For many, a diagnosis of dermatillomania comes at a time when picking at the skin has escalated to a level of serious concern for the individual who then searches for information on the internet or seeks out professional help. One of the first questions you are asked when you seek help from a health professional is, “How long have you been picking?” Many people cannot give a definitive answer to this question because there is no distinct starting point. Currently there is limited knowledge and awareness of the condition, often resulting in skin picking disorder being under-diagnosed. In recent times, a number of studies have been conducted documenting the age of onset and discussing possible reasons for its onset.
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From the studies and reports from individuals who have skin picking disorder, the age of onset seems to vary greatly from person to person. One study found that 47.5% of their 40 subjects reported onset of skin picking before 10 years of age. However, onset is also common in the teenage years when teen acne usually surfaces. What may initially start off as normal preoccupation with skin imperfections can escalate to a disorder when the individual experiences the sense of release and satisfaction characteristic of skin picking disorder, and then increasingly seeks out these feelings. Later onset in adulthood, while not common is also known to occur. Research also found that, while symptom severity, comorbidity and social functioning have a similar clinical picture regardless of age of onset, that the younger the age of onset, the less likely it is for the person to seek or receive treatment.
There is no definitive cause for the development of skin picking disorder. Some research suggests that there is an underlying genetic component due to the tendency for skin picking to be intergenerational. There seems to also be a strong proponent of comorbidity with Obsessive Compulsive Disorder (OCD). What can be agreed on is that skin picking disorder does not develop suddenly. There are many different reasons why people initially start picking at their skin, but it is only when this behaviour yields positive effects in terms of the relief or sense of control it provides in response to negative thoughts or emotions that are internally experienced during stressful or traumatic times, that the behaviour is perpetuated. Some individuals may start picking at a scab from a healing skin wound, at pimples, or acne on the body. The sense of release and sometimes enjoyment that is experienced outweighs the perception of unacceptability. In seeking these feelings again, the person experiences the impulse to engage in picking behaviour repeatedly. As this behaviour becomes more frequent, it becomes a habituated response to negative thoughts and emotions, making the impulse harder to control.
There are clear criteria set out by the Diagnostic and Statistical Manual 5 (DSM5) for the diagnosis of skin picking disorder. These guidelines include:
People with skin picking disorder have a compulsion to pick their skin frequently, often resulting in tissue damage, sometimes even infection. The impulse or urge to pick is so strong, some describe the experience as similar to that of a substance addiction.
One of the main differentiating criteria between dermatillomania and other conditions like obsessive compulsive disorder (OCD) and body dysmorphic disorder (BDD) is that the person is cognitively aware that the picking is undesirable and therefore tries to stop picking. One of the signs of a skin picking disorder is therefore a history of failed attempts to stop picking.
Despite the instant gratification experienced when picking, the person is acutely aware that what they are doing is destructive, and this causes them great distress. A key symptom of skin picking disorder is that immediately following picking, the person experiences intense shame and guilt about their behaviour. There is a desire to stop picking, but the inability to resist the impulse to pick, and this further reiterates feelings of guilt, as well as feelings of failure. Another sign is that often the impulse to pick encroaches on the person’s day to day functioning, particularly in severe cases when picking occurs more frequently. Skin pickers often report spending large amounts of time picking, causing them to be consistently late or to miss social events all together. In cases where the person experiences the urge to pick strongly at a time when they are unable to pick (e.g. in the company of others) they may find it difficult to concentrate. The damage caused by the skin picking is also a great source of embarrassment and shame, often resulting in the individual avoiding social situations where their scars may be more visible such as the beach, poolside or gym. In severe cases the person may become completely isolated from society in an attempt to prevent others seeing the damage they have caused to their skin. Another sign of this is that people with skin picking disorder often dress inappropriately for the weather. When the picking site is on the arms, neck or legs, attempts to hide these areas are made by wearing turtle necks or long sleeves despite the hot weather.
Some substances induce a physiological reaction on the skin such as itching or burning. If the person repetitively scratches at an itchy skin, this is not recognised as a skin picking disorder. If however, after the physiological skin condition subsides and the person continues to pick or scratch at the site, a skin picking disorder may have developed.
Some mental disorders result in psychosis characterised by tactile hallucinations. In these cases the person experiences a physiological reaction on the skin which is not there, such as the sensation of something crawling on the skin, itching or burning. This can lead to repetitive scratching, rubbing or picking to the point of tissue damage. In these instances, skin picking disorder is considered a diagnosis. Other conditions such as body dysmorphic disorder cause the person to have perceived flaws in their physical appearance which causes them psychological distress. In these cases the person may repetitively pick at the skin in an attempt to remove the perceived imperfection. This behaviour is therefore not viewed as destructive in purpose. Skin picking disorder also bears a striking resemblance to non-suicidal self-injury. However in these cases the person consciously intends to harm the body. People with skin picking disorder may consciously pick at the skin, but never with the view to harm the body, although this inevitably does occur. The desire to stop picking is therefore a fundamental criterion for the diagnosis of dermatillomania. Finally, stereotypic movement disorder whereby the person displays a pattern of repetitive stereotypical behaviours may also often present with skin picking, rubbing or scratching. The presence of this diagnosis is also an exclusionary factor when querying a diagnosis of dermatillomania.