Excoriation disorder
Excoriation disorder, more commonly known as dermatillomania, is a mental disorder on the obsessive–compulsive spectrum that is characterized by the repeated urge or impulse to pick at one's own skin, to the extent that either psychological or physical damage is caused. The exact causes of this disorder are unclear but are believed to involve a combination of genetic, psychological, and environmental factors, including stress and underlying mental health conditions such as anxiety or obsessive-compulsive disorder. Individuals with excoriation disorder may also experience co-occurring conditions like depression or body dysmorphic disorder. Treatment typically involves cognitive behavioral therapy and may include medications. Without intervention, the disorder can lead to serious medical complications.
Signs and symptoms
Episodes of skin picking are often preceded or accompanied by tension, anxiety, or stress. During these moments, there is commonly a compulsive urge to pick, squeeze, or scratch at a surface or region of the body, often at the location of a perceived skin defect. When picking, one may feel a sense of relief or satisfaction. In some cases, following picking, the affected person may feel depressed.The region most commonly picked is the face, but other frequent locations include the arms, legs, back, gums, neck, shoulders, scalp, abdomen, chest, and extremities such as the fingernails, cuticles, toenails, etc. Most patients with excoriation disorder report having a primary area of the body that they focus their picking on, but they will often move to other areas of the body to allow their primary picking area to heal. Individuals with excoriation disorder vary in their picking behavior; some do it briefly multiple times a day, while others can do one picking session that can last for hours. The most common way to pick is to use the fingers although a significant minority of people use tools such as tweezers or needles.
Skin picking often occurs as a result of some other triggering cause. Some common triggers are feeling or examining irregularities on the skin, and feeling anxiety or other negative feelings. This anxiety most commonly stems from a type of OCD, which can range in severity and often goes undiagnosed.
The act of skin picking can occur both consciously and unconsciously. Some individuals may be aware of their behavior but are unable to stop, while others may not realize they are picking until after damage has occurred. The level of awareness can fluctuate, and both forms can be present in the same person.
Complications arising from excoriation disorder include infection at the site of picking, tissue damage, and sepsis. Damage from picking can be so severe as to require skin grafting, and severe picking can cause epidermal abscesses. For example, in one reported case, a 58-year-old man with a history of OCD picked an extensive wound on his left foot, exposing underlying muscle tissue. Severe cases of excoriation disorder can cause life-threatening injuries. According to one reported case, a woman picked a hole through the bridge of her nose, which required surgery to fix, and a 48-year-old woman picked through the skin on her neck, exposing the carotid artery. Pain in the neck or back can arise due to prolonged bent-over positions while engaging in the behavior. Besides physical injuries, excoriation disorder can cause severe physical scarring and disfigurement.
Excoriation disorder can cause feelings of intense helplessness, guilt, shame, and embarrassment in individuals, and this greatly increases the risk of self-harm. Studies have shown that excoriation disorder presented suicidal ideation in 12% of individuals with this condition, suicide attempts in 11.5% of individuals with this condition, and psychiatric hospitalizations in 15% of individuals with this condition.
Causes
There have been many different theories regarding the causes of excoriation disorder, including biological and environmental factors.A common hypothesis is that excoriation disorder is often a coping mechanism to deal with elevated levels of turmoil, boredom, anxiety, or stress within the individual, and that the individual has an impaired stress response. A review of behavioral studies in individuals with developmental disorders and comorbid skin-picking found support in this hypothesis, in that skin-picking appears to be maintained by automatic reinforcement within the individual.
Neurological
There is limited knowledge regarding the neurobiology that drives excoriation disorder, and there have been few neuroimaging studies of those with excoriation disorder.Those individuals that have excoriation disorder along with other diagnosed conditions report differing motivations for their picking. Those with both OCD and excoriation disorder report that they will pick their skin due to perceived contamination of the skin, while those with both BDD and excoriation disorder reportedly pick to fix perceived imperfections in the skin.
