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Excoriation: What Is It and Why Is It in the DSM-5?

Woman popping zit
 

The Diagnostic and Statistical Manual of Mental Disorders serves as the “bible” of mental health practitioners, who rely on it to match diagnostic criteria with behaviors. The American Psychiatric Association periodically examines trends in mental health conditions and recent scientific evidence to revamp the criteria. The latest edition, the DSM-5, is slated for release in May 2013, and the APA recently approved several changes.

Among the new diagnoses is excoriation, which is associated with chronic skin-picking. The issue is most common among women between the ages of 30 and 45. It’s classified as an impulse control disorder and is related to obsessive compulsion.

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What Is Excoriation?
Although excoriation disorder is the name of the new “official” diagnosis, the issue has been studied for years—sometimes called neurotic excoriation, compulsive skin-picking, dermatillomania, and psychogenic skin-picking. The issue was not included in previous editions of the DSM because it is believed to sometimes be a symptom of another issue.

Skin-picking is common among people with autism spectrum as well as obsessive compulsion. When it does not co-occur with another issue, however, it qualifies for its own diagnosis. Symptoms of the issue include compulsive skin-picking that leads to injuries or wounds as well as stress. Skin-picking is relatively common. Some people pick their skin to the point of bleeding or pain by popping pimples, picking at hangnails, or peeling scabs.

Controversy Surrounding Diagnosis
Whenever the APA adopts new diagnoses or symptoms, there is always some controversy, and excoriation is no exception. Although the diagnosis has received considerably less attention than some other changes, some mental health experts have expressed concern. Because excoriation often is a symptom of an underlying issue, a separate diagnosis might stigmatize people by giving them multiple diagnoses when only one is necessary.

Some clinicians have argued that excoriation does not meet the criteria for a mental health diagnosis and is more akin to a habit. By creating diagnostic criteria for a habit, the DSM might eventually have to include other habits. However, excoriation does sometimes occur on its own, and people with the condition can experience considerable distress, so the APA opted to include it.

How Excoriation Is Treated
When compulsive skin-picking occurs, it’s important to rule out a potential medical cause such as allergies or infection. Occasionally, skin conditions can superficially resemble symptoms of excoriation. Further, excoriation can cause dermatological problems, so patients frequently need dermatological treatment along with mental health treatment.

Antidepressants are the first line of treatment for excoriation. Opioid antagonist medications, which interfere with the body’s ability to respond to endorphins and opioids, also are sometimes effective. Because compulsive skin-picking often co-occurs with anxiety, anti-anxiety medications can be helpful.

Psychotherapy that helps people develop better approaches for dealing with anxiety, enables them to develop better impulse control, and helps patients cope with changes to appearance as a result of excoriation is also a typical part of treatment.

References:

  1. American Psychological Association. APA concise dictionary of psychology. Washington, DC: American Psychological Association, 2009. Print.
  2. Brauser, D. (2012, December 3). Experts react to DSM-5 Approval. Medscape Reference. Retrieved from http://www.medscape.com/viewarticle/775526
  3. Colman, A. M. (2006). Oxford dictionary of psychology. New York, NY: Oxford University Press.
  4. Neurotic excoriations. (2012, June 27). Medscape Reference. Retrieved from http://emedicine.medscape.com/article/1122042-overview
  5. Neurotic excoriation. (n.d.). SkinPick. Retrieved from http://www.skinpick.com/neurotic-excoriation

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Comments
  • brenda December 23rd, 2012 at 12:46 PM #1

    What about pulling out one’s own hair? Is that kind of in the same category because I have a grandchild who does that.

  • Thom December 23rd, 2012 at 12:50 PM #2

    I do understand that this can be a condition in its own.But there are far too many people who do this.How exactly can it be determined whether it is a habit or a disorder?I think that makes the diagnosis so much more difficult.They had better left this out as being a disorder.

  • Daisy December 24th, 2012 at 8:51 AM #3

    While it may point to the presence of a different issue,I think it is overreaction to term skin picking as an independent disorder. Even stress and anxiety could be behind this. Why, they say people bite their nails in anxiety. Are we next going to have nail biting as an officially recognized disorder? Its just a habit and common behavior, let us rid ourselves of tags.

  • Lila December 24th, 2012 at 10:17 AM #4

    Do you think that by treating the underlying symptoms (stress, anxiety, whatever) you could then see an alleviation of the picking behavior?

  • susan December 24th, 2012 at 4:32 PM #5

    picking skin at times is one thing.but having a compulsion?that definitely doesn’t sound normal.ive known people who do this and also those that pull their hair compulsively.that definitely needs help.without an identity to that condition those people will never get help.whats wrong in being cured of something that you do out of compulsion?

  • WG December 24th, 2012 at 11:59 PM #6

    Any part of ur life that is not under ur control is a problem if u ask me.n if calling a spade a spade is a problem,then I dont understand where d critics of d decision to include this in DSM get their inspiration from!

  • Miri December 26th, 2012 at 11:09 AM #7

    I am never sure why this kind of compulsion starts.
    Where does this need to self injure and mutilate stem from?
    It makes me very confused.
    I would scream, yell, cry.
    Why do those who suffer from this do this instead?

  • Thomas December 30th, 2012 at 4:40 AM #8

    Why WOULDN”T this be in this manual? I mean, where else should it go? There is aobviously a mental issue if someone is doing this to the extreme.

  • Eric Hinojosa May 26th, 2013 at 2:51 PM #9

    @Brenda It’s called Trichotillomania (hair-pulling disorder).

