Dermatillomania (excoriation disorder): symptoms and causes

This mental disorder produces an uncontrollable urge to tear or pick at the skin.

Dermatomal excoriation disorder, also known as dermatillomaniaalso known as dermatillomania, consists of scratching and picking at parts of the skin, usually because of intense feelings of anxiety.

In this article we will describe symptoms, causes and treatment of dermatillomania.In this article we will describe the symptoms, causes and treatment of dermatillomania; in relation to this last aspect we will focus on the habit reversal technique.

What is dermatillomania?

Dermatillomania is a psychological disorder characterized by an intense and frequent impulse to intense and frequent urge to pinch, scratch or tear off parts of one's own skin.. The DSM-5 introduces it under the nomenclature "excoriation disorder" within the category of obsessive-compulsive disorder and related disorders, which also includes trichotillomania.

According to this diagnostic manual, excoriation disorder is defined as the habit of compulsive and repetitive scratching of the skin to the point of causing lesions. These can become considerable and there is a significant risk of infection in the damaged areas.

Although most experts point out the closeness of the the closeness of dermatillomania to obsessive-compulsive disordersOdlaug and Grant (2010) state that it is more similar to addictions because the act of pinching or scratching the skin involves pleasurable emotions. In contrast, in compulsive disorders, the rituals are aimed at reducing anxiety.

This disorder was first described in 1875 by Erasmus Wilson, who referred to it as "neurotic excoriations". Shortly thereafter, in 1898, Louis-Anne-Jean Brocq described several similar cases in adolescent girls with acne. Despite multiple references in the literature, until the DSM-5 dermatillomania had not been officially recognized..

Main symptoms and signs

The scientific literature reveals that feelings of anxiety and emotional tension trigger the episodes of dermatillomania. of dermatillomania. These are usually directed at a part of the skin where the person perceives some kind of imperfection, such as a pimple or flaking.

The face is the most common target of lesions, although they also occur frequently on the back, chest, scalp or extremities, especially nails and fingertips. Usually excoriations are usually made with the fingersHowever, sometimes the mouth or instruments such as needles are used.

These episodes may occur repeatedly during everyday life, but it is also possible to have only one episode per day with a very high duration and intensity. In general, people with dermatillomania focus on a single part of the body, except when it is badly damaged.

Dermatillomania can cause serious skin alterations, primarily damage to the affected tissues, the appearance of pustules and infections, sometimes even reaching the bloodstream. sometimes even reaching the Blood (septicemia). The excoriation may also scar or disfigure the skin, which increases the strong feelings of shame and guilt of people with dermatillomania.

Causes of this disorder

The motivations for dermatillomania episodes vary from person to person. However, a widely accepted hypothesis is that physiological activation, and in particular that resulting from psychosocial stress, triggers excruciating behaviors.triggers excoriation behaviors, which have an anxiolytic functionality.

While in obsessive-compulsive profiles dermatillomania is usually associated with the perception of skin contamination, in others closer to body dysmorphic disorder the purpose of these behaviors has to do with the attempt to eliminate physical imperfections.

A relationship has been found between dermatillomania and an increase in dopamine levels. increase in the levels of dopamine, involved in motor control.The excessive presence of this neurotransmitter, which occurs when consuming substances such as cocaine, seems to promote excoriation. The excessive presence of this neurotransmitter, which occurs when consuming substances such as cocaine, seems to promote excoriation.

On the other hand, it has been proposed that this disorder could have its biological basis in the frontostriatal motor circuit, which connects the frontal lobe regions on which cognitive functions depend with the basal ganglia, fundamental for automatic movements.

Psychological treatment: habit reversal

As with other disorders related to physical and motor habits, including tics, onychophagia, trichotillomania, stuttering or temporomandibular syndrome, dermatillomania can be managed by means of the habit reversal technique of Azrin and Nunn (1973), which is framed in cognitive-behavioral therapy.

This procedure consists of several steps. First, training is carried out to promote the detection of excoriation behaviors, which in many cases are automatic, as well as the stimuli that precede them, mainly sensations of emotional tension.

Then, a response is practiced that is incompatible with the a response that is incompatible with the negative habit is then practiced to execute it when the impulse appears, in this case, scratching the skin; this new behavior should become a habit that replaces the excoriation. An example would be to clench the fists to prevent the fingers from touching one's own body.

The remaining components of Azrin and Nunn's program consist of applying contingent reinforcement to the absence of excoriation (contingency management), teaching relaxation techniques to the client to decrease the anxiety that triggers the episodes, and finally systematically generalizing the skills to the context of daily life.

Bibliographical references:

• Azrin, N. H. & Nunn, R. G. (1973). Habit-reversal: a method of eliminating nervous habits and tics. Behavior Research and Therapy, 11(4): 619-28.

• Dell'Osso, B., Altamura, A. C., Allen, A., Marazziti, D. & Hollander, E. (2006). Epidemiologic and clinical updates on impulse control disorders: a critical review. European Archives of Psychiatry and Clinical Neurosciences, 256(8): 464-75.

• Odlaug, B. L. & Grant, J. E. (2010). Pathologic skin picking. American Journal of Drug and Alcohol Abuse, 36(5): 296-303.