¶ Excoriation Disorder
Welcome everyone to today's episode where we'll be more than scratching the surface into excoriation disorder . I'm Stacey .
And I'm Linton , and we're glad you could join us today .
So to start , excoriation disorder is characterized by repetitive and compulsive picking of the skin , leading to skin lesions and anxiety . To start , excoriation disorder is characterized by repetitive and compulsive picking of the skin , leading to skin lesions and anxiety . It's officially classified as an obsessive compulsive disorder in the DSM-5-TR .
That's right , Stacey . Let's break down the diagnostic criteria step by step . On the criteria of the DSM-5-TR First , the client has to show recurrent skin picking that results in skin lesions . This skin picking can't be attributed to any other medical condition or mental disorders .
Ah , Linton , looks like you finally broke down and purchased the DSM-5-TR rather than that ratty DSM-4 you've been carrying around .
Well , you know , I finally paid off my student loans and I had some extra cash laying around , so I took the big plunge .
Well , good thing you did , Linton , because the licensure exam is based on the DSM-5-TR Period . End of story . So if you're using the DSM-5 , chances are you might lose a few points because of the changes and additions of new diagnoses to the DSM-5-TR .
Okay , okay , okay , I get it , I get it .
All right , it's about time .
Yeah .
Back to excoriation disorder , all right . So according to the DSM-5-TR , skin picking has to cause clinically significant distress or impairment in relational occupational , social or educational functioning . There's that rose memory device where types of functioning that you created back in the day , linton . It sure comes in handy to remember the areas of functioning .
Additionally , excoriation disorder can't be better explained by symptoms of another mental disorder like delusions or hallucinations , right ?
So let's say that you're working on a case study and the client has eczema and their skin picking is causing them significant distress and impairment . They're missing work because of it . Would the excoriation specifier be low , medium or severe ? Stacey ? Which one ?
You are a trickster , Linton . First , we don't even know if the client actually has excreation disorder or if it's really a result from their medical condition of eczema . Second , even if they do have excreation disorder , there aren't any specifiers for that disorder . You are just so incorrigible .
Well , you can't blame a guy from trying .
Moving along , since we've already established that there are no specifiers . Thank you very much , Linton . Let's talk about symptom duration . For most mental disorders , the length of time that the client exhibits symptoms is often a key factor that helps you to differentiate between disorders . However , there's no minimum duration for excreation disorder .
That's why these two criterion recurrent skin picking , resulting in skin lesions and causes significant distress or impairment in functioning are so important . With this disorder , Skin picking is not considered a disorder unless it's happening often and it's severe enough to cause distress .
Exactly . Many people , including myself , pick up their skin occasionally , but excreation disorder it's happening over and over , frequently and persistently . Let's go down a rabbit hole here and dig into the type of development and course of a excreation disorder .
Okay , I'm a bunny hop skip and a jump ahead of you , linton .
Uh-huh .
So onset is often during early adolescence , around ages 11 to 15 . This is a time when individuals are more prone to having body-focused , repetitive behaviors . Many clients report that their skin picking really started with a dermatological condition that developed during your adolescence , sometimes something like acne , for example .
You would imagine that skin picking behaviors often increase during periods of increased stress . The client can also experience temporary remission of symptoms when those stressors decrease . The majority of clients with excreation , skin picking , disorder experience , waxing and waning of symptoms and continued psychosocial impairment over the course of their entire lives .
Excreation disorders often characterized by antecedent physiological sensations that precede the act of skin picking . Clients frequently report feelings of tension parietus , which is the fancy medical term for itchiness or other somatic discomfort before engaging in skin picking behaviors .
Their skin picking may provide temporary relief from itchy skin and reinforce their behavior through negative reinforcement .
Okay , so all you therapists out there be on the outlook for clients with skin lesions and scarring . Sometimes it's going to be a little tricky to know about that , because the client will try to camouflage them by using long sleeves or bandages . Adult clients often focus their picking on specific body regions , like the face , extremities or scalps .
Another red flag to watch out for is ritualistic behaviors , which frequently co-occur as well . These could include frequently checking mirrors , utilizing tools like tweezers to pick the skin or even saving scabs . Many clients engage in skin picking while in front of brightly lit mirrors to better visualize what they perceive as flaws .
Wow , good point . While shaming and secrecy often lead clients to pick skins in isolation , except for immediate family members , there's actually an active Facebook support group that has over 10,000 members , so you see , it's not just a minor number of individuals that are dealing with this problem .
So , Linton , how about some common comorbidities that are associated with excretion disorder ?
Sure excreation disorder demonstrates clinical overlap with other body focus , repetitive behaviors like Tricottoamania . Don't you like saying that ?
Say that ten times fast .
Which is characterized by compulsive hair pulling and usually up to 30% of excreation . Clients also struggle with Tricottoamania .
Yeah , and there are also high rates of comorbidity with anxiety disorders , depression , ocd and body dysmorphic disorder , and clients with body dysmorphic disorder obsess over perceived flaws and appearance which can actually fuel those skin picking behaviors .
