Dermatillomania
Encyclopedia
Dermatillomania is an impulse control disorder
characterized by the repeated urge to pick at one's own skin, often to the extent that damage is caused. Research has suggested that the urge to pick is similar to an obsessive compulsive disorder but others have argued that for some the condition is more akin to substance abuse disorder. The two main strategies for treating this condition are pharmacological and behavioral intervention.
Dermatillomania has never been classified as its own separate condition in the Diagnostic and Statistical Manual of Mental Disorders
, and is usually classified as a subset of impulse control disorder
. Dr. Dan Stein and others have argued that dermatillomania should have been included in the DSM-5
because the condition is clearly a behavioral pattern in some indivdiuals that has been long described in the medical literature and diagnostic criteria have been proposed.
. Researchers have noted the following similarities between trichotillomania and dermatillomania: the symptoms are ritualistic but there are no preceeding obsessions; there are similar triggers for the compulsive actions; both conditions appear to play a role in modifying the arousal level of the subject; and the age on onset for both conditions is similar. There is also a high level of comorbidity
between those that have trichotillomania and those that have dermatillomania. A notable difference between these conditions is that skin picking seems to be dominated by females whereas trichtillomania is more evenly distributed between the genders.
Research has also suggested that dermatillomania may be thought of as a type of obsessive compulsive disorder (OCD). Dermatillomania and OCD are similar in that they both involve "repetitive engagement in behaviors with diminished control" and also both generally decrease anxiety.
Nevertheless, Odlaug and Grant have suggested that dermatillomania is more akin to substance abuse disorder than OCD. They argue that dermatillomania differs from OCD in the following fundamental ways: (1) there is a much greater share of females with dermatillomania; (2) dermatillomania may be inherently pleasurable whereas OCD is not; (3) the treatments that are generally effective for patients with OCD, (i. e., SSRIs
and exposure therapy
) are not as successful in patients with dermatillomania; and (4) unlike OCD, picking the skin is rarely driven by obsessive thoughts. Odlaug and Grant have recognized the following similarities between individuals with dermatillomania and patients with addictions: (1) a compulsion to engage in the negative behavior despite knowledge of the harm; (2) a lack of control over the problematic behavior; (3) a strong urge to engage in the behavior prior to engagement; and (4) a feeling of pleasure while engaging in the behavior or a feeling of relief or reduced anxiety after engaging in the behavior. One study that supported the addiction theory of picking found that 79% of patients with dermatillomania reported a pleasurable feeling when picking.
Odlaug and Grant also argue that dermatillomania could have several different psychological causes, which would explain why some patients seem more likely to have symptoms of OCD, and others, of an addiction. They suggest that treating certain cases of dermatillomania as an addiction may yield more success than treating them as a form of OCD.
The region most commonly picked is the face, but other frequent locations include the arms, legs, back, gums, lips, shoulders, scalp, stomach, chest, and extremities such as the fingernails, cuticles, and toenails. Most patients with dermatillomania report having a primary area of the body that they focus their picking on, but they will often move to other areas of the body to allow their primary picking area to heal. Individuals with dermatillomania vary in their picking behaviour; some do it briefly multiple times a day while others can do one picking session that can last for hours. The most common way to pick is to use the fingers although a significant minority of people use tools such as tweezers.
Skin picking often occurs as a result of some other triggering cause. Some common triggers are feeling irregularities on the skin and feeling anxious or other negative feelings.
Complications arising from dermatillomania include: infection at the site of picking, tissue damage, and septicemia. Damage from picking can be so severe as to require skin grafting. Severe picking can cause epidural abscesses
. Severe cases of dermatillomania can cause life threatening injuries. For example, in one reported case a female picked a hole through the bridge of her nose, which required surgery to fix, and a 48-year old female picked through the skin on her neck exposing the carotid artery
. Besides physical injuries, dermatillomania can cause severe physical scarring and disfigurement.
Dermatillomania can cause feeling of intense guilt
, shame
, and embarrassment
in individuals, and this greatly increases the risk of self harm. Studies have shown that dermatillomania presented suicidal ideation
in 12% of individuals with this condition, suicide attempts in 11.5% of individuals with this condition, and psychiatric hospitalizations in 15% of individuals with this condition.
There have been many different theories regarding the causes of dermatillomania.
A common hypothesis is that dermatillomania is often a coping mechanism to deal with elevated levels of arousal or stress within the individual, and that the individual has an impaired stress response. A review of behavioral studies found support in this hypothesis in that skin-picking appears to be maintained by automatic reinforcement within the individual.
In contrast to neurological theories, there are some psychologist
that believe that picking behavior is a result of repressed rage felt toward authoritarian parents. A similar theory holds that overbearing parents can cause the behavior to develop in their children.
Those individuals that have dermatillomania along with other diagnosed conditions report differing motivations for their picking. Those with both OCD and dermatillomania report that they will pick their skin due to a perceived contamination of the skin, while those with both body dysmorphic disorder
(BDD) and dermatillomania reportedly pick to fix perceived imperfections in the skin.
