Dermatillomania, also known as excoriation disorder or skin-picking disorder, is a mental health condition characterized by repetitive and compulsive picking, scratching, or rubbing of the skin. This behavior often results in significant distress and can lead to physical damage, such as skin lesions, scars, and infections. Despite the negative consequences, individuals with dermatillomania find it challenging to control or stop their skin-picking impulses.
In this article, we will delve into the complexities of dermatillomania, exploring its symptoms, potential causes, and risk factors. We will also discuss the diagnostic process and various treatment options available for those struggling with this condition. Additionally, we will provide insights into living with dermatillomania and strategies for managing its impact on daily life.
What is Dermatillomania?
Dermatillomania, also known as excoriation disorder or skin-picking disorder, is a mental health condition characterized by repetitive and compulsive picking, scratching, or rubbing of the skin. Individuals with dermatillomania may pick at healthy skin, minor skin irregularities (e.g., pimples or calluses), open wounds, blisters, scabs, or other types of lesions. This behavior often results in significant distress and can lead to physical damage, such as skin lesions, scars, and infections.
Dermatillomania typically begins during adolescence, often with or after the onset of puberty around ages 13-15, but may also occur among children or adults. The condition affects between 1.4 and 5.4% of American adults and is experienced by women more often than men.
Despite the negative consequences, individuals with dermatillomania find it challenging to control or stop their skin-picking impulses. They may spend significant amounts of time, sometimes even several hours a day, on their picking behavior. People may use their fingers or other tools, such as tweezers, pins, or pimple extractors, to do their picking.
This disorder is usually chronic, with periods of time where there is no picking alternating with periods of greater symptom intensity. If untreated, skin-picking behaviors may come and go for weeks, months, or years at a time. Dermatillomania is often associated with other psychiatric conditions like autism, alcohol abuse, obsessive-compulsive disorder, body dysmorphic disorder, mood disorders, anxiety disorders, and borderline personality disorder.
Symptoms and Signs
Dermatillomania, or skin picking disorder, is characterized by repetitive and compulsive picking, scratching, or rubbing of the skin, leading to significant distress and physical damage. The symptoms and signs of dermatillomania can vary in severity and presentation among individuals.
Common Symptoms
The most common symptom of dermatillomania is the irresistible urge to pick at the skin, often in response to perceived skin irregularities or feelings of anxiety and tension. Individuals with dermatillomania may pick at healthy skin, minor skin irregularities (e.g., pimples or calluses), open wounds, blisters, scabs, or other types of lesions. The picking behavior is often accompanied by a sense of relief or satisfaction during the act, followed by feelings of shame, guilt, and anger afterward.
Boredom, bodily tension, and strong negative emotions are often reported as triggers for skin picking episodes. During these episodes, individuals may experience a loss of control, enter a trance-like state, and even feel positive sensations. However, after the episode, negative emotions such as shame, guilt, and anger toward oneself are common.
Physical Consequences
Dermatillomania can lead to various physical consequences, ranging from minor to severe. Repeated picking can cause skin lesions, scars, and infections. In extreme cases, the damage may be so extensive that it requires skin grafting. Severe picking can also result in epidermal abscesses and even life-threatening injuries, such as exposing the carotid artery in the neck.
The most commonly affected areas include the face, chest, shoulders, arms, and legs. However, individuals with dermatillomania may focus on multiple body areas, often moving to other regions to allow the primary picking area to heal. The severity of wounds and scars can range from mild to extreme, with some individuals experiencing wounds covering large areas of their body.
Psychological Impact
Dermatillomania can have a profound psychological impact on affected individuals. The disorder often leads to feelings of intense helplessness, guilt, shame, and embarrassment. These negative emotions can greatly increase the risk of self-harm and suicidal ideation. Studies have shown that 12% of individuals with dermatillomania experience suicidal thoughts, 11.5% have attempted suicide, and 15% have required psychiatric hospitalizations.
The disorder can also cause significant impairment in social, occupational, and other important areas of functioning. Individuals may avoid social situations or cover their skin to hide the damage caused by picking. The time spent on picking behavior can interfere with daily activities, leading to reduced quality of life and difficulties in relationships and work performance.
Dermatillomania is often associated with other psychiatric conditions, such as autism, alcohol abuse, obsessive-compulsive disorder, body dysmorphic disorder, mood disorders, anxiety disorders, and borderline personality disorder. Recognizing and addressing these comorbidities is crucial for effective treatment and management of the disorder.
Causes and Risk Factors
The exact causes of dermatillomania are not fully understood, but research suggests that a combination of genetic, environmental, and psychological factors may contribute to the development of this disorder.
Genetic Factors
Studies have shown that there may be a genetic component to dermatillomania. Individuals with a family history of obsessive-compulsive disorder (OCD), body-focused repetitive behaviors, or other mental health conditions may be at a higher risk of developing skin picking disorder. Twin studies have also indicated that genetic factors may play a role in the development of dermatillomania.