Studies have shown a linkage between dopamine and the urge to pick. Drugs such as cocaine and methamphetamine, which increase the pharmacological effects of dopamine, have been shown to cause uncontrollable picking in users. These drugs can create the sensation of formication, which feels like something is crawling on or under the skin. Thus, excoriation disorder could result from a dysfunction in the dopamine reward functions.
There may be another neurological explanation for excoriation disorder: individuals with the condition have less motor-inhibitory control, but show no sign of a difference in cognitive flexibility when compared to individuals without the condition. Motor-inhibitory control is a function of the right-lateralized frontostriatal circuit, which includes the right inferior frontal and bilateral anterior cingulate cortices. The impairment of motor-inhibitory control is similar to the neurological conditions of those who have problems suppressing inappropriate behaviors, and it has been suggested by at least one study that this may be similar to the mechanisms of substance use disorder.
Genetic components
There is significant evidence to suggest that skin picking disorders are due to inherited traits or genes. There have been multiple small studies with similar conclusions in regards to the SAPAP3 gene. Excessive grooming by mice has been observed by researchers after the deletion of the SAPAP3 gene. This observation led researchers to study the effects of the SAPAP3 gene on patients with trichotillomania—a disorder marked by the same behaviors directed at one's own head and body hair. This study revealed a significant link between a single nucleotide polymorphism within the SAPAP3 gene and trichotillomania.Diagnosis
There has been controversy over the creation of a separate category in the DSM-5 for excoriation disorder. Two of the main reasons for objecting to the inclusion of excoriation disorder in the DSM-5 are: that excoriation disorder may just be a symptom of a different underlying disorder, e.g. OCD or BDD, and excoriation disorder is merely a bad habit and that by allowing this disorder to obtain its own separate category it would force the DSM to include a wide array of bad habits as separate syndromes, e.g., nail-biting, nose-picking, hair pulling, etc. Stein has argued that excoriation disorder does qualify as a separate syndrome and should be classified as its own category because:- Excoriation disorder occurs as the primary disorder and not as a subset of a larger disorder.
- Excoriation disorder has well-defined clinical features.
- There is gathering data on the clinical features and diagnostic criteria for this condition.
- There is sufficient data to create this as a separate category for excoriation disorder.
- The incidence rate for excoriation disorder is high within the population.
- Diagnostic criteria for the disease have already been proposed.
- The classification of excoriation disorder as a separate condition would lead to better studies and better treatment outcomes.
- Classification as a separate condition would lead to more awareness of the disorder and encourage more people to obtain treatment.
However, a review of the scientific literature by Jenkins et al. on excoriation disorder as a separate category in the DSM-5 concluded that such a distinction requires more evidence. Because excoriation disorder is different from other conditions and disorders that cause picking of the skin, any diagnosis of excoriation disorder must take into account various other medical conditions as possible causes before diagnosing the patient with excoriation disorder. There are a variety of conditions that cause itching and skin picking including: eczema, psoriasis, diabetes, liver disease, Hodgkin's disease, polycythemia vera, systemic lupus, and Prader–Willi syndrome.
In order to better understand excoriation disorder, researchers have developed a variety of scales to categorize skin-picking behavior. These include the Skin-Picking Impact Scale and The Milwaukee Inventory for the Dimensions of Adult Skin-picking. The SPIS was created to measure how skin picking affects the individual socially, behaviorally, and emotionally.
As of the release of the fifth Diagnostic and Statistical Manual of Mental Disorders in May 2013, this disorder is classified as its own separate condition under "Obsessive Compulsive and Related Disorders" and is termed "excoriation disorder". The diagnostic material is as follows:
- Repeated picking of the skin, resulting in injuries
- Recurring attempts to stop picking while relapses continually occur
- Picking causes a substantial amount of distress and substantially impairs everyday functioning
- The picking is not caused or cannot be better explained by physiological effects of a substance or a medical disorder
- The picking is not more accurately attributed to another mental disorder