A Disorder in Search of a Name
Picking at one’s skin especially at blemishes, pimples, scabs or bug bites is a virtually universal behavior. Almost anyone they would admit to engaging in such picking on occasion. However 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 visible areas of their skin. The scars and lesions are often a source of significant shame and embarrassment. So much so that they may go to great lengths to cover the picked areas or avoid their being observed. This can lead to avoiding going out in public, avoiding getting hair cuts because of picking of the scalp, attempts to hide the picked areas with clothing such as long sleeves in summer, never wearing shorts or a skirt to hide picked areas on the legs, never wearing a bathing suit to hide areas of the body that have been picked and wearing heavy makeup to cover scabs and picked areas of the face.
This behavior is known by various names including neurotic excoriation, acne excoriee, psychogenic excoriation, dermatotillomania, pathological or compulsive skin picking, self-injury or self-mutilation and chronic skin picking. The abbreviation CSP which could stand for either compulsive or chronic skin picking has become more popular in recent years but is by no means widely recognized or accepted. When the individual denies they have produced the damage it may be labeled dermatitis artefacta. For many years this disorder had no official name and if it was diagnosed was listed as an impulse control disorder, not otherwise specialized. In 2013 a new version of the diagnostic manual used in the US was published. This manual (DSM-5) created a new category of Obsessive-Compulsive and related disorders. This new category included Trichtillomani (compulsive hair pulling), a better known disorder, also formerly classified as an impulse control disorder. Compulsive skin picking now had recognition as a distinct disorder, related to OCD. The problem also finally had a good name, Excoriation or skin picking disorder.. In the past compulsive skin picking was sometimes described as an associated feature of Obsessive-Compulsive Disorder, and it is very common in people with Trichotillomania and Body Dysmorphic Disorder (Stein, Hutt, Spitz, & Hollander, 1993). Many people describe it as a compulsion but it does not fit the definition as it is not typically done in a purposeful manner to reduce anxiety but more often done as an automatic behavior without obvious conscious thought or intent. Phenomenologically it is very similar to grooming behaviors observed in many species including familiar mutual grooming seen in primates (Stein et al, 1993). Indeed many people who pick also would like to do so to others and it may often occur in a non-pathological form in squeezing a partner’s 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 skin picking as well as family 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 may well be 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 common in females and an 8:1 ratio has been reported. The problem often first appears in childhood or teen years and the course is often chronic displaying a waxing and waning severity over the years. The CSP may occur at any time during the day but is often more severe in the evening. The average individual may spend hours a day engaged in picking. Most often picking is done using fingernails or fingers but some people also use tweezers, needles or other implements. Picking is often exacerbated by stress as well as changes in triggering conditions such as acne or other changes in status. For 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 subsequently destroyed the grafts and a second attempt was made to repair the area. Reportedly he continues to pick and the current set of grafts is failing to heal as expected. Commonly picking increases during times of stress. The areas picked are usually those that are easily accessible such as the face or upper extremities. Picking may be 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 may be manipulated, saved or even eaten. Picking may be 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. Ironically picking seems to be motivated by an effort to get things perfect especially in individuals with Body Dysmorphic Disorder.
It appears that individuals with skin picking disorder rarely seek formal treatment from mental health professionals and much more commonly consult dermatologists. The behavior is often assumed to be a bad habit and is usually the source of considerable shame and embarrassment. Most people who engage in skin picking will report they have been told to just stop by parents or significant others and perhaps by health care professionals 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 Skin Picking Disorder sufferers have reported they have brought it up with mental health professionals only to have it ignored or less frequently attributed to some “deeper” problem or trauma. 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 SSRI. This category of medications is effective for OCD so the extension to Skin Picking Disorder seems logical. While there is an dearth of data on treatment of Skin Picking Disorder experience would suggest that, like Trichotillomania, the response is substantially less robust than observed in OCD, There are reports of a 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 excoriation 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 the value of these approaches and some reports suggest insight therapy may actually be contraindicated (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). More recently Skin Picking Disorder and Trichotillomania have been referred to as body focused repetitive behaviors (BFRBs) and attempts to develop specialized cognitive behavioral treatments have continued. These approaches build on habit reversal and CBT based interventions as well as elements of emotion regulation and mindfulness.
In summary CSP appears to be a reasonably common but dramatically under treated disorder that is often responsive to specialized treatments based in CBT. The problem may also be responsive to self-help applications of CBT methods. Other resources include support groups and organizations devoted to helping people with BFRBs.
Dr Claiborn is a psychologist licensed in CA, DE, ME, 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.
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.