Studies have shown a linkage between dopamine
and the urge to pick. Drugs such as cocaine
and methamphetamine
that are dopamine agonists, which increase the pharmacological effects of dopamine, have been shown to cause uncontrollable picking in users. These drugs can create the sensation of formication
, which feels likes something is crawling on or under the skin. Additionally, drugs such as naltrexone
that are dopamine antagonists, which impede the pharmacological effects of dopamine, have shown some benefit in reducing picking behavior. Thus, dermatillomania could result from a dysfunction in the dopamine reward functions.
There may be another neurological explanation for dermatillomania: individuals who have dermatillomania have less motor-inhibitory control, but show no sign of difference in cognitive flexibility
, when compared to individuals without the condition. Motor-inhibitory control is a function of the right lateralized frontostriatal circuit
, which includes the right inferior frontal and bilateral anterior cingulate cortices
. The impairment of motor-inhibitory control is similar to the neurological conditions of those who have problems suppressing inappropriate behaviors, such as abusing methamphetamines.
(DSM IV). The addition has been proposed for the fifth edition of the DSM as a condition where there is an intrusive compulsion to pick at one's skin that cannot be accounted for by another medical condition or mental disorder; where feelings of tension or anxiety precedes picking; where picking causes damage; and where the picking results in immediate pleasure or relief but later causes distress or impairment to the subject. Most of the published literature uses a simplified two-factor definition; i.e., dermatillomania is 1) repetitive picking at the skin that 2) results in significant distress or social or occupational impairment.
There has been a debate as to whether to create a separate category in the DSM-V for dermatillomania. Two of the main reasons for objecting to the inclusion of dermatillomania in the DSM-V are: (1) that dermatillomania may just be a symptom of a different underlying disorder, e.g., OCD or BDD, and (2) that dermatillomania is merely a bad habit and that by allowing this disorder to obtain its own separate category it would force the DSM to include a wide array of bad habits as separate syndromes, e.g., nail biting and nose-picking. Stein has argued that dermatillomani does qualify as a separate syndrome and should be classified as its own category because: (1) dermatillomania occurs as the primary disorder and not as a subset of a larger disorder; (2) dermatillomania has well-defined clinical features; (3) there is gathering data on the clinical features and diagnostic criteria for this condition; (4) there is sufficient data to create this as a separate category for dermatillomani; (5) there incidence rate for dermatillomania is high within the population; (6) diagnostic criteria for the disease have already been proposed; (7) the classification of dermatillomania as a separate condition would lead to better studies and better treatment outcomes; and (8) classification as a separate condition would lead to more awareness of the disorder and encourage more people to obtain treatment.
Because dermatillomania is different from other conditions and disorders that cause picking of the skin, it is important that any diagnosis of dermatillomania take into account various other medical conditions as possible causes before diagnosing the patient with dermatillomania. There are a variety of conditions that cause itching and skin picking including: eczema
, psoriasis
, diabetes, liver disease
, Hodgkin's disease, polycythemia vera
, systemic lupus, and Prader-Willi syndrome
.
In order to better understand dermotillomania, researchers have developed a variety of scales to categorize skin-picking behavior. These include the Skin-Picking Impact Scale (SPIS), and The Milwaukee Inventory for the Dimensions of Adult Skin-picking. The SPIS was created to measure how skin picking affects the individual socially, behaviorally, and emotionally.
Individuals with dermatillomania often do not seek treatment for their condition largely due to feelings of embarrassment or belief that the condition cannot be treated. One study found that only 45% of individuals with dermatillomania ever sought treatment and only 19% ever received dermalogical treatment. Another study found that only 30% of individuals with this disorder sought treatment.
SSRIs have shown to be effective in the treatment of OCD and this has provided an argument in favor of treating dermatillomania with the same therapy. Unfortunately, the clinical studies have not provided clear support for this, because there have not been large double-blind placebo-controlled trials of SSRI therapy for dermatillomania. Review of treatment with SSRIs of dermatillomania have shown that the following may be effective in reducing picking behavior: doxepin
, clomipramine
, naltrexone
, pimozide
, and olanzapine
. Small studies of fluoxetine
, an SSRI, in treating dermatillomania showed that the drug reduced certain aspects of skin picking, as compared to placebo, but full remission was not observed. One small study of patients with dermatillomania treated with citalopram
, another SSRI, showed that those that took the drug significantly reduced their scores on the Yale-Brown Obsessive Compulsive Scale
compared to placebo, but that there was no significant decrease on the visual-analog scale of picking behavior.
While there have been no human studies of opioid antagonists for the treatment of dermatillomania, there have been studies showing that these products can reduce self-chewing in dogs with acral lick
, which some have proposed is a good animal model for dermatillomania. Furthermore, there have been case reports that support the use of these opioid antagonists to treat dermatillomania. Opioid antagonists work by affecting dopamine circuitry, thereby decreasing the pleasurable effects of picking.
Another class of possible pharmacological treatments are glutamatergic agents such as n-acetyl cysteine (NAC). These products have shown some ability to reduce other problematic behaviors such as cocaine addiction and trichotillomania. Some case studies and some small studies of NAC have shown a decrease in dermatillomania by treatment with NAC, as compared to placebo.
Topiramate
, an anti-epileptic drug, has been used to treat dermatillomania; in a small study of individuals with Prader–Willi syndrome, it was found to reduce skin-picking behavior.
