Excoriation disorder

Essential (Required) Features:

• Recurrent picking of one’s skin.
• Unsuccessful attempts to stop or decrease skin picking.
• Significant skin lesions resulting from picking behaviour.
• The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

Additional Clinical Features:

• Trichotillomania is a common comorbid condition in individuals with Excoriation Disorder. Furthermore, Excoriation (Skin Picking) Disorder commonly co-occurs with depressive and anxiety symptoms, Obsessive-Compulsive Disorder, and other body-focused repetitive behaviours (e.g., nail biting).
• The most commonly picked sites are the face, arms and hands, but many individuals pick from multiple body sites. Individuals may pick at healthy skin, at minor skin irregularities, at lesions such as pimples or calluses, or at scabs from previous picking. Most individuals pick with their fingernails, although a substantial minority use tweezers, knives, or other objects. The Essential Features emphasize that skin picking must lead to skin lesions. However, individuals with this disorder often attempt to conceal or camouflage evidence of skin picking (e.g., using make-up or clothing). Therefore, careful assessment including information from collateral sources may be required to ascertain the presence of Excoriation Disorder symptomatology.
• Individuals with Excoriation Disorder often spend significant amounts of time on their behaviour, sometimes several hours each day. Skin picking may endure for months or years before coming to clinical attention.
• Excoriation Disorder often presents with rituals surrounding the skin such as visually or tactilely examining the skin, orally manipulating, or eating the skin or scab after it has been picked.
• Skin picking behaviour is associated with a variety of reported effects including regulation of affect and arousal, tension-reduction, and promotion of pleasure, which presumably reinforce these behaviours. However, in the aftermath of skin picking, many individuals report a variety of negative affective states, such as a sense of loss of control or shame. Individuals with Excoriation Disorder report varying degrees of awareness of their skin picking behaviour.

Boundary with Normality (Threshold):

• Occasional picking of one’s skin (e.g., scabs, cuticles or acne) is normal and done by most people at some time in their lives. Some individuals bite their cuticles or surrounding skin; these behaviours do not qualify for a diagnosis of Excoriation (Skin Picking) Disorder. Excoriation Disorder involves recurrent picking and is associated with significant distress or impairment, which are not present in occasional, normal skin picking.

Course Features:

• Onset can occur at any age but most often coincides with onset or shortly after onset of puberty.
• The onset of Excoriation (Skin Picking) Disorder commonly occurs in association with dermatological condition, but the skin picking persists after the dermatological condition resolves.
• For some individuals an urge to pick at their skin may be preceded by emotional triggers such as increasing feelings of anxiety and tension or boredom. Others may pick at their skin in response to tactile sensitivity (i.e., skin irregularities) or bothersome skin sensations. In such cases, skin picking often results in an alleviation of tension, relief or a sense of gratification.
• Excoriation Disorder is generally considered a chronic condition. Some individuals may experience a waxing and waning of symptoms over weeks, months, or years at a time.

Developmental Presentations:

• Excoriation (Skin Picking) Disorder most often has its onset during adolescence typically corresponding to puberty. However, the emergence of symptoms can occur across the lifespan.
• Childhood-onset Excoriation Disorder is more prevalent among females.
• Automatic skin picking, which tends to occur unintentionally, outside of awareness, appears more frequently among individuals with childhood-onset Excoriation Disorder. Skin picking then appears to shift in adolescence and adulthood, as picking becomes focused. This picking appears to be generally intentional, connected to intense urges to pick, and often results in a sense of relief.

Sex- and/or Gender-Related Features:

• Prevalence rates for Excoriation Disorder are significantly higher for women.
• Men have an earlier age of onset for the disorder.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with other Obsessive-Compulsive or Related Disorders: Repetitive behaviours observed in Excoriation Disorder occur in other Obsessive-Compulsive or Related Disorders but these are typically related to specific foci of apprehension and are associated with distinct intent for each diagnostic entity. Individuals diagnosed with Obsessive-Compulsive Disorder may engage in skin picking behaviour (e.g., when they experience contamination obsessions that are associated with behaviours intended to pick the skin to remove contamination). Obsessions do not precede skin picking in Excoriation Disorder, and individuals with Obsessive-Compulsive Disorder often exhibit other compulsions that are unrelated to skin picking. Nonetheless, co-occurrence with Obsessive-Compulsive Disorder is common and both disorders may be diagnosed if warranted. Body Dysmorphic Disorder may be associated with picking as a means of improving the individual’s appearance by ‘removing’ acne or other perceived blemishes of the skin that the individual believes are ugly or that appear abnormal. Individuals with Excoriation Disorder do not pick skin with the sole purpose of correcting a perceived defect in appearance.
• Boundary with Stereotyped Movement Disorder: A stereotyped movement is a repetitive, seemingly driven nonfunctional motor behaviour (e.g., head banging, body rocking, self-biting). These behaviours rarely include skin picking behaviour but if they do, the behaviour tends to be composed of coordinated movements that are patterned and predictable. Furthermore, stereotyped movements are more likely to present very early in life (i.e., before 2 years of age), whereas Excoriation Disorder typically has a later onset.
• Boundary with Schizophrenia or Other Primary Psychotic Disorders: Individuals with Schizophrenia or Other primary psychotic disorders may pick at their skin in response to a delusion or hallucination. Individuals with Excoriation Disorder do not report skin picking secondary to delusions or hallucinations.
• Boundary with Prader-Willi Syndrome: Individuals with Prader-Willi Syndrome may have early onset of skin picking more consistent with a Stereotyped Movement Disorder. Prader-Willi Syndrome is usually associated with a constellation of other symptoms such as Mild to Moderate Disorder of Intellectual Development, neonatal and infantile hypotonia, feeding problems and poor weight gain in infancy followed by hyperphagia and morbid obesity in childhood.
• Boundary with medical conditions classified elsewhere and Disorders Due to Substance Use: The symptoms are not a manifestation of another medical condition (e.g., scabies). However, skin picking may emerge following or be worsened by the presence of another condition (e.g., acne) and a diagnosis of Excoriation Disorder may be applied in this circumstance if diagnostic requirements are met. Skin picking may also result from the use or misuse of stimulants (e.g., cocaine, methamphetamine, prescription stimulants), but Excoriation Disorder should not be diagnosed if the skin picking occurs exclusively in this context.
• Boundary with self-injurious and self-mutilating behaviours: Unlike self-injurious and self-mutilating behaviours, skin picking behaviours characteristic of Excoriation Disorder are not performed with the express purpose of self-injury though such injury may occur as a result.