Environmental Triggers
Various environmental factors can trigger or exacerbate skin picking behavior. These triggers may include:
- Stress and anxiety: Individuals may engage in skin picking as a coping mechanism to alleviate stress or anxiety.
- Boredom or idle time: Skin picking may occur during periods of boredom or when an individual is not engaged in other activities.
- Skin imperfections: The presence of acne, scabs, or other skin irregularities can trigger the urge to pick at the skin.
- Tactile sensations: Certain tactile sensations, such as itchiness or the feeling of something being “not quite right” on the skin, can lead to picking behavior.
Associated Mental Health Conditions
Dermatillomania is often associated with other mental health conditions, which may contribute to the development or maintenance of skin picking behavior. Some of these associated conditions include:
- Obsessive-compulsive disorder (OCD): Individuals with OCD may engage in skin picking as a compulsive behavior to alleviate anxiety or intrusive thoughts.
- Body dysmorphic disorder (BDD): People with BDD have a preoccupation with perceived flaws in their appearance, which can lead to skin picking in an attempt to “fix” these perceived imperfections.
- Anxiety disorders: Generalized anxiety disorder, social anxiety disorder, and other anxiety disorders may co-occur with dermatillomania, as skin picking can serve as a coping mechanism for anxiety.
- Depression: Skin picking disorder can be associated with depression, as individuals may engage in picking behavior as a form of self-harm or due to feelings of low self-esteem.
- Attention-deficit/hyperactivity disorder (ADHD): People with ADHD may be more prone to developing dermatillomania due to impulsivity and difficulty with self-regulation.
It is important to note that while these factors may contribute to the development of dermatillomania, not everyone with these risk factors will develop the disorder. Additionally, the presence of dermatillomania can exacerbate the symptoms of associated mental health conditions, creating a complex interplay between the disorders.
Diagnosis
Diagnosing dermatillomania involves a combination of physical examination, medical history review, and evaluation of symptoms based on specific diagnostic criteria. Healthcare providers look for signs of skin picking on the body and ask questions about the patient’s life circumstances and behaviors related to the condition.
To meet the diagnostic criteria for dermatillomania according to the DSM-5, an individual must exhibit:
- Recurrent skin picking resulting in skin lesions
- Repeated attempts to decrease or stop skin picking
- Skin picking that causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
- Skin picking that is not attributable to the physiological effects of a substance or another medical condition
- Skin picking that is not better explained by symptoms of another mental disorder
The diagnostic process may also involve ruling out other potential causes for the skin picking behavior, such as scabies or other skin-related conditions, through diagnostic tests and lab work. However, these tests are rarely needed to confirm the diagnosis of dermatillomania.
Screening tools, such as the Skin Picking Reward Scale (SPRS), can help define a patient’s motivations and feelings associated with skin picking. This psychometrically sound measure assesses the “wanting” and “liking” aspects of the behavior.
Additional tests that may be performed to rule out systemic diseases include:
- Complete blood count (CBC) with differential
- Chemistry profile
- Determination of thyrotropin levels
- Fasting plasma glucose level
In some cases, further testing may be necessary based on the patient’s history, such as a chest radiograph to rule out suspected lymphoma, assessments for contact dermatitis or food allergies, or a skin biopsy to exclude other pathologic conditions.
By carefully evaluating the presence of diagnostic criteria, ruling out other potential causes, and utilizing screening tools when appropriate, healthcare providers can accurately diagnose dermatillomania and develop an effective treatment plan tailored to the individual’s needs.
Treatment Options
Treatment for dermatillomania typically involves a combination of approaches, including medication, cognitive behavioral therapy (CBT), and habit reversal training. The goal of treatment is to reduce the frequency and intensity of skin picking behaviors, manage underlying psychological factors, and improve overall quality of life.
Medication
Selective serotonin reuptake inhibitors (SSRIs), a type of antidepressant, have shown some efficacy in treating dermatillomania. These medications work by increasing serotonin levels in the brain, which can help regulate mood and reduce compulsive behaviors. However, the effectiveness of SSRIs for dermatillomania is variable, and they often provide suboptimal responses.
N-acetylcysteine (NAC), an over-the-counter supplement, has also shown promise in treating dermatillomania. NAC is thought to modulate glutamate levels in the brain, which may help reduce compulsive behaviors. Studies have found that combining NAC with behavioral therapy can lead to better treatment outcomes.
Other medications that have been reported to be helpful in treating dermatillomania include anticonvulsant, opioid antagonist. However, more research is needed to establish the efficacy of these medications for dermatillomania.
Cognitive Behavioral Therapy (CBT)
CBT is a form of psychotherapy that focuses on identifying and changing negative thought patterns and behaviors. In the context of dermatillomania, CBT helps individuals recognize triggers for skin picking, develop coping strategies, and learn to manage stress and anxiety.
