Conditions of the skin and skin picking disorder

There are many conditions of the skin that can cause someone to excessively pick or scratch. This does not necessarily mean thy have exoriation or compulsive skin picking disorder. The Diagnostic and Statistical Manual (DSM) cleary defines the criteria required for  diagnosis of excoriation disorder. These are:

• Recurrent skin picking resulting in skin lesions
• Repeated attempts to decrease or stop skin picking
• The skin picking causes clinically significant distress or impairment in social, occupation, or other important areas of functioning
• The skin picking is not attributable to the psychological effects of a substance (e.g., cocaine) or another medical condition (e.g., scabies)
• 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)

The second point - "not attributable to another medical condition e.g. scabies" - is a particularly tricky one because it is not uncommon for excoriation disorder to co-occur with with medical conditions of the skin. By the criteria, if you have eczema which causes itchiness then excessive scratching would be because of the eczema not due to having compulsive skin picking disorder.

When Skin Conditions evolve into Compulsive Skin Picking

So how do we know if there is in fact presence of both a skin condition as well as a psychological disorder? The key is in understanding the picking patterns and identifying the triggers. One of the first aspects of our online therapy program is that you must develop a clear understanding of your picking patterns. This often involves keeping a record of your picking, detailing each time you pick or scratch, where you were, what you were thinking or feeling just prior to picking, and what you experience after picking or scratching. When reflecting on this pattern you need to identify if there are patterns of excessively scratching even when there was no itch, or whether you notice the excessive picking of scabs or popping of pimples even when there is no physical sensation to do so. It is also important to identify whether you experience an urge to pick at the skin, are mentally preoccupied with the 'act' of picking, or have a tendency to be preoccupied with 'pre-picking' behaviors like feeling, scanning or searching for 'imperfections'. These conditions all signify that the behavior has gone beyond a reaction to whatever sensation you get from your skin condition, to a psychological one. The question most people then ask is: "did my skin condition cause me to develop a skin picking disorder?"

There is still no clear understanding of what the true underlying cause of excoriation disorder is. And although there are strong correlations of excorition disorder with a number of other psychological problems such as depression and anxiety, high levels of stress, there is also evidence to suggest that there is a genetic predisposition. However the onset seems to be triggered by very different things in different people. What does seem to be the same for everyone is that compulsive skin picking does not appear suddenly. It is a gradual increase in frequency and intensity of thebehavior till it evolves into a full blown disorder. In the absence of a skin disorder it would be easy to idenotify when you first started engaging in skin picking or scratching. However for most people with chronic skin conditions they cannot pin point at exactly which point they started picking due to a mental trigger as opposed to picking becauase their skin condition caused them to feel itchy. It may very well be that the presence of a chronic skin condition is what triggers the onset of excoriation disorder or that conversely excessive picking and scratching of the skin exaccerbates the chronic skin condition. 

What's your trigger?

The trigger thought or feeling that causes the urge to pick is different for everyone. For some people it is stress, for others anxiety, while for others it is a visual or tactile cue. This is what distinguishes someone who scartches due to eczema from someone who scratches due to excoriation disorder. Some of the reported trigger patterns reported by skin pickers are:

• a rising sense of internal tension due to stress or anxiety  that needs to be relieved or released
• seeing the skin in the mirror and feeling compelled to 'remedy' the imperfections
• feeling bored or understimulated e.g. while watching Tv
• feeling overwhelmed by negative thoughts or emotions e.g. overwhelming anger or frustration, or feeling depressed

In all these scenarios the physical condition of the skin was not the trigger for the action. It may however be that through the chronic skin condition the learned behavior evolved. For example let's say an individual's skin condition causes their skin to be very dry and flaky and the person is scratching the itchy skin. Now let's say this individual is also experiencing a particularly stressful time and in the process of scratching they experince a sense of relief from this tension. The next time they feel stressed they will seek out hsi same sense of release whether or not the skin is itchy. With repetition of this patterns over time, a compulsion has developed as the urge becomes stronger.

Types of skin conditions

In a previous post we already dealth with eczema, but their are also many other chronic skin conditions that is vulnerable to the development of a compulsive skin pickign disorder.

Keratosis Pilaris:

This condion is harmless, but causes unsightly dry, small, small hard bumps and can sometimes come with redness, swelling or itchiness. someone with this condition may find themselves compelled to pick at or remove the dry bumps on the skin even when there is no itchiness and the visual cue ina mirror or feeling the bumps under the fingertips is often one of the triggers.

Psoriasis:

This condition results in a thick, red, bumpy rash covered with silvery scales that come and go at anytime. The rash tends to appear on the lower back, upper thighs and knees.

Rosacea:

This condition mainly affects the face, but can occur on other parts of the body. It can also cause the development of red solid bumps and pus-filled pimples.

Acne:

We are all familiar with acne. For some it is something that remains in our teen years, while for others it is a problem that continues into adulthood. Acne comes in all shapes and forms, from whiteheads, to blackheads, from puss-filled pimples to itchy red spots.

When faced with a duel diagnosis of any of these with excoriation disorder it is important that both conditions must be addressed simulataneously in order to break the cycle of picking.