Excoriation Disorder - Anatomy of Psych

What is excoriation disorder?

Excoriation disorder, also known as skin-picking disorder, is characterized by the repeated urge to pick at one's own skin, often to the extent that the individual causes significant skin damage. The prevalence of excoriation disorder is 1-2%, and it affects women more than men.

What does excoriation disorder look like?

Signs & Symptoms

Many individuals spend at least 1 hour per day picking, thinking about picking, and/or resisting urges to pick
Most commonly picked sites are on the face, arms, and hands, but many individuals pick from multiple body sites
There may be a sense of gratification, pleasure, or sense of relief when the skin or scab has been picked
Does not usually occur in the presence of other individuals, except in the presence of immediate family members

DSM-5 Criteria

Criterion A. Recurrent skin picking resulting in skin lesions.

Criterion B. Repeated attempts to decrease or stop skin picking.

Criterion C. The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion D. The skin picking is not attributable fo the physiological effects of a substance or another medical condition.

Criterion E. The sin picking disorder is not better explained by symptoms of another mental disorder.

Risk Factors

More common in individuals with obsessive-compulsive disorder and their first-degree family members

Prognosis

Often develops during the onset of adolescent and commonly begins with a dermatological condition such as acne
The illness course is chronic, with axing and waning symptoms if left untreated
Medical complications such as scarring, tissue damage, and infection can become life-threatening

Differential Diagnosis

Psychotic disorders
Obsessive-compulsive disorder
Body dysmorphic disorder
Body-focused repetitive behavior disorder
Neurodevelopmental disorders
Somatic symptom and related disorders
Nonsuicidal self-injury
Other medical conditions
Substance/medication-induced disorders

How is excoriation disorder investigated?

Skin Picking Impact Scale (SPIS)

Client rater
28-item scale to assess the psychosocial consequences of repetitive skin picking

Yale-Brown Obsessive Compulsive Scale Modified for Neurotic Excoriation (NE-YBOCS)

Clinician rater
Measures symptom severity

Skin Picking Scale - Revised (SPS-R)

Client rater
8-item scale to assess clinical severity of the skin picking behaviors

How is excoriation disorder treated?

Selective serotonin reuptake inhibitors (SSRI)
Naltrexone

Nursing Management

Ineffective coping

Causes & Behaviors:

Situational or maturational crises
Fear of failure
Ritualistic behavior or obsessive thoughts
Inability to meet basic needs
Inability to meet role expectations
Inadequate problem solving

Interventions:

Investigate the types of situations that increase anxiety and result in ritualistic behaviors
Increasingly encourage independence and give positive reinforcement for independent behaviors to enhances self-esteem and encourage repetition of desired behaviors over undesired behaviors
Gradually limit the amount of time allotted for ritualistic behavior as client becomes more involved in unit activities
Encourage the client to recognize situations that provoke obsessive thoughts or ritualistic behaviors
Provide positive reinforcement for adaptive, nonritualistic behaviors

References

[1] American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

[2] Boyd, M. A. (2019). Psychiatric & mental health nursing for Canadian practice. Wolters Kluwer.

[3] Townsend, M. C. (2015). Psychiatric mental health nursing. F.A. Davis.