Also known as excoriation disorder, or skin picking disorder (SPD), dermatillomania is a body-focused repetitive behavior (BFRB) where someone recurrently and compulsively picks at their skin to the point of injury. Dermatillomania behaviors include repetitive touching, rubbing, scratching, picking at, and digging into the skin and can target healthy or unhealthy skin, scabs, lesions, pimples, or other blemishes. Most people who suffer from this disorder pick at the face, arms, and hands. Some people use tools to poke, squeeze or lance the skin. Resulting injuries include skin discoloration, scarring, infections and in the most severe cases, severe tissue damage.
The skin picking behaviors of dermatillomania present differently based on the individual differences in each person.
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Dermatillomania can start at any time throughout the lifespan, but it most often starts between the ages of 9 and 13 at the start of puberty. One recent study of those with Dermatillomania showed that over 47.5% of those interviewed started to exhibit skin picking behaviors before the age of 10.
It begins for many reasons. For many patients, skin picking first began by scratching and picking at acne, but the compulsion to scratch and pick the skin continues even after the acne has vanished. Other types of skin conditions such as keratosis pilaris, psoriasis, and eczema can also act as a trigger. Grooming the skin with these conditions can be normal. However, those with dermatillomania exhibit excessive grooming disproportionate with the severity of the skin condition.
Another common age of onset is 30 - 45 years old. Onset at this age can occur for similar reasons such as acne and other skin conditions. It is also related to stressful life events and including marital conflicts, the death of friends or family, and unwanted pregnancies. Skin picking behaviors may also begin after a traumatic brain injury. Dementia is a degenerative brain disease which changes the brain physically. As parts of the brain degrade, the parts that control repetitive movements change structurally resulting in repetitive body movements. Examples include hand flapping, moving appendages, and even skin picking.
There is also evidence that dermatillomania can begin with medication. A recent article described a case where someone developed skin picking disorder after receiving treatment with methylphenidate for ADHD. Methylphenidate is a stimulant to the central nervous system used to treat hyperactive and impulsive ADHD. It acts by blocking the reuptake of neurotransmitters in the prefrontal cortex that contribute to impulsivity. Research suggests it may be useful for treating the impulsivity that accompanies skin picking disorder, but this case suggests that using stimulants can also backfire.
According to the Diagnostic and Statistical Manual of Mental Health Disorders 5th edition, 1.4% of the population suffers from dermatillomania. However, more recent findings suggest it affects between 2% and 3% of the population and three-quarters of them are female. Due to the shame and embarrassment associated with the disorder, many choose not to report it. Therefore, the prevalence of dermatillomania could be significantly higher.
The course of dermatillomania throughout the lifespan is chronic and cyclical. When it begins in early adolescence, it can be a confusing and disturbing experience. Especially when someone tries to stop and they do not understand why they cannot. At this age, the pressures of internal and external stigma cause stress on overall mental health which can make the urge to pick even worse. In many cases, as the person grows older and learns what it is, they seek treatment, accept the disorder, and learn how to recognize triggers and to choose other behaviors. While the disorder lasts a lifetime, people learn to manage the behaviors and to recognize triggers that correlate to more picking.
Symptoms Severity Decreases Over the Lifespan
The exact cause of dermatillomania is unknown, but neurologic theories provide insight. A cause is something directly connected with the disorder such as a physical abnormality or environmental trigger.
Correlates are associations. Meaning certain conditions occur more in people with dermatillomania which gives an indication of relatedness but relatedness does not mean cause. For example, lack of physical activity is correlated with poor cardiac health. Yet, there are plenty of people with low physicial activity who have good cardiac health and others with poor cardiac health who get plenty of exercise.
Research suggests that dermatillomania, like other BFRBs, is more common in people who have family members with similar disorders such as OCD (obsessive-compulsive disorder) or another BFRB (body-focused repetitive behavior). Although just having a family member with one of these disorders does not mean someone will develop dermatillomania. Research suggests there is a hereditary correlation, but not a cause.
