Advertisement

Treatment of an Adult with Excoriation (Skin-Picking) Disorder

  • Lauren S. Hallion
  • Jennifer M. Park
  • Nancy J. KeuthenEmail author
Chapter

Abstract

Pathological skin picking, known as excoriation (skin-picking) disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is a chronic and disabling obsessive-compulsive spectrum disorder characterized by repeated picking of the skin resulting in tissue damage. This chapter describes the successful treatment of a 33-year-old woman with moderate-to-severe excoriation disorder. Treatment comprised two assessment sessions followed by nine sessions of cognitive-behavioral therapy (CBT). Specific interventions included psychoeducation, self-monitoring and awareness training, stimulus control, competing response training, contingency management, cognitive restructuring, and dialectical behavior therapy (DBT) skills.

Keywords

OC spectrum Excoriation Skin-picking CBT DBT 

References

  1. American Psychiatric Association (APA). (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association.Google Scholar
  2. American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington: American Psychiatric Association.Google Scholar
  3. Antony, M. M., Bieling, P. J., Cox, B. J., Enns, M. W., & Swinson, R. P. (1998). Psychometric properties of the 42-item and 21-item versions of the depression anxiety stress scales in clinical groups and a community sample. Psychological Assessment, 10, 176–181.CrossRefGoogle Scholar
  4. Arnold, L. M., McElroy, S. L., Mutasim, D. F., Dwight, M. M., Lamerson, C. L., & Morris, E. M. (1998). Characteristics of 34 adults with psychogenic excoriation. Journal of Clinical Psychiatry, 59(10), 509–514.PubMedCrossRefGoogle Scholar
  5. Arnold, L. M., Mutasim, D. F., Dwight, M. M., Lamerson, C. L., Morris, E. M., & McElroy, S. L. (1999). An open clinical trial of fluvoxamine treatment of psychogenic excoriation. Journal of Clinical Psychopharmacology, 19, 15–18.PubMedCrossRefGoogle Scholar
  6. Arnold, L. M., Auchenbach, M. B., & McElroy, S. L. (2001). Psychogenic excoriation: Clinical features, proposed diagnostic criteria, epidemiology and approaches to treatment. CNS Drugs, 15(5), 351–359.PubMedCrossRefGoogle Scholar
  7. Azrin, N. H., & Nunn, R. G. (1973). Habit-reversal: A method of eliminating nervous habits and tics. Behaviour Research and Therapy, 11, 619–628.PubMedCrossRefGoogle Scholar
  8. Beck, A. T., Steer, R. A., & Brown, O. K. (1996). Beck depression inventory manual (2nd ed.). San Antonio: Psychological Corporation.Google Scholar
  9. Bloch, M. R., Elliott, M., Thompson, H., & Koran, L. M. (2001). Fluoxetine in pathologic skin picking: Open-label and double-blind results. Psychosomatics, 42(4), 314–349.PubMedCrossRefGoogle Scholar
  10. Bohne, A., Wilhelm, S., Keuthen, N. J., Baer, L., & Jenike, M. A. (2002). Skin picking in German students. Prevalence, phenomenology, and associated characteristics. Behavioral Modification, 26(3), 320–339.CrossRefGoogle Scholar
  11. Calikuşu, C., Kucukoncu, S., Tecer, O., & Bestepe, E. (2012). Skin picking in Turkish students: Prevalence, characteristics, and gender differences. Behavior Modification, 36, 49–66.PubMedCrossRefGoogle Scholar
  12. Deckersbach, T., Wilhelm, S., & Keuthen, N. J. (2003). Self-injurious skin picking: Clinical characteristics, assessment methods, and treatment modalities. Brief Treatment and Crisis Intervention, 3, 249–258.CrossRefGoogle Scholar
  13. First, M. B., Spitzer, R. L. Gibbon, M., & Williams, J. B. W. (1996). Structured clinical interview for DSM-IV axis I disorders, clinician version (SCID-CV). Washington: American Psychiatric Association.Google Scholar
  14. First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B. W., & Benjamin, L. S. (1997). Structured clinical interview for DSM-IV axis II personality disorders, (SCID-II). Washington: American Psychiatric Association.Google Scholar
  15. Flessner, C. A., & Woods, D. W. (2006). Phenomenological characteristics, social problems, and the economic impact associated with chronic skin picking. Behavior Modification, 30(6), 944–963.PubMedCrossRefGoogle Scholar
  16. Flessner, C. A., Busch, A. M., Heideman, P. W., & Woods, D. W. (2008). Acceptance-enhanced behavior therapy (AEBT) for trichotillomania and chronic skin picking: Exploring the effects of component sequencing. Behavior Modification, 32, 579–594.Google Scholar
  17. Fruensgaard, K., Hjortshoj, A., & Nielsen, H. (1978). Neurotic excoriations. International Journal of Dermatology, 17, 761–767.PubMedCrossRefGoogle Scholar
  18. Grant, J. E., Odlaug, B. E., & Kim, S. W. (2007). Lamotrigine treatment of pathological skin picking: An open–label study. The Journal of Clinical Psychiatry, 68, 1384–1391.PubMedCrossRefGoogle Scholar
  19. Grant, J. E., Oldaug, B. L., Chamberlain, S. R., Keuthen, N. J., Lochner, C., & Stein, D. J. (2012). Skin picking disorder. The American Journal of Psychiatry, 169, 1143–1149.PubMedCrossRefGoogle Scholar
