Psychogenic excoriation (also called neurotic excoriation, pathologic or compulsive skin picking, and dermatotillomania) is not yet recognized as a symptom of a distinct DSM-IV disorder.
The disorder is characterized by excessive scratching, gouging or squeezing normal skin or skin with minor surface irregularities. Excoriation may also occur in response to an itch or other skin sensation or to remove a lesion on the skin (e.g., acne excorie).
Most patients use fingernails to excoriate the skin, but the teeth and instruments (e.g., tweezers, nail files, pins or knives) also may be used (Arnold et al., 1998; Simeon et al., 1997). Excoriations are typically found in bodily areas that are easily reachable, and most patients excoriate multiple sites. The most common site of excoriation is the face (Arnold et al., 1998).
There is a 2% incidence of psychogenic excoriation among dermatology clinic patients, with higher prevalence among women (Gupta et al., 1986). Most studies report a mean age of onset between 30 and 40 years of age, and the reported mean duration of symptoms is 5.1 years, with the majority of patients having symptoms for 10 to 12 years (Gupta, et al., 1986; Simeon et al., 1997; Arnold et al., 1998). Psychogenic excoriation causes substantial distress in patients, with most experiencing impairment in social functioning and many reporting medical complications, some severe enough to warrant surgery (Arnold et al., 1998; Simeon et al., 1997).
The behavior in psychogenic excoriation sometimes resembles obsessive-compulsive disorder (OCD) in that it is repetitive, ritualistic and tension-reducing. Likewise, patients attempt-often unsuccessfully-to resist excoriating, a behavior they find "ego-dystonic" (Stein and Hollander, 1992). Some patients describe obsessions about an irregularity on the skin or preoccupations with having smooth skin and excoriate in response to those thoughts. The preoccupation with appearance can be severe enough to meet criteria for body dysmorphic disorder (BDD), a disorder also thought to be related to OCD (Phillips and Taub, 1995). The excoriation can also have features characteristic of impulse control disorders (ICDs) in that patients often find themselves acting automatically. They sometimes experience an increase in tension prior to scratching with transient pleasure or relief immediately afterwards.
In a recent study of the phenomenology of a group of 34 adults with psychogenic excoriation (Arnold et al., 1998), the majority (79%; N=27) had features of an ICD. Many of these patients with ICD symptoms also had either BDD (32%; N=11) or OCD (12%; N=4). A minority of patients had OCD alone (6%; N=2). Thus, skin-related behaviors spanned a compulsivity-impulsivity continuum from purely obsessive-compulsive to purely impulsive with mixed symptoms in between (McElroy et al., 1994).
Studies examining the psychiatric comorbidity of patients with psychogenic excoriation have found depressive and anxiety disorders to be common (Arnold et al., 1998; Gupta et al., 1987; Simeon et al., 1997). In a study of 34 adults with psychogenic excoriation, lifetime mood disorders were diagnosed in 27 (79%) of subjects; lifetime major depression (38%; N=13) and bipolar disorder type II (26%; N=9) were the most common (Arnold et al., 1998). The elevated prevalence of bipolar disorders in this group is consistent with the observation that impulse control disorders may have a strong association with bipolar disorders (McElroy et al., 1996; McElroy et al., 1994).
Lifetime anxiety disorder was diagnosed in 19 (56%) subjects, with panic disorder (21%; N=7), generalized anxiety disorder (21%; N=7) and specific phobia (21%; N=7) as the most common anxiety disorders.
There are few studies of the pharmacological treatment of psychogenic excoriation, but case reports and open trials demonstrate the responsiveness of psychogenic excoriation to serotonin reuptake inhibitors (SRIs) (Gupta and Gupta, 1993; Kalivas et al., 1996; Phillips and Taub, 1995; Stein et al., 1993; Stout, 1990). One controlled trial found that fluoxetine (Prozac) may be beneficial (Simeon et al., 1997).
To examine further the efficacy of SRIs in the treatment of psychogenic excoriation, 14 subjects were enrolled in an open-label, 12-week trial of fluvoxamine maleate (Luvox) (Arnold et al., 1999). The subjects were outpatients from a group of 34 subjects enrolled in Arnold et als. earlier study. All subjects met DSM-IV criteria for at least one comorbid psychiatric disorder, with mood disorder the most common (subjects with bipolar disorder type I were excluded from the trial).
The mean final fluvoxamine dose was 112.582.7 mg/day with a range of 25 mg/day to 300 mg/day. Treatment-associated adverse events-most commonly anorexia, nausea, fatigue, insomnia and headache-limited dose escalation. Four subjects withdrew because of treatment-associated side effects, and three withdrew for reasons that were unrelated to the study.
Both completers (N=7) and the entire group had significant improvement on a modified Yale-Brown Obsessive Compulsive Scale (Y-BOCS) (Goodman et al., 1989) that measured both preoccupation with skin and associated behaviors (time occupied, interference with functioning, distress, resistance and control). Approximately half of both the completers and the whole group had 30% or more improvement on the modified Y-BOCS score. Additional self-report data included eight visual analog scales that measured preoccupation with skin, skin appearance, skin sensations, severity of skin sensations, behaviors involving the skin, skin lesions, control over skin behaviors and a global assessment of
The seven completers had significant reduction in behaviors involving the skin (e.g. scratching, picking, gouging or squeezing) and in global assessment of symptoms. Endpoint analysis of all 14 subjects' self-reported data demonstrated significant improvement in the presence of skin sensations, skin appearance and lesions, behaviors involving the skin, control over skin behavior and global assessment. The mean score for depression as assessed by the 17-item Hamilton Rating Scale for Depression did not improve significantly, with a mean decrease from 13.910.0 to 8.98.5.
The results of this preliminary open trial suggest that fluvoxamine may be effective in reducing psychogenic excoriation, and this resulting effect seems to be independent of mood. The response to fluvoxamine is consistent with other studies of SRIs in the treatment of psychogenic excoriation (Stout, 1990; Gupta and Gupta, 1993; Stein et al., 1993; Phillips and Taub, 1995; Kalivas et al., 1996; Simeon et al., 1997). The improvement with fluvoxamine may be consistent with the view of psychogenic excoriation as an obsessive-compulsive spectrum disorder (Stein and Hollander, 1992; McElroy et al., 1994). While most subjects met DSM-IV criteria for ICD, many also had obsessive-compulsive symptoms, supporting the hypothesis that psychogenic excoriation lies on a compulsivity-impulsivity continuum (McElroy et al., 1993). A larger, controlled study is needed to confirm the responsiveness of psychogenic excoriation to fluvoxamine and to determine whether the presence of compulsive and/or impulsive features predicts treatment response to SRIs.
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