Dermatillomania and Body Dysmorphic Disorder (BDD)

Skin picking disorder, formerly known as dermatillomania, was recognized for the first time as an official medical condition in the fifth edition of the Diagnostic and Statistical Manual (DSM5) in 2013. This is a huge stride toward the increased awareness, improved diagnosis, and development of treatment options for the millions of people challenged by this condition. With its new found status, comes a new name, with the DSM5 referring to skin picking disorder as excoriation disorder.  According to the American Psychiatric Association (APA) it is estimated that between 2 and 4 percent of the population could be diagnosed with this disorder, and that resulting problems may include medical issues such as infections, skin lesions, scarring and physical disfigurement.

The criteria for the diagnosis of dermatillomania (excoriation disorder) as outlined in the DSM5 are as follows:

1. Recurrent skin picking resulting in skin lesions.
2. Repeated attempts to decrease or stop skin picking.
3. The skin picking causes clinically significant distress or impairment in social, occupation, or other important areas of functioning.
4. The skin picking is not attributable to the psychological effects of a substance (e.g., cocaine) or another medical condition (e.g., scabies).
5. The skin picking is not better explained by symptoms of another mental disorder (e.g., delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in body-dysmorphic disorder, stereotypes in stereotypic movement disorder, or intention to harm oneself in non-suicidal self-injury).

In point 5, the DSM5 specifically identifies skin picking disorder as separate to a condition called Body Dysmorphic Disorder (BDD). This is because of the striking similarities between the two, with questions raised in the past as to whether these two conditions are in fact one and the same. So what then is BDD?

What is Body Dysmorphic Disorder (BDD)?

According to The Merck Manual Online Medical Library, "People with body dysmorphic disorder believe they have a flaw or defect in their physical appearance that in reality is nonexistent or slight. The disorder usually begins during adolescence“. Since the addition of skin picking disorder in the DSM5, the criteria for BDD has remained largely unchanged from the DSM-IV. In body dysmorphic disorder, any part of the body, or even the body as a whole can be the target of these perceived flaws. People with BDD are also characteristically preoccupied with thoughts about these perceived flaws and with the need to correct them in pursuit of physical perfection. For some this may be a preoccupation with thinning hair, weight, physical features such as the size of the nose, ears or shape of the eyes, as well as the condition of the skin. These preoccupations and corresponding desire for perfection lead to repetitive behaviours that are aimed at correcting the perceived flaws. In the case of people with BDD where the disorder is centered around the condition of the skin, picking behaviour often occurs. In these cases the behaviours in someone with BDD and someone with dermatillomania present very similarly.

Is Dermatillomania a BDD?

As identified in the DSM5, skin picking disorder has specifically been defined as a disorder separate to BDD. Some of the main similarities between skin picking disorder and BDD are characterized by the repetitive and compulsive nature of the resulting behaviour and the social withdrawal that often develops over time:

• Compulsive mirror checking and skin touching:

This behaviour occurs in both BDD and dermatillomania with individuals having the need to constantly check the condition of the skin. However, in BDD the reason is usually an obsession with a perceived flaw where the person is preoccupied with the idea of the flaw. However with skin picking disorder the individual usually checks the skin looking for imperfections, with the intention of picking at it, not necessarily to remove the imperfections, but rather to experience the sensation of picking or removing the imperfection.

• Repetitive picking, rubbing or scratching at the skin:

Repetitive checking and touching of the skin inevitably leads to picking, scratching or rubbing of the area in both conditions. However, BDD is not isolated to the skin, with people with BDD often having preoccupations with other parts of the body as well. In addition, with removal of the perceived imperfection being the primary goal, body-on-body repetitive behaviours are not the only methods the person employs to remove the imperfection, often opting for cosmetic procedures such as laser treatments or even surgery. Dermatillomania on the other hand are always characterised by body-on-body activity such as the use of fingers, nails or tools such as tweezers or needles. The primary goal for picking is also different to BDD in that the individual seeks out the feelings associated with picking rather than the visual consequence.

So although the two disorders share a resemblance, there are also clear differences in why the behaviours occur. It is also possible that skin picking may start out as BDD, but when a release from stress or tension is experienced when picking at the skin, the person may seek out this feeling more and more over time, therefore resulting in the BDD developing into  skin picking disorder. One study that examined the prevalence and clinical correlates of pathological skin picking (PSP) in a large sample of individuals with body dysmorphic disorder (BDD), found that there is a high prevalence of PSP among individuals with BDD. This link is important for clinicians to consider when working with people with BDD for whom the skin is a particular preoccupation.