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

Woman popping zitThe 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.

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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  • brenda

    December 23rd, 2012 at 12:46 PM

    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

    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.

  • On the Front Line

    May 26th, 2016 at 2:20 PM

    I wish people who think a “picking disorder” is a habit could see first hand what a “picking disorder” looks like. It’s so much more than just a little picking. I think EVERYBODY has picked something in their life time but it’s not something we need to do or do it without even realizing we’re doing it to the point of bleeding and digging very deep into the skin for the calming effect it gives. I see this on a daily basis and I see the guilt and shame it brings. Medication does help but it as it is an OCD you also need a professional person like a therapist to help. I’ve been working with my teen for almost 2 years and it’s not something they want to do, it’s like an addiction and the cruel things about this disorder is you are physically attached to what you are addicted to. They have good days and very bad days and we spend lots of money to hide the damage in public and in school. Summer and Swimming is very hard. My teen has found a person on youtube that has shown her she’s not alone. It’s a difficult video to watch but it is what it is. It’s so much more than picking and if this condition isn’t recognized then all those that suffer from it will not be able to get the support and help that is needed to deal with this.

  • Sharon

    June 20th, 2016 at 5:40 PM

    I wonder if it’s possible that your teenager is being narcissistically abused. Victims of mental, emotional and psychological abuse often show signs of these and other related behaviors. No amount of medication or therapy will be as effective as removing the abusive person from their life… if this is the case. Also, Doctors and mental health practitioners are careless when dealing with victims because they just aren’t very comfortable with abusive situations and so they create their own reasons for the anxiety that causes the symptoms. Good luck to your teen, whatever the cause. I hope this issue is resolved for them soon.

  • Jennifer

    October 29th, 2016 at 2:15 PM

    I actually have this disorder. I have generalized anxiety disorder as well as social anxiety disorder. I literally CAN NOT stop myself when I pick! I hate how it destroys my face and makes people stare. I don’t WANT to do it, but even when my mind tells me to stop, my body doesn’t let me. I have been on anti-depression and anti-anxiety meds for 10 years but I still do this. Sometimes it is unconsciously and I can do it at hours at night lying in bed and not realize how long I have been digging into my skin. I hate doing this and I wish I could stop before I make permanent scars all over my face……btw I am 31, married, with an amazing 12 yr old son!

  • Daisy

    December 24th, 2012 at 8:51 AM

    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

    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

    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

    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

    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?

  • excoriation

    April 11th, 2014 at 12:25 PM

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

  • Thomas

    December 30th, 2012 at 4:40 AM

    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

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

  • Brianna

    July 9th, 2013 at 3:28 PM

    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

    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

    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

    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

    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.

  • Pam in NYC

    August 21st, 2014 at 3:10 PM

    I was ripping cuticles and tearing off callouses on my feet, and had been picking scabs and biting the skin off the inside of my cheeks, and pulling skin off my lips, and pulling out certain body hairs, and scarring my face my whole life as long as I can remember (born 1943). In 1998, I found out about a 12-step fellowship, Self-Mutilators Anonymous, and immediately got wonderful help to stop picking. I have never gone back to the extreme forms since then, but resumed gradually a very subtle version. I am aware that even the very subtle version ties a knit in my stomach, shuts down my breathing, and puts me into a sort of trance state where I’m not fully present to the situation I’m in. She a young woman called me 11 days ago about her version of this disorder very desperate for help, it galvanized me to start a little weekly meeting in my apartment to help both of us, and 2 more desperate scab- and cuticle-pickeds join us by speakerphone. We also started a 2nd weekly conference call. I saved my very helpful literature from 16 years ago. Anyone desperate who wants to join us is welcome. This is in addition to therapy for most, NOT instead of therapy. Pam in NYC

  • someone

    January 5th, 2014 at 1:12 PM

    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

    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

    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??

  • Rosanna

    August 3rd, 2014 at 1:27 PM

    Both

  • miapatti

    April 17th, 2014 at 8:53 PM

    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?

  • Jess

    April 21st, 2014 at 3:13 AM

    I suffer with excoriation and it is not just a habit. I bite and pick the skin around my fingernails and toenails and also the heels of my feet. It’s awful but I can’t seem to stop doing it, even though sometimes I bleed, and it can hurt for days. It has got to the point where I am embarrassed to have social interactions because I’m scared people will point it out. I think that it is right that excoriation should be considered a disorder, because it has a strongly negative impact on my life.

  • Liz

    April 30th, 2014 at 11:23 AM

    I also suffer from excoriation. I have since I was little, so much so that at one point my parents took me in to be checked. They thought it was a fungus or infection. I do have OCD tendencies and suffer from anxiety/depression. For me, picking is soothing, something I do when trying to focus or think about something, and can’t seem to stop picking because my skin isn’t smooth. If I try to stop picking my cuticles, I pick my lips. I haven’t found anything that helps, it can be very embarrassing. It becomes so very obvious when my skin gets wet or cold. I believe it could be a condition and/or a symptom.

