What is Excoriation (Skin-Picking) Disorder?
Causes and Risk FactorsExcoriation disorder can be triggered by stress, anger, boredom, or the desire to remove skin imperfections. Women are more likely to be affected than men by this disorder, with a prevalence ratio of 7:1.
Excoriation disorder is associated with anxiety and body dysmorphic disorders. Studies show that approximately 28% of individuals with body dysmorphic disorder also have excoriation disorder. Some evidence suggests that obsessive picking of skin has a familial component. In studies done on individuals with excoriation disorder, it was found that 28.3% to 43% of individuals with excoriation disorder also had a first-degree relative with the disorder.2
Signs and Symptoms
Time ConsumptionWhile individuals with excoriation disorder typically use their fingernails to pick at themselves, some individuals may use tweezers, pins, or knives to pick. Individuals may spend hours of their time consumed by obsessive skin-picking, leading to open wounds susceptible to infection. This behavior may come in waves, or in severe cases, individuals may engage in constant skin picking.
Is Excoriation Disorder the Same as OCD?
Is Skin Picking an OCD Trait?Skin picking can be a trait of obsessive-compulsive disorder. OCD skin picking is typically triggered by the individual’s need to remove perceived contaminants and dirt from the skin. Picking is motivated by fear of contaminants rather than to relieve emotional distress.
Because of this, OCD skin picking differs from the compulsive skin picking seen with excoriation. While OCD skin picking may be a behavior that occurs from time to time, for individuals with excoriation, it is an uncontrolled compulsion.
Can You Have Excoriation Disorder Without OCD?While individuals with OCD may also have excoriation disorder, it is possible to have a skin picking disorder and not OCD. OCD is characterized by uncontrollable recurring thoughts, obsessions, and ritualistic compulsive behaviors. Excoriation disorder is a skin-picking obsession that is associated with and sometimes misdiagnosed as OCD but ultimately can occur on its own without the presence of OCD.
Similarities Between Excoriation Disorder and OCD
DistressDistress is a common symptom of both OCD and skin excoriation. Individuals with excoriation disorder may be triggered to pick at themselves when they feel distressed to self-soothe. Additionally, individuals with this disorder may also have underlying distress related to their appearance because of their picking. Distress is also characteristic of OCD, as individuals may feel distressed by their symptoms. Similarly, this distress can also cause symptoms of OCD to worsen.
Lack of ControlBoth disorders also are marked by a lack of control. This lack of control for individuals with skin excoriation is related to obsessive skin picking. Individuals may pick unconsciously or be unable to stop themselves from picking. Similarly, OCD symptoms can also be out of an individual’s control. Individuals with OCD may find themselves unable to control their thoughts or behaviors, even if they recognize that what they are doing is excessive.3
ImpairmentIndividuals with OCD and excoriation experience impairment in different areas of their lives. Both disorders can impair work, relationships, and home life. Individuals with OCD may present as being late to work or unable to complete tasks because obsessive compulsions have taken priority.
For individuals with excoriation, impairment may be more physical, as medical attention is often necessary for skin lesions. Individuals with OCD and excoriation may find themselves “losing time” to their disorders, spending minutes to hours consumed by obsessive-compulsive behavior.
Lack of Social InteractionIndividuals with both excoriation and OCD also experience social impairment, characterized by a lack of social interaction. Individuals with OCD may be reluctant to interact with others out of fear of judgment surrounding their behavior. Similarly, the shame surrounding obsessive picking of skin can lead individuals with excoriation disorder to isolate themselves.
Differences Between Excoriation Disorder and OCD
Lack of Conscious AwarenessIndividuals who suffer from excoriation may not have conscious awareness of their behaviors. Often someone with excoriation may not notice that they have damaged their skin through picking until it is pointed out by someone else or until they begin to bleed.
Excoriation often begins as an unconscious behavior, later becoming a conscious way to self-soothe. Individuals with classic OCD have more awareness surrounding their compulsive behaviors and rituals, as they are created by the obsessive thought patterns that characterize OCD.
Requires Medical AttentionWhile medical intervention helps treat OCD, skin excoriation often requires medical attention due to the damage done to the body. Picking at the skin with fingernails or other foreign objects introduces bacteria into the body, which can lead to fatal infections. Septicemia, or blood poisoning by bacteria, is a risk factor for individuals with excoriation disorder. Severe tissue damage from picking can also warrant skin grafting to replace the damaged tissues.
Obsessions Are Not MandatoryUnlike with OCD, obsessive thought patterns do not always accompany excoriation. For individuals with OCD, obsessive thinking is a hallmark. Obsessive thoughts lead to anxiety, which then leads to compulsive behavior. In excoriation disorder, individuals may not have obsessive thoughts or conscious obsessions.
Compulsions Are Done to Reduce StressFor individuals with OCD, compulsions often increase anxiety and stress. In contrast, excoriation skin picking is done to reduce general stress. Individuals may feel triggered to pick when they are anxious, angry, or uncomfortable. Many individuals also experience pleasure from picking at themselves and providing relief from stress.
Excoriation Disorder Treatment
TherapiesTherapy is not a one size fits all experience, and the therapeutic approach used depends on various factors. Therapy for skin excoriation is ultimately aimed at increasing awareness. Cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and habit reversal training are commonly used for skin-picking. These therapies may be used in combination with medication and other therapies or on their own.4
Cognitive Behavioral TherapyCognitive behavioral therapy is often used in excoriation disorder treatment and effectively reduces symptom severity. Cognitive behavioral theory works by helping people understand themselves and the unhelpful thoughts behind skin-picking. CBT includes behavioral interventions to help individuals stop picking as well.
Acceptance and Commitment TherapyAcceptance and commitment therapy combined with habit reversal training is another option for excoriation disorder treatment. ACT is a mindfulness-based practice that encourages individuals to accept their negative thoughts and emotions as part of life.
ACT empowers individuals to change their behaviors and move through the change cycle. In combination with habit reversal training, this treatment can be very effective in excoriation disorder treatment. Habit reversal training is about helping an individual bring awareness to their picking, and then developing a contingency management system to tackle the issue.
MedicationsMedications can be used in excoriation disorder treatment but should be accompanied by therapy. This is because while medication is effective at controlling symptoms, it does not address or treat underlying mental health issues. To make lasting behavioral change, the underlying reasons behind obsessive picking must be addressed.
However, medication can help treat excoriation. Prozac and other selective serotonin reuptake inhibitors are typically what is prescribed as medication for excoriation disorder.