EXCORIATION DISORDER

Excoriation disorder (also referred to as chronic skin-picking or dermatillomania) is a mental illness related to obsessive-compulsive disorder. It is characterized by repeated picking at one’s own skin which results in skin lesions and causes significant disruption in one’s life. Obsessive-Compulsive Disorder (OCD) is a common, chronic and long-lasting disorder in which a person has uncontrollable, reoccurring thoughts (obsessions) and behaviours (compulsions) that he or she feels the urge to repeat over and over. People with OCD may have symptoms of obsessions, compulsions, or both. These symptoms can interfere with all aspects of life, such as work, school, and personal relationships.
Individuals may pick at healthy skin, minor skin irregularities (e.g., pimples or calluses), lesions, or scabs. This disorder is usually chronic, with periods of remission alternating with periods of greater symptom intensity. If untreated, skin-picking behaviours may come and go for weeks, months, or years at a time. It is common for individuals with this disorder to spend significant amounts of time, sometimes even several hours a day, on their picking behaviour.

Skin picking is a body-focused repetitive behaviour (BFRB) that typically begins during adolescence, commonly coinciding with, or following the onset of, puberty around ages 13-15, but may also occur among children (under 10 years old), or adults (between the ages of 30 and 45). Excoriation disorder affects approximately 1.4% of American adults and is experienced by women more often than men.

Skin picking behaviour which meets diagnostic criteria for Excoriation Disorder far exceeds “normal” grooming behaviour. Grooming behaviour 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 behaviour 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 behaviour 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.

Diagnosis

The first measure, the Skin Picking Scale (SPS), can be used to measure the client’s self-reported severity of skin picking behaviours. This measure consists of six items that relate to the frequency of picking urges an intensity of picking urges, time spent engaging in skin picking behaviours, interference of the behaviours in functioning, avoidance behaviours and the overall distress associated with the excoriation-related behaviours.

The second measure is the Skin Picking Impact Scale (SPIS). The SPIS is a self-report questionnaire designed to assess the impacts or consequences of repetitive skin picking (e.g., negative self-evaluation, social interference). Each of the scale’s 10 items is rated on a 6-point scale from 0 (none) to 5 (severe), resulting in a total score ranging from 0 to 50. The SPIS has high internal consistency, and scores appear to correlate with duration of picking, the satisfaction of picking and shame associated with picking.

The third measure is the Skin Picking Impact Scale-Shorter Version (SPIS-S). The SPIS-S is the shorter version of the SPIS consisting of only a 4-question scale (Snorrason et al., 2013). The SPIS and the SPIS-S have a similar factor structure and both have high internal consistency.

Signs of Skin Picking Disorder

It’s hard to say exactly when skin picking changes from a mild, nervous habit to a serious problem that needs treatment. It may help to ask the following questions:

• Does picking at your skin take up a lot of time during the day?
• Do you have noticeable scars from skin picking?
• Do you feel upset when you think about how much you pick your skin?
• Does picking at your skin get in the way of your social or professional life? For example, do you avoid the beach or the gym because people might see your scars? Or do you spend a lot of time covering up sores before work or social events?

Symptoms

• Recurrent skin picking that results in skin lesions
• Repeated attempts to stop the behaviour
• can’t stop picking your skin
• cause cuts, bleeding or bruising by picking your skin
• pick moles, freckles, spots or scars to try to “smooth” or “perfect” them
• don’t always realise you’re picking your skin or do it when you’re asleep
• pick your skin when you feel anxious or stressed
• The symptoms cause clinically significant distress or impairment
• The symptoms are not caused by a substance or medical, or dermatological condition
• The symptoms are not better explained by another psychiatric disorder

Skin picking disorder often develops in one of two ways:

1. After some kind of rash, skin infection, or small injury. You may pick at the scab or rash, which causes more injury to the skin and keeps the wound from healing. More itching leads to more picking and more scabbing, and the cycle continues.
2. During a time of stress. You may absently pick at a scab or the skin around your nails and find that the repetitive action helps to relieve stress. It then becomes a habit.

   

Causes

• boredom
• stress or anxiety
• negative emotions, such as guilt or shame
• skin conditions, such as acne or eczema
• other blemishes that the person wants to get rid of – these may not be noticeable to other people

Treatment

Medication:

Successful treatment may include the use of selective serotonin reuptake inhibitors (SSRIs), which are antidepressants that also help reduce obsessive thoughts and compulsive behaviours.

Cognitive-behavioural therapy (CBT):

Cognitive-behavioural therapy helps individuals understand how their thoughts and behaviour patterns are related in order to reduce repetitive behaviours. Individuals learn how to change their thoughts so that they can avoid picking at their skin.

Habit Reversal Training

Habit reversal training (HRT) is an effective strategy for working with clients who have excoriation disorder. HRT is a behavioural approach that involves helping clients gain awareness of their skin picking and then replace the picking with more adaptive behaviours. The first step of treatment is awareness training, which helps clients who are often unaware of their skin picking to associate factors, such as time of day and specific situations, to skin picking behaviour. To facilitate this awareness, a counsellor may point out in-session skin picking behaviour. After developing an awareness of antecedent situations (i.e., the situations that precede picking incidents), the counsellor and client collaboratively develop a competing response or another behaviour that is inconsistent with skin picking, to substitute for the skin picking behaviours. An example of an alternative behaviour would be clenching one’s fist each time a client notices that he or she is picking. This competing response, which should be one that is easily applicable in a number of situations, diminishes the urge or reduces its intensity.

