To diagnose dermatillomania (also called skin picking or excoriation disorder) accurately, it is important to understand that skin picking is not necessarily a problem because removing flaky skin or old scabs is normal. It only becomes a problem when a person finds it difficult to stop and the picking causes wounds. There are several steps to diagnose dermatillomania. First, it is useful to look at the different types of skin disorders and their symptoms. Second, there are official diagnostic criteria specified in DSM5. Third, a person can use an online questionnaire as a means of self-diagnosis. And finally, to confirm the diagnosis, one should talk to a physician, dermatologist, or psychiatrist.
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The simplest way to describe symptoms of dermatillomania is as an urge to pick at the skin. But the symptoms, and sometimes the underlying motives for the behavior, vary depending on the area of picking. Compulsive face picking doesn't typically start with a visible problem. Somebody with this issue will choose a spot that doesn't have any visible imperfections. It will then, with persistent picking, turn into a bleeding wound. This will make the person avoid others because the wound “makes them ugly”. Some people use compulsive face picking as a way to avoid others because they feel unworthy of affection. Scalp Picking involves finding blemishes and imperfections at the scalp. They can be imagined or real, but with persistent scratching and pulling a person will develop a sore wound on the head. This, then, becomes a valid target for more scratching and picking, creating a vicious cycle that is hard to break. When taken to extreme, this behavior can even cause bald spots. Picking at the acne usually starts during teenage years, when hormonal changes can cause an outbreak of pimples. This is especially troublesome because teenagers, who are undergoing the transition from childhood to adulthood, already have issues with self-esteem and a tendency to blow things out of proportion. The most important problem with this type of skin picking is that it can cause infection, skin discoloration, and scarring. Lip picking shows as peeling, biting, or chewing the skin on lips. While everyone can find it hard to resist pulling or biting off a bit of peeled skin on their lips, compulsive lip pickers go beyond that. Driven by stress, boredom, or worry, they can cause so much harm to their lips that ordinary activities, such as eating or kissing, feel unpleasant or even painful. Nail picking involves biting, chewing, and picking one's nails and cuticles. Again, it is normal to bite off damaged bits of nails that get stuck on whatever a person is handling, but when it becomes a matter of biting until they bleed, it's a sign of dermatillomania. Students suffering from nail picking often stop during school breaks, only to start over when they return to a stressful environment. Picking scabs can start as pure coincidence. A person can have a scab that has been caused by an accident and start picking at it. If it comes at a time when the person is under stress or emotionally vulnerable, the picking can have a soothing effect. Then it becomes self-perpetuating behavior that both relieves anxiety and makes the person feeling more anxious because the constant picking is painful. Regardless of where the skin picking occurs, it is often a sign of underlying obsessive-compulsive tendencies. For that reason, once it starts it will be hard to break without professional assistance.
Some skin picking is normal. If a nail becomes chipped or a person notices a bit of flaky skin peeling off, there's nothing wrong with picking at it until it goes away. That's why psychiatrists created official diagnostic criteria that make it easier to tell problematic skin picking from normal grooming. According to the DSM5, the standard manual for classifying mental disorders, dermatillomania can be diagnosed by the following characteristics. First, there must be recurrent skin picking resulting in skin lesions. Biting nails, scratching one's scalp, or picking at scabs is fine if it doesn't cause wounds. There must also be repeated attempts to decrease or stop skin picking. This is a sign a person noticed the problem getting out of hand, but feels powerless to stop it. Also, dermatillomania causes clinically significant emotional pain or dysfunction in relation to others. Finally, skin picking should not be related to substance abuse or a medical condition such as scabies, or connected to another mental disorder that causes a person to pick the skin.
Diagnosing one's disorder is often problematic because it's easy to either blow symptoms out of proportion or, in the other extreme, deny them altogether. However, as a first step toward realizing a person has a problem, they can use questionnaires available on many websites. Then they can decide whether to talk to a doctor who can perform a thorough evaluation. One such example is our own online dermatillomania test.
When it comes to discussing skin picking with a doctor, there are several options. A primary care physician or a dermatologist can inspect wounds for infections and check out any old scars that don't heal. If doctors are not familiar with dermatillomania, they need to be informed, in detail, which thoughts and feelings are behind the act of picking at the skin. While it's important to talk to a medical professional who can take care of physical wounds, a behavioral health professional (psychiatrist/psychologist) can find out more about what's going on in a patient's head. Skin picking often comes with other mental illnesses, such as obsessive-compulsive disorder, body dysmorphic disorder, anxiety, and alcohol abuse. Finally, a patient should approach a psychotherapist who will work out a plan of action to start changing the undesirable behavior. Cognitive behavioral therapy (CBT), with an emphasis on habit reversal training, is considered the most effective therapy for this disorder. It's important to note that sometimes even doctors can underestimate the severity of skin picking. If they suggest to “just stop doing it”, a patient should not be discouraged, but look for a professional who has experience handling excoriation disorder.