Skin picking disorder: prevalence, correlates, and associations with quality of life in a large sample

Acne excoriée: Diagnostic overview and management

Acne excoriée (AE) is a skin picking disorder (SPD) within the group of obsessive compulsive (OCD) and related disorders characterized by the compulsive manipulation of acne lesions. AE typically appears in females during adolescence or young adulthood and can cause significant disfigurement and psychosocial impairment. This disorder is under-recognized due to patient discomfort to disclose excoriation habits or lack of behavior awareness. It is imperative that dermatologists accurately diagnose and treat this disorder to minimize long-term damage to the skin. This review aims to provide an overview of the diagnosis and treatment options for AE.

Emotion regulation and executive functions in adolescents with skin picking disorder

AIM

This study aimed to investigate emotion regulation difficulties and executive functions of adolescent outpatients with skin picking disorder (SPD).

METHOD

Ninety six adolescents with SPD and ninety healthy controls were included in the study. All patients were diagnosed with SPD as per the diagnostic criteria of DSM-5. A battery of tests were implemented to evaluate emotional regulation strategies (i.e. acceptance,), as well as associations between those strategies and executive functions, and clinical variables (anxiety, depressive symptoms, impulsivity and illness characteristics).

RESULTS

The SPD group had significantly higher scores in inhibition (t = 2.982, p = 0.030), emotional control (t = 2.461, p = 0.016), and planning-organization (t = 2.139, p = 0.038) Multiple linear regression model explained a considerable amount of variance of executive functions in the patient group (Adjusted R²=66.4%). In the patient group, age at illness-onset and the severity of inhibiton were significantly associated with the disruptions in emotional control functions (For age at illness-onset, β= -0.45, t=-3.0, p = 0.012 and for BRIEF Inhibition scores, β = 0.31, t = 2.8, p = 0.008).

CONCLUSION

The results of this study suggest that those with SPD have more emotion regulation problems and poorer executive function skills compared to those without SPD. Deficits in emotional control were associated with inhibition process and age-onset of the illness.

Prevalence and gender distribution of excoriation (skin-picking) disorder: A systematic review and meta-analysis

Epidemiological studies of excoriation disorder have reported different prevalence estimates for this condition, limiting our understanding of its public health impact. We performed a systematic review and meta-analysis to collate epidemiological studies of excoriation disorder. We aimed to estimate the pooled prevalence and the female-to-male ratio of excoriation disorder in the general population. We searched Embase, PsycInfo, and PubMed up to May 2020 and updated the PubMed search in October 2021. Studies which reported the frequency of excoriation disorder in a sample from the general population were included in our meta-analyses. We made no restrictions regarding the definition or assessment of excoriation disorder. Data were pooled through random-effects meta-analyses. Of the 677 records identified through database searches, 19 studies involving 38,038 participants met our inclusion criteria. Meta-analyses demonstrated that excoriation disorder has an overall prevalence of 3.45% (95% CI 2.55, 4.65%) and impacts women more than men (female-to-male OR = 1.45; 95% CI 1.15, 1.81, p = 0.001). These findings underscore the public health impact of excoriation disorder, which will hopefully motivate future research focused on advancing our understanding and management of this condition.

The problem with picking: Permittance, escape and shame in problematic skin picking

OBJECTIVES

Problematic skin picking (SP) is a poorly understood experience characterised by a drive to pick the skin and related psychosocial impact. In the DSM-5, problematic SP is classified as 'excoriation (skin picking) disorder'. The aim of this article is to present a rare qualitative perspective on the lived experience of problematic SP, prioritising participants' voices and sense-making.

DESIGN

An in-depth qualitative study of individuals who self-identified as picking their skin problematically and experienced related distress.

METHODS

Seventeen UK-based participants were recruited online and interviewed about their SP. Participants were given choice of interview modality, including instant messenger platforms, telephone, email and Skype, to maximise comfort and improve the accessibility of the study. Transcripts were analysed using thematic analysis.

RESULTS

Three themes offering novel insight into the phenomenology of participants' SP are highlighted and explored: (1) how cognitions and circumstances drove and permitted SP, (2) how participants 'zoned out' while SP and the escape or relief that this attentional experience offered and (3) participants' feelings of shame and distress in how they felt their SP may appear to others.

CONCLUSIONS

This study contributes in-depth and novel ideas to the understanding of SP phenomenology and identifies how environmental factors, cognitions, contextual distress and shame may be considerations in therapeutic intervention. It presents the complexity of SP sense-making and demonstrates the need for individual formulation.

Appearance-related concerns in individuals with pathological skin picking-a comparison with individuals with dermatological conditions and skin-healthy controls

Introduction

Pathological skin picking (PSP) is an excessive behavior which characterizes Skin Picking Disorder. Individuals repeatedly pick their skin and cause skin lesions, but are unable to control the behavior, which can cause severe distress. Visible self-inflicted skin lesions can additionally affect individuals with PSP due to emerging appearance-related concerns. However, these concerns and their role in PSP have hardly been studied, especially not in comparison with individuals with dermatological conditions and skin-healthy controls.

