We are all familiar with the main symptoms of depression: sadness, lethargy, changes in appetite, feelings of hopelessness and failure, low self-esteem and suicidal thoughts or feelings. These are all very serious, and hard enough to handle in their own. But what happens when depression moves from the internal to the external? The physical symptoms of depression can be just as distressing as the mental ones: cutting, burning, and other forms of self-harm are common among people struggling with depression, but there are lesser-known conditions that can be triggered by depression. One of the least understood, and often un-diagnosed of these is dermatillomania.
Dermatillomania, also known as Skin Picking Disorder or Excoriation Disorder, is a condition in which a person habitually picks or scratches at their skin, usually on their face, until they do physical damage to themselves. People suffering from dermatillomania often engage in the picking unconsciously, in the same way other people might bite their nails or twirl their hair; the difference is that dermatillomania can lead to lacerations, bruises and permanent scarring. It’s something that people will attempt to hide at all costs: using make-up, long-sleeved clothing, or other means to conceal the damage. As with most conditions like it, dermatillomania is often inexplicable to the person with the condition, and even more confusing for his or her family and loved ones; there’s an urge to pick at freckles, blemishes, acne, or perceived imperfections on the skin that cannot be resisted. People suffering from dermatillomania often use tools like tweezers, clippers, and pins during ritualistic picking sessions. Dermatillomania can lead to facial scarring but, more importantly, it can lead to serious infections and diseases if the areas affected aren’t properly disinfected and covered.
It is important to distinguish compulsive skin picking from self-harming behaviours like cutting that are often associated with severe forms of depression. The key difference is that a behaviour is self-harming only if the intention is to cause harm to the body. Although both self-harming and dermatillomania provides a sense of release for the individual, the intention for engaging in these behaviours are different. People sufferring with dermatillomania do not wish to harm the body. In fact their motives for picking may be the complete opposite - to improve or correct imperfections. However the sense of relief and release that is often experienced after picking becomes irresistable, especially when struggling with intense, negative emotions such as depression. The inevitable damage that is caused by severe picking often causes the individual to feel shame and guilt.
Depression is characterized by feelings of intense sadness throughout the day, feelings of hopelessness, helplessness and worhtlessness, extreme fatigue and loss of apetite. These negative thoughts and emotions can take over an individual's life, leaving the person to feel like they have lost control. As with any mental illness, depression can turn someone into a person that they don’t know and don’t like: the disease controls every thought, every action, and every feeling. Suddenly, your grades are dropping, your work is poor, your relationships start failing. A possible link between dermatillomania and depression is stress: the onset of dermatillomania during early puberty and the late twenties is common. Between the pressures of schoolwork, the pains of puberty and bullying, and the later-in-life problems of trying to find a job and live on your own, this is a time of great stress. Without the proper coping mechanisms in place, many people find themselves crippled by the stress of school and work. As a result, they find themselves falling into the pit of depression and find the release experienced when picking the skin to be a way to cope as opposed to finding healthy alternatives. Many people with depression find it hard to seek help due to overwhelming feelings of guilt, shame, and hopelessness. Dermatillomania itself is hard to accept as a problem for many people experiencing it, and often goes undiagnosed due to lack of awareness of the condition, shame about the behaviour preventing them from seeking medical advice, or due to the behaviour often being justified as a form of overzealous grooming. The problem therefore continues to develop and the more habituated the behaviours become, the harder it is to break. The feelings of guilt and shame are associated with depression are therefore also perpetuated, setting off a vicious cycle of negative thoughs and negative behaviour.
The low self-esteem that comes with depression is a major trigger of dermatillomania; when someone with depression looks in the mirror, they see a body riddled with imperfections and flaws. One solution, in the mind of someone with dermatillomania, is to physically remove those blemishes the only way they know how: by picking them off. When the picking ritual leaves further scars and skin problems, the spiral of depression continues. Dermatillomania can lead people with the condition to isolate themselves from friends and colleagues in order to hide the scars from family members and friends they believe will judge them. This isolation can exaccerbate depressive symptoms; without a healthy support group, the sufferer can believe that their feelings of inadequacy and aloneness are justified.
There is hope, however, for anyone suffering from the dual conditions of depression and dermatillomania. Depression can be treated with therapy and anti-depressive medications, and while depression can be a recurring problem that occurs many times during a person’s lifespan it isn’t a hopeless fight. Cognitive behavior therapy and SSRIs (selective serotonin reuptake inhibitors) are two common forms of treatment for both depression and dermatillomania. Dermatillomania is also known to be treated pharmacologically with n-acetylcysteine. Habit Reversal Training can also be employed to treat patients suffering from dermatillomania; in this form of therapy, patients are trained to recognized and acknowledge situations which trigger their skin-picking behavior and to find alternative ways to deal with the stress. Some of the techniques taught in Habit Reversal Training can include putting oven mitts or gloves on your hands when you get the urge to pick and avoiding mirrors during times of high stress or when the desire to pick rises. This is one of the therapies employed by the online self-help program available on this site. Group therapy and having the support of family and friends is also essential to helping people suffering from dermatillomania and depression alike to recover.