{"id":294,"date":"2020-07-16T12:15:44","date_gmt":"2020-07-16T12:15:44","guid":{"rendered":"https:\/\/courses.lumenlearning.com\/abnormalpsych\/chapter\/excoriation-skin-picking-disorder\/"},"modified":"2024-06-26T17:58:15","modified_gmt":"2024-06-26T17:58:15","slug":"excoriation-skin-picking-disorder","status":"publish","type":"chapter","link":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/chapter\/excoriation-skin-picking-disorder\/","title":{"raw":"Excoriation (Skin-Picking) Disorder","rendered":"Excoriation (Skin-Picking) Disorder"},"content":{"raw":"<div class=\"textbox learning-objectives\">\r\n<h3>Learning Objectives<\/h3>\r\n<ul>\r\n \t<li>Describe some of the main features and factors in the development of excoriation disorder<\/li>\r\n<\/ul>\r\n<\/div>\r\n<b>Excoriation disorder<\/b>\u00a0is an obsessive-compulsive spectrum\u00a0disorder\u00a0that is characterized by the repeated urge or impulse to pick at one's own skin to the extent that either psychological or physical damage is caused.\r\n<div class=\"textbox examples\">\r\n<h3>Watch It<\/h3>\r\nWatch this video to better understand the experience of living with a skin-picking disorder.\r\n\r\nhttps:\/\/www.youtube.com\/watch?v=5WYpRZbF1Jg\r\n\r\nYou can view the <a href=\"https:\/\/course-building.s3-us-west-2.amazonaws.com\/Abnormal+Psychology\/transcripts\/WhatItsLikeToHaveASkinPickingDisorder_transcript.txt\" target=\"_blank\" rel=\"noopener\">transcript for \"What it's like to have a skin-picking disorder\" here (opens in new window)<\/a>.\r\n\r\n<\/div>\r\n<h2><span id=\"Signs_and_symptoms\" class=\"mw-headline\">Signs and Symptoms<\/span><\/h2>\r\n<div class=\"thumb tright\">\r\n<div class=\"thumbinner\">\r\n\r\n[caption id=\"\" align=\"alignright\" width=\"220\"]<img class=\"thumbimage\" src=\"https:\/\/upload.wikimedia.org\/wikipedia\/commons\/thumb\/1\/19\/Dermatillomania_fingers.JPG\/220px-Dermatillomania_fingers.JPG\" alt=\"Excoriation disorder\" width=\"220\" height=\"293\" \/> <strong>Figure 1<\/strong>. <a href=\"https:\/\/en.wikipedia.org\/wiki\/File:Dermatillomania_fingers.JPG\" target=\"_blank\" rel=\"noopener\">Compulsive picking of the knuckles (via mouth)<\/a> illustrating potentially temporary disfiguration of the\u00a0distal and proximal joints\u00a0of the\u00a0middle\u00a0and\u00a0little\u00a0fingers.[\/caption]\r\n\r\n<div class=\"thumbcaption\">\r\n<div class=\"magnify\"><span style=\"font-size: 1rem; text-align: initial;\">Episodes of skin picking are often preceded or accompanied by tension, anxiety, or stress.<\/span><span style=\"font-size: 1rem; text-align: initial;\">\u00a0In some cases, following picking, the affected person may feel depressed.<\/span><span style=\"font-size: 1rem; text-align: initial;\">\u00a0During these moments, there is commonly a compulsive urge to pick, squeeze, or scratch at a surface or region of the body, often at the location of a perceived skin defect. When picking, one may feel a sense of relief or satisfaction.<\/span><\/div>\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\nThe region most commonly picked is the face,<sup id=\"cite_ref-Odlaug_3-1\" class=\"reference\"><\/sup><sup id=\"cite_ref-DellOsso_6-1\" class=\"reference\"><\/sup>\u00a0but other frequent locations include the arms, legs, back, gums, neck, shoulders, scalp, abdomen, chest, and extremities such as the fingernails, cuticles, and toenails.\u00a0Most patients with excoriation disorder report having a primary area of the body that they focus their picking on, but they will often move to other areas of the body to allow their primary picking area to heal.\u00a0Individuals with excoriation disorder vary in their picking behavior; some do it briefly multiple times a day while others can do one picking session that can last for hours.\u00a0The most common way to pick is to use the fingers although a significant minority of people use tools such as tweezers or needles.\r\n\r\nSkin picking often occurs as a result of some other triggering cause.\u00a0Some common triggers are feeling or examining irregularities on the skin and feeling anxious or other negative feelings.