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(/* DSM-V Diagnostic Criteria for Excoriation (Skin-Picking) Disorder {{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = ...)
 
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{{SK}}  Compulsive skin picking; CSP; dermatillomania; neurotic excoriation; psychogenic excoriation
{{SK}}  Compulsive skin picking; CSP; dermatillomania; neurotic excoriation; psychogenic excoriation
==Overview==
==Overview==
'''Excoriation disorder''' (also known as '''dermatillomania,''' '''compulsive skin picking,''' '''neurotic excoriation,''' '''psychogenic excoriation,''' or  '''CSP''') is an [[impulse control disorder]] and form of [[self-injury]] characterized by the repeated urge to pick at one's own [[skin]], often to the extent that damage is caused. Excoriation disorder may be related to [[body dysmorphic disorder]] (BDD).
'''Excoriation disorder''' (also known as '''dermatillomania,''' '''compulsive skin picking,''' '''neurotic excoriation,''' '''psychogenic excoriation,''' or  '''CSP''') is an [[impulse control disorder]] and form of [[self-injury]] characterized by the repeated urge to pick at one's own [[skin]], often to the extent that damage is caused. Excoriation disorder may be related to [[body dysmorphic disorder]] (BDD).<ref name="pmid12080906">{{cite journal| author=Deckersbach T, Wilhelm S, Keuthen NJ, Baer L, Jenike MA| title=Cognitive-behavior therapy for self-injurious skin picking. A case series. | journal=Behav Modif | year= 2002 | volume= 26 | issue= 3 | pages= 361-77 | pmid=12080906 | doi=10.1177/0145445502026003004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12080906  }} </ref>


[[Image:Dermatillomania fingers.JPG|thumb|left|Compulsive picking of the knuckles (via mouth) illustrating disfiguration of the [[interphalangeal articulations of hand|distal and proximal joints]] of the [[middle finger|middle]] and [[little finger|little]] fingers.]]
[[Image:Dermatillomania fingers.JPG|thumb|left|Compulsive picking of the knuckles (via mouth) illustrating disfiguration of the [[interphalangeal articulations of hand|distal and proximal joints]] of the [[middle finger|middle]] and [[little finger|little]] fingers.]]
Sufferers of dermatillomania find skin picking to be stress relieving or gratifying, though it can still be as physically painful as it would be for a non-skin picker.
Sufferers of dermatillomania find skin picking to be stress relieving or gratifying, though it can still be as physically painful as it would be for a non-skin picker.


==Habits of excoriation disorder sufferers==
==Historical Perspective==
Episodes of skin picking are often preceded or accompanied by tension, anxiety, stress, or paranoia. During these moments, there is commonly a compulsive urge to pick, bite, or scratch at a surface or region of the body, often at the location of a perceived skin defect. Sufferers may experience relief from upsetting emotions by engaging in skin picking.
*Lous-Anne-Jean Brocq was the first person to mention excoriation disorder on paper. She used the term in 1898 to describe a patient who uncontrollably picked their [[acne]].


[[Image:Derma_me.JPG|thumb|left|Skin Picking results on arms, shoulders and chest are visible.
==Classification==
While this look can be a social disturbance, it is also a time-consuming habit.]]
*The DSM-5 changed excoriation disorder's classification from "[[impulse control disorder]]" to "excoriation (skin-picking) disorder.<ref>{{cite book | last = Black | first = Donald | title = DSM-5 guidebook : the essential companion to the Diagnostic and statistical manual of mental disorders, fifth edition | publisher = American Psychiatric Publishing | location = Washington, DC | year = 2014 | isbn = 978-1585624652 }}</ref>


