Excoriation (Skin-Picking) Disorder (SPD) is included, for the first time ever, as its own diagnostic category in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
It has been estimated that SPD affects around 1.4% of the general population. Research suggests that SPD has a tri-modal age of onset: before age 10, between ages 15-21, and between ages 30-45. SPD symptoms most commonly emerge during adolescence around the onset of puberty.
Greater than 75% of those diagnosed with the disorder (either in research or clinical settings) are female. While it is likely true that SPD affects more women than men, reported gender ratios may be artificially inflated by several factors including different attitudes regarding appearance for males and females and a greater likelihood that women seek treatment than men.
The most distinguishing symptom of SPD is the recurrent picking of one’s skin resulting in noticeable skin damage. Individuals pick from a variety of body areas (and often from multiple sites), but the most common are face, arms, and hands. Individuals may pick at healthy skin, minor skin imperfections, lesions, pimples, calluses, or at scabs that have formed from previous picking episodes. While most skin picking is done with the fingers, it not uncommon for individuals to use tools such as tweezers or pins. Individuals with SPD often spend at least 1 hour per day (sometimes several hours) picking their skin, thinking about their skin picking, and resisting the urge to pick.
Another important feature of SPD is the associated distress and impairment that results from skin picking behaviors. Pickers often report embarrassment or shame due to their picking behaviors and resulting appearance, as well as feeling a loss of control. SPD can also cause significant impairment in various areas of functioning, such as the avoidance of social situations.
The triggers for skin picking can vary considerably between and within individuals. Some individuals with SPD engage in more focused skin picking associated with specific emotional correlates such as boredom or anxiety. Individuals with focused picking may also pick in response to an uncomfortable sensation in their body. Focused pickers often report tension before the picking episode, or when they try to resist the skin picking, and a sense of relief, pleasure or gratification following the episode. For other individuals, the picking may be much more automatic with lowered awareness regarding when they engage in skin picking. Most individuals with SPD experience a mix of both focused and automatic picking.
SPD is listed in the Obsessive-Compulsive and Related Disorders section of the DSM-5. SPD shares many features with other body-focused repetitive behaviors, such as trichotillomania or pathological nail biting. Additionally, there are many similarities between SPD and other obsessive-compulsive spectrum disorders (i.e., Obsessive-Compulsive Disorder, Body Dysmorphic Disorder, and Tourette Syndrome).
The current DSM-5 (APA, 2013) diagnostic criteria for SPD include:
- Recurrent skin picking resulting in skin lesions.
- Repeated attempts to decrease or stop skin picking.
- Clinically significant distress or impairment in social, occupational, or other important areas of functioning as a result of skin picking.
- Picking cannot be due to the physiological effects of substances.
- The symptoms are not better explained by another psychiatric disorder.
Cognitive-Behavioral Treatment (CBT)
Current consensus suggests that CBT is the best treatment intervention for SPD. A form of CBT called Habit Reversal Training (HRT) is considered to be the core approach. This treatment package includes:
- Habit Awareness Training to bring greater attention to picking behaviors
- Competing Motor Responses to engage in actions incompatible with skin picking (i.e., fist-clenching) when the urge to pick is present
- Relaxation Techniques to reduce stress and potential triggering of the behavior
- Social Support to provide positive feedback, encouragement, and reminders to practice coping skills
Stimulus control is another intervention used in the treatment of SPD. Stimulus control is used to modify the environment to eliminate sensory input that would lead to skin picking or make it more difficult to engage in picking behavior. For example, if an individual tends to pick when they are alone, they may be encouraged to change their circumstances so that they spend more time around other people.
Clinicians may also use other treatment approaches to augment HRT and stimulus control. One such approach is Acceptance and Commitment Therapy (ACT). The goal of ACT is to teach skin pickers that when one is feeling the urge to pick or a negative emotion associated with picking, one can accept the urge or emotion without having to respond to it. Dialectic Behavior Therapy (DBT) is also often used to supplement CBT. DBT teaches pickers emotion regulation strategies as well as methods to tolerate uncomfortable emotions and urges.
Psychopharmacological (Medication) Treatment
Research exploring the efficacy of psychopharmacological interventions in the treatment of SPD is limited and few randomized control trials exist. The selective serotonin reuptake inhibitors (SSRIs), widely used in the treatment of depression, anxiety, and obsessive-compulsive disorder, may be effective in the treatment of skin picking. The specific medications which have been studied include fluoxetine (Prozac), citalopram (Celexa), escitalopram (Lexapro), fluvoxamine (Luvox), and sertraline (Zoloft). The mechanism of action in skin picking is not well understood; but it has been postulated that the SSRIs may reduce skin picking by targeting anxiety or depression which trigger picking behavior.
Other medications which have been used in the treatment of skin picking, although are less well studied, include N-acetylcysteine (NAC), naltrexone, olanzapine (Zyprexa), aripiprazole (Abilify), milk thistle and lithium. In particular and despite not yet having substantial research support, NAC and naltrexone are used commonly owing to their efficacy in hair-pulling disorder, a similar body-focused repetitive behavior.
MGH Excoriation Clinic and Research Unit
Dr. Nancy Keuthen, Ph.D., is the director of the Excoriation Clinic and Research Unit. She has an extensive research portfolio studying body-focused repetitive behaviors. She developed several self-report scales to assess picking severity and impact, studied the efficacy of medication treatment for skin picking and documented prevalence rates for this disorder. Dr. Keuthen is an editor of the text Trichotillomania, Skin Picking and Other Body-Focused Repetitive Behaviors. She has authored over 100 journal articles and chapters throughout her career. Additionally, Dr. Keuthen serves as the Vice-Chair (formerly the Chair) of the Scientific Advisory Board of the Trichotillomania Learning Center and is a member of the Scientific Advisory Board of the International Obsessive-Compulsive Disorder Foundation.
Dr. Lisa Zakhary, M.D., Ph.D., serves as the Director of Psychopharmacology in the Excoriation Clinic and Research Unit, and is an attending psychiatrist within the MGH OCD and Related Disorders Program. As a psychiatry resident, Dr. Zakhary co-founded the MGH Comprehensive Skin Management Clinic, a combined psychiatry and dermatology clinic offering multidisciplinary treatment for skin picking and other psychodermatologic disorders. She has published research examining dermatologists’ practices when treating obsessive-compulsive related disorders including skin picking and was awarded the Trichotillomania Learning Center Resident Scholarship. In addition, she is an active educator and speaks internationally on the treatment of obsessive-compulsive and related disorders to audiences ranging from medical providers to the community.
Our clinic mission is to provide state-of-the-art clinical care for the treatment of SPD symptoms and the alleviation of suffering. Our clinic is committed to improving current treatments for SPD through our program of research. We offer both cognitive-behavioral treatment and medication management approaches reflecting the latest empirical advances in treatment outcome studies.
For more information about our clinical services, please contact us at (617) 726-6766.