\r\n\r\nComplications arising from excoriation disorder include infection at the site of picking, tissue damage, and\u00a0sepsis. Damage from picking can be so severe as to require\u00a0skin grafting. Severe picking can cause\u00a0epidermal abscesses. Severe cases of excoriation disorder can cause life-threatening injuries. For example, in one reported case, a female picked a hole through the bridge of her nose, which required surgery to fix, and a 48-year-old female picked through the skin on her neck exposing the\u00a0carotid artery. Pain in the neck or back can arise due to prolonged bent-over positions while engaging in the behavior. Besides physical injuries, excoriation disorder can cause severe physical scarring and disfigurement.\r\n\r\n[caption id=\"\" align=\"alignleft\" width=\"220\"]<a class=\"image\" href=\"https:\/\/en.wikipedia.org\/wiki\/File:Excoriation_disorder_affecting_face.jpg\"><img class=\"thumbimage\" src=\"https:\/\/upload.wikimedia.org\/wikipedia\/en\/thumb\/2\/25\/Excoriation_disorder_affecting_face.jpg\/220px-Excoriation_disorder_affecting_face.jpg\" alt=\"https:\/\/en.wikipedia.org\/wiki\/Excoriation_disorder\" width=\"220\" height=\"165\" \/><\/a> <strong>Figure 2<\/strong>. Compulsive picking of face using nail pliers and tweezers.[\/caption]\r\n\r\n<div class=\"thumbcaption\">\r\n<div class=\"magnify\"><span style=\"font-size: 1rem; text-align: initial;\">Excoriation disorder can cause feelings of intense helplessness,\u00a0guilt,\u00a0shame, and\u00a0embarrassment\u00a0in individuals, and this greatly increases the risk of self-harm.\u00a0Studies have shown that excoriation disorder presented\u00a0suicidal ideation\u00a0in 12% of individuals with this condition,\u00a0suicide attempts\u00a0in 11.5% of individuals with this condition, and psychiatric hospitalizations in 15% of individuals with this condition.<\/span><\/div>\r\n<\/div>\r\n<div><\/div>\r\n<h2>Causes<\/h2>\r\nThere have been many different theories regarding the causes of excoriation disorder including biological and environmental factors. A common hypothesis is that excoriation disorder is often a coping mechanism to deal with elevated levels of turmoil, arousal, or stress within the individual, and that the individual has an impaired stress response.<sup id=\"cite_ref-Odlaug_3-7\" class=\"reference\"><\/sup>\u00a0A review of behavioral studies found support in this hypothesis in that skin picking appears to be maintained by automatic reinforcement within the individual. In contrast to neurological theories, there are some\u00a0psychologists\u00a0who believe that picking behavior can be a result of repressed rage felt toward\u00a0authoritarian\u00a0parents.\u00a0A similar theory holds that overbearing parents can cause the behavior to develop in their children.\r\n\r\nClinical studies have posited that there is a strong link between traumatic childhood events and excoriation disorder. Those with self-injurious disorders of the skin are found to also frequently report childhood sexual abuse. While attempting to produce diagnostic criteria for excoriation disorder, researchers conversed with 10 patients with the disorder and found that a majority reported personal problems before the picking began, and four reported on abuse they suffered in childhood or adolescence.[footnote]Yal\u00e7in M, Tellio\u011flu E, Yildirim DU, Savrun BM, \u00d6zmen M, Aydemir EH (December 2015). \"Psychiatric Features in Neurotic Excoriation Patients: The Role of Childhood Trauma\". Noro Psikiyatri Arsivi. 52 (4): 336\u2013341. doi:10.5152\/npa.2015.9902. PMC 5353104. PMID 28360736[\/footnote]\r\n<h3><span id=\"Neurological\" class=\"mw-headline\">Neurological<\/span><\/h3>\r\nStudies have shown a linkage between\u00a0dopamine\u00a0and the urge to pick. Drugs such as\u00a0cocaine\u00a0and\u00a0methamphetamine, which increase the pharmacological effects of dopamine, have been shown to cause uncontrollable picking in users. Central nervous system stimulants may create the sensation of\u00a0<strong>formication<\/strong>, which feels like something is crawling on or under the skin.\u00a0Thus, excoriation disorder could result from a dysfunction in the dopamine reward functions.\r\n\r\n[caption id=\"attachment_4488\" align=\"alignright\" width=\"300\"]<img class=\"wp-image-4488 size-medium\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/5351\/2020\/07\/17183157\/MRI_anterior_cingulate-300x229.png\" alt=\"MRI slice with highlighting indicating location of the anterior cingulate cortex, which is towards the front of the head, in the middle, close to the limbic system.\" width=\"300\" height=\"229\" \/> <strong>Figure 3<\/strong>. The\u00a0anterior cingulate cortex, part of the right-lateralized frontostriatal circuit, is shown here. We know that it plays a role in motor-inhibitory control and may be associated with excoriation disorder.