Comorbid Substant Use Disorders are common in clients with excreation disorder and may exacerbate skin picking behaviors . Associations between excreation disorder and personality traits , such as an underlying grasping for perfectionism , which may underline fixations on minor skin imperfections that trigger picking behaviors , are also a consideration .
Assessment of substance use and related traits is indicated , given the frequency of these comorbidities . Personality disorders that commonly exhibit perfectionistic traits will include obsessive compulsive personality disorder . The key diagnostic feature is perfectionism , rigid adherence to rules and preoccupation with ordinariness and control .
Clients have realistically high standards and become distressed if they are unable to maintain them . Did you have a story about that , stacey ?
Tell us a compulsive personality disorder . Oh yes , this would be my beloved German grandmother .
She really had a very I'll call it a rigid adherence to rules and structure , and so much so you know where you would use the sink or use the shower or something , and she would go in right afterwards and wipe everything down so that there weren't any water droplets there . So she was really preoccupied with high sense of orderliness and control , for sure .
So someone with that type of personality is also really susceptible to excreation .
Mm-hmm exactly .
Narcissistic personality disorder is another one . People with narcissistic personality disorder have a need to seem as perfect and the best at doing everything . Their sense of self-importance depends on being superior and flawless . Avoid personality disorder . Those with avoid personality disorder frequently feel inadequate and have sensitivity to criticism .
Their perfectionism stems from fear of disapproval and rejection .
Mm-hmm .
Schizotypal personality disorder can have obsession or paranoid personality traits reflected in rigid patterns of thinking and behavior aimed at reducing imperfections . Dependent personality disorder professionalistic traits are used as an effort to gain approval .
And finally , borderline personality disorder Perfectionism may emerge as an overcompensating behavior to deal with chronic feelings of emptiness and ineffectiveness and avoidance of what Stacy .
Abandonment . Well , yes , that was an excellent overview of how those personality disorders can also kind of have that shared link of , you know , perfectionistic tendencies , and you could see the skin picking behaviors involved there .
So if you have a question on the exam as to what evidence based treatment approaches are effective for treating excreation disorder , what would you consider , linton ?
You guessed it Stacy , your favorite cognitive behavioral therapy . He says sarcastically CBT is the most common treatment for excreation disorder . With CBT , you , as a therapist , focus on challenging the client's professionalistic thinking .
And how about habit reversal training ? I've heard of that in the context of treating repetitive behaviors .
Right Habit . Reversal training is a key component of CBT that she used to treat excreation disorder . This is where the client learns to recognize picking triggers and uses competing responses , which are behaviors that make it impossible to engage in that unwanted habit , like clenching fists to interrupt the picking response .
By having the individual practice these incompatible behaviors whenever the urge arises , the unwanted picking habit can be effectively interrupted over time . Consistently using competing responses allows the new desirable behavior to take hold , breaking the habitual cycle .
Any other interventions in that CBT category ? Linton .
Yes , there are . Stimulus control is another strategy that can be effective . This involves modifying the client's environment to remove triggers and make picking more difficult , like limiting access to tools or mirrors , and exposure and response prevention , when you gradually expose the client to picking triggers while preventing picking responses to reduce anxiety .
Okay , so CBT is the frontline treatment , including habit reversal , training , stimulus control and exposure and response prevention .
You got it , Stacey .
Okay .
Yes .
And then there's acceptance and commitment therapy and formed exposure , and this is another approach that can help with skin picking .
Act focuses on accepting uncomfortable internal experiences , like urges to pick in the case of excretion disorder , without judging them or acting on them , and this is different than trying to resist or get rid of these urges , which can actually make them stronger . In exposure therapy .
From an ACT perspective , the individual intentionally brings on urges to pick while practicing mindfulness and acceptance of those urges without acting on them , and the overall goal is to experience and observe the urge without reacting to it .
This builds tolerance , and acceptance of the urge is a temporary state that will pass rather than something that needs to be acted on right away .
¶ Treatment and Support for Excration Disorder
For medication . Selective serotonin reuptake inhibitors , or SSRIs , like fluoroxatine , are commonly prescribed to help manage underlying anxiety and depression , but medication should always be combined with therapy for the best results .
Exactly and as it kind of goes without saying . But we'll say here , just to make sure we're on the same page , that as a therapist it's outside of your scope medication recommendation , so you'll always refer to a psychiatrist for that .
So a comprehensive treatment plan also addresses any comorbid conditions contributing to skin picking , like obsessive compulsive disorder rituals or body dysmorphic obsessions . It's also key to watch for secondary infections that may develop and provide referrals to dermatologists as needed .
Absolutely Improving body image and self-esteem can reduce picking behaviors . Support groups can provide validation and accountability and using a caring , a non-judgmental approach , such as Person-centered therapy by our friend Carl Rogers .
Is critical because Of the shame that many people feel around excreation disorder .
Right right , and you need to validate how distressing , yet hard to control , compulsive skin picking can be .
Great point . Well , we have covered a lot of ground today about the complexity of excreation disorder . Thank you all so much for joining us today . We hope you found this overview very helpful and we'll put it to good use on your exam .
So while you're here , you might want to reach out to us about any other topics you'd like to cover in the future episodes and remember .
Keep making the videos .