Excoriation disorder & skin-picking disorder

Until recently, chronic skin peeling disorder, which can harm human self-esteem, was classified as impulse control disorder along with the hair-pulling disorder. In fact, these two disorders can be classified as impulse disorders in that there are urges to pull the hair and peel the skin, respectively. However, the DSM-5 classifies them as an obsessive-compulsive disorder by focusing on compulsive behavior.

Compulsive skin picking must have been practiced throughout human history. However, for the first time, the French dermatologist Louis Brocq reported the symptoms of constant scratching of acne at the end of the 19th century. This symptom was interpreted by Adamson in 1915 as neurodermatitis caused by anxiety or a neurotic reaction to acne. It was also understood by Plewing and Kligman in 1975 as an impulsive act for young women to reduce their attractiveness from a psychoanalytic standpoint. It was later classified as an obsessive-compulsive disorder due to the recognition that skin picking disorder could be the result of an organic mental disorder (Misery et al. 2012).

 

Symptoms of skin picking Disorder:

The main symptom of this disorder is the compulsive urge to pick, scratch, dig or scrub certain areas of the skin when stressed or anxious, often recognized as skin texture damage (Dell'Osso et al., 2006). They usually have a tendency to scrub off the skin as a reaction to feeling anxious or depressed, or in some cases when a defect is discovered on the skin. In many cases, the skin is peeled off by hand, but tools such as needles or tweezers are also used to scrub the skin. People with this disorder tend to put a lot of effort into hiding their damaged skin, avoiding relationships with other people, and going out to large gatherings. Ultimately, this disorder negatively affects people's mental and physical well-being. Studies have shown that clients with this disorder experience feelings of helplessness, embarrassment, guilt, and shame in the face of the urge to peel or pick skin. About 15% of people with this disorder experience hospitalization, 12% suicidal thoughts, and 11% suicide attempts (Orlaug and Grant, 2010). Hair-pulling disorder (Trichotillomania) and skin picking disorder are similar in that they are both compulsive conscious behaviors, triggered by anxiety or depression, and onset in childhood. It is classified as an obsessive-compulsive disorder because it involves repetitive, uncontrollable behaviors that are specifically aimed at reducing anxiety (Stein et al., 2010).

 

Diagnosis of Skin Picking Disorder:

Skin picking disorders listed in DSM-5 for the first time are diagnosed as follows.

A. Recurrent skin picking resulting in skin lesions.

B. Repeated attempts to decrease or stop skin picking.

C. The skin picking causes clinically significant distress or impairment in social, occupational,

or other important areas of functioning.

D. The skin picking is not attributable to the physiological effects of a substance (e.g., cocaine)

or another medical condition (e.g., scabies).

E. The skin picking is not better explained by symptoms of another mental disorder (e.g., delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder, stereotypies in stereotypic movement disorder, or intention to harm oneself in non-suicidal self-injury).

 

Epidemiology:

The prevalence of this disorder is estimated to be 1.4-5.4% of the population. About half of the disorder develops before the age of 10 and is more common in women. It often begins with the appearance of acne but tends to persist even after the acne has resolved. It is also strongly correlated with traumatic experiences in childhood and stress in adults.

Skin Picking disorder often accompanies other psychiatric disorders, particularly those related to mood and anxiety. About half of patients with body dysmorphic disorder and about 10% of patients with hair pulling and obsessive-compulsive disorder also have skin picking disorder (Stein et al., 2010). The incidence of this disorder is increased in individuals with developmental disabilities, particularly Smith-Magenis and Prader-Willi syndromes. Also, the prevalence of this disorder increases psychosocially, along with social and occupational disabilities, financial difficulties, and medical problems (Stein et al., 2010).

 Causes of skin picking disorders:

As with many other mental health problems, the exact cause of skin picking disorders is not specifically known. In general, in addition to genetic causes, various social and psychological causes can be considered. People with a family history of skin picking or obsessive-compulsive disorder are more exposed to the disorder. In addition, in the case of women who are experiencing sexual conflicts in particular in psychosocial aspects, they try to reduce their sexual attractiveness through skin picking behavior, which tends to develop into a disorder. On the other hand, children raised by authoritarian parents express their repressed anger through skin picking, which develops into a disorder (Lang et al., 2010). Also, many people feel great pain from picking or peeling their skin. However, picking can provide temporary relief from stress and anxiety. Therefore, it can be said that stress and anxiety are closely related to this disorder. In particular, as mentioned above, skin picking disorders are common with other disorders. That is, it appears with obsessive-compulsive disorder, body dysmorphic disorder, hair-pulling disorder, and also major depressive disorder. People with the obsessive-compulsive disorder do skin picking with the conviction that their skin is contaminated, while people with body dysmorphic disorder do it themselves to correct skin imperfections (Odlaug and Grant, 2010). Also, about 38% of people with skin picking disorder have hair-pulling disorder. Naturally, depression can trigger picking disorder behavior. Research on the link between this disorder and brain function is not yet sufficient. However, it is known that dopamine has a significant effect on the induction of this disorder.

 

Treatment of peeling disorders:

Many people experience skin damage and pain through the act of picking the skin. Nevertheless, there are not many people who visit counseling centers or dermatologists for this disorder. Skin Picking behavior leads to depression and other mood disorders because it causes shame and low self-esteem. Also, skin picking hurts the skin. Because of this, it causes infection of the skin and causes deformation and discoloration of the skin.

Cognitive-behavioral therapy along with drug therapy is effective for the treatment of skin picking disorder.

There are no systematic studies on whether SSRI antidepressants, which are mainly used for the treatment of the obsessive-compulsive disorder, are effective for the treatment of skin picking disorder. However, in general, selective serotonin reuptake inhibitors such as Prozac are the most commonly used drugs. Tricyclic antidepressants (doxempin, clomipramine), typical and atypical neuroleptics (pimozide, olanzapine), and the dompamine-blocking opioid antagonist naltrexone are known to be effective in the treatment of skin picking disorder.

Cognitive-behavioral therapy, which provides strategies for people with this disorder to reduce and eliminate their obsessive thoughts, feelings, and behaviors, can be a good option. In particular, competing response training, habit reversal training (replacing skin peeling with other actions instead of peeling), awareness training (self-monitoring, identification of triggers for the behavior), and stimulus control (changing the environment to help suppress the action - wearing gloves or putting on a band-aid), which are used for the treatment of tic disorders, help to suppress skin picking behavior. In addition, acceptance and commitment therapy, which can be called the third generation of cognitive-behavioral therapy, is very helpful.