ADHD and skin picking

There are many people on dermatillomania support forums who report to have ADHD, asking if the two disorders are related, and vice versa on ADHD forum. Attention deficit disorder with or without hyperactivity or ADHD, is a disorder typically diagnosed in childhood and is characterized by inattentiveness or hyperactive-impulsivity. Although diagnosis of ADD required the presence of symptoms before the age of 7, it is a disorder that extends into adult life. According to the Diagnostic and Statistical Manual (DSM) the criteria for the diagnosis of ADHD are:

• presence symptoms of clinical significant functional impairment e.g. social, academic, or self-care; and in two or more functional areas i.e. school, home, work
• symptoms present before the age of 7
• symptoms are not better accounted for by another mental disorder
• for the inattentive type - ADD, at least six symptoms in inattentiveness i.e. lack of attention to details/careless mistakes; lack of sustained attention; poor listener; failure to follow through on tasks; poor organization; avoids tasks requiring sustained mental effort; loses things; easily distracted; forgetful - must be present for at least 6 continuous months
• for the hyperactive-impulsive type - ADHD, at least 6 symptoms i.e. fidgeting/squirming; leaving seat; inappropriate running/climbing; difficulty with quiet activities; "on the go;" excessive talking; blurting answers; can't wait turn; intrusive - must be present for at least 6 continuous months
• for the combined type the criteria for both inattentive and hyperactive-impulsivity types must be met

It is estimated that 8-10% of school-aged children have ADHD and appears to be commonly co-occurring with body-focussed repetitive behaviors (BFRBs) such as compulsive hair pulling and skin picking.

Is there a link between ADHD and skin picking?

The link between ADHD and dermatillomania has not been extensively researched or documented. However it is evident that it is something that needs the attention of the research community. It is challenging enough to have to deal with either one of these disorders, so having to cope with both at the same time is extremely stressful. As described above the DSM requires that the symptoms of ADHD be present befire the age of 7 for a diagosis to be considered. However BFRBs like dermatillomania can have onset at any age. To date, the definitive cause of dermatillomania is not known, with evidence pointing to genetics as well as biological and neurological factors. From the evidence, what is apparent is that the trigger for the onset of compulsive skin picking is different for each person and can therefore occur at any age. In cases of comorbidity with ADHD the question is often raised as to whether ADHD in fact causes compulsive skin picking. While there may be a correlation between ADHD and the onset of dermatillomania, there is no evidence to suggest a causal relationship. So the question then remains, why is ADHD so often accompanied by the onset of skin picking?

The sensory link

Children and adults with ADHD often have difficulties with sensory integration, with sensory integration impairment often seen to be one of the underlying causes of ADHD. Sensory integration is the brain's ability to filter, sort and make sense of all the sesnory input it receives constantly. The inability to regulate the senses leads to either being overstimulated or understimulated. For people with ADHD this therefore either leads to hyperactivity and impulsiveness or distractability and difficulty concetrating respectively. Incidentally, sensory integration has also been associated with BFRBs, whereby the acto of picking the skin, pulling the hair or bitig the nails provides a form of sensory input that either dampens an overstimulated brain or stimulates an understimulated one. It would thus make sense that skin picking is a response to the sensory needs of some people with ADHD.

The medication link

Just as there is more than one underlying cause for ADHD, so too can there not be a blanket treatment of ADHD. The problem is that healthcare and modern medicine still operates on a very medical model way of thinking where the first solution is always medication. This is because it is perceived as the fastest way to see results, even if the result is not sustainable over time, as our bodies build up a tolerance to the medication. Ideally, medication should only be used as a supplement or last resort solution. Pharmacology for ADHD only addresses the symptoms of the disorder and not the cause. A drug commonly prescribed in the management of ADHD is methylphenidate - commonly known under various trade names such as Concerta or Ritalin. Methylphenidate is a central nervous system stimulant which acts to increase dopamine, an important chemical used in the transmission of signals between nerve cells in the brain; in particular those associated with reward related cognition, such as positive reinforcement. There have been many individual's with ADHD and dermatillomania or concerned parents that have reported that the urge to stop picking diminished when they stopped taking the medication. If picking is a side effect of the medication, it cannot be considered a BFRB, however it may be that the medication exacerbates the symptomes of an already existing skin picking disorder. It may be that stimulating the central nervous system leads to hyperstimulated neural pathways, which as we have established is sometimes relieved by acts of hair pulling and skin picking. Compulsive skin picking disorder does not have a sudden onset. It is a behavioral disorder that develops over time. The more you experience a positive experience such as release from stress or tension or stimulation of the neural pathways, the more you will engage in the same behavior. Over time the frequency or severity of the behavior increases until the bad habit eventually evolves into a clinical disorder.

There certainly is not sufficient research in this area. But it can stated that while ADHD or the treating medication does not cause dermatillomania, that people diagnosed with dermatillomania can can also have a diagnosis of dermatillomania and that the two disorders should be managed holistically and simultaneously.