There is a relationship between obsessive-compulsive disorder (OCD) and skin picking disorder. Skin picking is considered a disorder on the OCD spectrum of disorders and they are often mistaken for each other. About 8-21 percent of individuals who have OCD will have a co-occurring skin picking disorder. However, in one study, people with skin picking disorder were more likely to have co-occurring body-repetitive behaviors such as nail biting or trichotillomania while people with OCD were more likely to have co-occurring body dysmorphic disorder.
Anxiety and depression are strongly correlated with skin picking disorder. Multiple studies found that people with high rates of anxiety experienced more severe skin picking symptoms. The same occurs with depression. These findings are consistent in the research; however, it seems to be a cycle of behavior and anxiety intermingled with skin picking behaviors where it is difficult to discern which causes the other. Picking may trigger anxiety, anxiety trigger picking, or both. Many experts agree that the initial trigger does not matter, only that treatment should include addressing anxiety and depression as well as skin picking.
Shame is a negative evaluation of self that affects mood, thoughts, and behaviors. Shame is not just a negative evaluation of behavior or habit. The negativity surrounding a behavior or habit is generalized to the whole person, and one ends up feeling like a bad person because they engage in a behavior. Those who experience shame tend to socially isolate, hide feelings and behaviors, and have higher severity of symptoms not only of skin picking disorder but anxiety and depression. Shame also increases suicide risk and functional impairment.
In research, there are multiple types of impulsivity. Attentional impulsivity is the ability to keep attention on something while motor impulsivity is the ability to control behavior. Some people with skin picking disorder do so because they have trouble with impulsivity. Those with skin picking disorder who score high on attentional and impulsivity measures are more likely to have more severe picking behaviors. While neuroscience continues to work on finding ways to counter impulsivity through medicine, there are cognitive behavioral therapies that focus on the distinct types of impulsivity.
The first-time symptoms of skin picking start during a significant hormonal change in the body. Also, a study of 1,471 women aged 10-60 found a relationship between hormonal changes and an increase in “focused” picking behavior. These women described picking behavior as more severe when hormones were changing throughout their lives. To the body, hormonal changes are stressful, and many other mental health issues are affected by them. Research from the World Health Organization suggests hormonal changes involved in perimenopause, or the 2-8 years before menopause, can cause mood and anxiety symptoms to worsen. Therefore, if hormone changes can worsen mood and anxiety symptoms, it can be assumed that skin picking behavior tied to anxiety may also worsen.
Thyroid hormones manage homeostasis of the skin. If the thyroid malfunctions, the skin is unable to regulate itself.
There are four major thyroid malfunctions:
The skin is a complex organ that consists of thyroid receptors throughout its multiple layers. The mechanisms by which all this occurs is complicated and affected by genetics. However, to simplify, thyroid hormones tell skin when to grow, how to grow, and how hair should grow. Skin also takes direction on moisture and redness from the thyroid hormones. When thyroid hormones are out of balance, the skin reacts. When the skin receives too much thyroid hormone, the skin increases in smoothness, moisture, and warmth. The skin may itch, grow red, and manifest hives. When thyroid levels are too low, the skin may turn yellow, decrease in temperature, and dry out which leads to calcification or dry, scaly skin. When this happens, dry, scaly skin can crack open, and the wounds take much longer to heal.
Thyroid hormones and stress also have strong links. The thyroid gland works in tandem with the adrenal glands which regulates cortisol in response to stress. When a person handles stress well, the adrenal glands release a bit of cortisol to enhance the body until stress resolves. Cortisol slows down thyroid function. Think of when anxiety hits and what happens to your skin. Do you ever get nervous and your hands feel cold, clammy and dry? That is a short-term version of thyroid hormone reduction. However, if stress recurs often, the body’s metabolism slows, and thyroid hormone levels drop.
