Autism Spectrum Disorder (ASD) and autism are both general terms for a group of complex disorders of brain development and are characterized by difficulties in social interaction, verbal and nonverbal communication and repetitive behaviours. One of the most distressing aspects of Autism is the occurrence of repetitive self-injurious behavior such as head banging, hair pulling, face slapping, and skin picking, scratching or pinching. So is there a link between autism and excoriation disorder? Psychiatric comorbidity certainly is common in ASD with one study finding that 24.7% of their study sample of autistic subjects had comorbidity with another disorder of Tourette syndrome, chronic tics, trichotillomania, enuresis, or encopresis. But the reverse correlation does not hold true in that for the most part those with skin picking disorder have no direct or genetic link with ASD. So why then do so many with ASD engage in this same compulsive behavior and can this provide some clues as to why those without ASD do the same?
Image: Mütter Museum of The College of Physicians of Philadelphia
The Mütter Museum of The College of Physicians of Philadelphia began as a donation from American surgeon Thomas Dent Mütter, MD (1811-1859), who was determined to improve and reform medical education. The aim of the museum is to help the public gain insight into the the mysteries and the beauty of the human body to learn about the history of medicine, diagnosis and treatment of illness and disease. Today, the Museum enjoys a steadily rising reputation with annual attendance exceeding 130,000 visitors, and has been featured on countless TV programs and specials and is the subject of two best-selling books.
We have previously discussed NAC or N-acetyl cysteine and its benefits in the management of compulsive skin picking behaviors on this blog, describing what NAC is and how it works. We discussed the 2009 study conducted by Dr. Jon Grant, one of the leading experts on body-focussed repetitive behaviors (BFRBs), which showed that 56% of the subjects reported “much or very much” reduction in hair pulling in subjects with trichotillomania (another BFRB) on NAC compared to 16% on a placebo. However, till now there has been no research to our knowledge of any research into its effectiveness with excoriation disorder specifically. So we were very excited to stumble across an academic article published just this month detailing a study, in which the researchers experimented with two antioxidant supplements—N-acetylcysteine and glutathione—to treat mice with skin-picking disorder.
Critical Voices (CV) is part of a growing movement to understand medicine, health and wellbeing as subjects which demand ethical judgements, empathy and wisdom, with insights from science and the arts. By bringing together health professionals, patients, researchers, artists, writers, campaigners and the wider public they aim to provoke challenging insights, conversation and debate on some of the most critical areas of our lives.
In July, Critical Voices hosted Liz Atkin, a visual artist based in London, who has been challenged by skin picking disorder for more than 20 years. In September last year we featured a post about an interview by BBC radio’s Felicity Finch with Liz Atkin, who talks about her disorder and the impact her art has had on her journey to recovery. According to Liz, her art has helped her heal in a very huge and powerful way. She has been able to express very deep feelings that she previously did not have the language to express.
In May 2013 excoriation disorder, or compulsive skin picking disorder was added to the revised Diagnostic and Statistical Manual (DSM5). This is a significant, positive step for those suffering from this condition as it acknowledges that there is a clinical component to the behavior. This recognition by the American Psychiatric Association (APA) is largely due to the efforts of those health professionals who have identified the sore lack of research and understanding of body-focussed repetitive behaviors (bfrbs). It is the recent upsurge in research that has led to the inclusion of these disorders in the DSM5 and it is research that will lead to improved understanding of the causes and treatments for compulsive skin picking.
Excoriation disorder does not discriminate. Research into compulsive skin picking seem to indicate that this disorder has no boundaries with regards to age of onset, gender, race or nationality. There does not seem to exist a set pattern of onset, with age of onset varying greatly from one individual to the next. According to one study, a staggering 47.5% of their 40 subjects reported onset of skin picking before 10 years of age. Research also seems to suggest that the younger the age of onset, the less likely it is for the person to seek or receive treatment. This is not surprising given insight into self and the need to seek help is an abstract cognitive skill that only develops later in life. Children are dependent on their caregivers to identify when all is not well and take ensure that they receive the care they require.
Every year the Trichotillomania Learning centre (TLC) holds a conference highlighting new research, challenges and advancements in the field of Body-Focused Repetitive Behaviors (BFRBs) such as trichotillomania and dermatillomania. This year the conference was held 10-12 April in Arlington, Virginia. The conference is aimed at people of all ages who live with hair pulling, skin picking and other BFRBs; their families and loved ones, and professionals who want to improve their knowledge and ability to treat these disorders. Even younger children and teenagers are welcome, with special programs specifically for this group. This year the opening address was even delivered by 16-year-old BFRB advocate Mackensie Freeman. If you missed the conference this year, save the date for next year, because next years conference has already been set for 15-17 April, in Dallas Texas, with registration for the conference opening in December 2015.
Inositol has been named as one of the potentially effective pharmacological treatments for body-focussed repetitive behaviors (bfrbs) such as trichotillomania and dermatillomania. To date there is only one published uncontrolled study by Dr. Seedat in 2001 in which 3 women with compulsive skin picking were treated with inositol, and were seen to improve even up to 16 weeks post follow-up. Dr. Fred Penzel, a member of the Scientific Advisory Board for the Trichotillomania Learning Centre (TLC), also highly recommends the use of inositol based on his observations of the positive effects in his work with trichotillomania patients at the clinic where he practices and describes its use in detail in his book The Hair-Pulling Problem : A Complete Guide to Trichotillomania.
Have you heard of Dr. Pimple Popper? I recently stumbled acorss an article about Dr Sandra Lee, a dermatologist and cosmetic surgeon who goes by the name of Dr Pimple Popper on Instagram and YouTube. Through these popular forms of social media, Dr Lee is broadcasting videos and images of pimples being popped and squeezed, and cysts oozing or exploding with pus. some of you may be wondering...why would anyone want to post this kind of images onto social media, and who would watch it? Well according to the article Dr Pimple Popper caters to more than 200, 000 followers! She describes her audience as either hardcore or softcore poppers:
“There’s hardcore poppers and softcore ones. A “softpop” is a simple blackhead extraction, an easy pop. A “hardpop” is more hardcore - maybe a cyst or lipoma popped out via excisional surgery. There may be pus, there may be blood, and there is always a “pop”,” she said.
The Trich Learning Centre (TLC) recently hosted a webinar with Brian L. Odlaug, MPH, a Visiting Researcher in the Faculty of Health & Medical Sciences at University of Copenhagen, Denmark. Mr. Odlaug is the co-author of three books on the treatment of addictive-impulsive-compulsive disorders and has authored over 125 peer-reviewed articles and book chapters. He is a peer-reviewer for over 30 journals, a grant reviewer for the European Commission and National Research Foundation of South Africa, and is a professional member of several patient advocacy groups.
The webinar focussed on the current state of research in skin picking disorder, including an overview of the research conducted / published over the past year. Specifically, the webinar aimed to help participants understand why we use different types of brain imaging (i.e., MRI, fMRI, DTI, etc), what these techniques mean, and where in the brain the current research has focused.