Skin-picking and Self-injurious Behavior

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:

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

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