Methods

The present cross-sectional study (n = 453, 83.9% female, 15.9% male, 0.2% diverse) aimed at analyzing appearance-related concerns and mental health outcomes between four groups: Individuals with PSP and dermatological conditions (SP/DC; n = 83), PSP without dermatological conditions (SP; n = 56), dermatological conditions without PSP (DC; n = 176) and skin-healthy controls (SH, n = 138). We compared questionnaire data on dysmorphic concerns, appearance-based rejection sensitivity, and body dysmorphic symptoms, as well as PSP-symptoms and mental health outcomes (depression, anxiety, and self-esteem) between groups.

Results

The analyses showed a significant multivariate group effect in the appearance-related variables, F(6, 896) = 19.92, Wilks' Λ = 0.78, p < 0.001, and mental health outcomes, F(6, 896) = 16.24, Wilks' Λ = 0.81, p < 0.001. The SP/DC group had the strongest appearance-related concerns and mental health impairments, followed by the SP group, the DC group and the SH group. The SP/DC group and SP group only differed significantly with regard to dysmorphic concerns, but not in other variables. The DC group was less affected but still showed higher dysmorphic concerns and mental health impairments than skin-healthy controls. In contrast to the PSP groups, the other two groups did not exceed clinically relevant cut-off scores.

Discussion

The present study shows that individuals with PSP exhibit strong appearance-related concerns, regardless of the presence or absence of underlying or comorbid dermatological conditions. These findings shed new light on the importance of appearance-related concerns in Skin Picking Disorder and the role of PSP as a potentially overlooked risk factor in dermatological patients. Therefore, appearance-related concerns should be explicitly addressed in dermatological and psychotherapeutic settings. Future studies should also include longitudinal and experimental analyses to more clearly classify the role of appearance-related concerns in the etiology of PSP and Skin Picking Disorder.

Habit Reversal Training and Variants of Decoupling for Use in Body-Focused Repetitive Behaviors. A Randomized Controlled Trial

Background

Behavioral interventions hold promise in improving body-focused repetitive behaviors (BFRBs), such as hair pulling and skin picking. The effect of combining different treatment techniques is currently unknown.

Methods

In the framework of a randomized controlled crossover trial, 334 individuals with at least one BFRB were allocated either to a waitlist control or to three experimental conditions (1:1:1:1). Participants in the experimental condition received self-help manuals teaching habit reversal training (HRT), decoupling (DC) and decoupling in sensu (DC-is) during a six-week period. Treatment conditions differed only in the order of manual presentation. We examined whether applying more than one technique would lead either to add-on or interference effects.

Results

The three treatment conditions were significantly superior to the waitlist control group in the improvement of BFRBs according to intention-to-treat analyses at a medium effect size (all p ≤ 0.002, d = 0.52 - 0.54). The condition displaying DC first significantly reduced depressive symptoms (p = 0.003, d = 0.47) and improved quality of life (p = 0.011, d = 0.39) compared to the waitlist control. Those using more techniques concurrently showed the strongest decline in BFRB symptoms, even after controlling for days practiced. Participants rated all manuals favorably, with standard DC and HRT yielding greatest acceptability.

Discussion

Results tentatively suggest the concurrent application of different behavioral treatments for BFRBs leads to add-on effects. Results were superior when DC was practiced first, with positive effects extending to depressive symptoms and quality of life. Integrating the three techniques into one self-help manual or video along with other treatment procedures (e.g., stimulus control techniques) is recommended.

Trigeminal trophic syndrome in a pediatric patient with diffuse intrinsic pontine glioma

A 13-year-old girl with a history of diffuse intrinsic pontine glioma (DIPG) suffered from progressively worsening facial ulcerations secondary to paresthesia-induced self-excoriation. She was diagnosed with trigeminal trophic syndrome (TTS) induced by DIPG and struggled to heal her lesions in the background of this excoriation disorder. A multidisciplinary approach that included mood disorder management with sertraline and amitriptyline helped diminish paresthesia, improve her quality of life, and promote healing of the ulcers despite the progression of her DIPG. This case highlights the multifactorial complexity of TTS in pediatric patients and the need for successful management strategies.

Childhood maltreatment, traumatic experiences, and posttraumatic stress disorder in pathological skin picking: An online case-control study

OBJECTIVE

Although traumatic stress including childhood maltreatment (CM) has a profound impact on mental health, its relation to pathological skin picking (PSP) has been understudied and results remain inconclusive. Likewise, posttraumatic stress disorder (PTSD) as the most typical sequelae of traumatic stress has hardly been investigated in those with PSP. The objective of our online case-control study was to shed further light on this issue.

METHODS

Using an anonymous online survey, 325 adult participants with PSP defined by Skin Picking Scale-Revised (SPS-R) scores ≥ 7 as well as Skin Picking Impact Scale (SPIS) scores ≥ 7 were administered the Childhood Trauma Questionnaire (CTQ), the Short Screening Scale for DSM-IV PTSD (PTSD-7) including a list of traumatic events, and a brief measure of psychopathological distress. They were compared to an age-, sex-, and education-matched control group recruited online by means of analyses of variance (ANOVA).

