Dermatillomania and Autism

Autism Spectrum Disorder (ASD) and autism are both general terms for a group of complex disorders of brain development and are characterized by difficulties in social interaction, verbal and nonverbal communication and repetitive behaviours. One of the most distressing aspects of Autism is the occurrence of repetitive self-injurious behavior such as head banging, hair pulling, face slapping, and skin picking, scratching or pinching. So is there a link between autism and excoriation disorder? Psychiatric comorbidity certainly is common in ASD with one study finding that 24.7% of their study sample of autistic subjects had comorbidity with another disorder of Tourette syndrome, chronic tics, trichotillomania, enuresis, or encopresis. But the reverse correlation does not hold true in that for the most part those with skin picking disorder have no direct or genetic link with ASD. So why then do so many with ASD engage in this same compulsive behavior and can this provide some clues as to why those without ASD do the same?

Is it self-harm?

It is often posed whether there is some element of self-harming behavior in compulsive skin pickers and hair pullers. Certainly picking at one’s skin excessively till it bleeds and scars does harm the body after all, and the act itself can sometimes be very painful and yet the person continues to do it. However one of the key distinctions in diagnosing excoriation disorder according to the Diagnostic and Statistical Manual (DSM5) is that the person who engages in the picking does not voluntarily do so, that it is in response to an overwhelming urge to do the picking and not from the desire to hurt the body, and in fact desires to stop the behavior but is unable to do so. This is in stark contrast to deliberate self-harm where the person experiences the urge to feel pain and therefore voluntarily inflicts pain on the body. In addition, skin picking often has both a focussed and automatic component in that many times people who compulsively pick their skin are not even aware they are doing it until they have already caused damage. In contrast self-harming is always focussed and deliberate. So then what about the self-injurious behavior in ASD? Is this self-harm or something else? When looking at the difference between ASD self-harm and in those without, the key difference is in the presentation of the behaviors. People with ASD often engage in a similar set of actions such as excessive picking at the skin, in a repetitive and rhythmic way. Because this type of presentation of ASD often occurs with profound communication difficulties, it is difficult to ascertain the reasons the individual might feel the need to behave in this way. One of the causes purported is the role of inefficient sensory stimulation and modulation, one of the common characteristics of ASD. Some people function at a low level of arousal and engaging in self-harm helps to increase this. Alternatively, if the person is sensitive to high arousal, self-harm could act as a release of tension from this. The other possible reason cited is that social and communication difficulties in people with ASD may lead to the use of drastic behaviors such as self-harm as a way of communicating a need. In uncomfortable situations or if asked to do something unwanted, engaging in a harmful behaviour can help the individual to escape from the experience, or even a way of just letting people know that they don’t like it. Can we draw some similarities to the causes for people with excoriation disorder experiencing the urge to pick?

A sensory outlet?

Compulsive skin pickers often describe a sense of release of tension after they have pulled a scab or popped a pimple. It is this feeling that the individual craves when they experience the urge to pick. This could be seen to be similar to those with over-responsive sensory processing disorder who struggle to modulate their sensory experiences and require a sensory “outlet”. Many skin pickers also describe their automatic picking to occur when they are bored. This can be seen as similar to those with under-responsive sensory processing disorders who require stimulation to remain alert and active. In seeking sensory stimulation or sensory soothing, there is a tendency to target sites where there are many nerve endings such as the hands, feet, mouth and scalp. Therefore behaviours such as hair pulling, skin picking, and nail biting are commonly seen in people with sensory processing disorder. These same behaviours, when engaged in repetitively by someone who is not known to have sensory processing disorder or ASD, causes damage to the targeted site, results in psychological or social impairment, and consequently become classified as body-focussed repetitive behaviours (BFRBs).

Communicating what?

One could say that communication impairment has nothing to do with compulsive skin picking where there is no ASD or other learning disability present. However, perhaps there are lessons to be learnt in the reasons those who do struggle to communicate choose to compulsively pick their skin. For many skin pickers, the urge to pick often follows a stressful situation or the presence of negative thoughts and emotions the person may be experiencing. Cognitive-behavioral therapy is thought to be the most effective form of treatment for BFRBs. One aspect of this is called Mindfulness which encourages the individual to be more aware of the thoughts and emotions they are experiencing and learning to deal with these in healthy ways as opposed to keeping them bottled up inside. It may be that skin picking is a manifestation of a mental or emotional need that need to be met that the brain is struggling to communicate with the individual and it presents in the tangible call for action through the act of picking. These are of course all hypotheses based on the similarities in the behaviors of those with ASD and from the reports of those who are afflicted by skin picking disorder. More research should be conducted on these possible links as it may contribute to a better understanding toward more effective treatment and management.