Stress and skin picking are closely related. Multiple research studies found that those with skin picking disorder and high rates of stress experienced more severe symptoms and people with severe picking behaviors report increased stress. Skin picking also causes increased stress due to the damage caused by the skin and the stigma associated with the disorder. Many people with this illness pick at their skin causing damage to multiple layers of skin. Without treatment, skin wounds can lead to scabs, scarring, and infections leaving visible evidence often observed but misunderstood by others. The body reacts to the physical damage by releasing more cortisol and thyroid hormone to heal the wounds but also risks overload causing the slower metabolism, low thyroid hormone production, and slow wound healing. Then the person is stuck with wounds that are difficult to hide.
There are many triggers for compulsive skin picking, but some of them are physical. For example, some people who pick at their skin start by trying to correct an imperfection. Sometimes the flaws are blemishes, and sometimes they are invisible to all except the person plagued with the compulsion. In other cases, sensations such as itching or burning of the skin inspire picking behavior, and when the picking behavior reduces the physical sensations, the cycle will continue each time the sensation occurs. Other times, the compulsion to pick is aimed at scabs or the breaks in the skin caused by dryness and cracking.
The cause for dermatillomania is unclear. One of the most common hypotheses is that skin picking is an impaired stress response. When a person is experiencing elevated levels of turmoil, arousal, or stress, they cope with it by picking at their skin. Research reinforces this hypothesis because the action appears to be maintained by automatic self-reinforcement in the person exhibiting the behavior. Though most scientists agree that the causes of dermatillomania are firmly rooted neurologically, there are those that believe it is associated with one’s environment. Many psychologists believe that those with skin picking disorder do it because of repressed rage or other unexpressed feelings. Additionally, studies have shown a correlation between dopamine and the desire to pick the skin.
People with dermatillomania usually hide the disorder from family and friends. It is difficult for anyone to share intimate secrets, especially those that other people may not understand. Many people with dermatillomania go to a dermatologist, physician or mental health provider for help with other problems but never mention they compulsively pick at their skin. For example, someone may go to a dermatologist about a skin infection, but not fully disclose how the infection occurred. In many cases, people with dermatillomania go undiagnosed and improperly treated for a long time.
For a dermatillomania diagnosis, a person must NOT be suffering from one of many other conditions that can cause skin picking. For these reasons, doctors, mental health professionals, and scientists use several tools to understand and diagnose skin picking disorder. These assessments include the Skin-Picking Impact Scale (SPIS) and the Milwaukee Inventory for the Dimensions of Adult Skin-Picking. Both differentiate dermatillomania from other conditions as well as track and measure how it affects the patient in a social, behavioral, and emotional context.
Dermatillomania is categorized within a group of disorders called Body-Focused Repetitive Behaviors (BFRBs). However, it is often confused with other conditions. Common misdiagnoses result because the picking behavior is a result of a medical condition, confused with OCD, Body Dysmorphic Disorder (BDD) and in some cases, Non-suicidal Self-Injury (NSSI).
A few of the medical conditions that also cause skin picking include eczema, psoriasis, diabetes, liver disease, Hodgkin’s disease, polycythemia vera, systemic lupus, and Prader-Willi syndrome.
Drugs including cocaine and methamphetamine are known to cause uncontrollable picking and itching in users. Drug users may pick at the skin for several reasons, including the sensation of something crawling on or under the skin, also known as formication. When the effects of the drugs wear off, so do picking behaviors.
There are cases when a person with OCD picks at their skin and cases where people with dermatillomania have OCD. However, the main difference is that the behavior of picking drives someone with dermatillomania not intrusive or obsessive thoughts. Whatever stimulates the urge, once picking occurs, the urge is satisfied. On the other hand, a person with OCD may feel a compulsion to pick their skin but the drive behind it will be intrusive or obsessive thoughts. After the person picks, the thoughts will still be there.
