When people first hear about skin picking, they do not think of it as a serious problem. There is not much awareness about the condition and those with it often feel embarrassed or ashamed to discuss it. Additionally, the term skin picking does not convey the full extent of its symptoms or that it is a very serious disorder known medically as dermatillomania.
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The fact is that dermatillomania or skin picking disorder (SPD) is often a serious problem. Many people also misunderstand it. People that suffer from dermatillomania exhibit symptoms that include repetitive touching, rubbing, scratching, picking at, and digging into their skin. Some people do this to remove irregularities or perceived imperfections while others do it obsessively for other reasons. The behaviors associated with dermatillomania often result in the discoloration of skin and eventual scarring. Severe tissue damage can even occur in the most serious of cases. Dermatillomania is classified as a Body-Focused Repetitive Behavior (BFRB). These are disorders in which the person’s behavior has the potential to harm or damage their body and physical appearance. In this way, skin picking disorder is very similar to hair pulling disorder (trichotillomania). BFRBs occur for a variety of different reasons. They often correlate with feelings of anxiety, fear, excitement, and boredom. Some people even find that repeatedly picking their skin is pleasurable. People have been known to pick their skin for numerous hours in a day. When dermatillomania becomes this serious, it often impacts the person’s work life and their social and family relationships.
As mentioned above, dermatillomania is classified as a BFRB (Body-Focused Repetitive Behavior). Dermatillomania itself is defined as “repetitive and compulsive picking of the skin which results in tissue damage.” Officially, dermatillomania is classified as excoriation disorder by the DSM-5 (since 2013). Skin picking is grouped with other body-focused compulsive disorders because it demonstrates a similar urge. Researchers have often noted just how similar trichotillomania (hair pulling) and dermatillomania are. In particular they note that the symptoms of both are ritualistic. The patient does not need any preceding obsessions to take part in either behavior. Both are triggered by similar conditions and the age onset in each is similar.
Dermatillomania begins for many reasons. For many patients, skin picking first began with the onset of acne as a teenager. The acne is scratched at and picked at. The compulsion to scratch and pick the skin continues even after the acne has vanished. Other types of skin conditions can act as the onset for dermatillomania. These commonly include keratosis pilaris, psoriasis, and eczema. It is important to note that grooming the skin with these conditions can be normal. However, those with dermatillomania exhibit excessive grooming. The amount of skin grooming is disproportionate with the severity of the skin condition. Whether skin picking is brought about by acne or another skin condition, the majority of cases first arise in adolescents. But dermatillomania also commonly first occurs in adults. Another common age of onset is 30 years old to 45 years old. Onset at this age can occur for the same reasons: acne and other skin conditions. It is also related to stressful life events. These include marital conflicts, death of friends or family, and unwanted pregnancies. Because skin picking is related to Obsessive Compulsive Disorder (OCD), its onset can often be linked up to the onset of other symptoms of OCD. 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.
Dermatillomania affects a surprising number of people worldwide. Though the research is not set in stone, the most recent findings suggest that it affects between 2% to 3% of the general population. Furthermore, many cases are gone unreported, are not recognized, or are not given any public/media attention. This means that the actual prevalence of dermatillomania could be significantly higher.
The causes for dermatillomania are not very clear. It has been shown that there is a strong hereditary link. It can often be viewed as a learned behavior. It is often a maladaptive behavior. It is associated with poor coping skills, obsessive and compulsive thoughts, too little or too much stimulation, and sometimes abuse. Often dermatillomania is associated with Body Dysmorphic Disorder. Anxiety and depression are often related. There are several theories regarding the causes of dermatillomania. One of the most common hypotheses is that skin picking is an impaired stress response. When a person is experiencing high levels of turmoil, arousal, or stress, they cope with it by picking at their skin. This hypothesis is reinforced by research 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 the environment one grew up in. Many psychologists express the belief that those with skin picking disorder do it as a result of repressed rage or other unexpressed feelings. Additionally, studies have shown a correlation between dopamine and the desire to pick the skin. Drugs including cocaine and methamphetamine have both been long known to cause uncontrollable picking and itching in users. The reasons for this, however, are often quite removed from those of dermatillomania. Drug users may pick at the skin for various reasons, including the sensation that there is something crawling on or under the skin (the sensation is also known as formication).
