Dermatillomania, also known as neurotic excoriation, compulsive skin picking, or psychogenic excoriation, is an impulse control disorder typified by a person’s continual urge to pick at their skin. This is usually to the point where external damage is caused. An estimated 1. 4 to 5. 4% of the global population has it, so it is a fairly uncommon disorder. It generally occurs in women (about 85%), and onset usually begins in adolescence with the onset of acne.
While it is classified as a subcategory of impulse control disorder in the DSM, a few researchers debate whether the disorder is more akin to a type of substance abuse disorder or obsessive compulsive disorder (OCD). There has been a recent push to present dermatillomania —and trichotillomania— as separate and distinct disorders in the DSM-V. Because dermatillomania is so different from most impulse control disorders, specialists have to make sure that there are no medical conditions (eczema, psoriasis, Hodgkin’s disease, etc. that may be causing the skin picking. There is also a fairly new scale called the Skin-Picking Impact Scale (SPIS) used to measure the effect the disorder has on an individual physically, emotionally, socially, and behaviorally. There are many indications of dermatillomania. The most obvious is of course excessive skin picking, particularly before or during moments of high stress or anxiety. There may also be an intense urge to bite, chafe, or scratch one’s flesh, generally in one localized area of the body.
The most common places for compulsive skin pickers to pick are the face, stomach, scalp, chest, the limbs, cuticles, and surprisingly, the gums. The amount of time spent skin picking varies from person to person, some spending only a few minutes, others using hours on in. While most dermatillomania sufferers use their fingers, there is a noted minority that prefers tools like cuticle-clippers, safety pins, or tweezers. Dermatillomania also presents some psychological symptoms.
Those with the disorder may feel intense shame or guilt which causes anxiety and, consequently, more skin picking and more anxiety. Many do not talk about it with others and/or blame other skin problems. About 15% of all sufferers end up hospitalized in psychiatric care. Roughly 12% experience suicidal thoughts, and of that percentage, 11. 5% actually make attempts. Dermatillomania has a high rate of comorbidity, mostly with anxiety and mood disorders. About 55% of all compulsive skin pickers also have an Axis-I disorder. 8% may also have trichotillomania, 31 to 54% bipolar I or II, and 38% are reported with some sort of substance abuse. Children with developmental disabilities are also at an increased risk of developing dermatillomania. There are a few theories on what causes dermatillomania, but most therapists focus on cognitive and behavioral. The cognitive perspective asserts that those who compulsively pick their skin suffer from maladaptive thoughts that lead them to believe that the skin they’re picking is imperfect or contaminated and needs to be removed.
The behavioral stance, however, is that the picking is a coping mechanism, that provides alleviation during stressful moments and/or high arousal during normal times. Behavioral studies that support this theory show that the neurotic habit is sustained for the instant reward within the subject. There is also the psychodynamic theory which says that the skin picking is an act of anger, repressed since childhood, toward enmeshed, authoritarian parents. Little support is given with this concept. Treatment for dermatillomania is rather limited.
Most clinicians either go the behavioral therapy route or to pharmacology. The most prescribed drug for the disorder are Selective serotonin re-uptake inhibitors (SSRIs), like clomipramine, fluoxetine, and pimozide. SSRIs are psychotropics normally used as antidepressants. They increase serotonin levels by limiting its reuptake into the presynaptic cell. There is scarce research to prove SSRIs’ true effectiveness in reducing impulse control disorder, but many psychiatrists state that they do see a reduction in their patients’ obsessive behaviors.
Clinicians may also prescribe n-acetyl cysteine, which is proven beneficial for those with trichotillomania and cocaine addiction. As for behavioral treatments, for dermatillomania, habit reversal training is the most common therapy. Habit reversal training involves teaching a patient to recognize their “tic” and replace it with a more appropriate or comfortable response. Studies have shown that this type of treatment in conjunction with awareness training reduces skin-picking behavior in those individuals with dermatillomania that do not have other psychological disabilities.