Another theory is that dermatillomania is a repetitive motor response. Behaviors associate with OCD are compulsive rituals essential to satisfying an obsession. The age of onset is also different. Dermatillomania usually starts in early adolescence while OCD usually starts in late adolescence. Treatment is different for BFRBs and OCS. Because of the behavioral focus of BFRBs, treatment targets behaviors such as in Habit Reversal Training. OCD is about thoughts and treatment targets thoughts and uses exposure and response prevention therapy. Selective serotonin reuptake inhibitors (SSRIs) help in treating OCD but in people with dermatillomania, they do not work as well.
A person with body dysmorphic disorder is obsessed with a defect in their physical appearance which can be real or imagined. Sometimes people with BDD will pick at their skin excessively, but the picking is directed at the perceived defect. For someone with dermatillomania, the goal is not to fix a defect. It may start out that way, but the compulsion to pick is the main driver of behavior.
When a person hurts themselves without suicidal intent, it is called non-suicidal self-injury (NSSI) and can include cutting, burning, or scratching. Theories about NSSI believe it is thought to serve a purpose for relieving devastating negative emotion, punishing oneself, demonstrating anger toward oneself, or for influencing others. While there are similarities between focused dermatillomania and NSSI, NSSI is a purposeful decision to hurt oneself as opposed to the compulsive urge to pick.
Sadly, very few people with dermatillomania, between 30% and 45%, seek treatment. Although it is a lifelong, chronic condition which means that medical science has no cure, treatment is possible. It takes time and consists of learning how to manage triggers, urges and behaviors affiliated with skin picking. Treatment needs to include the physical, psychological, and social aspects involved with the behaviors. Recovery is a whole-person, whole-lifestyle endeavor which works on behavior management, emotional regulation, and thought management. It also works with people on the effects of shame, embarrassment, and stigma. A social network of encouragement from others who struggle with similar disorders allows for an exchange of information and innovative coping strategies.
Dermatillomania that goes undiagnosed or confused with other mental disorders often results in more harm. Seek an expert in body-focused repetitive behaviors (BFRBs) when looking for a therapist. They know how to properly assess for behaviors and triggers, and they have knowledge about the latest evidence-based treatments. They also understand that everyone experiences the disorder differently and can guide you through improving your self-awareness to identifying the types of treatments that will work for your unique situation.
Selective Serotonin Reuptake Inhibitors (SSRIs) show effectiveness for managing OCD and some people with dermatillomania report satisfactory results. Doxepin, clomipramine, naltrexone, olanzapine, and pimozide all may be useful in the reduction of skin picking behaviors, but clinical studies have not shown unmistakable evidence due to the lack of randomized controlled trials.
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Dermatologists are physicians who specialize in treating conditions of the skin. Dermatillomania tends to result in visits to a dermatologist to get help with problems from chronic skin damage. How often do dermatologists recognize a compulsive body-focused repetitive behavior and refer a patient to a therapist or psychiatrist for help?
During training, dermatologists are taught about the interconnectedness between the skin and the nervous system. Not only do some skins condition worsen during periods heightened nervous system activity such as stress and anxiety, but skin conditions often provide fuel to heighten the nervous system. In dermatology, the interconnection between the skin and the psychosocial dimension of skin conditions is called psychocutaneous medicine. Despite receiving initial training, many dermatologists neglect the role of psychology.
The good news is that there are clinics that offer psychodermatology and treatment for psychocutaneous disorders, but they are rare. Dermatologists can help their patients by recognizing the connection between mental health issues such as anxiety, depression, OCD, and psychosis, all recognized as factors in other skin disorders such as vitiligo, psoriasis, and dermatillomania. Showing patients that they understand by validating a patient’s experience is powerful for those who reach out for treatment for skin lesions that result from picking. Creating an open environment where people do not have to hide their picking behaviors will facilitate earlier treatment and less skin damage. Second, they can educate patients to take care of their skin and finally, dermatologists can refer their patients to mental health professionals who specialize in body-focused repetitive behaviors.