which meets diagnostic criteria for Excoriation Disorder far exceeds “normal” grooming behavior. Grooming behavior may thus be conceptualized as occurring on a continuum, with normal, washing, and exfoliating on one end of the continuum, extending to picking, scraping, or gouging that results in scarring or disfigurement on the other end.

 

The onset of Excoriation Disorder typically occurs in early adolescence, although pathological skin picking can begin at any age. The course of the disorder is considered to be chronic, with symptoms that tend to wax and wane over time. There is emerging evidence that skin picking is both environmentally and biologically influenced.

 

Excoriation Disorder tends to be heterogeneous in nature. Those who engage in skin picking tend to pick from multiple body sites, for extended periods of time, targeting both healthy and previously damaged skin. Body sites may change over time. Although the function of the behavior varies, it is often experienced as assistive in the regulation of emotional activation. Commonly reported triggers include: an urge or physical tension prior to picking, unpleasant emotions, cognitions (e.g., permission-giving thoughts, beliefs about how the skin should look or feel), sensations (e.g., a bump, sore spot), and/or a displeasing aspect of his or her appearance (e.g., visible blemish). Commonly reported experiences following picking behavior include urge reduction, sense of relief or pleasure, psychosocial difficulties or embarrassment, avoidance, reduced productivity, emotional sequelae such as anxiety or depression, skin infections, scars, lesions, and/or disfigurement.

The impact of Excoriation Disorder on one's life may be significant.

Individuals struggling with pathological skin picking may experience shame and embarrassment, and as a result may avoid certain social situations, activities, and medical care. Furthermore, they often go to great lengths to cover, hide, or camouflage damaged skin. 

Evidence-based treatment for Excoriation Disorder includes a specific Cognitive-Behavioral Therapy (CBT) - Habit Reversal Training (HRT). HRT includes awareness training (i.e., self-monitoring), the identification of behavior triggers, stimulus control (modifying the environment to decrease the likelihood of picking behavior), and competing for response training (identifying a substitution behavior that is incompatible with skin picking). Acceptance and Commitment Therapy (ACT) and Dialectical Behavior Therapy (DBT) skills training, as adjunctive strategies, have been demonstrated to be helpful in reducing problematic grooming behavior in studies of a related disorder, trichotillomania.

There is no FDA-approved pharmacological treatment for Excoriation Disorder. Some individuals find antidepressants somewhat helpful (specifically, Selective Serotonin Reuptake Inhibitors [SSRIs]), particularly if there is a co-occurring anxiety or mood disorder which influences picking behavior; however, studies supporting their efficacy evidence mixed results. N-Acetyl Cysteine (NAC), a dietary supplement and amino acid that affects glutamate levels in the brain, has shown some promise in decreasing the behavior in adult women.

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Sources:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 5th ed. Washington, DC: American Psychiatric Association; 2013:251-4.

Grant, J., Odlaugh, B., Chamberlin, S., Keuthen, N., Lochner, C., & Stein, D. (2012)." Skin Picking Disorder." Am J Psychiatry, 169:1143–1149.

Grant JE, Odlaug BL (2009). "Update on pathological skin picking". Curr Psychiatry Rep 11 (4): 283–8.

Trichotillomania Learning Center. (2011). Expert Consensus Treatment Guidelines for Trichotillomania, Skin Picking, and Other Body-Focused Repetitive Behaviors.

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