Excoriation Disorder DSM-5 698.4 (L98.1)
DSM-5 Category: Obsessive-Compulsive and Related Disorders
Introduction
Excoriation disorder, also known as dermatillomania, skin-picking disorder and neurotic or psychogenic excoriation, is a new entry in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013). It is a disorder of impulse control characterized by the urge to pick at the skin, even to the extent that damage is caused. It is analogous to trichitillomania, the urge to pull one’s own hair, that was in the DSM-4 (American Psychiatric Association, 2000) but has now been anglicized to hair-pulling disorder. Both are classified with the obsessive-compulsive disorders, but some analogies have been suggested to substance use disorders.
Obsessive picking at the skin has undoubtedly taken place for centuries, but the first formal description of acne excorieé was published by Louis Brocq at the end of the 19th Century (Brocq, 1898). Excoriated acne was placed by dermatologists in the category of neurodermatitis, representing a neurotic reaction to acne (Adamson, 1915) or the exacerbation of urticaria by anxiety (Wrong, 1954), and the psychoanalytical literature has ascribed compulsive skin picking to attempts by young women to reduce their attractiveness because of psychosexual conflicts (Plewig and Kligman, 1975). A growing consensus that skin excoriation could be the result of organic mental disorder (Misery et al., 2012) has led to the classification of skin picking with the obsessive-compulsive disorders. Several celebrities have recently been linked to the disorder, although it has no current spokespersons as does hair-pulling disorder. Psychogenic skin excoriation also figures in the 2010 film Black Swan.
Symptoms of Excoriation Disorder
The cardinal symptom is a compulsive urge to pick, squeeze or scratch an area of skin, often a perceived skin defect, when under stress or experiencing anxiety (Dell’Osso et al., 2006). The face is predominantly involved, followed by the extremities and scalp; there is often a primary site of skin picking, but the skin picking is sometimes shifted to allow an injured area to heal (Orlaug and Grant, 2010). Picking is usually done for brief periods at a time but may be engaged in incessantly, particularly by developmentally disabled patients (Lang et al., 2010). The fingers are usually used to pick, but some patients excoriate the skin with tools such as needles or tweezers, and are apt to do this in response to feeling anxious or depressed or after examining the skin and finding perceived irregularities (Stein et al., 2010).
Patients report feelings of helplessness, embarrassment, guilt and shame in the face of these urges, and 15 per cent of patients have had psychiatric hospitalizations, 12 per cent suicidal thoughts and 11 per cent suicide attempts (Orlaug and Grant, 2010). Skin-picking has been analogized to the compulsive hair pulling of trichitillomania because both are obsessive ritualistic behaviors but are not preceded by obsessive thoughts, both are triggered by anxiety or depression, both actions reduce the patient’s arousal level and both conditions have their onset in childhood. Both hair-pulling and skin-picking have been categorized in the obsessive-compulsive disorders because they involve repetitive behaviors with diminished control that reduce patient anxiety (Stein et al., 2010).
At the same time, arguments have been made against dermatillomania being an obsessive-compulsive disorder, and in fact against its being a disorder at all. One argument against a specific diagnosis is that skin-picking is just another symptom of obsessive-compulsive or body-dysmorphic disorder, and another is that skin-picking is simply a bad habit like nose-picking. The justification for a separate DSM-5 diagnosis is that skin excoriation can occur as a primary disorder without other obsessions or compulsions and with no concerns about bodily abnormality, appears to be common in the population and can be effectively treated if patients can be encouraged to seek help for a disorder (Stein et al., 2010). It has been suggested that skin-picking disorder is more like substance abuse than obsessive-compulsive disorder (Orlaug and Grant, 2010): excoriation disorder patients are disproportionately female, skin- picking is rarely driven by obsessive thoughts, many of the treatments for obsessions and compulsions do not help skin excoriation and many patients report that skin-picking is pleasurable. A compulsion to engage in a problematic behavior despite its causing harm, inability to control the behavior once started, a strong urge to engage in the behavior before commencing it and relief of anxiety or feelings of pleasure while engaging in the behavior are characteristics associated with addictions.
Diagnostic Criteria
The DSM-5 differentiates obsessive-compulsive from anxiety disorders, because the obsessive thoughts and repetitive behaviors characteristic of the former conditions are not necessarily accompanied by feelings of anxiety. The previous DSM-4 specifier of “poor insight”, meaning that the patient was either aware of the abnormal nature of obsessions or compulsions or not, has been expanded to constitute a spectrum, ranging from “ good/fair” insight (awareness that thoughts and behaviors are abnormal) to “absent” insight (complete conviction of the appropriateness of the thoughts and behaviors).
The diagnosis requires constant or recurrent picking at the skin, resulting in skin lesions. Individuals must have made repeated attempts to stop the excoriation, which has caused significant distress or social or occupational impairment. The symptoms cannot be due to the effects of a drug, and should not be better explained by a medical or another mental disorder.
Epidemiology
The prevalence of the condition is estimated between 1.4 and 5.4 per cent of the population. Community surveys have suggested that 4 to 5 per cent have skin-picking, while telephone surveys have found skin-picking to the point of causing lesions in 16 per cent and criteria for the diagnosis in 1 to 2 per cent, and 2 per cent of dermatology patients have skin excoriation. About half of patients have onset before age 10, with a significant minority developing dermatillomania between 30 and 45 years of age (Orlaug and Grant, 2010). There is a marked female preponderance, and symptoms often begin with the onset of acne but persist after the acne resolves, or are associated with childhood traumatic experiences or follow adult stresses (Dell’Osso et al., 2006).