RESULTS

The PSP sample scored significantly higher on the CTQ dimensions of sexual and emotional abuse as well as emotional neglect with small to moderate effect sizes (d between 0.27 and 0.49). Accounting for psychological distress, the only significant difference related to emotional abuse with a small effect (d = 0.23). Participants with PSP reported significantly more traumatic experiences in adulthood than the control group (59.1% vs. 38.2%; χ²_{(1; N=638)} = 28.02, p < .001). Among those with PSP, a probable diagnosis of PTSD was found in 44 (13.5%) compared to zero cases in the control group.

CONCLUSIONS

Our findings indicate that emotional abuse in childhood may be of relevance in skin picking. Since exposure to traumatic events in adulthood as well as PTSD seem to be more frequent in those with PSP compared to a control group, it might be worthwhile to consider these factors in the assessment of patients with skin picking.

Discriminative and Affective Processing of Touch: Associations with Severity of Skin-picking

Skin-picking is a common behavior in the general population that generally serves emotion regulation (e.g., reduction of tension). However, recent research suggests it may also be associated with changes in tactile processing sensitivity. Along these lines, the present study examined whether the severity of skin-picking (SOSP) is related to discriminative and affective touch processing. A total of 160 participants (59 males, 101 females, mean age = 31 years) completed two tactile discrimination tests (two-point discrimination, surface texture discrimination), as well as a well-validated affective touch paradigm (delivery of soft/slow touch, which is found to be generally pleasant). A hierarchical regression analysis was carried out to investigate the association between SOSP, age, sex, and indicators of tactile sensitivity. Replicating previous findings, females reported higher SOSP. While the performance in the discrimination tests did not predict SOSP, affective touch processing was associated with SOSP. Participants with high SOSP reported an urge to pick their skin after being softly touched. This seems paradoxical since previous findings have suggested skin-picking may be carried out to manage negative affective states. Our findings add to the literature describing altered sensitivity and responsivity to specific tactile stimuli in individuals with excessive skin-picking.

Body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms in a large sample of adolescents

Few studies have investigated body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms in adolescents and how they relate to mental health, quality of life, suicide attempts, and non-suicidal self-harm. We used a quota sampling procedure and contacted 100 secondary centres in the Southeast of Spain, of which 34 participated in the study. A sample of 5,345 adolescents (12–18 years) completed dimensional measures of body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms. The proportion of adolescents with clinically significant symptoms within each symptom type was estimated and associations with other indicators of mental health examined. Clinically significant body-dysmorphic symptoms were reported by 3.7%, hoarding by 0.9%, hair-pulling by 0.7%, and skin-picking by 1.8%. Body-dysmorphic symptoms were more common in girls and in those over 14 years of age. Body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms were moderately to strongly associated with obsessive-compulsive symptoms, internalizing symptoms, externalizing symptoms, and poor quality of life. Those with significant body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms were much more likely to have attempted suicide and engaged in non-suicidal self-harm during the last twelve months than those without such symptoms. Body-dysmorphic symptoms showed the strongest associations with internalizing symptoms and poor quality of life. Limitations are the sole use of self-report and a sample from only two regions in Spain, but findings suggest that body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms are common and impairing during adolescence.

The Global Prevalence of Primary Psychodermatologic Disorders: A Systematic Review

The management of primary psychodermatologic disorders (PPDs) (i.e., psychiatric disorders with dermatologic presentation) is challenging. The scarceness of reported prevalence hinders the development of coordinated interventions to improve healthcare delivery. This review aimed to explore the global prevalence of PPDs. The review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses statement. Of the 4632 identified publications, 60 were included. Five PPDs were investigated from the included studies: delusional parasitosis (n=9), skin picking disorder (n=26), trichotillomania (n=22), tanning dependence (n=5), and repetitive nail biting (n=6). Delusional parasitosis was rare in the general population (prevalence ranging from 0.0002% to 0.03%), with higher rates in the psychiatric settings (outpatient=0.5%; inpatient=0.1%). Other pathologic or subclinical forms of PPDs had a minimum prevalence of 0.3% (median=7.0%; mean=17.0%). The distribution of the prevalence rates was highly skewed, with large differences based on the study setting (e.g., dermatologic settings, psychiatric settings, and general population). The most common condition was pathologic skin picking (prevalence, 1.2%-11.2%) in the general population. Its rates were higher in the psychiatric settings (obsessive-compulsive disorder, 38.5%; Tourette syndrome, 13.0%; body dysmorphic disorder, 26.8%-64.7%). The prevalence of trichotillomania in the general population ranged from 0.6% to 2.9%, while that of pathologic tanning and nail biting could not be ascertained as the studies were mainly in students (range; 12.0%-39.3% and 3.0%-10.1%, respectively). In conclusion, PPDs are common, especially in the dermatologic and psychiatric settings. Further population-based studies are needed to determine more accurate prevalence rates.