, cognitive-behavioral therapy, and acceptance-enhanced behavior therapy.
Several studies have showed that habit reversal training associated with awareness training reduces skin-picking behavior in those individuals with dermatillomania that do not have psychological disabilities. Habit reversal training can included awareness enhancement and competing response training. For example, in one study the competing response training required participants to make a closed fist for one minute instead of picking or in response to condition that usually provokes picking behavior.
One treatment method is to have individuals wear a form of protective clothing that limits the ability of the patient to pick at his body, e.g., gloves or face mask.
Other behavioral treatments attempt to change behavior through providing different incentives. Under Differential Reinforcement of Other Behavior (DRO), a patient is rewarded if manages to abstain from the picking behavior for a certain amount of time.. In contrast to DRO, Differential Reinforcement of Incompatible Behavior (DRI) rewards an individual for engaging in a alternative behavior that cannot physically occur at the same time as the problem behavior (e.g. sitting on your hands instead of picking at your skin). Lastly, differential reinforcement of alternative behavior rewards behavior that is not necessarily incompatible with the target behavior but serves the same function as the target behavior (e.g., providing people with a competing behavior to occupy their time instead of skin picking).
Another form of behavioral approach is to use punishment. This can either be verbal punishment, by telling the person no when they did the activity, or physical punishment, by making them do arm exercises, or spraying water at them when they engage in picking behavior..
All of these techniques have been reported to have some success in small studies, but none has been tested in large enough population to provide definitive evidence of their effectiveness.
Estimates of prevalence of the condition range from 1.4 to 5.4% in the general population. One U.S. telephone survey found that 16.6% of respondents "picked their skin to the point of noticeable tissue damage" and that 1.4% would qualify as meeting the requirements of dermatillomania. Another community survey found a rate of 5.4% had dermatillomania. A survey of college students found a rate of 4%. One study found that among non-disabled adults, 63% of individuals engaged in some form of skin picking and 5.4% engaged in serious skin picking. Lastly, a survey of dermatology patients found that 2% suffered from dermatillomania.
In many patients dermatillomania begins with the onset of acne
in adolescence, but the compulsion continues even after the acne has gone away. In those dermatillomania patients with acne, the grooming of the skin is disproportionate to the severity of the acne. Certain stressful events including marital conflicts, deaths of friends or family, and unwanted pregnancies have been linked to the onset of the condition. If dermatillomani does not occur during adolescence another common age of onset is between the ages of 30 to 45. Additionally, many cases of dermatillomania have been documented to begin in children under the age of 10. One small survey of patients with dermatillomania found that 47.5% of them had an early onset of dermatillomania that began before age 10.
Dermatillomania is more common in females than in males.
Dermatillomania has a high rate of comorbidity with other psychiatric conditions, especially with mood and anxiety disorders . One survey of patients with dermatillomania found that 56.7% also had a DSM-IV Axis-I disorder and 38% had alcohol- or drug-abuse problems. Studies have shown the following rates of psychiatric conditions found in patients with dermatillomania: trichotillomania
(38.3%), substance abuse
(38%), major depressive disorder (approximately 31.7% to 58.1%), anxiety disorders (approximately 23% to 56%), obsessive-compulsive disorder
(approximately 16.7% to 68%), and body dysmorphic disorder
(approximately 26.8% to 44.9%). There are also higher rates of dermatillomania in patients in psychiatric facilities; a study of adolescent psychiatric inpatients found that dermatillomania was present in 11.8% of patients. It is also present at high rates with some other conditions: 44.9% of patients with body dysmorphic disorder
also have dermatillomania; 8.9% of patients with OCD have dermatillomania; and 8.3% of patients with trichotillomania have dermatillomania.
Skin picking is also common in those with certain developmental disabilities; for example, Prader–Willi syndrome and Smith–Magenis syndrome. Studies have shown that 85% of people with Prader–Willi syndrome also engage in skin-picking. Children with developmental disabilities are also at an increased risk for dermatillomania.
Dermatillomania also correlates with "social, occupational, and academic impairments, increased medical and mental health concerns (including anxiety, depression, obsessive–compulsive disorder) ... and financial burden ... " Dermatillomania also has a high degree of mobidity with occupational and marital difficulties.
Substance abuse is often present, and individuals with dermatillomania are twice as likely to have first-degree relatives
who have substance-abuse disorders (alcohol or drugs) than those without the condition.
, a television documentary series that focuses on treatment of anxiety disorders.
Impulse control disorder
Impulse control disorder is a set of psychiatric disorders including intermittent explosive disorder, kleptomania, pathological gambling, pyromania , and three body-focused repetitive or compulsive behaviors of trichotillomania , onychophagia and dermatillomania...
characterized by the repeated urge to pick at one's own skin, often to the extent that damage is caused. Research has suggested that the urge to pick is similar to an obsessive compulsive disorder but others have argued that for some the condition is more akin to substance abuse disorder. The two main strategies for treating this condition are pharmacological and behavioral intervention.
