Excoriation (Skin Picking) Disorder

What Causes Excoriation (Skin Picking) Disorder?

Doctors and researchers have not yet determined precisely what causes SPD, but they have identified several risk factors that increase an individual’s likelihood of developing the disorder.

• Genetic Predisposition. Having a parent, sibling, or child who has been diagnosed with SPD may increase the chance that you will also be diagnosed with the disorder. In addition, a family history of mood or anxiety disorders may also increase risk. Researchers have made some progress in identifying genes that may play a role in the development of OCD-related disorders. Still, more research is necessary to determine the precise genetic connections.
• Environmental Factors. Symptoms of SPD often seem to be triggered by stress. Childhood traumas may also be a risk factor for the development of the disorder.
• Age. SPD often develops in adolescence. However, it may emerge at any stage of life.

Is Excoriation (Skin Picking) Disorder Hereditary?

Researchers have long suspected that biological factors rather than environmental factors primarily cause OCD, and some scientists believe that SPD is related to OCD. Studies of families in which SPD occurs strongly suggest that a genetic component may be responsible.

How Is Excoriation (Skin Picking) Disorder Detected?

Because the onset of SPD often occurs in adolescence, detecting the early signs of the disorder often falls on parents. Eventually, the compulsive symptoms will become so severe that they interfere with the child’s functioning, but they may be subtle at first.

Potential warning signs of SPD include:

• Avoidance of social situations
• Wearing makeup or clothing that covers areas of skin damage
• Problems in relationships with family or friends

How Is Excoriation (Skin Picking) Disorder Diagnosed?

To diagnose SPD, a doctor will first rule out other potential medical causes of the symptoms. If the symptoms seem to meet the diagnostic criteria for SPD, the patient will likely be referred to a mental health professional for further assessment.

Diagnostic steps may include:

• A physical exam. This exam will rule out physical conditions that could be causing the symptoms.
• Blood tests. These tests will look at the patient’s blood chemistry for signs of illnesses that might explain the symptoms.
• Psychological assessments. These assessments may take the form of questionnaires or talk sessions with a mental health professional to assess the patient’s mood, mental state, and mental health history. Family members or caregivers may also be asked to participate in these assessments.

The results of the psychological assessments will be compared to the diagnostic criteria for SPD in the Diagnostic and Statistical Manual of Mental Disorders. Comparing these criteria will help a mental health professional decide whether the symptoms indicate SPD or another psychiatric problem (obsessive-compulsive personality disorder, anxiety disorders, or depression).

The diagnostic criteria for SPD include:

• Chronic skin picking behavior that causes damage to the skin
• Unsuccessful attempts to stop skin picking behavior
• Another mental or medical disorder doesn’t better explain skin picking behavior
• Symptoms cause significant distress or impairment in social, occupational, or other daily functioning

How Is Excoriation (Skin Picking) Disorder Treated?

SPD currently has no cure, but a combination of medications and psychotherapy may effectively reduce the severity of symptoms in many patients. Unfortunately, many sufferers will need to continue treatment for the rest of their lives to manage their symptoms, and some patients may not respond to treatment at all.

Medication

Several different medications may be used to treat and manage SPD symptoms, and individual medication plans depend on the patient’s age, the patient’s responsiveness to treatments, and the severity of their symptoms.

• Antidepressants. Clomipramine or serotonin reuptake inhibitors (SSRIs) may be prescribed to treat SPD symptoms in adults and children over the age of 10.
• Other Medications. The amino acid N-acetylcysteine may have some benefit for people with SPD.

Psychotherapy

The most commonly used therapeutic approach is cognitive-behavioral therapy (CBT). This process focuses on helping the patient identify a pattern of harmful thoughts and construct strategies and solutions for dealing with them that don’t interfere with functionality.

Other types of therapy sometimes used to treat SPD include habit reversal training.

How Does Excoriation (Skin Picking) Disorder Progress?

People with SPD often feel shame and embarrassment due to their compulsions, and their self-esteem generally suffers. Attempts to avoid embarrassing or humiliating situations can lead to social isolation, which may feed feelings of depression or anxiety. These negative feelings, in turn, may make the symptoms of SPD worse.

Left untreated, SPD may eventually lead to long-term mental and physical complications, including:

• Lack of close relationships
• Emotional distress
• Depression
• Anxiety
• School or work problems
• Damage to the skin, bleeding, scarring, or infections

How Is Excoriation (Skin Picking) Disorder Prevented?

SPD cannot be prevented, but early diagnosis and a consistent treatment plan can help manage symptoms and prevent them from becoming as disruptive as they would be if they were left untreated. Faithful adherence to a treatment plan, especially if it’s working well, can also help to prevent a relapse into a state of severe symptoms. Therefore, it’s essential for those diagnosed with SPD to seek regular evaluation from their mental health providers and stick to any prescribed medication plan.

Excoriation (Skin Picking) Disorder Caregiver Tips

Caregivers for someone with SPD should consider these tips to help the sufferer and themselves to cope with the disorder:

• Learn as much as possible about the disorder.
• Seek out appropriate professional treatment for the sufferer.
• Do everything possible to support the sufferer in the pursuit of treatment.
• Find ways to have positive experiences with the sufferer that don’t focus on the disorder.
• Find a support group for caregivers.