  • Claudia Miles, LMFT

    May 27th, 2014 at 7:31 PM

    Excoriation or skin picking disorder has been added into the DSM V after many years of consideration because it is a real disorder that has a genetic link. Skin picking disorder is one of a group of what are known as Body Focused Repetitive Behaviors (BFRBs) and includes compulsive hair pulling disorder aka Trichotillomania, nail and cuticle biting and cheek biting. I’m a therapist in Los Angeles and have worked with Trichotillomania and skin picking disorder for 17 years. Both are considered to be related to OCD. In the case of skin picking, there is often a compulsion to pick to smooth out and “perfect” the skin. No surprise perhaps that many who have skin picking disorder are “perfectionists.” Trich on the other hand is more IMpulsive. It tends to be done unconsciously. In reply to the person who said that because a lot of people do it, if should not be considered in a disorder: The estimate is 2-4% of the population suffers from these disorders. Simply picking at one’s skin does not mean you have excoriation disorder. But when that picking takes over and causes the person great distress and they are unable to stop, it indeed is a disorder. Trichotillomania has been in the DSM for quite some time but skin picking has not. Now that the Board has included it, and it’s considered a “legit” disorder countless people who were too ashamed to seek treatment will get help. And countless parents will have it explained to them and will see in black and white that this is a REAL disorder and their child cannot help it. There is nothing more excruciating than listening to a young person who cannot stop picking and is already upset, tell me that their parent or parents punishes them for doing something they cannot help doing. The fact that it is in the DSM will help so many people who spend their lives in hiding because they believe skin picking is “their fault.” Until people are able to stop blaming themselves and accept that this OCD-related disorder is real, they won’t be able to get help. The DSM Committee read a great deal of scientific data before making the decision to include excoriation disorder in the DSM. They looked at multiple studies and academic papers and genetic research results. They certainly did not make the decision lightly. And it is changing people’s lives for the better. I can assure everyone that skin picking disorder and hair pulling disorder are very real and there has even been a gene identified for these disorders. I myself started pulling my hair out at age 3 (no trauma) although I have now been pull free for 20 years. Further, I have had parents call me who have children who are as young as a year old l who are pulling out hair. (One child pulled her mom’s hair out while mom was breast feeding; another started pulling at 18 mos old and by age three was pulling out her sister’s hair while they both were sleeping. I have helped people to recover but it certainly isn’t easy. Being in the DSM allows many more resources to be made available.

  • Rosanna

    August 3rd, 2014 at 1:26 PM

    I have always bit my nails until they hurt.
    I guess because my Mother also
    Had a very mean streak.
    But after being in an abusive Marriage for 16 years .I also tear off my toe nails. As well as tear the skin from my fingers.I have Bipolar Anxiety Agoraphobia and PTSD..

  • Sharon

    June 20th, 2016 at 5:55 PM

    I know several people with a similar history of abuse that developed strange behaviors like these. Chronic and ongoing abuse can cause Complex-PTSD. Have you looked into narcissistic abuse or CPTSD? Hope you’ve been able to find the answers you’re looking for.

  • Nancy P.

    September 26th, 2014 at 10:07 AM

    I am 55 years old and just now started seeking treatment for spd. I was a little girl, just 2 or 3 years old when I started. I don’t know exactly why I started this but I know I was in a stressful situation. By having these conversations perhaps we can expel this torturous demon who demands that we de-skin ourselves.

  • emp

    September 26th, 2014 at 12:32 PM

    Thanks Nancy for sharing that good luck in your treatment amazing to see how many other ppl have this too

  • Mary

    November 2nd, 2014 at 10:10 PM

    I have noticed due to all my stress the hair pulling more and more. I also do something that I can’t find anything on. I take a very sharp hat pin and stick it in my scalp till I hear it pop. Sometimes it bleeds but usually doesn’t. After I have stick it in my scalp several times I rest and then keep doing it. Of coarse not doing it in front of anyone because I am afraid of what they would say. Then my scalp feels weird and hurts a little. my hair pulling I do like getting the knot and pulling till it breaks through. My hair gets very frizzy and I know I am causing a lot of damage to my hair. I am quite concerned about the damage on my scalp and can this cause a brain tumor or major hair loss. I don’t know why I am doing this but I can’t stop.

  • Mike M.

    December 3rd, 2014 at 12:02 PM

    For BRENDA, pulling out hair is called Trichotillomania. And it is related to excoriation, aka dermatillomania.

    Mike RN

  • cookie

    January 13th, 2015 at 8:37 PM

    I just turned 60. I started picking after I had severe itching on my legs and feet. I would scratch until I was bleeding then as the sores started to heal I started picking at them. The itching slowly stopped but I started picking on any bump on my face and my arms and shoulders. This all started about 9 months ago after my demanding, disabled sister moved into my home. My stress level is off the charts! Prior to that I never had any skin issues. My heart goes out to anyone who suffers from this disorder. I have been spending more time by myself and trying not to stress, it seems to help and my doctor has me on antidepressants. It is what it is!

  • Just a girl

    December 24th, 2015 at 7:26 AM

    Hi I was diagnosed with an anxiety/panic disorder along with PTSD and I’m manic depressive I ave been on anti depressants and anti anxiety meds consistently for 3 years. I have started to pick unconousely the last couple of years. My arms and legs look like I have chicken pox I pick at any sign of bump or redness including pimples on my face ( but those don’t happen often ) other than the sores I have pretty clear skin and don’t break out often. I tell people I calcium deposits that turn into these sores but I don’t think that’s true. I am glad this information in out there for me to have and understanding that I’m not alone with this compultion.

  • Mary

    March 19th, 2016 at 5:50 AM

    I suffered from tric or hair pulling from the age of 12 until I started wearing a wig at about 45. My urge to pull my hair out very slowly went away. I continued to need to wear a wig due to the years of pulling my hair did not regrow in certain areas. When I was about 55 I noticed that I started to skin pick or repeatedly pick scabs. This has slowly but steadily gotten worse. So disheartening to spend most of my life battling trich and now SPD. I am now 63 and I started severely picking on my legs about 6 months ago and now my legs are a terrible mess. I need to get help before they become infected or I become septic. I’m still embarrassed to my Dr.

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