The regions most commonly affected by this are the [[face]], [[human back|back]], [[scalp]], [[stomach]], [[chest]], and extremities such as the [[hand]]s, [[foot|feet]], and [[arm]]s. Physical indicators of dermatillomania most commonly expressed in these areas are [[swelling (medical)|swelling]], [[scar]]ring, and [[callus]]ing due to damage to the affected region's [[Epidermis (skin)|epidermis]].  
*Excoriation disorder was originally known as "[[dermatillomania]]" before the DSM-5.<ref name="pmid20575652">{{cite journal| author=Odlaug BL, Grant JE| title=Pathologic skin picking. | journal=Am J Drug Alcohol Abuse | year= 2010 | volume= 36 | issue= 5 | pages= 296-303 | pmid=20575652 | doi=10.3109/00952991003747543 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20575652  }} </ref>


Aware of the damage they are inflicting, many sufferers feel and recognize a need to stop the behavior but are physically and mentally unable to do so without aid.  Additionally, the behavior's addict-like characteristics are very similar to the expression of [[trichotillomania]], or the compulsive pulling of hair from the body.
*The inability to control the urge to pick is similar to [[trichotillomania]].<ref>http://www3.interscience.wiley.com/cgi-bin/abstract/90513484/ABSTRACT?CRETRY=1&SRETRY=0</ref> Recent research suggests that, like trichotillomania, dermatillomania may be an [[impulse control disorder]].  This is part of the [[Obsessive-Compulsive Spectrum Disorder|obsessive compulsive disorder spectrum]].<ref>[http://www.brainexplorer.org/ocd/OCD_Related_%20Spectrum_%20Disorders.shtml Brain Explorer - Focus on Brain Disorders - OCD - Related Spectrum Disorders<!-- Bot generated title -->]</ref>


Many dermatillomania sufferers find that the disorder interferes with daily life. Plagued by shame, embarrassment, and humiliation, they may take measures to hide their disorder by not leaving the home, wearing long sleeves and pants in summer, or covering visible damage to skin with cosmetics and/or bandages. The disorder is typically found among females more than males.{
*In some animal models, it has been shown that animals that who excessively pull their hairs have more [[endorphin]] [[receptor]]s in their [[brain]] than animals who do not. Endorphin receptors enable endorphins to have an effect on the brain. If this is true for humans, people who are particularly compulsive about their repetitive habits may have more endorphin receptors in their brain as well. This may explain why sufferers get more enjoyment out of picking their scabs than others.


== Causes==
==Pathophysiology==
The inability to control the urge to pick is similar to trichotillomania.<ref>http://www3.interscience.wiley.com/cgi-bin/abstract/90513484/ABSTRACT?CRETRY=1&SRETRY=0</ref> Recent research suggests that, like trichotillomania, dermatillomania may be an [[impulse control disorder]].  This is part of the [[Obsessive-Compulsive Spectrum Disorder|obsessive compulsive disorder spectrum]].<ref>[http://www.brainexplorer.org/ocd/OCD_Related_%20Spectrum_%20Disorders.shtml Brain Explorer - Focus on Brain Disorders - OCD - Related Spectrum Disorders<!-- Bot generated title -->]</ref>
*Those suffering from excoriation disorder have very damaged skin, as a result of picking at it constantly.


In some animal models, it has been shown that animals that who excessively pull their hairs have more endorphin receptors in their brain than animals who do not. Endorphin receptors enable endorphins to have an effect on the brain. If this is true for humans, people who are particularly compulsive about their repetitive habits may have more endorphin receptors in their brain as well. This may explain why sufferers get more enjoyment out of picking their scabs than others.
[[Image:Derma_me.JPG|thumb|left|Skin Picking results on arms, shoulders and chest are visible.
While this look can be a social disturbance, it is also a time-consuming habit.]]


