child & youth Mental Health Series Today’s topic: Speaker: Dr. Erin Kelly November 15, 2018
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Goals • What is Excoriation Disorder? • How does it typically present? • Differential diagnoses? • Clinical Correlates? • Management?
Excoriation (Skin Picking) Disorder • Repetitive picking, rubbing, scratching, digging, or squeezing of skin, with or without instrumentation, resulting in visible tissue damage and impairment in functioning • Part of a group of disorders characterized by “self - grooming behaviour” in which hair, skin, nails are manipulated. “Body Focused Repetitive Behaviours” or BFRBs
Excoriation (Skin Picking) Disorder • Occasional picking at cuticles, acne, scabs, callouses, and other skin abnormalities is a very common human behaviour • Animals engage in BFRBs too! • Great apes, monkeys pull hair, overgroom, pick nits off themselves and others • Birds pull out feathers • Mice pull their own hair and others • Cats and dogs lick and bite, leaving injury and bald areas
Excoriation (Skin Picking) Disorder • New diagnosis included in DSM – 5 • New chapter of Obsessive-Compulsive and Related Disorders • Considered a “Body Focused Repetitive Behaviour” along with hair pulling, nail biting, nose picking, lip and cheek biting • DSM-5 lists Excoriation Disorder and Trichotillomania as clinically important as they are the most common BFRBs
Excoriation (Skin Picking) Disorder Synonyms : dermatillomania psychogenic excoriation lichen simplex chronicus neurodermatitis neurotic excoriation acne excoriee
DSM - 5 • Recurrent skin picking resulting in skin lesions • Repeated attempts to decrease or stop skin picking • The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning • The skin picking is not attributable to the physiologic effect of a substance (eg, cocaine) or another medical condition (eg, Scabies) • The skin picking is not better explained by symptoms of another mental disorder (eg, delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance as in Body Dysmorphic Disorder, stereotypes in stereotypic movement disorder, or intention to harm oneself in non- suicidal self-injury)
Genetic Predisposition? • Higher number of BFRB’s in family members of those with trichotillomania compared to the general population • Higher concordance in identical twins vs. fraternal for trichotillomania • Temperament, environment, family stress factors also play a role
Prevalence • Studies estimate 5% of the population engage in skin picking that would require clinical intervention • 4% in college students • 2% in dermatology clinics • Adolescent inpatients = 11.8% in one study. Goes unrecognized! • More common in females • Onset between 13-15 yrs
Common Presentations • Lesions of different sizes, extent, severity • All stages of healing may be present, with active lesions and/or post-inflammatory hypo- or hyperpigmentation • Appearance also depends on method (usually fingers/fingernails but can be teeth, tweezers, scissors, pins) • Deeper lesions = ulceration, infection, scarring, disfigurement
Common Presentations • Symmetrical distribution in hands reach • Most often face (nose, forehead, cheeks, chin) • Extensor surfaces of arms and/or legs • Scalp • Cuticles • Shoulders • Back • Perianal region • Scrotal area
Common Presentations • Target multiple body sites for extended periods of time • Target healthy and previously damaged skin
Common Presentations • May begin with urge to manipulate small, benign lesions such as acne, insect bites, scab, inflammation, a wart, mole, or keratin plug • May start as manipulation of intact skin that is itchy, burning or in pain • Skin may be perfectly normal
Common Presentations • Episode of picking may last 6-10 minutes • May involve hours • Private activity that peaks in the evening • Context – sedentary - looking in mirror, talking on phone, bathing, lying in bed, watching TV, reading, etc. • Not conscious of the behaviour at times and other times very focused • May run hand over skin in search of perceived abnormality
Common Presentations • Patients report an urge and tension/anxiety/distress that builds until they pick • Some report a desire to improve their skin and permission giving cognitions about how their skin should look/feel when they see/feel a bump, sore spot, pimple • “Just a habit” that is mindless • Derive pleasure
Common Presentations After picking behaviour may report: • urge reduction • sense of relief/reduction of anxiety • sense of pleasure
Common Presentations • shame and embarrassment • social isolation • cover up skin with make-up, clothing • avoid being seen without make-up, going to the beach/swimming, wearing shorts • avoid intimacy • time management issues due to amount of time it takes to conceal • avoid medical care
Common Presentations May need medical attention: - Infection - Open wounds - Scarring/Disfigurement - Needing skin grafts
Is Skin Picking Self-Harm? • Body Focused Repetitive Behaviours are separate and distinct from self-injurious behaviours • Skin picking not intended to cause physical pain as in cutting or other self-injurious behaviour in order to distract from emotional pain • Skin picking not significantly associated with interpersonal difficulties, Borderline Personality Disorder, past trauma, self-harm (lower rates than general population) • Skin picking is correlated with other BFRB’s like trichotillomania • Skin picking is akin to “self - soothing” not “self - harm”
Differential Diagnoses Primary skin conditions: Atopic Dermatitis Psoriasis Scabies Bullous Pemphigoid Systemic Illness w/ pruritus: Uremia Cholestasis and primary biliary cholangitis
Differential Diagnosis Systemic Illness w/ pruritus cont’d: Polycythemia vera Lymphoma Solid tumors Hyperthyroidism Iron deficiency HIV
Differential Diagnosis Substance/Medication induced pruritus: Cocaine – itch during withdrawal, delusional parasitosis Methamphetamine – “meth mites”, delusional parasitosis Methylphenidate – infrequent side effect of pruritus
Differential Diagnosis Other Psychocutaneous syndromes: Dermatitis artifacta Delusional infestation Body Dysmorphic Disorder Nail picking disorder (onychotillomania) Pachydermodactyly (superficial digital fibromatosis)
Clinical Correlates • Grant and Chamberlain (2017) • First large study of clinical variables and relationship to illness severity in 125 adults aged 18-65 with SPD. • Mean age of SPD onset reported was 12.9 years. • Most picked skin from multiple sites
Clinical Correlates • Used semi-structured interview (SCID), HAM-A, HAM-D, Skin Picking Symptom Assessment Scale (SP-SAS), Sheehan Disability Scale (SDS), Barratt Impulsivity Scale, Eysenck Impulsiveness Questionnaire (EIQ), measures for cognitive flexibility, Stop Signal Task for motor inhibition • Increased severity of SPD associated with higher impulsivity, higher state anxiety/depression, having a current anxiety disorder, having a lifetime history of substance use disorder
Comorbidities - Adults • OCD • Learning Disorders • Depression • Eating Disorders • Bipolar Disorder • Alcohol use Disorder • Other BFRB disorders such as Trichotillomania, onychophagia • Feature of Prader-Willi Syndrome
Children and Youth • Odlaug and Grant (2007) examined clinical characteristics and psychiatric comorbidity in 40 participants aged 17-65, comparing childhood-onset (before age 10) to later onset • Severity = time spent picking per day, intensity and frequency of thoughts and urges to pick, and social and occupational functioning.
Children and Youth • Age of onset = time picking began, even if it didn’t meet full criteria • Semi-Structured Interview SCID-I for comorbidities • Severity – Clinical Global Impression Scale (CGI), Yale-Brown Obsessive Compulsive Scale Modified for Neurotic Excoriation (NE-YBOCS), Sheehan Disability Scale
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