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Skin-picking and Self-injurious Behavior

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Skin-picking as a form of self-injurious behavior

Amy Gedeon

Penn State College of Medicine

September 2002

Self-Mutilation

Intentional infliction of bodily injury to oneself, without intent to die

Three types

1. Severe but infrequent – e.g. amputation; associated with psychosis

2. Stereotypic – function as self-stimulation; e.g. head-banging

3. Moderate – episodic and compulsive; e.g. self-cutting, skin picking, and trichotillomania

Clinical Characteristics of Skin Picking

Also known as “neurotic excoriation”, “self-inflicted dermatoses”, and

“dermatillomania”

Most common site is face, but lips, scalp, arms, hands, and legs also affected
Fingernails most commonly used, but picking with tweezers, pins, teeth, and other instruments is also described
More than half of all individuals who skin pick also report histories of stereotypic behaviors such as body rocking, thumb sucking, knuckle cracking, cheek chewing, and head banging
Time spent picking varies from 5 minutes to 12 hours daily

Many report increased picking at night, when tired

Many affected patients seek dermatology services instead of psychiatric treatment

May report sensations such as itching, tingling, burning, or an uncontrollable urge to pick their skin

Prevalence

Occurs more often in women than in men
Prevalence rate of self-mutilation in US population is 1-2%
No published reports of the incidence of skin picking in a psychiatric population

Course of Illness

Usually gradual and long-term
Mean age of onset reported to be adolescence to early adulthood
Uncertain how skin picking is acquired and maintained
Many patients report increasing levels of tension prior to skin picking and a sense of relief or satisfaction following the picking, as found in trichotillomania
Some patients experience an altered state of consciousness while picking, resembling a dissociative state – report that they do not experience pain while picking

Association with Axis I and Axis II Psychiatric Disorders

Skin picking not included in DSM-IV’s impulse-control disorders
A symptom of another psychiatric disorder or a syndrome in itself?
Skin picking can be related to Obsessive-compulsive disorder (OCD)

Two studies reported that half of patients with compulsive skin picking met criteria for OCD; another study reported only 2 out of 24 met OCD criteria
Often a response to obsessions (i.e. symmetry) and done in a ritualistic manner

Can also be related to Body Dysmorphic Disorder (BDD)

Study of 123 BDD patients - 27% engaged in skin-picking
Results from skin preoccupation, camouflaging of perceived defects, and excessive grooming behaviors
BDD patients who skin pick were more likely to have personality psychopathology than those who did not

Association with Mood Disorders

High rate of mood disorders, ranging from 48% to 79%, among skin picking patients has been reported

Association with Anxiety Disorder

56% - 65% of skin picking patient suffer from an anxiety disorder

Association with Medication/Drugs

Use of cocaine, methylphenidate, phenelzine, amphetamine, and anticholinergic drugs may produce tactile sensations which lead to skin picking
38% co-morbidity of substance abuse and skin picking

Association with Genetic Disorders

Skin picking associated with Lesch-Nyhan syndrome, Prader Willi syndrome, or mental retardation

Comorbid personality disorders in skin picking

One study found 71% of skin picking patients met criteria for a personality Disorder
OCD and Borderline personality disorders most frequent

Monosymptomatic hypochondriasis

May present as skin picking
Now referred to as delusional disorder – patients may cause skin damage in response to imagined parasites

Biological etiology of skin picking

Compulsive feather picking in birds and compulsive paw licking in dogs has been documented
Administration of amphetamines leads to self-injurious behavior in horses, rats, and dogs

Implication of B-endorphins

Lack of pain during picking episodes may be related to opioid dysregulation
Study by Gillberg, et al, demonstrated elevated levels of B-endorphin in CSF of patients with self-injurious behavior
But why the dysregulation of opioid regulatory system in some patients?
Pain leads to release of B-endorphins

Kirkmayer and Carrol’s theory suggests that victims of childhood physical abuse may have elevated levels of B-endorphin in CSF because of repeated exposure to pain, or from being prohibited to reacting physically to the infliction of pain
Self-injury stimulates release of endorphins – leads to release of tension

Is reinforcing and leads to maintenance of self-injurious behavior

Psychological Theories of Skin Picking

Suyemoto’s theory of Ambivalence – Patient’s ambivalence of the desire for life or death

Skin picking allows the patient to alleviate feelings of guilt by sacrificing a body part while allowing themselves to live

Skin picking as a sequelae of childhood abuse

Abuse results in self-hatred or self-directed anger. Picking may be used as a coping mechanism for dealing with emotional pain (i.e. physical pain distracts the individual).
Child learns that self-injurious behavior is reinforcing through family modeling of abuse, where pain is linked to caring or control. Thus, self-harm behavior is reinforced by the environment.

Treatment

SSRI’s (selective serotonin reuptake inhibitors) – reported to have good results
Double-blind, placebo-controlled study of the SSRI fluoxetine found significant improvement at doses of 20 mg/day (non-responders increased to 40 mg/day and eventually 60 mg/day)
SSRI’s also effective in treating skin picking in Prader Willi Syndrome
Psychological treatments – very little published regarding cognitive and behavioral therapy, although they may be helpful

Conclusion

Much variability occurs in terms of frequency, length, and triggers of skin picking
Barriers to reaching conclusions include small sample sizes and convenience sampling
More research needed to determine prevalence of skin picking among various diagnostic categories

References:

Neziroglu, Fugen: Mancebo, Maria. Skin picking as a form of self-injurious behavior. Psychiatric Annals. 2001; 31(9): 549-55.

Bloch, et al. Fluoxetine in Pathologic Skin-Picking. Psychosomatics. 2001; 42(4): 314-19.

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