Most people with SPD also suffer from other brain and mental health-related issues, a condition called co-morbidity. Here are a few of the disorders commonly associated with SPD:

• About half of people with SPD suffer from depression or an anxiety disorder.
• About half of people with SPD also experience obsessive-compulsive disorder (OCD).
• Approximately 38% of people with SPD also have trichotillomania (hair-pulling disorder).
• A quarter of people with SPD have a panic disorder.
• About a quarter of people with SPD  also have borderline personality disorder.
• About 39% of people with SPD have an alcohol or substance use disorder.

Excoriation (Skin Picking) Disorder Brain Science

Researchers are currently working on studies to find the source of SPD behaviors. Some studies have found differences in the brains of people with SPD compared to healthy brains. These differences include structural changes in the anterior cingulate cortices. Previous studies have identified similar brain abnormalities in people with the hair-pulling disorder called trichotillomania (TTM), suggesting that the two conditions are fundamentally related.

The diverse parts of the brain implicated in SPD and TTM are responsible for varied functions, but a common thread among them is control of movement. Some researchers believe that interaction between these brain areas regulates how susceptible we are to developing habitual behaviors and how good we are at suppressing habits when they’re inappropriate. So it’s possible that impaired function in these parts of the brain could make someone with SPD more prone to ritualistic hair-pulling behavior and less able to control that behavior.

Excoriation (Skin Picking) Disorder Research

Title: N-Acetyl Cysteine in Pathologic Skin Picking

Stage: Completed

Principal investigator: Jon E. Grant, MD, JD, MPH

University of Chicago

Chicago, IL  

The proposed study aims to evaluate the comparative efficacy of N-acetyl cysteine to placebo in pathologic skin picking. Thirty subjects with pathologic skin picking will receive 12 weeks of double-blind treatment with N-acetyl cysteine or a matching placebo. The hypothesis to be tested is that N-acetyl cysteine will be more effective than placebo in patients with pathologic skin picking.

Pathologic skin picking involves repetitive, ritualistic, or impulsive picking of otherwise normal skin leading to tissue damage, personal distress, and impaired functioning. Although skin picking has been described in the medical literature for over one hundred years, it remains a poorly understood psychiatric issue and often goes undiagnosed and untreated.

Picking behavior does not by itself suggest a psychiatric disorder. Pathology exists in the focus, duration, and extent of the behavior, as well as the reasons for picking, associated emotions, and resulting problems. Patients with PSP report thoughts of picking or impulses to pick that are irresistible, intrusive, and/or senseless. These thoughts, impulses, or behaviors also cause marked distress for patients and significantly interfere with other activities. Unlike normal picking behavior, the pathologic form of skin picking is recurrent and usually results in noticeable skin damage.

Thirty subjects with pathologic skin picking will receive 12 weeks of double-blind treatment with N-acetyl cysteine or a matching placebo. The hypothesis to be tested is that N-acetyl cysteine will be more effective than placebo in patients with pathologic skin picking. The proposed study will provide needed data on treating an often disabling disorder that currently lacks a clearly effective treatment.

Title: Memantine in Body-Focused Repetitive Behaviors

Stage: Recruiting

Principal investigator: Jon E. Grant, MD, JD, MPH

University of Chicago

Chicago, IL

This study is eight weeks long and involves subjects taking memantine or a placebo. If they are randomly assigned to the memantine arm and are eligible to participate in the study, they will take 10mg once daily of memantine for two weeks, then 20mg for the remaining six weeks. Efficacy and safety measures will be performed at each visit. Participants will be randomized to receive either memantine or a placebo on a 1:1 basis. This blinding will be maintained by the IDS pharmacy at the University of Chicago.

The proposed study aims to evaluate the efficacy and safety of memantine in 80 subjects with DSM-5 trichotillomania (TTM) or skin picking disorder (SPD).

The hypothesis to be tested is that memantine will be more effective and well-tolerated in adults with trichotillomania or skin picking disorder compared to placebo. The proposed study will provide needed data on treating a disabling disorder with no current treatments options.

This will be one of few studies assessing the use of pharmacotherapy to treat TTM and SPD in adults. Assessing the efficacy and safety of memantine will help inform clinicians about additional treatment options for adults suffering from this disorder.

Title: Double-Blind Lamictal (Lamotrigine) in Neurotic Excoriation

Stage: Completed

Principal investigator: Jon E. Grant, MD, JD, MPH

University of Chicago

Chicago, IL

The proposed study aims to evaluate the comparative efficacy of Lamictal (lamotrigine) to placebo in neurotic excoriation. Thirty subjects with neurotic excoriation will receive 12 weeks of double-blind treatment with Lamictal (lamotrigine) or a matching placebo. The hypothesis to be tested is that Lamictal (lamotrigine) will be more effective than placebo in patients with neurotic excoriation. The proposed study will provide needed data on treating a disabling disorder that currently lacks a clearly effective treatment.

The study will consist of 12 weeks of double-blind treatment with Lamictal (lamotrigine) compared to placebo (1:1) in 30 subjects with neurotic excoriation.