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).
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Cognitive-Behavioral Treatment (CBT)
Individuals will be engaged in a 12+ week program using cognitive behavioral therapy. 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 which includes using the comprehensive behavioral model. 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. This type of therapy helps you find ways to alter your physical environment so you’re less likely to pick. If you pick at blemishes on your face, for example, you might put a piece of tape on the floor in front of your bathroom mirror as a reminder to stay far enough away to keep from seeing the blemishes that trigger the desire to pick. If you target your fingers, you might wear gloves or bandages as a physical barrier and cue that reminds you to stop, even when the behavior starts unconsciously.
Clinicians may also use other treatment approaches to supplement 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.
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 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.
What Is Excoriation/Dermatillomania
The primary characteristic of Skin Picking Disorder (also known as Dermatillomania or Excoriation) is the repetitive picking at one’s own skin to the extent of causing damage. Usually, but not always, the face is the primary location for skin picking. However, Skin Picking Disorder may involve any part of the body. Individuals with Skin Picking Disorder may pick at normal skin variations such as freckles and moles, at actual pre-existing scabs, sores or acne blemishes, or at imagined skin defects that nobody else can observe. Individuals with Dermatillomania may also use their fingernails or teeth, as well as tweezers, pins or other mechanical devices. As a result, Skin Picking Disorder may cause bleeding, bruises, infections, and/or permanent disfigurement of the skin.
Sometimes skin picking is preceded by a high level of tension and a strong "itch" or "urge". Likewise, skin-picking may be followed by a feeling of relief or pleasure. A skin picking episode may be a conscious response to anxiety or depression, but is frequently done as an unconscious habit. Individuals with Skin Picking Disorder often attempt to camouflage the damage caused to their skin by using make-up or wearing clothes to cover the subsequent marks and scars. In extreme cases, individuals with Dermatillomania may avoid social situations in an effort to prevent others from seeing the scars, scabs, and bruises that result from skin 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:
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- 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.