==Differential Diagnosis==
==Differential Diagnosis==
Excoriation disorder must be differentiated from:
*Neurodevelopmental disorders
*Neurodevelopmental disorders
:*[[Prader-Willi syndrome]]
:*[[Prader-Willi syndrome]]
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==Epidemiology and Demographics==
==Epidemiology and Demographics==
===Prevalence===
===Prevalence===
The prevalence of excoriation (skin-picking) disorder is 1,400 per 100,000 (1.4%) of the overall population.<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
*The prevalence of excoriation (skin-picking) disorder is approximately 1,400 per 100,000 (1.4%) individuals worldwide.<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
*About 2% of [[dermatology]] patients suffer from excoriation disorder.<ref name="pmid20575652">{{cite journal| author=Odlaug BL, Grant JE| title=Pathologic skin picking. | journal=Am J Drug Alcohol Abuse | year= 2010 | volume= 36 | issue= 5 | pages= 296-303 | pmid=20575652 | doi=10.3109/00952991003747543 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20575652  }} </ref>
===Age===
*The age of onset for excoriation disorder is likely either under 10 years old or between 30 and 45 years old.<ref name="pmid20575652">{{cite journal| author=Odlaug BL, Grant JE| title=Pathologic skin picking. | journal=Am J Drug Alcohol Abuse | year= 2010 | volume= 36 | issue= 5 | pages= 296-303 | pmid=20575652 | doi=10.3109/00952991003747543 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20575652  }} </ref>


==Risk Factors==
==Risk Factors==
Common risk factors in the development of excoriation disorder include:
*Genetic predisposition
*Genetic predisposition
*[[Obsessive-compulsive disorder]]([[OCD]])<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
*[[Obsessive-compulsive disorder]]([[OCD]])<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
==Natural History, complications, and prognosis==
===Natural History===
*The symptoms of excoriation disorder usually develop either under 10 years of age or between 30 and 45 years old.<ref name="pmid20575652">{{cite journal| author=Odlaug BL, Grant JE| title=Pathologic skin picking. | journal=Am J Drug Alcohol Abuse | year= 2010 | volume= 36 | issue= 5 | pages= 296-303 | pmid=20575652 | doi=10.3109/00952991003747543 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20575652  }} </ref>
===Complications===
*There are no known complications associated with excoriation disorder.
===Prognosis===
*Those who suffer from this disorder tend to wear long sleeved clothing, even in warm weather, to hide any damaged skin. They are hindered by embarrassment when going out in public. If excoriation disorder is left untreated, it can last as long as 21 years.


==Diagnostic Criteria==
==Diagnostic Criteria==
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*E. The skin picking is not better explained by symptoms of another mental disorder (e.g., [[delusions]] or tactile [[hallucinations]] in a [[psychotic disorder]], attempts to improve a perceived defect or flaw in appearance in [[body dysmorphic disorder]], stereotypies in [[stereotypic movement disorder]], or intention to harm oneself in non suicidal self-injury).
*E. The skin picking is not better explained by symptoms of another mental disorder (e.g., [[delusions]] or tactile [[hallucinations]] in a [[psychotic disorder]], attempts to improve a perceived defect or flaw in appearance in [[body dysmorphic disorder]], stereotypies in [[stereotypic movement disorder]], or intention to harm oneself in non suicidal self-injury).
}}
}}
==History and Symptoms==
*History of picking at the the skin
*History of personal issues such as abuse that may lead to these behaviors.
*Acne already preexisting on the body.
==Laboratory Findings==
*There are no diagnostic laboratory findings associated with excoriation disorder.
==Other Imaging Studies==
*There are no other imaging findings associated with excoriation disorder.
==Other Diagnostic Studies==
There are no other diagnostic studies associated with excoriation disorder.
==Medical Therapy==
*[[SSRI]]s, glutamateric agents, and [[opioid antagonist]]s can all help in treating excoriation disorder.
**SSRIs are effective in treating [[obsessive-compulsive disorder]], which is closely related to excoriation disorder.
*[[Skin picking]], which is the defining symptom of excoriation disorder, can be treated by using [[antidepressant]], [[anti-anxiety]], [[anti-epileptic]], and [[antipsychotic]] medications.<ref name="pmid20575652">{{cite journal| author=Odlaug BL, Grant JE| title=Pathologic skin picking. | journal=Am J Drug Alcohol Abuse | year= 2010 | volume= 36 | issue= 5 | pages= 296-303 | pmid=20575652 | doi=10.3109/00952991003747543 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20575652  }} </ref>
==Psychotherapy==
*[[Habit reversal training]], acceptance and commitment therapy, acceptance-enhanced behavioral therapy, and [[cognitive behavioral therapy]] were all used to help treat excoriation disorder.
*These strategies help reduce skin picking behavior in individuals with excoriation disorder, but no psychological issues.<ref name="pmid20575652">{{cite journal| author=Odlaug BL, Grant JE| title=Pathologic skin picking. | journal=Am J Drug Alcohol Abuse | year= 2010 | volume= 36 | issue= 5 | pages= 296-303 | pmid=20575652 | doi=10.3109/00952991003747543 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20575652  }} </ref><ref name="pmid16960655">{{cite journal| author=Dell'Osso B, Altamura AC, Allen A, Marazziti D, Hollander E| title=Epidemiologic and clinical updates on impulse control disorders: a critical review. | journal=Eur Arch Psychiatry Clin Neurosci | year= 2006 | volume= 256 | issue= 8 | pages= 464-75 | pmid=16960655 | doi=10.1007/s00406-006-0668-0 | pmc=1705499 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16960655  }} </ref><ref name="pmid19963341">{{cite journal| author=Lang R, Didden R, Machalicek W, Rispoli M, Sigafoos J, Lancioni G et al.| title=Behavioral treatment of chronic skin-picking in individuals with developmental disabilities: a systematic review. | journal=Res Dev Disabil | year= 2010 | volume= 31 | issue= 2 | pages= 304-15 | pmid=19963341 | doi=10.1016/j.ridd.2009.10.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19963341  }} </ref>
==Brain Stimulation Therapy==
*There is no brain stimulation therapy associated with excoriation disorder.


