Skin Picking and Other Habitual Disorders

There are a number of body focused repetitive behavioral disorders (BFRBs), which include skin picking disorder, trichotillomania, thumb sucking, lip biting, and others, observed Jon Grant, MD, JD, MPH, professor, department of Psychiatry and Behavioral Neuroscience, University of Chicago, Illnois. The diagnostic criteria for these disorders, according to the DSM-5, are recurrent skin picking (resulting in lesions); repeated attempts to decrease or stop; and clinical significant distress or impairment. Additionally, they cannot be attributed to another medical condition or substance. The majority of these patients are female (76.9%), 2% of all dermatology patients, with a mean age of onset in adolescence, and again in their 30s.

The shared attributes of a patient with skin picking disorder include impaired inhibitory control, impaired stop signal reaction time, increased rates to act impulsively in response to negative emotions, as well as a tendency to act impulsively in response to pleasurable emotions.

For trichotillomania, diagnostic criteria includes recurrent pulling of one’s hair, resulting in hair loss; repeated attempts to decrease or stop; and significant distress or impairment. The typical age of onset is 10 to 13 years, about equal in male and female children.

For patients of all ages, trichotillomania reduces quality of life, as these patients usually have low self-esteem and increased social anxiety, fail to pursue job advancement, with anxiety and/or depression due to pulling.

In general, BFRBs are preceded by negative emotions, an unwillingness to relax, with increased tension generated by these negative emotions/stressful events.

Top habit reversal therapies include self-monitoring/awareness training, competing responses (behavior that is physically incompatible with pulling for a period of time until the urge subsides), and stimulus control (modify environment to reduce triggers). Suggested medications include fluoxetine and citalopram, with N-acetylcysteine noted to reduce the occurrence of skin picking.

In conclusion, said Grant, “BFRBs are common disorders, with evidence suggesting heterogeneity within the disorders. Remember that treatments need to take into account personal aspects of the patient’s life, and that clinical, cognitive and brain imaging may be useful for developing more targeted treatment options.”

Reference

Grant J. Skin picking and other habitual disorders. SPD 2022 47th Annual Meeting. July 8, 2022. Indianapolis, Indiana.