  20. Hayes, S. L., Storch, E. A., & Berlanga, L. (2009). Skin picking behaviour: An examination of the prevalence and severity in a community sample. Journal of Anxiety Disorders, 23, 314–319.PubMedCrossRefGoogle Scholar
  21. Keuthen, N. J., Deckersbach, T., Wilhelm, S., Hale, E., Fraim, C., Baer, L., et al. (2000). Repetitive skin picking in a student population and comparison with a sample of self-injurious skin-pickers. Psychosomatics, 41(3), 210–215.PubMedCrossRefGoogle Scholar
  22. Keuthen, N. J., Deckersbach, T., Wilhelm, S., Engelhard, I., Forker, A., O’Sullivan, R. L., et al. (2001a). The skin picking impact scale (SPIS): Scale development and psychometric analyses. Psychosomatics, 42, 397–403.PubMedCrossRefGoogle Scholar
  23. Keuthen, N. J., Wilhelm, S., Deckersbach, T., Engelhard, I. M., Forker, A. E., Baer, L., & Jenike, M. A., (2001b). The skin picking scale: Scale construction and psychometric analyses. Journal of Psychosomatic Research, 50, 337–341.PubMedCrossRefGoogle Scholar
  24. Keuthen, N. J., Jameson, M., Loh, R., Deckersbach, T., Wilhelm, S., & Dougherty, D. D. (2007). Open-label escitalopram treatment for pathological skin picking. International Clinical Psychopharmacology, 22, 268–274.PubMedCrossRefGoogle Scholar
  25. Keuthen, N. J., Koran, L. M., Aboujaoude, E., Large, M. D., & Serpe, R. T. (2010). The prevalence of pathologic skin picking in US adults. Comprehensive Psychiatry, 51, 183–186.PubMedCrossRefGoogle Scholar
  26. Linehan, M. (1993a). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford.Google Scholar
  27. Linehan, M. M. (1993b). Skills training manual for treating borderline personality disorder. New York: Guilford.Google Scholar
  28. Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990). Development and validation of the penn state worry questionnaire. Behaviour Research Therapy, 28, 487–495.PubMedCrossRefGoogle Scholar
  29. Miller, W. R., & Rollnick, S. (2013). Motivational interviewing, third edition: Helping people change. New York: Guilford.Google Scholar
  30. Monzani, B., Rijsdijk, F., Cherkas, L., Harris, J., Keuthen, N., & Mataix-Cols, D. (2012). Prevalence and heritability of skin picking in an adult community sample: a twin study. American Journal of Medical Genetics Part B: Neuropsychiatric Genetics, 159(5), 605–610.Google Scholar
  31. Neziroglu, F., Rabinowitz, D., Breytman, A., & Jacofsky, M. (2008). Skin picking phenomenology and severity comparison. Primary Care Companion to the Journal of Clinical Psychiatry, 10, 306.PubMedCentralPubMedCrossRefGoogle Scholar
  32. Odlaug, B. L., & Grant, J. E. (2008). Clinical characteristics and medical complications of pathologic skin picking. General Hospital Psychiatry, 30(1), 61–66.PubMedCrossRefGoogle Scholar
  33. Odlaug, B. L., & Grant, J. E. (2012). Pathologic skin picking. In J. E. Grant, N. J. Keuthen, D. W. Woods, & D. J. Stein (Eds.), Clinical manual for the treatment of trichotillomania, skin picking, and other stereotypic movement disorders (pp. 21–42). Washington: American Psychiatric Association.Google Scholar
  34. Schuck, K., Keijsers, G. P., & Rink, M. (2011). The effects of brief cognitive behaviour therapy for pathological skin picking: A randomized comparison to wait-list control. Behaviour Research Therapy, 49, 11–17.PubMedCrossRefGoogle Scholar
  35. Simeon, D., Stein, D. J., Gross, S., Islam, N., Schmeidler, J., & Hollander, E. (1997). A double-blind trial of fluoxetine in pathologic skin picking. Journal of Clinical Psychiatry, 58(8), 341–347.PubMedCrossRefGoogle Scholar
  36. Snorrason, I., Smari, J., & Olafsson, R. P. (2011). Motor inhibition, reflection, impulsivity, and trait impulsivity in pathological skin picking. Behavior Therapy, 42, 521–532.PubMedCrossRefGoogle Scholar
  37. Teng, E. J., Woods, D. W., & Twohig, M. P. (2006). Habit reversal as a treatment for chronic skin picking: A pilot investigation. Behavior Modification, 30(4), 411–422.PubMedCrossRefGoogle Scholar
  38. Tucker, B. T., Woods, D. W., Flessner, C. A., Franklin, S. A., & Franklin, M. E. (2011). The skin picking impact project: Phenomenology, interference, and treatment utilization of pathological skin picking in a population-based sample. Journal of Anxiety Disorders, 25, 88–95.PubMedCrossRefGoogle Scholar
  39. Wilhelm, S., Keuthen, N. J., Deckersbach, T., Engelhard, I. M., Forker, A. E., Baer, L., et al. (1999). Self-injurious skin picking: Clinical characteristics and comorbidity. Journal of Clinical Psychiatry, 60(7), 454–459.PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  • Lauren S. Hallion
    • 1
  • Jennifer M. Park
    • 1
  • Nancy J. Keuthen
    • 2
    Email author
  1. 1.Massachusetts General Hospital/Harvard Medical SchoolBostonUSA
  2. 2.OCD and Related Disorders ProgramMassachusetts General HospitalBostonUSA

Personalised recommendations