Classification
Dermatillomania is defined as "repetitive and compulsive picking of skin which results in tissue damage."Dermatillomania has never been classified as its own separate condition in the Diagnostic and Statistical Manual of Mental Disorders
Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
, and is usually classified as a subset of impulse control disorder
Impulse control disorder
Impulse control disorder is a set of psychiatric disorders including intermittent explosive disorder, kleptomania, pathological gambling, pyromania , and three body-focused repetitive or compulsive behaviors of trichotillomania , onychophagia and dermatillomania...
. Dr. Dan Stein and others have argued that dermatillomania should have been included in the DSM-5
DSM-5
The next edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders , commonly called DSM-5 , is currently in consultation, planning and preparation...
because the condition is clearly a behavioral pattern in some indivdiuals that has been long described in the medical literature and diagnostic criteria have been proposed.
Similiarities with other conditions
The inability to control the urge to pick is similar to the urge to compulsively pull one's own hair, i.e., trichotillomaniaTrichotillomania
Trichotillomania, which is classified as an impulse control disorder by DSM-IV, is the compulsive urge to pull out one's own hair leading to noticeable hair loss, distress, and social or functional impairment. It is often chronic and difficult to treat....
. Researchers have noted the following similarities between trichotillomania and dermatillomania: the symptoms are ritualistic but there are no preceeding obsessions; there are similar triggers for the compulsive actions; both conditions appear to play a role in modifying the arousal level of the subject; and the age on onset for both conditions is similar. There is also a high level of comorbidity
Comorbidity
In medicine, comorbidity is either the presence of one or more disorders in addition to a primary disease or disorder, or the effect of such additional disorders or diseases.- In medicine :...
between those that have trichotillomania and those that have dermatillomania. A notable difference between these conditions is that skin picking seems to be dominated by females whereas trichtillomania is more evenly distributed between the genders.
Research has also suggested that dermatillomania may be thought of as a type of obsessive compulsive disorder (OCD). Dermatillomania and OCD are similar in that they both involve "repetitive engagement in behaviors with diminished control" and also both generally decrease anxiety.
Nevertheless, Odlaug and Grant have suggested that dermatillomania is more akin to substance abuse disorder than OCD. They argue that dermatillomania differs from OCD in the following fundamental ways: (1) there is a much greater share of females with dermatillomania; (2) dermatillomania may be inherently pleasurable whereas OCD is not; (3) the treatments that are generally effective for patients with OCD, (i. e., SSRIs
Selective serotonin reuptake inhibitor
Selective serotonin re-uptake inhibitors or serotonin-specific reuptake inhibitor are a class of compounds typically used as antidepressants in the treatment of depression, anxiety disorders, and some personality disorders. The efficacy of SSRIs is disputed...
and exposure therapy
Exposure therapy
Exposure therapy is a technique in behavior therapy intended to treat anxiety disorders and involves the exposure to the feared object or context without any danger in order to overcome their anxiety. Procedurally it is similar to the fear extinction paradigm in rodent work...
) are not as successful in patients with dermatillomania; and (4) unlike OCD, picking the skin is rarely driven by obsessive thoughts. Odlaug and Grant have recognized the following similarities between individuals with dermatillomania and patients with addictions: (1) a compulsion to engage in the negative behavior despite knowledge of the harm; (2) a lack of control over the problematic behavior; (3) a strong urge to engage in the behavior prior to engagement; and (4) a feeling of pleasure while engaging in the behavior or a feeling of relief or reduced anxiety after engaging in the behavior. One study that supported the addiction theory of picking found that 79% of patients with dermatillomania reported a pleasurable feeling when picking.
Odlaug and Grant also argue that dermatillomania could have several different psychological causes, which would explain why some patients seem more likely to have symptoms of OCD, and others, of an addiction. They suggest that treating certain cases of dermatillomania as an addiction may yield more success than treating them as a form of OCD.
Signs and symptoms
Episodes of skin picking are often preceded or accompanied by tension, anxiety, or stress. 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.The region most commonly picked is the face, but other frequent locations include the arms, legs, back, gums, lips, shoulders, scalp, stomach, chest, and extremities such as the fingernails, cuticles, and toenails. Most patients with dermatillomania report having a primary area of the body that they focus their picking on, but they will often move to other areas of the body to allow their primary picking area to heal. Individuals with dermatillomania vary in their picking behaviour; some do it briefly multiple times a day while others can do one picking session that can last for hours. The most common way to pick is to use the fingers although a significant minority of people use tools such as tweezers.
Skin picking often occurs as a result of some other triggering cause. Some common triggers are feeling irregularities on the skin and feeling anxious or other negative feelings.
Complications arising from dermatillomania include: infection at the site of picking, tissue damage, and septicemia. Damage from picking can be so severe as to require skin grafting. Severe picking can cause epidural abscesses
Abscess
An abscess is a collection of pus that has accumulated in a cavity formed by the tissue in which the pus resides due to an infectious process or other foreign materials...
. Severe cases of dermatillomania can cause life threatening injuries. For example, in one reported case a female picked a hole through the bridge of her nose, which required surgery to fix, and a 48-year old female picked through the skin on her neck exposing the carotid artery
Carotid artery
Carotid artery can refer to:* Common carotid artery* External carotid artery* Internal carotid artery...
. Besides physical injuries, dermatillomania can cause severe physical scarring and disfigurement.