Excoriation disorder is frequently comorbid with other psychiatric disorders, especially those involving mood and anxiety. Obsessive-compulsive disorders are disproportionately represented, and about 40 per cent have drug or alcohol use disorders. Skin-picking is more common in psychiatric inpatients than in the general population. About half of patients with body dysmorphic disorder and slightly less than 10 per cent of those with hair-pulling and obsessive-compulsive disorders also have skin –picking (Stein et al., 2010). The incidence is also increased in developmentally disabled individuals, particularly those with Smith-Magenis and Prader-Willi syndromes. As many as 85 per cent of the latter may have skin-picking (Lang et al., 2010). Psychosocial morbidity is high, with marked increases in social and occupational disability, financial difficulty and medical problems (Stein et al., 2010).
Causes
In addition to self-disfigurement to reduce attractiveness due to psychosexual conflicts, psychodynamic explanations of skin excoriation have invoked repressed rage of children against authoritarian parents (Lang et al., 2010). Dermatillomania has also been suggested to be a maladaptive coping mechanism for stress or anxiety in individuals with impaired coping, such as with developmental disability (Lang et al., 2010). Patients with obsessive-compulsive disorder report picking because they become convinced that their skin is contaminated, while those with body dysmorphic disorder excoriate themselves in order to fix perceived skin imperfections (Odlaug and Grant, 2010).
Dopamine is felt to be involved in skin-picking, although there have as yet been no studies of brain imaging or function. Use of drugs that enhance dopamine levels or effect, such as cocaine and methamphetamine, can cause intense skin-picking, while dopamine antagonists will ameliorate skin-picking, and in particular naltrexone, which blocks the dopaminergic reward system and is used to treat addiction, is sometimes effective against dermatillomania. In comparison to control subjects, excoriation disorder patients show impaired motor inhibitory control, which is mediated by a frontostriatal circuit that links the right inferior frontal cortex and both anterior cingulate gyri; the circuit is involved in the suppression of inappropriate behaviors, and such motor inhibition is impaired in methamphetamine users (Odlaug and Grant, 2010).
Treatment of Excoriation Disorder
Although skin-picking causes distress and impairment, only 30 to 45 per cent of patients appear to seek treatment, and as few as 19 per cent have received dermatology evaluation (Odlaug and Grant, 2010). SSRI antidepressants are the mainstay of treatment of other obsessive-compulsive disorders but have not been systematically studied here; tricyclic antidepressants (doxepin, clomipramine), typical and atypical neuroleptics (pimozide, olanzapine) and the dopamine-blocking opioid antagonist naltrexone have been effective for skin-picking. The SNRI antidepressant citalopram reduced scores on measures of obsession such as the Yale-Brown Obsessive Compulsive Scale, but did not decrease observed skin excoriation(Odlaug and Grant, 2010). N-acetylcysteine, a mucolytic and cough suppressant, decreases hair-pulling and cocaine use, and has been beneficial in a single study of skin-picking, while the antiepileptic drug topiramate alleviated skin excoriation in Prader-Willi syndrome (Lang et al., 2010).
Behavioral treatments are helpful in excoriation patients with and without psychological disabilities. Habit reversal training is coupled with awareness training to focus attention on the picking behavior, and competing response training teaches patients to execute a different motor response, for example making a fist, in situations that usually trigger skin-picking (Lang et al., 2010). Acceptance and commitment therapy and cognitive behavioral therapy have been effective in cognitively-intact patients (Ruiz, 2010), while differential reinforcement of non-picking behavior, training in other behaviors that occupy the time and energy expended in excoriation and if necessary the use of protective clothing that covers picked-at areas of skin have been shown effective for developmentally handicapped patients (Lang et al., 2010).
References
Adamson, H.G. (1915). Acne urticaria and other forms of “neurotic excoriation”. Br J Dermatol, 27, 1-12.
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders, ed. 4. Washington, DC: APA Press.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, ed. 5. Washington, DC: APA Press.
Brocq, M.L. (1898). {Acne excorieé of young women and its treatment.} Journal des Practiciens, 12, 193-197 (Fr).
Dell’Osso, B., Altamura, A.C., Allen, A. et al. (2006). Epidemiological and clinical updates on impulse control disorders: a critical review. Eur Arch Psychiat Clin Neurosci, 256(8), 464-475.
Lang, R., Didden, R., Michalechek, W. et al. (2010). Behavioral treatment of chronic skin-picking in individuals with developmental disabilities: a systematic review. Res Dev Disabil, 31(2), 304-315.
Orlaug, B.L., Grant, J.E. (2010). Pathologic skin picking. Am J Drug Alcohol Abuse, 36(5), 296-303.
Misery, L., Chastaing, M., Touboul, S. et al. (2012). Psychogenic skin excoriations: Diagnostic criteria, semiological analysis and psychiatric profiles. Acta Derm Venereol,92(4), 416-418.
Plewig, G., Kligman, A.M. (1975). Acne: Morphogenesis and Treatment. New York: Springer, 217.
Ruiz, J.F. (2010). A review of Acceptance and Commitment Therapy (ACT) empirical evidence: Correlational, experimental psychopathology, component and outcome studies. Int J Psychology Psychol Ther, 10(1), 125-162.
Stein, D.J., Grant, J.E., Franklin, M.E. et al. (2010). Trichitillomania (hair pulling disorder), skin picking disorder and stereotypic movement disorder: toward DSM-V. Depress Anxiety, 27(6), 611-626.
Wrong, N.M. (1954). Excoriated acne of young females. Arch Dermatol Syphilol, 70, 576-582.
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