Autoaggressive dermatoses in the practice of a dermatovenereologist

The article presents clinical cases of autoaggressive dermatoses from the own practice of authors. In the first case, the patient turned to a cosmetologist for the purpose of aesthetic correction of scars; it was found that she inflicted self-harm unconsciously against the background of long-term depression and psycho-emotional stress associated with instilling a sense of guilt for the absence of children in the family. Against the background of the recurrent nature of the skin process, the patient is strongly recommended consultation and treatment by a psychotherapist. The following two cases share common features: the presence of parasites under the skin, with which patients independently fought with radical methods. The first patient was identified retrospectively upon admission to the venereology department, and according to the patient, he already cured the tick on his own. In the second case, the demonstrative type of behavior and flaunting his own state attracts attention. This patient with a diagnosis of neurotic excoriations (dermatozoic delusions?), examination by a neurologist and a psychotherapist is recommended.

Pediatric skin picking disorder: A review of management

Skin picking disorder (SPD) commonly presents in childhood; often, families will first turn to dermatologists for evaluation. It is imperative that dermatologists accurately diagnose and treat the disorder as children are vulnerable to face significant negative psychosocial impacts. This article reviews the limited literature on the management of SPD in pediatric patients to better prepare dermatologists for educating families and recommending treatment options. We discuss studies evaluating behavioral and pharmacologic therapies, as well as emerging skin barrier treatments.

Pain perception and physiological correlates in body-focused repetitive behavior disorders

BACKGROUND

Behaviors typical of body-focused repetitive behavior disorders such as trichotillomania (TTM) and skin-picking disorder (SPD) are often associated with pleasure or relief, and with little or no physical pain, suggesting aberrant pain perception. Conclusive evidence about pain perception and correlates in these conditions is, however, lacking.

METHODS

A multisite international study examined pain perception and its physiological correlates in adults with TTM (n = 31), SPD (n = 24), and healthy controls (HCs; n = 26). The cold pressor test was administered, and measurements of pain perception and cardiovascular parameters were taken every 15 seconds. Pain perception, latency to pain tolerance, cardiovascular parameters and associations with illness severity, and comorbid depression, as well as interaction effects (group × time interval), were investigated across groups.

RESULTS

There were no group differences in pain ratings over time (P = .8) or latency to pain tolerance (P = .8). Illness severity was not associated with pain ratings (all P > .05). In terms of diastolic blood pressure (DBP), the main effect of group was statistically significant (P = .01), with post hoc analyses indicating higher mean DBP in TTM (95% confidence intervals [CI], 84.0-93.5) compared to SPD (95% CI, 73.5-84.2; P = .01), and HCs (95% CI, 75.6-86.0; P = .03). Pain perception did not differ between those with and those without depression (TTM: P = .2, SPD: P = .4).

CONCLUSION

The study findings were mostly negative suggesting that general pain perception aberration is not involved in TTM and SPD. Other underlying drivers of hair-pulling and skin-picking behavior (eg, abnormal reward processing) should be investigated.

Prevalence of pathological skin-picking in dermatological patients

OBJECTIVE

The prevalence of pathological skin-picking (PSP) has predominantly been studied in students and the community, but not yet in dermatological patients. However, those may be at increased risk of PSP because it is often triggered by the feel or look of the skin. Thus, its prevalence among patients with a physician-diagnosed dermatological disease remains to be determined.

METHODS

A consecutive series of 460 adult patients attending a dermatological university outpatient clinic was administered the 8-item Skin Picking Scale-Revised (SPS-R). They also reported demographic data and rated the severity of their skin disease. The dermatologist evaluating the patient provided his/her diagnosis.

RESULTS

PSP as defined by SPS-R scores ≥7 was reported by 121 participants (26.3%). It was significantly more frequent in patients with atopic dermatitis (AD, OR = 3.23; 95% CI: 1.95-5.68) and psoriasis (OR = 1.64; 95% CI: 1.00-2.67), but less frequent in those with malignant epithelial skin tumors (OR = 0.10; 95% CI: 0.02-0.43). PSP was not associated with female gender or younger age.

CONCLUSIONS

Our findings indicate that PSP affects about one in four patients with skin disease. In particular, individuals suffering from atopic dermatitis may represent a high-risk population for PSP deserving early recognition and adequate treatment.

Skin picking disorder: Does a person's sex matter?

BACKGROUND

Skin picking disorder (SPD) is characterized by recurrent picking with scarring or tissue damage. Although research suggests that less than one-half of people with SPD are male, there is little clinical information about men with SPD.

METHODS

We recruited 95 non-treatment-seeking adults as part of a cross-sectional study of SPD. Men (n = 17) and women (n = 78) with SPD were compared on clinical and cognitive measures. Sex differences in the demographic and clinical characteristics, skin picking sites, and presence of comorbidities were examined using analysis of variance for continuous variables and likelihood ratio Chi-square tests for categorical variables.

RESULTS

Men were significantly more likely than women to report a first-degree relative with skin picking or hair pulling disorders (P = .0174). Men were less likely to pick from their scalps and backs and picked from fewer sites. Men and women did not significantly differ on skin picking severity, disability, impulsivity, or quality of life.