Dermatillomania can cause feeling of intense guilt
Guilt
Guilt is the state of being responsible for the commission of an offense. It is also a cognitive or an emotional experience that occurs when a person realizes or believes—accurately or not—that he or she has violated a moral standard, and bears significant responsibility for that...
, shame
Shame
Shame is, variously, an affect, emotion, cognition, state, or condition. The roots of the word shame are thought to derive from an older word meaning to cover; as such, covering oneself, literally or figuratively, is a natural expression of shame....
, and embarrassment
Embarrassment
Embarrassment is an emotional state of intense discomfort with oneself, experienced upon having a socially unacceptable act or condition witnessed by or revealed to others. Usually some amount of loss of honour or dignity is involved, but how much and the type depends on the embarrassing situation...
in individuals, and this greatly increases the risk of self harm. Studies have shown that dermatillomania presented suicidal ideation
Suicidal ideation
Suicidal ideation is a common medical term for thoughts about suicide, which may be as detailed as a formulated plan, without the suicidal act itself. Although most people who undergo suicidal ideation do not commit suicide, some go on to make suicide attempts...
in 12% of individuals with this condition, suicide attempts in 11.5% of individuals with this condition, and psychiatric hospitalizations in 15% of individuals with this condition.
Causes
A common hypothesis is that dermatillomania is often a coping mechanism to deal with elevated levels of arousal or stress within the individual, and that the individual has an impaired stress response. A review of behavioral studies found support in this hypothesis in that skin-picking appears to be maintained by automatic reinforcement within the individual.
In contrast to neurological theories, there are some psychologist
Psychology
Psychology is the study of the mind and behavior. Its immediate goal is to understand individuals and groups by both establishing general principles and researching specific cases. For many, the ultimate goal of psychology is to benefit society...
that believe that picking behavior is a result of repressed rage felt toward authoritarian parents. A similar theory holds that overbearing parents can cause the behavior to develop in their children.
Neurological
There is only a limited knowledge regarding the neurobiology that drives dermatillomania, and there have been no neuroimaging studies of patients with dermatillomania.Those individuals that have dermatillomania along with other diagnosed conditions report differing motivations for their picking. Those with both OCD and dermatillomania report that they will pick their skin due to a perceived contamination of the skin, while those with both body dysmorphic disorder
Body dysmorphic disorder
Body Dysmorphic Disorder is a type of mental illness, a somatoform disorder, wherein the affected person is exclusively concerned with body image, manifested as excessive concern about and preoccupation with a perceived defect of his or her physical features...
(BDD) and dermatillomania reportedly pick to fix perceived imperfections in the skin.
Studies have shown a linkage between dopamine
Dopamine
Dopamine is a catecholamine neurotransmitter present in a wide variety of animals, including both vertebrates and invertebrates. In the brain, this substituted phenethylamine functions as a neurotransmitter, activating the five known types of dopamine receptors—D1, D2, D3, D4, and D5—and their...
and the urge to pick. Drugs such as cocaine
Cocaine
Cocaine is a crystalline tropane alkaloid that is obtained from the leaves of the coca plant. The name comes from "coca" in addition to the alkaloid suffix -ine, forming cocaine. It is a stimulant of the central nervous system, an appetite suppressant, and a topical anesthetic...
and methamphetamine
Methamphetamine
Methamphetamine is a psychostimulant of the phenethylamine and amphetamine class of psychoactive drugs...
that are dopamine agonists, which increase the pharmacological effects of dopamine, have been shown to cause uncontrollable picking in users. These drugs can create the sensation of formication
Formication
Formication is the medical term for a sensation that resembles that of insects crawling on the skin. It is one specific form of a set of sensations known as paresthesia, which also include the more common prickling, tingling sensation of "pins and needles"...
, which feels likes something is crawling on or under the skin. Additionally, drugs such as naltrexone
Naltrexone
Naltrexone is an opioid receptor antagonist used primarily in the management of alcohol dependence and opioid dependence. It is marketed in generic form as its hydrochloride salt, naltrexone hydrochloride, and marketed under the trade names Revia and Depade...
that are dopamine antagonists, which impede the pharmacological effects of dopamine, have shown some benefit in reducing picking behavior. Thus, dermatillomania could result from a dysfunction in the dopamine reward functions.
There may be another neurological explanation for dermatillomania: individuals who have dermatillomania have less motor-inhibitory control, but show no sign of difference in cognitive flexibility
Cognitive flexibility
Cognitive flexibility is the term used to describe one of the executive functions; a function which is an important component of human behavior; the ability to switch behavioral response according to the context of the situation...
, when compared to individuals without the condition. Motor-inhibitory control is a function of the right lateralized frontostriatal circuit
Frontostriatal circuit
Frontostriatal circuits are neural pathways that connect frontal lobe regions with the basal ganglia that mediate motor, cognitive, and behavioural programs within the brain and receive inputs from dopaminergic, serotonergic, noradrenergic, and cholinergic cell groups that modulate information...
, which includes the right inferior frontal and bilateral anterior cingulate cortices
Anterior cingulate cortex
The anterior cingulate cortex is the frontal part of the cingulate cortex, that resembles a "collar" form around the corpus callosum, the fibrous bundle that relays neural signals between the right and left cerebral hemispheres of the brain...