[\/caption]\r\n\r\nThere may be another neurological explanation for excoriation disorder: individuals with the condition have less motor-inhibitory control, but show no sign of difference in\u00a0cognitive flexibility, when compared to individuals without the condition. Motor-inhibitory control is a function of the right-lateralized\u00a0frontostriatal circuit, which includes the right inferior frontal and bilateral\u00a0anterior cingulate cortices. The impairment of motor-inhibitory control is similar to the neurological conditions of those who have problems suppressing inappropriate behaviors, such as abusing methamphetamine.\r\n<h3>Epidemiology<\/h3>\r\nThe prevalence of excoriation disorder is not well understood. Estimates of prevalence of the condition range from 1.4 to 5.4% in the general population. One U.S. telephone survey found that 16.6% of respondents \"picked their skin to the point of noticeable tissue damage\" and that 1.4% would qualify as meeting the requirements of excoriation disorder.\u00a0Another community survey found a rate of 5.4% had excoriation disorder. A survey of college students found a rate of 4%.[footnote]Odlaug BL, Grant JE (September 2010). \"Pathologic skin picking\". The American Journal of Drug and Alcohol Abuse. 36 (5): 296\u2013303. doi:10.3109\/00952991003747543. PMID 20575652[\/footnote]\u00a0One study found that among non-disabled adults, 63% of individuals engaged in some form of skin picking and 5.4% engaged in serious skin picking.[footnote]Lang R, Didden R, Machalicek W, Rispoli M, Sigafoos J, Lancioni G, Mulloy A, Regester A, Pierce N, Kang S (2010). \"Behavioral treatment of chronic skin-picking in individuals with developmental disabilities: a systematic review\". Research in Developmental Disabilities. 31 (2): 304\u201315. doi:10.1016\/j.ridd.2009.10.017. PMID 19963341[\/footnote]\u00a0Lastly, a survey of dermatology patients found that 2% suffered from excoriation disorder.\u00a0Excoriation disorder is statistically more common in females than in males.\r\n\r\nIn some patients, excoriation disorder begins with the onset of\u00a0acne\u00a0in adolescence, but the compulsion continues even after the acne has gone away. Skin conditions such as keratosis pilaris, psoriasis, and eczema can also provoke the behavior. In patients with acne, the grooming of the skin is disproportionate to the severity of the acne.\u00a0Certain stressful events including marital conflicts, deaths of friends or family, and unwanted pregnancies have been linked to the onset of the condition.\u00a0If excoriation disorder does not occur during adolescence, another common age of onset is between the ages of 30 to 45.\u00a0Additionally, many cases of excoriation disorder have been documented to begin in children under the age of 10. One small survey of patients with excoriation disorder found that 47.5% of them had an early onset of excoriation disorder that began before age 10.\u00a0Traumatic childhood events may initiate the behavior.\r\n<h2>Coborbidity<\/h2>\r\nExcoriation disorder has a high rate of\u00a0comorbidity\u00a0with other psychiatric conditions, especially with mood and anxiety disorders.\u00a0One survey of patients with excoriation disorder found that 38% also had alcohol- or drug-abuse problems.\u00a0Studies have shown the following rates of psychiatric conditions found in patients with excoriation disorder:\u00a0trichotillomania\u00a0(38.3%),\u00a0substance abuse\u00a0(38%),\u00a0major depressive disorder\u00a0(approximately 31.7% to 58.1%),\u00a0anxiety disorders\u00a0(approximately 23% to 56%),\u00a0OCD (approximately 16.7% to 68%), and\u00a0body dysmorphic disorder\u00a0(approximately 26.8% to 44.9%).\u00a0There are also higher rates of excoriation disorder in patients in psychiatric facilities; a study of adolescent psychiatric inpatients found that excoriation disorder was present in 11.8% of patients.\u00a0It is also present at high rates with some other conditions: 44.9% of patients with\u00a0body dysmorphic disorder\u00a0also have excoriation disorder; 8.9% of patients with OCD have excoriation disorder; and 8.3% of patients with trichotillomania have excoriation disorder.\r\n\r\nExcoriation disorder has been the subject of several episodes of\u00a0<em>Obsessed<strong>,<\/strong><\/em> a television documentary series that focuses on treatment of anxiety disorders. Skin picking is shown as a symptom of Nina Sayers' anxiety and OCD in the movie\u00a0<i>Black Swan<\/i>.