CBT for dermatillomania often incorporates techniques such as cognitive restructuring, which involves challenging and reframing negative thoughts related to skin picking, and relaxation training, which teaches individuals how to manage stress and anxiety through techniques like deep breathing and progressive muscle relaxation.
Studies have shown that CBT can be an effective treatment for dermatillomania, with some individuals experiencing significant reductions in skin picking behaviors and associated distress. CBT can be delivered in individual or group settings, and recent research suggests that internet-based CBT programs may also be effective for treating dermatillomania.
Habit Reversal Training
Habit reversal training is a behavioral intervention that helps individuals replace skin picking with healthier behaviors. The process involves several stages, beginning with awareness training, in which individuals monitor their skin picking behaviors, associated thoughts, and emotions to identify triggers and understand the relationship between thoughts, emotions, and picking.
Once awareness is established, individuals learn to engage in competing responses when the urge to pick arises. These competing responses can include activities such as clenching fists, pressing fingertips together, or engaging in a brief relaxation exercise. The goal is to replace the picking behavior with a less harmful alternative that still provides some level of sensory stimulation or tension relief.
Habit reversal training also incorporates techniques from acceptance and commitment therapy (ACT), which helps individuals learn to accept and manage urges to pick without acting on them. ACT strategies include mindfulness, cognitive defusion (learning to view thoughts as separate from oneself), and values-based behavioral commitments.
Research has shown that habit reversal training can be effective in reducing skin picking behaviors in the short term, although long-term efficacy is less well-established. Combining habit reversal training with other forms of CBT, such as cognitive restructuring and relaxation training, may lead to more comprehensive and lasting treatment outcomes.
Living with Dermatillomania
Living with dermatillomania can be challenging, but there are various strategies and support systems that can help individuals manage their symptoms and improve their quality of life. By implementing daily coping strategies, seeking support from others, and taking preventative measures, those with dermatillomania can work towards reducing the impact of the disorder on their daily lives.
Daily Coping Strategies
Individuals with dermatillomania can employ several daily coping strategies to manage their urges to pick at their skin. One effective method is to keep hands busy by engaging in activities such as squeezing a soft ball, wearing gloves, or using fidget toys. Identifying triggers, such as specific times or locations where skin picking is more likely to occur, can help individuals avoid or prepare for these situations.
Practicing resistance by gradually increasing the time between urges to pick and the act of picking itself can help build self-control. When the urge to pick arises, individuals can try caring for their skin in a positive manner, such as applying moisturizer, instead of giving in to the urge. Keeping the skin clean to avoid infection is also important.
Support Systems
Sharing experiences and seeking support from others can be incredibly beneficial for those living with dermatillomania. Telling friends and family about the disorder can help them understand and provide support, such as recognizing when an individual is picking and offering gentle reminders to stop. Support groups, whether in-person or online, can provide a safe space for individuals to connect with others who understand their struggles and share coping strategies.
Professional support, such as therapy with a mental health professional experienced in treating body-focused repetitive behaviors, can provide individuals with valuable tools and techniques to manage their symptoms. Cognitive-behavioral therapy (CBT) and habit reversal training are often used to help individuals identify and change negative thought patterns and behaviors associated with skin picking.
Preventative Measures
Taking preventative measures can help reduce the likelihood of skin picking episodes. Keeping nails trimmed and avoiding keeping tools like tweezers or pins easily accessible can remove potential aids for picking. Engaging in alternative behaviors, such as using fidget toys or stress balls, can provide a substitute for the sensory stimulation that skin picking may provide.
Maintaining a consistent skincare routine, including regular cleansing and moisturizing, can help keep the skin healthy and reduce the temptation to pick at perceived imperfections. Identifying and managing stress through techniques such as deep breathing, meditation, or exercise can also help prevent skin picking episodes triggered by stress or anxiety.
Living with dermatillomania requires ongoing effort and self-compassion. It is important for individuals to be patient with themselves and celebrate small victories along the way. With the right combination of coping strategies, support systems, and preventative measures, individuals with dermatillomania can work towards managing their symptoms and improving their overall well-being.
Conclusion
Dermatillomania is a complex mental health condition that can significantly impact an individual’s physical and emotional well-being. While the exact causes remain unclear, a combination of genetic, environmental, and psychological factors likely contribute to the development of this disorder. Accurate diagnosis and appropriate treatment, which may include medication, cognitive-behavioral therapy, and habit reversal training, are crucial for managing symptoms and improving quality of life.
Living with dermatillomania can be challenging, but by implementing daily coping strategies, seeking support from loved ones and professionals, and taking preventative measures, individuals can work towards reducing the impact of the disorder on their daily lives. With perseverance, self-compassion, and the right resources, those struggling with dermatillomania can make significant progress in managing their symptoms and enhancing their overall well-being.