  • Brianna July 9th, 2013 at 3:28 PM #10

    I actually do suffer from excoriation. I can say that it is very compulsive. It is not like I want to do it, in fact I really don’t want to, but it’s a strong impulse. I think some counselling and therapy would extremely help those like me, and I agree with the DSM-V.

  • Jessica July 30th, 2013 at 8:54 PM #11

    I also suffer from skin picking. I have been doing it since childhood. Until I read this article, I always thought it was anxiety related. I have been diagnosed with anxiety and obsessive compulsive disorder. I know how you feel about the compulsion / impulses to pick. I don’t even realize I am doing it sometimes, but other times it’s all I think about. In your comment you mentioned therapy for the issue. Have you tried it or had any luck? I’m on high doses of both Anafranil and Sertraline, both used to treat OCD. Please let me know if anything has helped you. I’m desperate!

  • Donald Durham August 16th, 2013 at 1:31 PM #12

    The following should not be considered disrespectful of dermatologists, nor in any way minimizing of the emotional distress that individuals with compulsive skin-picking experience – but I’m wondering now that Excoration is in the DSM 5 if it also means that dermitologists suffer from Excoriation Disorder by Proxy??!! :-)

  • janet October 27th, 2013 at 8:56 PM #13

    I have suffered with this for years and I am mortified as to what my body looks like right now. I have been to a dermatologist, therapist, and no one really seems to know what to do with me. My skin has at least 100 opening sores, and yes I eat the scabs too, I have no idea why that is. I am not sure if I will ever get over this. I am so depressed over this.

  • mike January 3rd, 2014 at 2:20 PM #14

    I use ice when i start scanning my skin for a place to pick. I let it melt in my hand and try mindfulness/and breathing exercises. I also cut way back on sugar and gluten and cut myself off from coffee. These all helped. Not overnight I’ve been working with therapist on it for about 9 mo.

    Hope this is helpful.

  • someone January 5th, 2014 at 1:12 PM #15

    RE: Mike’s comment.

    I came across this website looking for something separate but saw your comment on the side newsfeed. I clicked as I have an increasingly disruptive compulsion to pull out hairs from one area on my head and to “pick” that area as well. It began a lot when I focused really hard on not biting my nails anymore (well, made some subconscious decision to try to grow them since I hated feeling like I had stubby kid fingers/not very “feminine” for a grown woman). Anyhow, I did not consciously begin to pick at my head and such and it’s entirely embarrassing to even write this but it gives some sort of “release” from doing so. I do mostly when I am absorbed in thought, or for a self-calming technique. As I’ve been struggling with techniques (wearing gloves inside , lol) …your tip just was like, wow! I have never thought of such a technique and am going to definitely try this especially in the evening when I “zone out” and tend to do it. Thank you for sharing!

  • Dana Marie Flores January 20th, 2014 at 5:06 PM #16

    Brenda~ Compulsive hair pulling is called Trichotillomania and really is sister to dermatillomania or compulsive skin picking. Millions of people do these behaviors w/o having any other major mental health problems and is definitely not just a habit. Go to Trich.org for more info on hair pulling and skin picking. You are not alone!

  • excoriation April 11th, 2014 at 12:23 PM #17

    This addition to the DSM is what made me look into this problem of mine..

    I wanted to start a support group locally but this could be way better. Its been moved from an anxiety subcategory to an OCD diagnosis. Do any of you struggle with this? Do you think it’s ocd or anxiety based??

  • excoriation April 11th, 2014 at 12:25 PM #18

    For me its more about the satisfaction maybe? Theres an instant gratification I suppose..

  • miapatti April 17th, 2014 at 8:53 PM #19

    I used to have this. or rather, i have it so much less now, that it is not a problem. I definitely think it is OCD related. When I was younger I had little bumps on my arms, and I picked them until it looked like I had chicken pocks. I did it for long periods of time, many times a day. I also picked at my face and back – black heads, pimples, any time bump. I would be aware of what I was doing, and totally unaware. Some of my friends and family would tell me to “stop picking” because I would do it unconsciously in public or while talking to them. I still pick at my face, occassionally look for little bumps on my arm that I can squeeze, and catch myself out in public, scanning my back with my fingers – looking for bumps to pop. Now that I am older, have less bumpy skin, I am almost “normal”. But now I get occasional hairs on my chin, and am cannot go to the bathroom without searching for a hair to pull out of my chin. I also am \feeling for hairs on my chin all day. long. Again – everything is much less extreme. It doesn’t prevent me from having a normal functioning life. For me to almost get over this – I had to come up with a tool box full of tricks that helped distract me or make it more difficult to pick and pop – including cutting my nails really short, wearing long sleeves, and keeping incredibly busy outside of my home with other people around. Eventually it simply slowed down. I think age helps, having clearer skin, and just working on not doing it. The more I was able to distract or stop myself, the more I was able to distract and stop myself until it became easier. It was a process of years, and every year got a little better until I would go long periods of time without picking or thinking about picking. Now, I am like a regular person who checks their skin and pops a pimple every once in a while. I will admit I am a little obsessed about the hairs on my chin. I actually look forward to a hair growing in, because I enjoy pulling it out – like I used to enjoy popping pimples and blackheads. I feel like I am getting something out of my body that shouldn’t be there. It is definitely pleasure and relief that I feel when I pop or pull. And for me, it definitely got better.

    Does anyone think a therapy / support group for this would be helpful?

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