Dermatillomania is marked by the obsessive or compulsive picking of the skin. During periods of tension, anxiety, or stress, patients exhibit the uncontrollable urge to pick, squeeze, or scratch the skin. Most patients suffering from skin picking disorder focus their picking on the locations of actual or perceived skin defects. The most commonly targeted area is the face. The arms, legs, back, lips, stomach, chest, shoulders, and scalp are also frequent locations of picking. The fingernails, cuticles, and toenails are often picked at as well. Interestingly, most patients have a primary area of the body where they focus all of or the majority of their picking. However, it is important to note that as these primary areas become damaged, most of those with dermatillomania begin picking at other areas to allow the primary picking areas to heal. Those with dermatillomania exhibit a wide range of picking behaviors. Some pick as little as a few times per day, briefly without even knowing it. Others spend hours upon hours picking at individual areas. Skin picking is almost always done with the fingernails. In some cases, tweezers or other tools are used. Skin picking can cause a number of complications. Infection at the picking site is perhaps the most prevalent. Tissue damage is a close second. Some cases can be severe enough to warrant skin grafting. Permanent scarring and physical disfigurement are common effects of skin picking. Dermatillomania can cause mental effects as well as physical effects. Helplessness, guilt, shame, and embarrassment are common. At the same time, these feelings loop around on themselves and increase the likelihood of self-harm including continued picking. Studies show that 11.5% of those with dermatillomania make suicide attempts.
The diagnosis of dermatillomania is complicated. A separate category for the disorder has recently been created in the DSM-V. Many object to skin picking disorder having its own category. They claim that dermatillomania might just be a symptom of a different disorder (such as OCD or BDD) and that it might just be a bad habit (akin to nail-biting and nose-picking). Dermatillomania qualified for its own category because skin picking is the primary disorder and the disorder as a whole has clearly defined clinical features. An important part of the diagnosis of dermatillomania is to take into account other medical conditions that can cause skin picking. For one to really have dermatillomania, they need NOT be suffering from one of many other conditions that can cause skin picking. 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. For these reasons, a variety of scales are used for doctors and scientists to better understand and diagnose skin picking disorder. These scales include the Skin-Picking Impact Scale (SPIS) and the Milwaukee Inventory for the Dimensions of Adult Skin-Picking. Both were created to track and measure how dermatillomania affects the patient in a social, behavioral, and emotional context.
Despite the prevalence of dermatillomania, little is known about effective treatments for the disorder. The current treatments are divided into two main categories. These are pharmacological therapy and behavioral therapy. Many of those suffering from dermatillomania never seek treatment for the disorder. Part of the reason for this is that it is not a widely recognized disorder. Individuals suffering from it might feel embarrassed or alienated. Others might feel that there is no real treatment for it. In fact, recent studies have found that only a small percentage (between 30% anf 45%) of those with dermatillomania sought treatment.
There are several different types of pharmacological treatment for skin picking disorder. The most common type of treatment is Selective Serotonin Reuptake Inhibitors (SSRI). These have been shown to be highly effective in treatments for OCD. Because of this, they have been widely used for treating dermatillomania. Clinical studies have not shown any clear support of this because tests involving double-blind placebos have not yet been completed. Doxepin, clomipramine, naltrexone, andolanzapine, and pimozide all may be effective in the reduction of skin picking behaviors.
Behavioral treatments for dermatillomania are far more common than pharmacological treatments. These treatments include cognitive-behavioral therapy, acceptance-enhanced behavioral therapy, acceptance and commitment therapy, and habit reversal training. Habit reversal, in particular, has been shown to be effective. Encouraging patients to occupy their hands throughout the day, with fidget toys for instance, has also shown success at treating the disorder. Dermatillomania, or skin picking disorder, is a surprisingly prevalent problem worldwide. It is a disorder where patients exhibit an uncontrollable urge to pick at the skin, often resulting in physical injury. The information discussed above gives a brief overview on all that you need to know about dermatillomania.