CONCLUSIONS

These data indicate that SPD is similarly impairing for men and women, but men may have higher familial loading and a somewhat different distribution and frequency of picking sites. Sex differences in SPD merit more detailed consideration in larger samples, including addressing potentially higher genetic/familial loading in males.

Pathological Skin Picking: Phenomenology and Associations With Emotions, Self-Esteem, Body Image, and Subjective Physical Well-Being

Pathological skin picking (PSP) refers to the repetitive manipulation of the skin causing wounds, scars, emotional distress, and social impairment. Skin picking disorder was first recognized as a distinct disorder in the DSM-5 and is still understudied in terms of phenomenology, etiology, and associated consequences. However, the body-related pathology suggests that the relation to the own body might be a crucial factor in PSP. Previous studies provided first insights that affected individuals show a more negative body image and lower self-esteem than healthy individuals. The present study sought to investigate skin picking phenomenology, related emotions as well as associations with self-esteem, body image, and subjective physical well-being. The study was conducted as an open online study, and recruitment was generally targeted to individuals of full age and in addition specifically to individuals with PSP. A total of 363 individuals (82.9% female; age: M = 32.6, SD = 13.92) participated and answered various self-report measures. Nearly half of the sample exceeded the cutoff score for pathological skin picking (N = 163; 44.9%). The results suggest that boredom, bodily tension and strong negative feelings often precede PSP episodes. During the episode most individuals seem to experience a loss of control, trance and positive feelings. After the PSP episode, shame, guilt, anger and anger toward themselves are most prominent. As expected, skin picking severity was positively associated with body image disturbances and negatively with self-esteem, and subjective physical well-being. When controlling for depressive symptoms, all associations were reduced, but those with body image disturbances (r = 0.44; p < 0.001), self-esteem (r = -0.27; p < 0.001), subjective physical well-being (r = -0.22; p < 0.001), and peace of mind (r = 0.30; p < 0.01) remained significant. Moreover, greater skin damage due to skin picking was moderately associated with higher body image disturbances. The results indicate that PSP severity is associated with a negative body image and low self-esteem, and suggest that it may be warranted to consider these aspects in the development of future interventions for PSP. However, relations with body image and self-esteem should be examined in longitudinal studies investigating causal relationships between body image, self-esteem and skin picking. Moreover, PSP phenomenology and the role of specific emotions should be investigated in more detail.

Trichotillomania and Skin-Picking Disorder: An Update

Trichotillomania (hair pulling disorder) and skin-picking (excoriation) disorder are common neuropsychiatric disorders (each with a point prevalence of around 2%) but are underrecognized by professionals. Affected individuals repeatedly pull out their own hair or pick at their skin, and these symptoms not only have a negative impact on these individuals because of the time they occupy but can also lead to considerable physical disfigurement, with concomitant loss of self-esteem and avoidance of social activities and intimate relationships. The behaviors may also have serious physical consequences. Trichotillomania and skin picking frequently co-occur, and both disorders commonly present with co-occurring depression, anxiety, impulsive, and obsessive-compulsive disorders. Behavioral therapy currently appears to be the most effective treatment for both. Pharmacotherapy, in the form of N-acetylcysteine or olanzapine, may also play a role in treatment.

Suicidality in patients with obsessive-compulsive and related disorders (OCRDs): A meta-analysis

INTRODUCTION

Previous meta-analyses showed that OCD is associated with a substantial risk of suicidal behaviours. Conclusive rates of suicidal ideation (current and lifetime) and suicide attempts based on pooled prevalence rates have not so far been calculated using meta-analysis for the other DSM-5 Obsessive-Compulsive and Related Disorders (OCRDs).

OBJECTIVES

This meta-analysis aims to separately calculate the pooled prevalence rates of lifetime suicide attempts and current or lifetime suicidal ideation in BDD, Hoarding Disorder (HD), Skin Picking Disorder (SPD) and Trichotillomania (TTM) and to identify factors associated with increased suicide rates.

METHODS

Our protocol was pre-registered with PROSPERO (CRD42020164395). A systematic review and meta-analysis following PRISMA reporting guidelines was performed by searching in PubMed/Medline, PsycINFO, Web of Science and CINAHL databases from the date of the first available article to April 20th, 2020. Stata version 15 was used for the statistical analysis. Given the small number of studies in TTM and SPD, the two grooming disorders were grouped together. Meta-analyses of proportions based on random effects (Der-Simonian and Laird method) were used to derive the pooled estimates.

RESULTS

Thirty-eigth studies (N = 4559 participants) were included: 23 for BDD, 8 for HD, 7 for Grooming Disorders. For BDD, the pooled prevalence of lifetime suicide attempts, current and lifetime suicidal ideation was, respectively 35.2% (CI:23.4-47.8), 37.2% (CI:23.8-51.6) and 66.1% (CI:53.5-77.7). For HD, the pooled prevalence of lifetime suicide attempts, current and lifetime suicidal ideation was 24.1% (CI:12.8-37.6), 18.4% (CI:10.2-28.3) and 38.3% (CI:35.0-41.6), respectively. For Grooming Disorders, the pooled prevalence of lifetime suicide attempts and current suicidal ideation were 13.3% (CI:5.9-22.8) and 40.4% (CI:35.7-45.3), respectively (no data available for lifetime suicidal ideation).

