Dermatillomania

Skin Picking Disorder

Dermatillomania is considered an impulse control disorder that is characterized by repeated picking, squeezing, or scratching of one's own skin, usually to the point where damage is caused.

The origin of the word comes from the following Greek terms:

  • Derma - skin
  • Till – pull, plow
  • Mania - madness

So Dermatillomania can roughly be translated to mean an illness (or madness) consisting of overwhelming urges to pull and plow away (or pick) at one’s skin.

People with this disorder (also called Compulsive Skin Picking or CSP) often pick at the skin that is easiest to reach, particularly the face, arms, and chest. But really no part of the body is off limits when it comes to skin picking.

What Causes Compulsive Skin Picking?

The cause of this disorder is most likely a combination of biological and environmental factors.

Many animals engage in excessive skin picking, scratching, or self-grooming during times of high stress or when certain alterations are made to their genes or neurotransmitter levels.

Some have theorized that Compulsive Skin Picking is a result of an out-of-control grooming mechanism in the brain. Others have suggested that Dermatillomania stems from frustrations over relationships and attachments (since evolutionarily speaking, most mammals groom each other in order to bond and form attachments with one another).

Compulsive Skin Picking is often observed in people who have Obsessive-Compulsive Disorder (or other disorders within the Obsessive-Compulsive Spectrum).

For instance, about a quarter of people with OCD also have CSP, and about a quarter of people with Body Dysmorphic Disorder (BDD) also have CSP.

Dermatillomania is thought to be most closely related to Trichotillomania (or repetitive hair-pulling). These types of disorders often run in families.
Some studies have suggested two separate types of Compulsive Skin Picking and Trichotillomania: one type being more closely related to OCD and the other type being more similar to addiction.

Obviously more research needs to be done on the disorder in order to understand it more fully, but we do know that there are certain key reasons as to why people continue the behavior despite the often destructive and devastating results to their appearance and self-esteem.

Self-Soothing:

Episodes of skin picking are often preceded or accompanied by feelings of tension, anxiety, or stress. When stressed, many people feel a need for self-soothing. They often experience relief by engaging in skin picking. Skin picking has a kind of soothing effect on their nervous systems, and reduces levels of stimulation.

Stimulation:

Contrastingly, when people are overly bored or inactive, skin-picking can provide a kind of excitement, rush, or stimulation for the nervous system. It may help keep a person alert or awake when they would otherwise become bored or distracted.  Many people with Dermatillomania report picking for hours on end and often long into the night, staying awake and alert much later than they would on a night when they didn't pick.

Perfectionism:

Skin-pickers may stand in front of mirrors and intensely scrutinize every inch of their faces and body for the tiniest irregularity. They will then try to fix it, in hopes of achieving a perfect complexion. Of course shame and depression often result, because the skin-pickers almost always end up looking much worse than they did before picking their skin.

Dermatillomania often turns into a self-perpetuating cycle. Picking tends to lead to shame and anxiety (not to mention more breakouts), which can result in more picking.

Aware of the damage they are inflicting, sufferers almost always feel a need to stop the behavior but are physically and mentally unable to do so without aid.

Picking can become a major focus of life and can interfere with relationships, work, and overall happiness. People with CSP often feel crazy and out of control, but don’t know what to do or where to go for help. Fortunately, CSP is gaining more and more recognition as a real disorder and thus treatment options are expanding.

What Treatments Work?

Medication:

The most effective and commonly prescribed medications for Dermatillomania are:
  • Antidepressants (including SSRIs or Tricyclic Antidepressants) - generally work by increasing levels of serotonin in the brain, but may also alter levels of neuropeniphrine and/or dopamine depending on the specific medication prescribed.
  • Opioid Antagonists (such as Naltrexone) - work by blocking opioid receptors, which are generally associated with addicting behaviors and the cravings or urges associated with such addictions. These medications would be especially effective for those who get temporary rushes of pleasure by engaging in picking.
  • Antipsychotics - work by decreasing levels of dopamine in the brain. Overly high levels of dopamine are associated with anxiety and the seeking of self-soothing. These medications may be particularly useful for those who primarily pick in order to soothe themselves and calm their anxiety (as opposed to those who engage in picking because they really enjoy it and get pleasure from doing it).

Psychotherapy:

Cognitive-behavior therapy has been studied as an effective means of treating skin-picking and related disorders. Therapy may involve several different techniques, such as:
  • Habit Reversal Training (HRT) - a four-step process that teaches a person how to relax, how to breathe and feel centered, and to perform muscle response exercises. HRT includes self-monitoring and stimulus control (described below), along with social support.
  • Self-Monitoring - a process of making a person with CSP more aware of their behaviors. Since picking can often be unconscious for some, simply keeping a log of the times and durations of picking episodes can help increase awareness and thereby sometimes help a person to stop.
  • Stimulus Control (SC) - a behavioral treatment that helps sufferers identify and eliminate, avoid, or change the environmental factors, moods, or circumstances that trigger picking. The goal is to consciously control these triggers so that the person can learn to engage in alternative, healthy behaviors in response to their urges. For example if picking usually occurs while alone, the person will be encouraged to spend more time with others. If the picking occurs in front of the mirror, then the person may be asked to cover the mirrors in their home.
  • Competing Response - a technique designed to give the person an alternative to picking. This can include fidget toys, knitting, beading, or other activities to keep the hands busy. Whenever a person is tempted to pick, they would be encouraged to engage in a competing response requiring the use of their hands so that they would be physically unable to pick, thereby interrupting the pattern.

These techniques are all temporary means of helping the person learn to resist the urge to pick. The more the urge is resisted, over time the weaker the urge becomes. Once the urge fades, these techniques become less necessary. The length of time it takes to extinguish the behavior depends on how long the person has had the problem and how diligent they are in resisting the urges. Although therapy typically lasts from 10-12 weeks, it can take up to 12 months for the urge to pick to finally fade away.

Natural Remedies:

There are a couple natural supplements that are gaining recognition as being effective in treating Dermatillomania and related disorders:

  • Inositol: This is a B-vitamin which is said to help calm anxiety and potentially reduce urges to pick at one's skin. Inositol needs to be taken in large quantities, but it won't build up to toxic levels because it's a water soluble vitamin.
  • N-acetyl-L-cysteine (NAC): This supplement is quickly gaining popularity as a natural supplement to treat Dermatillomania and Trichotillomania. Apparently it works by affecting the levels of GABA in your brain, which is an inhibitory or calming neurotransmitter. The recommended effective dosage is between 1200mg and 2400mg per day. It's sugessted to start off taking 600mg twice a day (once in the morning and once at night, or at times you are most likely to pick) and then increase your daily dosage gradually if you don't notice any results after a few weeks.

Self Help & Online Resources

Even today, when compulsive skin picking is no longer a disorder without a name, there still isn't widespread knowledge about its existence. Finding a clinician that has experience in treating skin picking can be difficult, and also the shame associated with the disorder may cause many sufferers to avoid seeking treatment. But thanks to the internet, information about Dermatillomania is being spread, and there are a growing number of online resources that can help CSP sufferers. One resource worth mentioning is the Skin Picking/Dermatillomania Center. This online resource contains tons of comprehensive information, a list of treatment providers, community support, and self-help guides.



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