Normal Behavior or Mental Illness?
Several new diagnoses will appear in the soon to-be-released Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-V). In fact, quite a bit of controversy surrounds the inclusion of several of these new “disorders” in what is considered to be the mental health world’s diagnostic “bible,” as many question their validity and appropriateness for inclusion.
Among the new DSM-V disorders is Excoriation (Skin Picking) Disorder, classified within the Obsessive Compulsive and Related Disorders. It is understandable that the initial public reaction to this release of information has been skeptical (at best). News outlets have begun to question the validity of the diagnosis. Readers have begun to leave comments such as, “Great, now we’re all mentally ill.”
Yes, everyone picks at his or her skin at some point; however, Excoriation Disorder far exceeds “normal” grooming behavior. Think of grooming behavior as occurring on a continuum, with normal, washing and exfoliating on one end of the continuum, extending to picking, scraping, or gouging that results in scarring or disfigurement on the other end.
A Case Example
Daphne is an attractive, intelligent twenty-six year old woman who works long hours as a surgical assistant, a job she very much enjoys. She lives alone in a one-bedroom apartment. She is not currently in a relationship. Although Daphne considers herself “on the market”, she reports that she is reluctant to date, as she is self-conscious and embarrassed of her body. She explains this as she rolls up the pant legs of her work scrubs to reveal her legs, which are covered in scars. She then removes her sweater to reveal her arms, which are similarly marked.
Daphne explains that she spends two hours each morning applying make-up to her face to cover discoloration and blemishes from picking her facial skin. She tells me that she finds it easier to cover her legs and arms with clothing. Daphne has made many attempts to stop picking, but feels like she “can’t help it.” She describes her typical picking urge as an attempt to make a given spot look less red, less scabbed, less, bumpy, or to speed the healing process. She knows that picking at the spot rarely results in this improvement, and moreover, results in further damage; however, she proceeds. She stated that she wants to stop; yet she spends approximately 45 to 90 minutes per day engaged in skin picking. She describes herself as frustrated and somewhat isolated as a result of her picking.
DSM-V Diagnostic Criteria for Excoriation (Skin Picking) Disorder will include:
- Recurrent skin picking that results in skin lesions
- Repeated attempts to stop the behavior
- The symptoms cause clinically significant distress or impairment
- The symptoms are not caused by a substance or medical, or dermatological condition
- The symptoms are not better explained by another psychiatric disorder
The Straight Facts
- Excessive skin picking occurs in up to 5.4% of U.S. adults.
- Those who engage in skin picking tend to pick from multiple body sites, for extended periods of time, targeting both healthy and previously damaged skin.
- Commonly reported antecedents (experiences prior to skin picking) include: an urge or physical tension prior to picking, unpleasant emotions, cognitions, or sensations, and a displeasing aspect of his or her appearance.
- Commonly reported consequences (experiences following picking behavior) include: urge reduction, sense of relief, or pleasure, psychosocial difficulties or embarrassment, avoidance, reduced productivity, and emotional sequelae such as anxiety or depression, scars, lesions, disfigurement.
- There is emerging evidence that skin picking is both environmentally and biologically influenced.
- The study of skin picking (and other body focused repetitive behaviors – BFRBs) is still in its infancy. There remains a great deal to learn.
Habit Reversal Training (HRT), a form of Cognitive Behavioral Therapy (CBT), is the most studied, evidence-based treatment at this time for skin picking and other BFRBs. Some HRT plans include additional components, but all HRT plans consist of:
1) Awareness training – to monitor and increase the awareness of the behavior
2) Competing Response Training – substituting a competing response for picking behavior that is incompatible with picking
3) Social Support – gaining support from loved one and the community
Comprehensive Behavioral Treatment (ComB) was developed by Dr. Charles Mansueto and colleagues from a growth of HRT as a cognitive behavioral means of more comprehensively and individually tailoring treatment plans. Although there is no formal outcome data at present, ComB is considered among the standard of care. It is currently undergoing clinical trial. The ComB treatment involves:
1) Assessment – Awareness training through and self-monitoring of behavior
2) Identify Target Modalities – Behavior “triggers” are identified which may include Sensory, Cognitive (thoughts), Affective (feelings), Motor, and Place/Environmental factors.
3) Choose Target-Specific Intervention Strategies – Based upon behavior analysis information (information regarding behavior “triggers” and consequences), interventions are chosen. Interventions vary widely and are cognitive behavioral in nature.
4) Evaluation – Assess effectiveness of strategies and implement additional strategies, as needed
Acceptance and Commitment Therapy (ACT) and Dialectical Behavior Therapy (DBT) strategies, as adjunctive strategies, have been demonstrated to be helpful in reducing problematic grooming behavior in studies of a related disorder, trichotillomania.
Medication – Only four controlled skin picking medication studies have been published to date. Two studies examined the use of fluoxetine (Prozac). Both studies, although involved very small sample sizes, found that fluoxetine was more helpful than placebo in improving skin picking. The remaining two studies produced non-significant findings. Serotonin Reuptake inhibitors (SRIs) and Selective Serotonin Reuptake Inhibitors (SSRIs) are considered to be the most useful prescription at this time. N-Acetyl Cysteine (NAC), an amino acid demonstrated to be moderately effective in a study of adults with trichotillomania, is currently being studied in adults with skin picking.
There is such a thing as a seemingly normal behavior gone awry, to the point at which it is no longer normal. Excoriation (Skin Picking) Disorder can be a devastating problem. It is my hope that with time and education, we will be able to acknowledge the significance of this problem and provide the help that is so desperately needed.
Photo available at 123rf.com
Deibler, M. (2013). Normal Behavior or Mental Illness?. Psych Central. Retrieved on February 11, 2016, from http://blogs.psychcentral.com/therapy-that-works/2013/04/normal-behavior-or-mental-illness/