CONCLUSIONS

The OCRDs as a group are associated with relatively high rates of suicidal behaviour. Through indirect comparisons, we infer that BDD has the greatest risk. Comorbid substance abuse, possibly reflecting poor underlying impulse control, is associated with higher rates of suicidal behaviour in BDD. Our data emphasize the need for clinicians to consider the risk of suicidal behaviour in the management of patients presenting with all forms of OCRDs.

Trichotillomania-psychopathological correlates and associations with health-related quality of life in a large sample

BACKGROUND

Relatively few studies have assessed the prevalence, correlates, and independent impact on quality of life (QoL) of trichotillomania (TTM) in large samples.

METHODS

Consecutive participants (N = 7639) were recruited from a cross-sectional web-based study. Sociodemographic data were collected and several validated self-reported mental health measures were completed (Minnesota Impulsive Disorders Interview, Hypomania checklist, Fagerström Test for Nicotine Dependence, Alcohol Use Disorders Identification Test, Early Trauma Inventory Self Report-Short Form, and the Symptom Checklist-90-Revised Inventory). Health-related QoL was assessed with the World Health Organization QoL abbreviated scale (WHOQOL-Bref). Multivariable models adjusted associations to potential confounders.

RESULTS

The sample was predominantly composed of young females (71.3%; mean age: 27.2 ± 7.9 years). The prevalence of probable TTM was 1.4% (95% confidence intervals [CI]: 1.2-1.7), and was more common among females. Participants with probable TTM had a greater likelihood of having co-occurring probable depression (adjusted odds ratio [ORadj] = 1.744; 95% CI: 1.187-2.560), tobacco (ORadj = 2.250; 95% CI: 1.191-4.250), and alcohol (ORadj = 1.751; 95% CI: 1.169-2.621) use disorders. Probable TTM was also independently associated with suicidal ideation (ORadj = 1.917; 95% CI: 1.224-3.003) and exposure to childhood sexual abuse (ORadj = 1.221; 95% CI: 1.098-1.358). In addition, a positive screen for TTM had more impaired physical and mental QoL.

CONCLUSIONS

TTM was associated with a positive screen for several psychiatric comorbidities as well as impaired physical and psychological QoL. Efforts towards the recognition and treatment of TTM across psycho-dermatology services are warranted.

Excoriation (skin-picking) disorder among adolescents and young adults with acne-induced postinflammatory hyperpigmentation and scars

A plethora of health-related concerns, including skin disorders, are particularly common during the critical periods of adolescence and young adulthood. Their reactions to skin-related disorders can be different from their reactions to other disorders. While medical problems could be physiologically impacting, skin disorders like excoriation disorder can, in addition, directly affect their physical appearance in ways that have psychological consequences like anxiety, low self-esteem, and impaired quality of life. The increasing prevalence of excoriation disorder has resulted in its inclusion in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the eleventh edition of the International Classification of Diseases (ICD-11) manuals as one of the obsessive-compulsive disorders (OCD)-related disorders. However, health care professionals may not often recognize this important entity especially among adolescents and young adults with acne vulgaris presenting with chronic or recurrent acne-induced postinflammatory hyperpigmentation and scars. A number of self-reported tools are available for use in screening and/or assessment of excoriation disorder and to aid its management. While both pharmacologic and non-pharmacologic therapies are available, patient education is important. Physicians who usually make first contact with patients, such as Family Medicine Physicians, Pediatricians, Dermatologists, and Aesthetic Medicine Physicians, should have a relatively high index of suspicion for this disorder, especially in those presenting rather frequently with new or repeat lesions. Prompt referral to licensed mental health specialists is encouraged in order to ensure the provision of holistic care to affected persons.

Dermatillomania: Strategies for Developing Protective Biomaterials/Cloth

Dermatillomania or skin picking disorder (SPD) is a chronic, recurrent, and treatment resistant neuropsychiatric disorder with an underestimated prevalence that has a concerning negative impact on an individual’s health and quality of life. The current treatment strategies focus on behavioral and pharmacological therapies that are not very effective. Thus, the primary objective of this review is to provide an introduction to SPD and discuss its current treatment strategies as well as to propose biomaterial-based physical barrier strategies as a supporting or alternative treatment. To this end, searches were conducted within the PubMed database and Google Scholar, and the results obtained were organized and presented as per the following categories: prevalence, etiology, consequences, diagnostic criteria, and treatment strategies. Furthermore, special attention was provided to alternative treatment strategies and biomaterial-based physical treatment strategies. A total of six products with the potential to be applied as physical barrier strategies in supporting SPD treatment were shortlisted and discussed. The results indicated that SPD is a complex, underestimated, and underemphasized neuropsychiatric disorder that needs heightened attention, especially with regard to its treatment and care. Moreover, the high synergistic potential of biomaterials and nanosystems in this area remains to be explored. Certain strategies that are already being utilized for wound healing can also be further exploited, particularly as far as the prevention of infections is concerned.