. The impairment of motor-inhibitory control is similar to the neurological conditions of those who have problems suppressing inappropriate behaviors, such as abusing methamphetamines.
Diagnosis
Dermatillomania is not specifically defined in the fourth edition of the Diagnostic and Statistical Manual of Mental DisordersDiagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
(DSM IV). The addition has been proposed for the fifth edition of the DSM as a condition where there is an intrusive compulsion to pick at one's skin that cannot be accounted for by another medical condition or mental disorder; where feelings of tension or anxiety precedes picking; where picking causes damage; and where the picking results in immediate pleasure or relief but later causes distress or impairment to the subject. Most of the published literature uses a simplified two-factor definition; i.e., dermatillomania is 1) repetitive picking at the skin that 2) results in significant distress or social or occupational impairment.
There has been a debate as to whether to create a separate category in the DSM-V for dermatillomania. Two of the main reasons for objecting to the inclusion of dermatillomania in the DSM-V are: (1) that dermatillomania may just be a symptom of a different underlying disorder, e.g., OCD or BDD, and (2) that dermatillomania is merely a bad habit and that by allowing this disorder to obtain its own separate category it would force the DSM to include a wide array of bad habits as separate syndromes, e.g., nail biting and nose-picking. Stein has argued that dermatillomani does qualify as a separate syndrome and should be classified as its own category because: (1) dermatillomania occurs as the primary disorder and not as a subset of a larger disorder; (2) dermatillomania has well-defined clinical features; (3) there is gathering data on the clinical features and diagnostic criteria for this condition; (4) there is sufficient data to create this as a separate category for dermatillomani; (5) there incidence rate for dermatillomania is high within the population; (6) diagnostic criteria for the disease have already been proposed; (7) the classification of dermatillomania as a separate condition would lead to better studies and better treatment outcomes; and (8) classification as a separate condition would lead to more awareness of the disorder and encourage more people to obtain treatment.
Because dermatillomania is different from other conditions and disorders that cause picking of the skin, it is important that any diagnosis of dermatillomania take into account various other medical conditions as possible causes before diagnosing the patient with dermatillomania. There are a variety of conditions that cause itching and skin picking including: eczema
Eczema
Eczema is a form of dermatitis, or inflammation of the epidermis . In England, an estimated 5.7 million or about one in every nine people have been diagnosed with the disease by a clinician at some point in their lives.The term eczema is broadly applied to a range of persistent skin conditions...
, psoriasis
Psoriasis
Psoriasis is an autoimmune disease that appears on the skin. It occurs when the immune system mistakes the skin cells as a pathogen, and sends out faulty signals that speed up the growth cycle of skin cells. Psoriasis is not contagious. However, psoriasis has been linked to an increased risk of...
, diabetes, liver disease
Liver disease
Liver disease is a broad term describing any single number of diseases affecting the liver.-Diseases:* Hepatitis, inflammation of the liver, caused mainly by various viruses but also by some poisons , autoimmunity or hereditary conditions...
, Hodgkin's disease, polycythemia vera
Polycythemia vera
Polycythemia vera is a blood disorder in which the bone marrow makes too many red blood cells. It may also result in the overproduction of white blood cells and platelets. Most of the health concerns associated with polycythemia vera are caused by the blood being thicker as a result of the...
, systemic lupus, and Prader-Willi syndrome
Prader-Willi syndrome
Prader–Willi syndrome is a rare genetic disorder in which seven genes on chromosome 15 are deleted or unexpressed on the paternal chromosome...
.
In order to better understand dermotillomania, researchers have developed a variety of scales to categorize skin-picking behavior. These include the Skin-Picking Impact Scale (SPIS), and The Milwaukee Inventory for the Dimensions of Adult Skin-picking. The SPIS was created to measure how skin picking affects the individual socially, behaviorally, and emotionally.
Treatment
Knowledge about effective treatments for dermatillomania is sparse despite the prevalence of the condition. There are two major classes of therapy for dermatillomania: pharmacological and behavioral.Individuals with dermatillomania often do not seek treatment for their condition largely due to feelings of embarrassment or belief that the condition cannot be treated. One study found that only 45% of individuals with dermatillomania ever sought treatment and only 19% ever received dermalogical treatment. Another study found that only 30% of individuals with this disorder sought treatment.
Pharmacological
There are several different classes of pharmacological treatment agents that have some support for treating dermatillomania: (1) SSRIs; (2) opioid antagonists; and (3) glutamatergic agents. In addition to these classes of drugs, some other pharmacological products have been tested in small trials as well.SSRIs have shown to be effective in the treatment of OCD and this has provided an argument in favor of treating dermatillomania with the same therapy. Unfortunately, the clinical studies have not provided clear support for this, because there have not been large double-blind placebo-controlled trials of SSRI therapy for dermatillomania. Review of treatment with SSRIs of dermatillomania have shown that the following may be effective in reducing picking behavior: doxepin
Doxepin
Doxepin is a psychotropic agent with tricyclic antidepressant and anxiolytic properties, known under many brand-names such as Aponal, the original preparation by Boehringer-Mannheim, now part of the Roche group; Adapine, Doxal , Deptran, Sinquan and Sinequan...
