I have something new to talk about with my therapist next week. I thought it was just a bad habit I hadn’t managed to break….

All from articles on: http://www.ocfoundation.org/

Compulsive Skin Picking (Neurotic Excoriations)

Exerpt from the
Jenike, Baer, Minichiello book,
“OCD: Practical Management”
(1998, Mosby)

Neurotic excoriations are lesions produced by patients as a result of repetitive skin picking (e.g., Gutpa et al., 1987; Stein et al., 1993). The behavior takes the form of an extensive cleaning ritual (Van Moffaert, 1992), and the patients intend to remove small irregularities on the skin. In more severe cases the habit is uncontrollable and may turn into an urge to dig deep into the skin. Unlike patients with dermatitis artefacta, those with neurotic excoriations usually admit the self-inflicted nature of their lesions (Gutpa et al., 1987). Skin picking occurs secondary to delusions of parasitosis, but these patients have a psychotic character and differ from those with typical presentations of neurotic excoriations.

… The lesions are in areas of the body that the patients can easily reach, such as face, upper and lower extremities, and upper back (Obermayer, 1955). They are usually a few millimeters in diameter and crusted, weeping or scarred (Griesemer & Nadelson, 1979, Obermayer, 1955). The excoriations are produced with fingernails or small instruments such as tweezers or pins. Picking occurs most frequently in the evening or at night (Freunsgaard, 1984; Zaidens, 1964).

Visual inspection and touching of the skin often precedes picking. Patients describe an uncontrollable urge to pick blemishes, and a temporary feeling of relief when blemishes are removed. This is soon replaced by a sense of disgust, depression or anxiety (Phillips & Taub, 1995).

Stressful circumstances usually increase picking behaviors. Some patients describe being in an almost trancelike state while picking at lesions. Patients often report that they try to resist the urge, but they usually find it difficult to control. A few of the patients we saw in our clinic looked somewhat disfigured because of scarring that resulted from skin picking. Most of them had mild acne. Patients were very embarrassed about their behavior and camouflaged the resulting lesions with make-up or clothing. Skin picking typically does not occur in the presence of other people. Occasional patients reported picking at other people’s skin. Several studies described patients suffering from neurotic excoriations as “perfectionistic or having obsessive-compulsive traits, depressive symptoms, anxiety, hysteria, hypochondriasis” (for a review see Gutpa, et al., 1986). The lack of modern diagnostic criteria limits the value of these studies. Skin picking has many similarities with OCD, since it is ego-dystonic, repetitive, ritualistic and temporarily relieves tension (Gutpa & Gutpa, 1993; Stein et al. 1993; Stout, 1990). The compulsive and self-destructive quality of the behavior also resembles nailbiting and Trichotillomania. …
Demographics and Course

No data is available on the rate of occurrence of neurotic excoriations in the general population, but the incidence is estimated to be 2% among dermatology patients (Griesemer, 1978). Prevalence is higher in women than in men (Freunsgaard, 1984; Fisher & Pearce, 1974) and the mean age of onset is in the range of 30 to 40 years. However, some researchers reported a peak in the 20s (Obermayer, 1955). The intensity of compulsive skin picking seems to fluctuate, and the mean duration of symptoms is reported to be 5 years (Seitz, 1953) with the majority of patients having symptoms for 10-12 years (Freunsgaard, 1984).

Treatment

Although dermatologic treatment may help to improve the skin condition, the treatment for neurotic excoriations is primarily psychiatric. Several case reports describe that these patients benefit from treatment with serotonin reuptake inhibitors (Gutpa & Gutpa, 1993; Stein et al., 1993; Stout, 1990). In our anecdotal experience, the patients responded well to the use of SRI medications and/or with behavior therapy. Sometimes, symptoms have been completely eliminated with these approaches.

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Some disorders that closely resemble OCD and may respond to some of the same treatments. They are trichotillomania (compulsive hair pulling), body dysmorphic disorder (imagined ugliness), and habit disorders, such as nail biting or skin picking.

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What if I feel as if I’ve failed because I need a drug to help me?

A way to think about the use of medication for OCD is to compare your illness with a common medical disorder such as diabetes. There is growing evidence that OCD is, a neurologic or medical illness not simply a result of some problem in the environment or of improper upbringing. As the diabetic needs insulin to live a normal life, some OCD patients need anticompulsive medication to function normally. Diabetics often feel angry and upset about having to take insulin. There is no evidence that OCD is a result of anything that the patient or their parents have done. It is best to consider it a chemical or neurologic disorder affecting a part of the brain.