In Brief
Skin picking might initially seem harmless or just a nervous habit, but when done persistently and excessively, it can actually indicate a more serious condition. For some, this behavior can cause significant distress and disrupt daily life. In order for mental health professionals to treat this disorder, they first need to grasp its complexities and the impact on those who struggle with it.
Excoriation disorder, also known as skin-picking disorder or dermatillomania, is a mental health condition that often goes overlooked and deserves more focus in clinical training. Despite its prevalence and the challenges it brings to individuals, misconceptions about the disorder persist, which hinders proper diagnosis and treatment. By exploring the classification, significance, and common misunderstandings of excoriation disorder, therapists can better support those seeking help.
Let’s take a look at the main aspects of excoriation disorder: including insights into its diagnostic criteria, misconceptions that often surround this condition, the ways it affects individuals' well-being, as well as the importance of accurate understanding and compassionate care in therapy.
What is Excoriation Disorder?
The DSM-5 classifies excoriation disorder as an obsessive-compulsive and related disorder. It involves repeatedly picking at one's skin, leading to skin lesions and significant distress or impairment. According to the DSM-5 estimates suggest that 1.4% of the general population may experience excoriation disorder, although three-quarters or more of individuals with the disorder are female. Despite its significant impact, people often misunderstand excoriation disorder as merely a cosmetic issue, a habit gone awry, or a lack of self-control.
People with excoriation disorder can develop it at different ages, but it most commonly begins during adolescence, often around or shortly after puberty. The disorder typically starts with a skin condition, such as acne. The areas affected by skin picking may change over time. The condition tends to be chronic, with periods of worsening and improvement if left untreated. For some, the disorder may fluctuate, coming and going over weeks, months, or even years.
Understanding the Diagnosis
To accurately diagnose excoriation disorder, mental health professionals need to be familiar with the DSM-5 criteria. The main diagnostic features include:
- Criterion A. Recurrent skin picking resulting in skin lesions.
- Criterion B. Repeated attempts to decrease or stop skin picking.
- Criterion C. The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- Criterion D. The skin picking is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., scabies).
- Criterion 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 nonsuicidal self-injury).
Although excoriation disorder is labeled under the obsessive-compulsive disorder category of mental illnesses, it's important to distinguish excoriation disorder from OCD and other conditions that may involve similar behaviors. While it shares some similarities with disorders like OCD and body dysmorphic disorder (BDD), excoriation disorder has unique features:
- OCD: Unlike OCD, which is driven by unwanted and intrusive obsessions, skin picking is not triggered by obsessive thoughts. Additionally, individuals with excoriation disorder often experience a sense of relief or satisfaction after picking, whereas OCD compulsions do not provide a feeling of reward. Lastly, excoriation disorder frequently results in self-inflicted skin damage, whereas OCD rarely involves self-injury.
- BDD: People with BDD have a preoccupation with perceived flaws in their appearance, which may lead to skin picking. However, their primary concern is the appearance of the skin, rather than the act of picking.
- Trichotillomania: Similar to excoriation disorder, trichotillomania (hair-pulling disorder) involves repetitive body-focused behaviors that provide a sense of relief or gratification. However, while excoriation disorder focuses on picking the skin, trichotillomania involves pulling out hair from the scalp, eyebrows, or other body areas. Both conditions can lead to noticeable physical damage, but they are distinct in their target behaviors and triggers.
Causes and Risk Factors
Although little is known about the exact cause of excoriation disorder, much of the current research has been based on previous research conducted on trichotillomania (hair-pulling disorder) Let's examine the key elements that contribute to current theories about the onset and maintenance of this condition:
- Psychological factors: Stress, anxiety, and difficulties with emotional regulation often trigger skin-picking behaviors. Individuals may resort to picking as a maladaptive way to temporarily relieve negative emotions or distress.
- Biological and genetic influences: Research suggests a genetic component to excoriation disorder, with studies indicating higher prevalence among first-degree relatives. Additionally, neurotransmitter imbalances, particularly in the dopamine system, may contribute to the compulsive nature of skin picking.
- Environmental and social factors: Stressful life events, significant transitions, or periods of heightened stress can trigger or worsen the condition.
It's important to note that excoriation disorder often appears alongside other mental health conditions, such as anxiety disorders, mood disorders, and body dysmorphic disorder (BDD). The presence of these comorbidities can complicate the clinical picture and require a comprehensive treatment approach that addresses both the skin-picking behaviors and the underlying psychological factors.
The Behavioral and Psychological Impact of Excoriation Disorder
Excoriation disorder significantly affects an individual's physical and emotional well-being. The persistent picking and scratching lead to visible skin damage, ranging from minor lesions to severe tissue damage and scarring. In some cases, the wounds get infected, requiring medical attention. These physical outcomes often come with considerable emotional distress and social challenges.
The effects of excoriation disorder reach beyond just skin issues:
- Shame and embarrassment: Many with excoriation disorder feel intense shame and embarrassment about their appearance and actions. They might go to great lengths to hide their skin damage, resulting in social withdrawal and isolation.
- Self-esteem and body image: The scars and marks from skin picking can deeply affect a person's self-esteem and perception of their body. They might feel unattractive, flawed, or even repulsive, which can perpetuate the compulsion to pick.
- Interference with daily life: Excoriation disorder can take up a significant amount of time and energy, disrupting work, school, and personal relationships. The constant urge to pick, along with the associated shame and distress, can make it challenging to participate in daily activities and maintain a regular routine.