, clomipramine
Clomipramine
Clomipramine is a tricyclic antidepressant . It was developed in the 1960s by the Swiss drug manufacturer Geigy and has been in clinical use worldwide ever since.- Indications :...
, naltrexone
Naltrexone
Naltrexone is an opioid receptor antagonist used primarily in the management of alcohol dependence and opioid dependence. It is marketed in generic form as its hydrochloride salt, naltrexone hydrochloride, and marketed under the trade names Revia and Depade...
, pimozide
Pimozide
Pimozide is an antipsychotic drug of the diphenylbutylpiperidine class. It was discovered at Janssen Pharmaceutica in 1963. It has a high potency compared to chlorpromazine . On a weight basis it is even more potent than haloperidol. It also has special neurologic indications for Tourette syndrome...
, and olanzapine
Olanzapine
Olanzapine is an atypical antipsychotic, approved by the FDA for the treatment of schizophrenia and bipolar disorder...
. Small studies of fluoxetine
Fluoxetine
Fluoxetine is an antidepressant of the selective serotonin reuptake inhibitor class. It is manufactured and marketed by Eli Lilly and Company...
, an SSRI, in treating dermatillomania showed that the drug reduced certain aspects of skin picking, as compared to placebo, but full remission was not observed. One small study of patients with dermatillomania treated with citalopram
Citalopram
Citalopram brand names: Celexa, Cipramil) is an antidepressant drug of the selective serotonin reuptake inhibitor class. It has U.S...
, another SSRI, showed that those that took the drug significantly reduced their scores on the Yale-Brown Obsessive Compulsive Scale
Yale-Brown Obsessive Compulsive Scale
The Yale–Brown Obsessive Compulsive Scale, sometimes referred to as Y-BOCS, is a test to rate the severity of obsessive–compulsive disorder symptoms....
compared to placebo, but that there was no significant decrease on the visual-analog scale of picking behavior.
While there have been no human studies of opioid antagonists for the treatment of dermatillomania, there have been studies showing that these products can reduce self-chewing in dogs with acral lick
Lick granuloma
A lick granuloma, also known as acral lick dermatitis, is a skin disorder in dogs resulting from an urge to lick the lower portion of the leg. The lesion from the incessant licking is a thickened, firm, oval plaque.-Causes:...
, which some have proposed is a good animal model for dermatillomania. Furthermore, there have been case reports that support the use of these opioid antagonists to treat dermatillomania. Opioid antagonists work by affecting dopamine circuitry, thereby decreasing the pleasurable effects of picking.
Another class of possible pharmacological treatments are glutamatergic agents such as n-acetyl cysteine (NAC). These products have shown some ability to reduce other problematic behaviors such as cocaine addiction and trichotillomania. Some case studies and some small studies of NAC have shown a decrease in dermatillomania by treatment with NAC, as compared to placebo.
Topiramate
Topiramate
Topiramate is an anticonvulsant drug. It was originally produced by Ortho-McNeil Neurologics and Noramco, Inc., both divisions of the Johnson & Johnson Corporation. This medication was discovered in 1979 by Bruce E. Maryanoff and Joseph F. Gardocki during their research work at McNeil...
, an anti-epileptic drug, has been used to treat dermatillomania; in a small study of individuals with Prader–Willi syndrome, it was found to reduce skin-picking behavior.
Behavioral
Behavioral treatments include habit reversal trainingHabit reversal training
Habit reversal training is a "multicomponent behavioral treatment package originally developed to address a wide variety of repetitive behavior disorders"....
, cognitive-behavioral therapy, and acceptance-enhanced behavior therapy.
Several studies have showed that habit reversal training associated with awareness training reduces skin-picking behavior in those individuals with dermatillomania that do not have psychological disabilities. Habit reversal training can included awareness enhancement and competing response training. For example, in one study the competing response training required participants to make a closed fist for one minute instead of picking or in response to condition that usually provokes picking behavior.
Behavorial treatments in developmentally disabled
There are several different behavioral interventions that have been tested to treat dermatillomania in the developmentally disabled.One treatment method is to have individuals wear a form of protective clothing that limits the ability of the patient to pick at his body, e.g., gloves or face mask.
Other behavioral treatments attempt to change behavior through providing different incentives. Under Differential Reinforcement of Other Behavior (DRO), a patient is rewarded if manages to abstain from the picking behavior for a certain amount of time.. In contrast to DRO, Differential Reinforcement of Incompatible Behavior (DRI) rewards an individual for engaging in a alternative behavior that cannot physically occur at the same time as the problem behavior (e.g. sitting on your hands instead of picking at your skin). Lastly, differential reinforcement of alternative behavior rewards behavior that is not necessarily incompatible with the target behavior but serves the same function as the target behavior (e.g., providing people with a competing behavior to occupy their time instead of skin picking).
Another form of behavioral approach is to use punishment. This can either be verbal punishment, by telling the person no when they did the activity, or physical punishment, by making them do arm exercises, or spraying water at them when they engage in picking behavior..
All of these techniques have been reported to have some success in small studies, but none has been tested in large enough population to provide definitive evidence of their effectiveness.