==Treatment==
==Cost Effectiveness of Therapy==
Few [[mental health]] practitioners have studied the disease, as many of these cases go unreported, but some individuals have found relief through [[cognitive-behavioral therapy]]. Hypnosis, self-hypnosis and meditation have also been useful for some patients.  They are also sometimes prescribed medications, such as those prescribed for obsessive compulsive disorder. For example, artificial fingernails (acrylic or gel) have been found to be useful to some in stopping the picking behavior.


==Future or Investigational Therapies==
==References==
==References==
{{Reflist|1}}
{{Reflist|1}}

Latest revision as of 17:15, 16 January 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2] Yashasvi Aryaputra[3]

Synonyms and keywords: Compulsive skin picking; CSP; dermatillomania; neurotic excoriation; psychogenic excoriation

Overview

Excoriation disorder (also known as dermatillomania, compulsive skin picking, neurotic excoriation, psychogenic excoriation, or CSP) is an impulse control disorder and form of self-injury characterized by the repeated urge to pick at one's own skin, often to the extent that damage is caused. Excoriation disorder may be related to body dysmorphic disorder (BDD).[1]

Compulsive picking of the knuckles (via mouth) illustrating disfiguration of the distal and proximal joints of the middle and little fingers.

Sufferers of dermatillomania find skin picking to be stress relieving or gratifying, though it can still be as physically painful as it would be for a non-skin picker.

Historical Perspective

  • Lous-Anne-Jean Brocq was the first person to mention excoriation disorder on paper. She used the term in 1898 to describe a patient who uncontrollably picked their acne.

Classification

  • In some animal models, it has been shown that animals that who excessively pull their hairs have more endorphin receptors in their brain than animals who do not. Endorphin receptors enable endorphins to have an effect on the brain. If this is true for humans, people who are particularly compulsive about their repetitive habits may have more endorphin receptors in their brain as well. This may explain why sufferers get more enjoyment out of picking their scabs than others.

Pathophysiology

  • Those suffering from excoriation disorder have very damaged skin, as a result of picking at it constantly.
Skin Picking results on arms, shoulders and chest are visible. While this look can be a social disturbance, it is also a time-consuming habit.