It's important to recognize that skin picking often serves a deeper psychological purpose. For many, it functions as a coping mechanism for handling stress, anxiety, or other negative emotions. The act of picking might offer temporary relief or a feeling of control, reinforcing the behavior over time. In some cases, skin picking becomes an automatic response to tension or discomfort, occurring almost unconsciously.
Assessment and Diagnosis
Accurate assessment and diagnosis of excoriation disorder are important for providing effective treatment. Mental health professionals use various screening tools, clinical interviews, and comprehensive assessments to gather a complete picture of the individual's skin-picking behaviors and their impact on daily life.
Several recommended tools for screening excoriation disorder include:
- Skin Picking Scale (SPS): A 6-item self-report measure that assesses the severity of skin-picking behaviors, focusing on urge frequency and intensity, time spent picking, interference with functioning, avoidance, and overall distress.
- Rosenberg Self-Esteem Scale (RSES): Skin-picking disorder can affect a person’s self-esteem, so the RSES is an appropriate tool in assessing that aspect of what might be going on.
When conducting a comprehensive assessment, clinicians should obtain a thorough history of the individual's skin-picking behaviors, exploring onset, triggers, frequency, patterns of occurrence, and associated emotional states. Key strategies include:
- Functional analysis: Examining the relationship between stimuli and skin-picking behaviors through behavior scales, interviews with family members or close contacts when appropriate, thought logs, and direct report of the client in problematic settings.
- Diagnostic interviews: Using semi-structured interviews like the Diagnostic Interview for Skin Picking Problems (DISP) to evaluate DSM-5 criteria and clinical features of excoriation disorder, including the frequency and duration of picking episodes.
Differential diagnosis is important to distinguish excoriation disorder from other skin-related or psychiatric conditions. Some key considerations:
- Dermatological conditions: Rule out underlying medical causes for skin lesions, such as psoriasis, eczema, or infections.
- Obsessive-compulsive disorder (OCD): While skin picking can be a symptom of OCD, excoriation disorder is characterized by the primary urge to pick, rather than picking in response to obsessive thoughts or fears.
- Body dysmorphic disorder (BDD): Individuals with BDD may engage in skin picking due to a preoccupation with perceived skin flaws, but their primary concern is the appearance of the skin rather than the act of picking itself.
Treatment Approaches for Excoriation Disorder
Treating excoriation disorder involves addressing the psychological, behavioral, and emotional factors contributing to the condition. A combination of evidence-based therapies, medication, and self-help strategies can effectively reduce skin-picking behaviors and improve overall well-being.
Cognitive behavioral therapy (CBT) serves as the main psychological intervention for excoriation disorder. CBT focuses on identifying and modifying the thoughts, beliefs, and behaviors that perpetuate skin picking. A key component of CBT for excoriation is habit reversal training (HRT), which involves:
- Awareness training: Assisting individuals in recognizing triggers and early signs of skin-picking urges.
- Competing response training: Teaching alternative behaviors to replace skin picking, such as clenching fists or using fidget toys.
- Cognitive restructuring: Challenging and reframing distorted thoughts and beliefs related to skin picking.
Dialectical behavior therapy (DBT) also offers an effective treatment approach for excoriation disorder. DBT emphasizes emotion regulation, distress tolerance, and mindfulness skills to help individuals manage the intense emotions and impulsivity associated with skin picking. Through DBT, clients learn to:
- Identify and label emotions
- Practice mindfulness and grounding techniques
- Develop healthier coping strategies for stress and anxiety
Alternative therapies can complement traditional treatment approaches for excoriation disorder. Mindfulness-based stress reduction (MBSR) and acceptance and commitment therapy (ACT) teach individuals to observe their thoughts and emotions without judgment, promoting a greater sense of self-awareness and acceptance. ACT also assists clients in clarifying their values and committing to actions aligned with those values, even in the presence of difficult thoughts or urges. Support groups for individuals with body-focused repetitive behaviors (BFRBs) provide a safe space for sharing experiences, learning from others, and building a sense of community.
Working with Clients: Building a Therapeutic Alliance
A strong therapeutic alliance forms the foundation for effective treatment of excoriation disorder. Creating a safe, non-judgmental environment helps clients feel comfortable discussing their skin-picking behaviors and the emotional challenges they face. Therapists should focus on building trust and rapport from the start, showing empathy, understanding, and a sincere desire to support the client's well-being.
Normalizing the client's experiences plays a key role in building a therapeutic alliance. Many individuals with excoriation disorder struggle with shame, stigma, and feelings of isolation. Therapists can assist by:
- Providing psychoeducation: Explain that excoriation disorder is a recognized mental health condition and that the client is not alone in their struggles.
- Sharing success stories: Provide the client with information about individuals who have successfully managed their skin-picking behaviors, such as through supportive online forums or reputable websites, instilling hope and motivation.
- Encouraging self-compassion: Guide clients in developing a more compassionate and understanding view of themselves and their experiences.
Setting realistic goals collaboratively with the client is important for maintaining motivation and progress. Break down larger objectives into smaller, achievable milestones that allow the client to experience success and build confidence in their ability to manage their skin-picking behaviors. Regularly assess progress and adjust the treatment plan as needed to ensure that the therapy remains effective and tailored to the client's evolving needs
Sources
Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013)