Prognosis
Individuals with dermatillomania 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 home, wearing long sleeves and pants in summer, or covering visible damage to skin with cosmetics and/or bandages. Activities such as typing may be painful for those who pick at their fingers or hands.Epidemiology
The prevalence of dermatillomania is not well understood.Estimates of prevalence of the condition range from 1.4 to 5.4% in the general population. One U.S. telephone survey found that 16.6% of respondents "picked their skin to the point of noticeable tissue damage" and that 1.4% would qualify as meeting the requirements of dermatillomania. Another community survey found a rate of 5.4% had dermatillomania. A survey of college students found a rate of 4%. One study found that among non-disabled adults, 63% of individuals engaged in some form of skin picking and 5.4% engaged in serious skin picking. Lastly, a survey of dermatology patients found that 2% suffered from dermatillomania.
In many patients dermatillomania begins with the onset of acne
Acne
Acne is a general term used for acneiform eruptions. It is usually used as a synonym for acne vulgaris, but may also refer to:*Acne aestivalis*Acne conglobata*Acne cosmetica*Acne fulminans*Acne keloidalis nuchae*Acne mechanica...
in adolescence, but the compulsion continues even after the acne has gone away. In those dermatillomania patients with acne, the grooming of the skin is disproportionate to the severity of the acne. Certain stressful events including marital conflicts, deaths of friends or family, and unwanted pregnancies have been linked to the onset of the condition. If dermatillomani does not occur during adolescence another common age of onset is between the ages of 30 to 45. Additionally, many cases of dermatillomania have been documented to begin in children under the age of 10. One small survey of patients with dermatillomania found that 47.5% of them had an early onset of dermatillomania that began before age 10.
Dermatillomania is more common in females than in males.
Dermatillomania has a high rate of comorbidity with other psychiatric conditions, especially with mood and anxiety disorders . One survey of patients with dermatillomania found that 56.7% also had a DSM-IV Axis-I disorder and 38% had alcohol- or drug-abuse problems. Studies have shown the following rates of psychiatric conditions found in patients with dermatillomania: trichotillomania
Trichotillomania
Trichotillomania, which is classified as an impulse control disorder by DSM-IV, is the compulsive urge to pull out one's own hair leading to noticeable hair loss, distress, and social or functional impairment. It is often chronic and difficult to treat....
(38.3%), substance abuse
Substance abuse
A substance-related disorder is an umbrella term used to describe several different conditions associated with several different substances .A substance related disorder is a condition in which an individual uses or abuses a...
(38%), major depressive disorder (approximately 31.7% to 58.1%), anxiety disorders (approximately 23% to 56%), obsessive-compulsive disorder
Obsessive-compulsive disorder
Obsessive–compulsive disorder is an anxiety disorder characterized by intrusive thoughts that produce uneasiness, apprehension, fear, or worry, by repetitive behaviors aimed at reducing the associated anxiety, or by a combination of such obsessions and compulsions...
(approximately 16.7% to 68%), and body dysmorphic disorder
Body dysmorphic disorder
Body Dysmorphic Disorder is a type of mental illness, a somatoform disorder, wherein the affected person is exclusively concerned with body image, manifested as excessive concern about and preoccupation with a perceived defect of his or her physical features...
(approximately 26.8% to 44.9%). There are also higher rates of dermatillomania in patients in psychiatric facilities; a study of adolescent psychiatric inpatients found that dermatillomania was present in 11.8% of patients. It is also present at high rates with some other conditions: 44.9% of patients with body dysmorphic disorder
Body dysmorphic disorder
Body Dysmorphic Disorder is a type of mental illness, a somatoform disorder, wherein the affected person is exclusively concerned with body image, manifested as excessive concern about and preoccupation with a perceived defect of his or her physical features...
also have dermatillomania; 8.9% of patients with OCD have dermatillomania; and 8.3% of patients with trichotillomania have dermatillomania.
Skin picking is also common in those with certain developmental disabilities; for example, Prader–Willi syndrome and Smith–Magenis syndrome. Studies have shown that 85% of people with Prader–Willi syndrome also engage in skin-picking. Children with developmental disabilities are also at an increased risk for dermatillomania.
Dermatillomania also correlates with "social, occupational, and academic impairments, increased medical and mental health concerns (including anxiety, depression, obsessive–compulsive disorder) ... and financial burden ... " Dermatillomania also has a high degree of mobidity with occupational and marital difficulties.
Substance abuse is often present, and individuals with dermatillomania are twice as likely to have first-degree relatives
Degree of relationship
Degree of relationship is a measurement of kinship, and may generally be measured as either one vertical or horizontal step in a standard family tree....
who have substance-abuse disorders (alcohol or drugs) than those without the condition.
History
The first known mention of dermatillomania in the print can be found in 1898 by the French dermatologist Brocq, describing an adolescent female patient who had uncontrolled picking of acne.Dermatillomania in the media
Dermatillomania has been the subject of several episodes of ObsessedObsessed (TV series)
Obsessed is an American documentary series that began airing on the A&E Network on May 29, 2009. The series depicts the real-life struggle and treatment of people with anxiety disorders, including obsessive-compulsive disorder, panic disorder, social anxiety disorder, and general anxiety...
, a television documentary series that focuses on treatment of anxiety disorders.