Skin picking treatment with the Rothbaum cognitive behavioral therapy protocol: a randomized clinical trial

Introduction:

Although behavioral therapies can effectively treat skin picking disorder (SPD), there is no standardized treatment for improving SPD and its comorbidities and there is no group intervention option. This trial aimed to adapt the Rothbaum trichotillomania protocol to SPD (Study 1) and test its efficacy for treating SPD and comorbidities in individual and group formats (Study 2).

Methods:

The adapted protocol was applied to 16 SPD patients, who were allocated to group or individual treatment (Study 1). Afterwards, 54 patients were randomly allocated to treatment in an individual (n=27) or group format (n=27) (Study 2). In both studies, assessments of SPD severity, anxiety, depression, clinical status and skin lesion severity were performed at baseline and the endpoint.

Results:

The adapted protocol was feasible in both treatment modalities (Study 1) and led to high SPD remission rates (individual 63%; group 52%), with no significant difference between intervention types (p = 0.4) (Study 2). SPD, anxiety, and depression symptoms and objective patient lesion measures improved after treatment. There was large effect size for SPD symptom improvement in both treatment types (Cohen’s d: group = 0.88; individual = 1.15) (Study 2).

Conclusion:

The adapted Rothbaum protocol was effective for SPD remission, comorbidities, and skin lesions, both in individual and group formats.

Clinical trial registration:

NCT03182478

Prevalence of skin picking (excoriation) disorder

Skin picking (excoriation) disorder is a mental health condition characterized by repetitive picking of one's skin leading to tissue damage as well as functional impairment and/or distress. A convenience sampling of 10,169 adults, aged 18-69 years, representative of the general US population, completed a survey to establish occurrence of skin picking disorder. 213 participants (2.1%) (55.4% female) identified as having current skin picking disorder and 318 (3.1%) (54.1% female) reported lifetime skin picking disorder (i.e. current or past). Those with current skin picking disorder were significantly more likely to be female compared to those who never had skin picking (Likelihood Ratio, LR chi-square = 31.705, p < 0.001). Mental health comorbidities were common with generalized anxiety disorder (63.4%), depression (53.1%), and panic disorder (27.7%) being the most frequently endorsed. This study suggests that skin picking disorder is relatively common in the general population and typically characterized by high rates of comorbidity.

Estimated Frequency of Psychodermatologic Conditions in Alberta, Canada

BACKGROUND

Psychodermatologic disorders are difficult to identify and treat. Knowledge about the prevalence of these conditions in dermatological practice in Canada is scarce. This hampers our ability to address potential gaps and establish optimal care pathways.

OBJECTIVES

To provide an estimate of the frequencies of psychodermatologic conditions in dermatological practice in Alberta, Canada.

METHODS

Two administrative provincial databases were used to estimate the prevalence of potential psychodermatological conditions in Alberta from 2014 to 2018. Province-wide dermatology claims data were examined to extract relevant International Classification of Disease codes as available. Claims were linked with pharmacy dispensation data to identify patients who received at least 1 psychoactive medication within 90 days of the dermatology claim.

RESULTS

Of 243 963 patients identified, 28.6% had received at least 1 psychotropic medication (mean age: 47.9 years; 67.5% female). Rates of concurrent psychotropic medications were highest for pruritus and related conditions (46.7%), followed by urticaria (44.5%) and hyperhidrosis (32.8%). Among patients with psychotropic medications, rates of antidepressants were highest (56.3%), followed by anxiolytics (37.1%). Across billing codes, besides hyperhidrosis (71.2%), diseases of hair (61.4%) and psoriasis (59.1%) had the highest rates of antidepressant dispensations. Patients with atopic dermatitis had the highest rates for anxiolytic prescriptions (54.3%).

CONCLUSION

In a 5-year window, more than a quarter of the identified dermatology patients in Alberta received at least 1 psychotropic medication, pointing to high rates of potential psychodermatologic conditions and/or concurrent mental health issues in dermatology. Diagnostic and care pathways should include a multidisciplinary approach to better identify and treat these conditions.

Obsessive-compulsive or addiction? Categorical diagnostic analysis of excoriation disorder compared to obsessive-compulsive disorder and gambling disorder

Excoriation disorder (ED) is currently classified in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders' Obsessive-compulsive and Related Disorders section (OCRD). However, there remain debates regarding whether ED is related to obsessive-compulsive disorder (OCD) or whether it is better conceptualized as a behavioral addiction. The present research compared the diagnostic overlap and psychiatric comorbidities of 121 individuals seeking treatment for ED (n = 40), OCD (n = 41) and gambling disorder (GD) (n = 40). ED was more likely to overlap with OCD (n = 14) than GD (n = 3). Compared to OCD, ED had similar frequencies of other body focused repetitive behaviors (BFRBs), but higher frequency of addictive behaviors (Odds Ratio - OR = 11.82). In comparison to GD, ED had similar frequencies of addictive behaviors, but higher frequency of BFRBs (OR=19.67). The results support the recent classification of ED as an OCRD. However, ED presents an association with behavioral addictions that suggests a mixed impulsive-compulsive nature. A limitation of the present research was the use of a non-validated semi-structured clinical interview to diagnose impulse control disorders. Future research should examine other characteristics (e.g., epidemiology, neurobiology, genetics, treatment response) to further investigate whether ED should remain classified as an OCRD.

