Organized Chaos - Volume 6
Skin Picking: A Disorder In Search Of A Name
by James M. Claiborn
Picking at one's skin especially at blemishes, pimples, scabs or bug bites is a behavior, that is virtually universal. Almost anyone would admit to engaging in such picking on occasion. A small percentage of people engage in this type of behavior frequently enough and/or extensively enough to cause themselves significant problems including widespread scarring, and noticeable wounds on their skin. The scars and lesions are often a source of significant shame and embarrassment. They may go to great lengths to cover the picked areas or avoid being observed. This leads to avoiding going out in public, getting hair cuts because of picking the scalp, hiding the picked areas with clothing such as long sleeves in summer, never wearing shorts or a skirt to hide picked areas on the legs.Other behaviors are never wearing a bathing suit because areas of the body have been picked or wearing heavy make up to cover scabs and picked areas of the face.
This behavior is known as neurotic excoriation, acne excoriee, psychogenic excoriation, dermatotillomania, pathological or compulsive skin picking, self-injury or self-mutilation and chronic skin picking. The abbreviation CSP stands for either compulsive or chronic skin picking. It has become more popular in recent years but is not widely recognized or accepted. When the individual denies the damage they produced it may be labeled dermatitis artefacta. In the DSM-IV there is no specific disorder name for this problem. It is very similar to the better-studied problem Trichotillomania which is classified as an impulse control disorder. CSP best fits in DSM as an impulse control disorder not otherwise specified since like Trichotillomania it has both compulsive and impulsive features. CSP is described as an associated feature of Obsessive-Compulsive Disorder. It is very common among people with OCD and common among people with related disorders such as Trichotillomania and Body Dysmorphic Disorder (Stein, Hutt, Spitz, & Hollander, 1993). Many people describe it as a compulsion but it does not fit the definition. It is not typically done in a purposeful manner to reduce anxiety but more often as an automatic behavior without obvious conscious thought or intent. Phemonologically it is very similar to grooming behaviors observed in many species including familiar mutual grooming seen in primates (Stein et al, 1993). Many people who pick also would like to do so to others and it often occur in a non-pathological form in squeezing a partners pimples or fixing the edge of a ragged piece of skin. Some patients describe a need to get something out of their skin such as a thread or string.
While this problem is the source of considerable distress in those who engage in CSP as well as family members who are distressed when they see it or the results, CSP has been the subject of very little research to date. Epidemiology is poorly understood although it is a common problem. It has been observed in 2% of patients in a dermatology clinic and 3.8% of a college student population (Arnold, Auchenbach & McElroy 2001). Like Trichotillomania it appears substantially more in females and has an 8:1 ratio reported. The problem often first appears in childhood or teen years. The course is often chronic displaying a waxing and waning severity over the years. CSP occurs at any time during the day but is often more severe in the evening. The average individual spends hours a day engaged in picking. Most often picking is done using fingernails or fingers but some people use tweezers, needles or other implements. Picking is often exacerbated by stress as well as changes in triggering conditions such as acne. Ror example, it seems to fluctuate in association with menstrual changes in many women worsening during PMS days. Most often the result of picking is multiple scars and open sores where picking has occurred recently. In rare cases picking may be so extensive as to lead to serious or even life threatening damage. There is a reported case of one individual who picked at an area of the neck sufficiently that he finally eroded the carotid artery leading to near fatal hemorrhage. I have corresponded with the spouse of a man who has picked a large area on his neck so extensively that skin grafts were necessary. He destroyed the grafts and a second attempt was made to repair the area. He continues to pick and the current set of grafts is failing to heal as expected. Picking increases during times of stress. The areas picked are usually those that are easily accessible such as the face or upper extremities. Picking is preceded by searching for rough areas, bumps and other irregularities or visual searches for imperfections that need to be corrected. Pickers often report satisfaction when the results are somehow desirable such as getting a large amount of pus out of a pimple. The material picked is manipulated, saved or even eaten. Picking is sometimes carried out in a trance like state where the individual emerges after long periods to be confronted by the results of hours of the activity. Picking is motivated by an effort to get things perfect especially in individuals with Body Dysmorphic Disorder.
It appears that individuals with CSP rarely seek formal treatment from mental health professionals. Most commonly dermatologists are consulted. The behavior is often assumed to be a bad habit and is the source of shame and embarrassment. Most people who engage in CSP will report they have been told to just stop by parents or significant others. Although apparently most often it is simply ignored or not remarked on by primary care physicians or others who can not escape seeing the results. A number of CSP sufferers have reported they have brought it up with mental health professionals only to have it ignored. When treatment is offered it is often in the form of medication. Because it is often seen as a compulsion a common approach to treatment is prescription of an Selective Serotonim Reuptake Inhibitors. This category of medications is effective for OCD so the extension to CSP seems logical. While there is a dearth of data on treatment of CSP, experience would suggest that like Trichotillomania the response is less robust than observed in OCD, There are reports of good therapeutic response to SSRIs dosages similar to those used for OCD (Arnold et al. 2001). However there are also reports of SSRIs leading to exacerbation or even emergence of the problem in individuals who did not previously show it (Denys, van Megen & Westenberg 2003). Other treatments offered include insight oriented or supportive psychotherapy and hypnosis. There is no data at this point to substantiate value of these approaches but some reports suggest insight therapy may actually be contradicted (Gupta, Gupta & Haberman 1987). A specific behavioral approach known to work for tic disorders and Trichotillomania called habit reversal along with cognitive techniques have been applied with good results (Deckersbach, Wilehelm, Keuthern, Baer & Jenike 2002, Arnold et al 2001).
In summary CSP appears to be a common but dramatically under treated disorder that is often responsive to a behavioral treatment approach. The problem is also responsive to self-help applications of these behavioral methods. Other resources include support groups such as an email list made up of hundreds of pickers who exchange methods of controlling the problem, dealing with social problems associated with it, and offering a safe community where the picker can learn they are not alone. One such list, called Picaderms, is found on Yahoo and membership is restricted to individuals who have the problem.
Dr. Claiborn is a psychologist licensed in NH and NY and is the author with Cherry Pedrick of The Habit Change Workbook a self-help book, which describes the application of habit reversal to problems like CSP.
References:
Arnold, L. M., Auchenbach, M. B., & McElroy, S.L. (2001), "Psychogenic excoriation, clinical features, proposed diagnostic criteria, epidemiology and approaches to treatment", CNS Drugs, 15, 351-359.
Deckersbach, T., Wilhelm S., Kuthen N. J, Baer L. & Jenike M. A. (2002), "Cognitive-behavioral therapy for self-injurious skin picking: A case series", Behavior Modification, 26, 361-377.
Denys, D., van Megen H. J. G. M. & Westenberg HGM (2003), "Emerging skin-picking behavior after serotonin reuptake inhibitor-treatment in patients with obsessive-compulsive disorder: possible mechanisms and implications for clinical care". Journal of Psychopharmacology 17: 127-129.
Gupta, M. A., Gupta, A. K,, & Haberman H. F. (1987), "The self-inflicted dermatoses: a critical review", General Hospital Psychiatry, 9, 45-52.
Stein, D. J., Hutt, C. S., Spitz, J. L. & Hollander, E. (1993), "Compulsive skin picking and Obsessive-compulsive disorder", Psychosomatics, 34, 177-181.