The next step in HRT is the establishment of a contingency management system or token economy involving rewards and punishments. This type of treatment approach allows the clients’ behaviours to be rewarded as they make successive approximations toward the goal. Rewards and punishments must be meaningful to clients, and they also must be specific and timely. At first, rewards are extrinsic, such as verbal praise or toys with children. As target behaviours are reached (e.g., reduced skin picking), clients begin to access more intrinsic reinforcers (e.g., an increased sense of self-esteem, feelings of belonging within the community/society).

Acceptance and Commitment Therapy

Acceptance and commitment therapy (ACT), when used in conjunction with HRT, demonstrates clinical promise in treating those who have excoriation disorder through the use of multiple clinical case studies, demonstrated that Acceptance-Enhanced Behavioral Therapy (i.e., ACT plus HRT) decreased excoriation symptomology in three of four participants in their case study research.

ACT uses mindfulness techniques to teach acceptance of negative thoughts and emotions and then combines behaviour-change techniques to address unhealthy behaviours. Initially, the counsellor helps the client investigate previous attempts to curb skin picking behaviours (such as avoidance or relaxation while picking). Then, the client and counsellor work to distinguish between urges to pick (i.e., thoughts, feelings, sensations) and actual skin picking, emphasizing that even if urges are acted upon, they will soon return. As such, the focus is on increased distress tolerance and acceptance of urges. The difficulty of controlling urges can be illustrated through metaphors in which the client gains control and a position of power over an undesirable, yet steadfast external circumstance (e.g., working is unavoidable, but you can find a job you enjoy).

Next, using ACT treatment, the client’s ability to control his or her own thoughts and behaviours is highlighted. This emphasis on controlling behaviour stands in contrast to most clients’ natural inclination to focus on controlling or avoiding external situations. Next, the counsellor and client work to modify and change the thoughts and feelings associated with urges to pick. The client and counsellor address six processes that contribute to healthy, flexible living: present-moment awareness; acceptance (as opposed to avoidance); nonjudgmental awareness of one’s thoughts; values clarification; changing, rather than reducing, unhelpful thoughts; and short- and long-term behavioural goals.

Pharmacotherapy

If pharmacotherapy is used to treat excoriation disorder, it should be used in conjunction with counselling; medication can control physical symptoms, but contributing mental health factors must be addressed in order to holistically help the client make enduring behaviour changes. Selective serotonin reuptake inhibitors, specifically Fluoxetine (Prozac), have been shown to be effective in treating excoriation disorder and other BFRB. Therefore, additional research on the effectiveness of medication is needed. Counsellors should provide intentional treatments for clients while taking into account unique client considerations.

Special Considerations

Although those with excoriation disorder might go to great efforts to conceal their wounds from others, they are likely to admit to skin picking behaviours when effectively questioned by a mental health professional. It is important to ensure the clients with excoriation disorder are physically well (i.e., free from medical complications associated with picking), and a referral to medical professionals to ensure physical safety and appropriate medical care may be necessary.

Collaborative relationships with other professionals can be helpful when working with a client who has excoriation disorder. If clients are provided with psychopharmaceutical interventions, counsellors should take care to communicate with the prescribing physician in order to help the client maintain proper medication schedules and to potentially provide psychoeducational support to the client. Although consultation with a dermatologist is not always necessary, this valuable resource should be integrated into treatment when possible, and open communication can ensure that clients are receiving the support that they need.

Stimulus control
This therapy involves making changes to your environment to help curb skin picking. For example, you might try wearing gloves or Band-Aids to help prevent feeling the skin and getting the urge to pick. Or you might cover mirrors if seeing facial blemishes or pimples brings on picking behaviour.

Co-occurring Illnesses
Excoriation disorder often co-occurs with obsessive-compulsive disorder, trichotillomania (hair-pulling), and major depressive disorder. One study indicates that 38% of individuals with excoriation disorder have co-occurring trichotillomania.

Other body-focused repetitive behaviours (BFRBs), such as nail biting, may also coincide with excoriation. [3]
Skin picking disorder is considered a type of repetitive “self-grooming” behaviour called “Body-Focused Repetitive Behavior” (BFRB). Other types of BFRBs include pulling or picking of the hair or nails that damage the body.

It is classified in the DSM-V (a compendium of psychiatric diagnoses) as a type of obsessive-compulsive disorder because of the compulsive urge to perform repetitive behaviours.
distress because of the disorder. They may feel embarrassed by the condition of their skin. They may also feel ashamed because they seem unable to stop themselves from engaging in this harmful behaviour.

This perceived lack of control is very similar to the compulsions in obsessive-compulsive disorder (OCD). Like OCD, the desire to skin-pick is frequently described as a compelling urge that is often preceded by a strong emotion. However, unlike OCD compulsions, people with skin-picking disorder report a pleasurable gratification from picking.

Another difference between OCD and skin-picking is the behaviour may not be preceded by an obsession or intrusive thought. In fact, the behaviour is often performed without any conscious awareness of it. The same is true of hair-pulling disorder (trichotillomania). This distinction has led some professionals to suggest that perhaps hair-pulling and skin-picking are more similar to each other, than to OCD.

Like hair-pulling, skin-picking may require medical attention. This is because skin-picking can cause lesions that become infected. The unsightly lesions and scars can cause embarrassment. Therefore, people may attempt to hide or camouflage these areas. Other people intentionally chose to pick at sites, such as the scalp or the back, where the skin-picking is not easily visible to others.

REFERENCES

http://tpcjournal.nbcc.org/excoriation-disorder-assessment-diagnosis-and-treatment/

https://www.nhs.uk/conditions/skin-picking-disorder/

http://www.mentalhealthamerica.net/conditions/excoriation-disorder-skin-picking-or-dermatillomania