EXCORIATION (SKIN-PICKING) DISORDER

Skin-picking disorder (SPD) is characterized by repetitive and excessive plucking/picking behavior that damages the skin tissue without any underlying dermatological problem.¹ People with SPD tend to tear out small irregularities in the skin or skin lesions such as acne, calluses, scars or scabs that have remained from previous picking behavior. Patients with skin-picking disorder spend a significant portion of their time in picking behavior. The time they devote to picking skin may cause them to be late or unable to participate in work, school, and social activities.² The skin picking behavior may be in the forms of squeezing, scratching, rubbing, biting the skin. These behaviors can be performed on problematic skin (acne, crusting) or on healthy skin.³ Most patients pick more than one area on their body. Face is the most picked area. The skin of the neck, back, head, ears, chest, arms and feet can also be picked. The factors that trigger skin-picking behavior are various. In some patients, the attacks start during sedentary activities such as watching TV and reading books, while for others, anxiety, fatigue, and feeling anxious or angry start attacks.²

Psychosocial stress is associated with exacerbation of peeling behavior in 30-90% of patients, and the action can be continued until pain or bleeding occurs, and this situation can sometimes last for several hours. The act of tearing the skin with a nail is formed with a desire that is very difficult to resist as a result of the tension felt, and it is thought that by this way, the emotional balance can be maintained in anxious people.⁴

While SPD has been evaluated within the spectrum of impulse control disorders by some authors, it has been associated with the spectrum of obsessive-compulsive disorders by some. Some other authors classify SPD as self-harm with primary psychological/psychiatric reasons.⁴ Taking into account the heterogeneous nature of the clinical picture, Arnold et al. developed some criteria for diagnosis of patients with chronic skin pickling; consciously 'compulsive picking'; ‘impulsive picking’ in response to unwanted emotions, ‘mixed type’ with impulsive and compulsive features accompanied by minimal awareness. It has been reported that those with compulsive behavior perform the scraping on the lesions in order to have a complete smooth skin, and those with impulsive behaviors perform the pulling as a result of an increasingly severe urge before pulling the skin and feel satisfaction and relief afterwards. In the mixed type, both of the characteristics of the other two subtypes appear.⁵

Literature on the genetics and pathophysiology of skin-picking disorder show that SPD is common with obsessive-compulsive disorder (OCD), body dysmorphic disorder, trichotillomania (hair-eyebrow-eyelash plucking) and it is claimed that all these disorders share a common genetic predisposition factor in the development of obsessive-compulsive spectrum disorders.⁶ Studies found that many people with SPD have an excessive desire to pick skin and experience a great sense of pleasure and satisfaction during the attacks. Some researchers have suggested that the "abnormal reward processing" process may be one of the underlying causes of SPD.⁷

In the study conducted with 1916 university students by Odlaug et al., SPD was found to be significantly associated with lifelong affective, anxiety, eating, and impulse control disorders and substance use.⁸  In the study conducted with individuals with skin-picking behavior, Wilhelm et al. found that the most common axis I diagnoses were anxiety disorders, mood disorders, OCD, body dysmorphic disorder, alcohol use disorder, and the most common axis II diagnoses were obsessive-compulsive personality disorder and borderline personality disorder.⁹

Assoc. Prof. Dr. Canan Tanıdır 



References

1. Salihoğlu G, Hocaoğlu Ç. Deri Yolma Bozukluğu. Hocaoğlu Ç, editör. DSM-5’in Yeni Tanıları. Ankara: Türkiye Klinikleri; 2018. p.34-41.
2. Aydın Çetinay P, Gülseren L. Deri Yolma Bozukluğu. Psikiyatride Güncel Yaklaşımlar- 2014; 6(4):401-428.
3. Selles RR, McGuire JF, Small BJ, Storch EA. A systematic review and meta analysis of psychiatric treatments for excoriation (skin-picking) disorder. Gen Hosp Psychiatry. 2016 Jul-Aug;41:29-37.
4. Yalçın M, Tellioğli E, Yıldırım DU, Savrun BM, Özmen M, Aydemir EH.  Nörotik Ekskoriyasyon Hastalarında Psikiyatrik Özellikler: Çocukluk Çağı Travmalarının Rolü. Arch Neuropsychiatr 2015; 52: 336-341
5. Arnold LM. Phenomenology and therapeutic options for dermatotillomania. Expert Rev. Expert Rev Neurother 2002; 2:725-730.)
6. Odlaug BL, Hampshire A, Chamberlain SR, Grant JE. Abnormal brain activation in excoriation (skin picking) disorder: evidence from an executive planning fMRI study. Br J Psychiatry. 2016 Feb;208(2):168-74.
7. Snorrason I, Olafsson RP, Houghton DC, Woods DW, Lee HJ. 'Wanting' and 'liking' skin picking: A validation of the Skin Picking Reward Scale. J Behav Addict. 2015 Dec;4(4):250-62.
8. Odlaug BL, Lust K, Schreiber LR, Christenson G, Derbyshire K, Grant JE. Skin picking disorder in university students: health correlates and gender differences. Gen Hosp Psychiatry 2013; 35:168-173.
9. Wilhelm S, Keuthen NJ, Deckersbach T, Engelhard IM, Forker AE, Baer L et al. Self-injurious skin picking: clinical characteristics and comorbidity. J Clin Psychiatry. 1999 Jul;60(7):454-9.