Differential Diagnosis

Excoriation disorder must be differentiated from:

  • Neurodevelopmental disorders
  • Other disorders
  • Other medical conditions
  • Somatic symptom and related disorders
  • Substance/medication-induced disorders

Epidemiology and Demographics

Prevalence

  • The prevalence of excoriation (skin-picking) disorder is approximately 1,400 per 100,000 (1.4%) individuals worldwide.[6]
  • About 2% of dermatology patients suffer from excoriation disorder.[3]

Age

  • The age of onset for excoriation disorder is likely either under 10 years old or between 30 and 45 years old.[3]

Risk Factors

Common risk factors in the development of excoriation disorder include:

Natural History, complications, and prognosis

Natural History

  • The symptoms of excoriation disorder usually develop either under 10 years of age or between 30 and 45 years old.[3]

Complications

  • There are no known complications associated with excoriation disorder.

Prognosis

  • Those who suffer from this disorder tend to wear long sleeved clothing, even in warm weather, to hide any damaged skin. They are hindered by embarrassment when going out in public. If excoriation disorder is left untreated, it can last as long as 21 years.

Diagnostic Criteria

DSM-V Diagnostic Criteria for Excoriation (Skin-Picking) Disorder [6]

  • A. Recurrent skin picking resulting in skin lesions.

AND

  • B. Repeated attempts to decrease or stop skin picking.

AND

  • C. The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

AND

  • D. The skin picking is not attributable to the physiological effects of a substance (e.g.,cocaine) or another medical condition (e.g., scabies).

AND

History and Symptoms

  • History of picking at the the skin
  • History of personal issues such as abuse that may lead to these behaviors.
  • Acne already preexisting on the body.

Laboratory Findings

  • There are no diagnostic laboratory findings associated with excoriation disorder.

Other Imaging Studies

  • There are no other imaging findings associated with excoriation disorder.

Other Diagnostic Studies

There are no other diagnostic studies associated with excoriation disorder.

Medical Therapy

Psychotherapy

  • These strategies help reduce skin picking behavior in individuals with excoriation disorder, but no psychological issues.[3][7][8]

Brain Stimulation Therapy

  • There is no brain stimulation therapy associated with excoriation disorder.

Cost Effectiveness of Therapy

Future or Investigational Therapies

References

  1. Deckersbach T, Wilhelm S, Keuthen NJ, Baer L, Jenike MA (2002). "Cognitive-behavior therapy for self-injurious skin picking. A case series". Behav Modif. 26 (3): 361–77. doi:10.1177/0145445502026003004. PMID 12080906.
  2. Black, Donald (2014). DSM-5 guidebook : the essential companion to the Diagnostic and statistical manual of mental disorders, fifth edition. Washington, DC: American Psychiatric Publishing. ISBN 978-1585624652.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 Odlaug BL, Grant JE (2010). "Pathologic skin picking". Am J Drug Alcohol Abuse. 36 (5): 296–303. doi:10.3109/00952991003747543. PMID 20575652.
  4. http://www3.interscience.wiley.com/cgi-bin/abstract/90513484/ABSTRACT?CRETRY=1&SRETRY=0
  5. Brain Explorer - Focus on Brain Disorders - OCD - Related Spectrum Disorders
  6. 6.0 6.1 6.2 6.3 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
  7. Dell'Osso B, Altamura AC, Allen A, Marazziti D, Hollander E (2006). "Epidemiologic and clinical updates on impulse control disorders: a critical review". Eur Arch Psychiatry Clin Neurosci. 256 (8): 464–75. doi:10.1007/s00406-006-0668-0. PMC 1705499. PMID 16960655.
  8. Lang R, Didden R, Machalicek W, Rispoli M, Sigafoos J, Lancioni G; et al. (2010). "Behavioral treatment of chronic skin-picking in individuals with developmental disabilities: a systematic review". Res Dev Disabil. 31 (2): 304–15. doi:10.1016/j.ridd.2009.10.017. PMID 19963341.


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