Should skin picking disorder be considered a diagnostic category? A systematic review of the evidence

OBJECTIVES

The aim of this study was to conduct a systematic review of the literature to collect, analyse and synthesise the evidence on skin picking disorder as defined by Arnold's criteria or the Diagnostic and Statistical Manual of Mental Disorders - fifth edition (DSM-5) and to examine whether skin picking disorder warrants inclusion in the DSM-5 as a distinct disorder.

METHOD

The databases CINAHL, Medline, Embase and PsycINFO were searched for articles published between January 2008 and May 2018. Eligible articles were empirical studies that used Arnold's or DSM-5 criteria to diagnose skin picking disorder, published in English, with participants aged 18 years or older. The methodological quality of included studies was assessed according to the National Health and Medical Research Council's guidelines and suggested nosological classification of skin picking disorder were summarised. Eligible studies were assessed against the five criteria proposed by Blashfield and colleagues to determine the validity of the inclusion of skin picking disorder in the DSM-5.

RESULTS

A total of 20 studies were considered eligible out of 1554. Most of the papers were case-control studies with small clinical samples. Only one out of Blashfield's five criteria was met; there were commonly accepted diagnostic criteria and assessment scales present in the literature. However, at the time of review, the criterion of 50 published articles (25 of which are required to be empirical) was not met; there had been no publication specifically assessing the clinical utility or validity of skin picking disorder and no studies addressing the differentiation of skin picking disorder from other obsessive-compulsive and related disorders.

CONCLUSION

Only a small proportion of published studies on skin picking disorder have employed validated criteria. The current literature fulfills only one of Blashfield's five criteria for the inclusion of skin picking disorder as a specific entity in psychiatric diagnostic manuals. Further empirical studies on skin picking disorder are needed in order to substantiate skin picking disorder as a disorder distinct from related disorders under the obsessive-compulsive and related disorders category.

Skin-Picking Disorder: A Guide to Diagnosis and Management

Skin-picking disorder, also known as excoriation disorder or psychogenic skin excoriations, is an obsessive-compulsive and related disorder that is classified with other body-focused repetitive-behavior disorders in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Skin-picking disorder is associated with significant comorbidity and psychosocial dysfunction. The disorder has a female predominance across studies, and the average age of onset is variable but commonly in adolescence and adulthood. A full clinical and dermatologic examination and multidisciplinary approach is important in the diagnosis of this condition. There is no specific or recommended treatment option, but cognitive-behavioral therapy, particularly habit-reversal therapy and acceptance and commitment therapy have shown promise. Various pharmacological interventions have also been described to treat this condition in case reports and open and controlled trials. Specific classes of agents implemented include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors, antipsychotics, and glutaminergic-modulating agents. SSRIs and N-acetylcysteine have been shown to be the most effective of the pharmacological interventions.

Prevalence and correlates of clinically significant body-focused repetitive behaviors in a non-clinical sample

BACKGROUND

Body-focused repetitive behaviors (BFRBs) are repetitive, ritualized behaviors focused on the body, involving compulsively damaging one's physical appearance or causing physical injury. They include skin picking, hair pulling, nail biting, and lip or cheek biting and chewing. This study sought to examine prevalence, clinical correlates and quality of life (QoL) impairment associated with these conditions in a non-clinical sample of adults.

METHOD

An online survey was completed by N = 1378 participants. Comparisons were made between those self-reporting body-focused repetitive behavior to those without, on a range of clinical correlates (depression, anxiety, obsessive-compulsive symptoms, body dysmorphic symptoms, fear of negative evaluation) and QoL domains.

RESULTS

Three-hundred and eighteen participants (23%) reported the presence of a probable BFRB; n = 85 (6%) nail biting, n = 88 (6%) lip or cheek biting/chewing, n = 187 (14%) skin picking, and n = 39 (2%) hair pulling. There were significant differences between those with and without a probable BFRB (pBFRB) across all clinical variables investigated, with the pBFRB group reporting higher levels of symptoms. The BFRB group reported reduced QoL on some domains. Few differences emerged between the BFRB groups, although individuals with probable skin picking reported higher levels of body image concern, than those with other pBFRB conditions, and there was a trend toward probable skin picking to endorse higher levels of OCD symptoms and anxiety. There were no significant differences between the BFRB groups on QoL domains.

CONCLUSION

Although differences were found between those with a pBFRB and those without, there were few differences between the different pBFRB groups, indicating that all BFRB conditions are concerning. Skin picking may be one of the more severe of the BFRB presentations, although the small number of differences between the groups may reflect a single pathological grooming factor underlying the BFRBs. These findings underscore the importance of recognizing that all body-focused behaviors can cause significant distress, impairment, and reduced QoL, and highlights the need for timely and accurate identification of these conditions by health professionals.