\r\n<div class=\"textbox key-takeaways\">\r\n<h3>Key Takeaways: Excoriation Disorder<\/h3>\r\n<iframe title=\"Excoriation Disorder\" src=\"https:\/\/lumenlearning.h5p.com\/content\/1291225604668309728\/embed\" width=\"1088\" height=\"694\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><script src=\"https:\/\/lumenlearning.h5p.com\/js\/h5p-resizer.js\" charset=\"UTF-8\"><\/script>\r\n\r\n<\/div>\r\n<div class=\"textbox exercises\">\r\n<h3>Link to Learning<\/h3>\r\n<a href=\"https:\/\/www.youtube.com\/watch?v=mlt3o6dnGqA\" target=\"_blank\" rel=\"noopener\">Watch this Ted talk by artist Liz Atkin<\/a> and listen to her tell her own story of struggle and recovery in dealing with excoriation disorder.\r\n\r\n<\/div>\r\n<div class=\"textbox tryit\">\r\n<h3>Try It<\/h3>\r\nhttps:\/\/assess.lumenlearning.com\/practice\/e2c89f68-dada-4c43-b2d1-83f181010631\r\n\r\n<\/div>\r\n<div class=\"textbox learning-objectives\">\r\n<h3>Glossary<\/h3>\r\n<b>excoriation disorder: <\/b>an obsessive-compulsive spectrum\u00a0disorder\u00a0that is characterized by the repeated urge or impulse to pick at one's own skin to the extent that either psychological or physical damage is caused\r\n\r\n<strong>formication: <\/strong>the sensation of something that is crawling on or under the skin\r\n\r\n<\/div>","rendered":"<div class=\"textbox learning-objectives\">\n<h3>Learning Objectives<\/h3>\n<ul>\n<li>Describe some of the main features and factors in the development of excoriation disorder<\/li>\n<\/ul>\n<\/div>\n<p><b>Excoriation disorder<\/b>\u00a0is an obsessive-compulsive spectrum\u00a0disorder\u00a0that is characterized by the repeated urge or impulse to pick at one&#8217;s own skin to the extent that either psychological or physical damage is caused.<\/p>\n<div class=\"textbox examples\">\n<h3>Watch It<\/h3>\n<p>Watch this video to better understand the experience of living with a skin-picking disorder.<\/p>\n<p><iframe loading=\"lazy\" id=\"oembed-1\" title=\"What it&#39;s like to have a skin-picking disorder\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/5WYpRZbF1Jg?feature=oembed&#38;rel=0\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>You can view the <a href=\"https:\/\/course-building.s3-us-west-2.amazonaws.com\/Abnormal+Psychology\/transcripts\/WhatItsLikeToHaveASkinPickingDisorder_transcript.txt\" target=\"_blank\" rel=\"noopener\">transcript for &#8220;What it&#8217;s like to have a skin-picking disorder&#8221; here (opens in new window)<\/a>.<\/p>\n<\/div>\n<h2><span id=\"Signs_and_symptoms\" class=\"mw-headline\">Signs and Symptoms<\/span><\/h2>\n<div class=\"thumb tright\">\n<div class=\"thumbinner\">\n<div style=\"width: 230px\" class=\"wp-caption alignright\"><img loading=\"lazy\" decoding=\"async\" class=\"thumbimage\" src=\"https:\/\/upload.wikimedia.org\/wikipedia\/commons\/thumb\/1\/19\/Dermatillomania_fingers.JPG\/220px-Dermatillomania_fingers.JPG\" alt=\"Excoriation disorder\" width=\"220\" height=\"293\" \/><\/p>\n<p class=\"wp-caption-text\"><strong>Figure 1<\/strong>. <a href=\"https:\/\/en.wikipedia.org\/wiki\/File:Dermatillomania_fingers.JPG\" target=\"_blank\" rel=\"noopener\">Compulsive picking of the knuckles (via mouth)<\/a> illustrating potentially temporary disfiguration of the\u00a0distal and proximal joints\u00a0of the\u00a0middle\u00a0and\u00a0little\u00a0fingers.<\/p>\n<\/div>\n<div class=\"thumbcaption\">\n<div class=\"magnify\"><span style=\"font-size: 1rem; text-align: initial;\">Episodes of skin picking are often preceded or accompanied by tension, anxiety, or stress.<\/span><span style=\"font-size: 1rem; text-align: initial;\">\u00a0In some cases, following picking, the affected person may feel depressed.<\/span><span style=\"font-size: 1rem; text-align: initial;\">\u00a0During these moments, there is commonly a compulsive urge to pick, squeeze, or scratch at a surface or region of the body, often at the location of a perceived skin defect. When picking, one may feel a sense of relief or satisfaction.<\/span><\/div>\n<\/div>\n<\/div>\n<\/div>\n<p>The region most commonly picked is the face,<sup id=\"cite_ref-Odlaug_3-1\" class=\"reference\"><\/sup><sup id=\"cite_ref-DellOsso_6-1\" class=\"reference\"><\/sup>\u00a0but other frequent locations include the arms, legs, back, gums, neck, shoulders, scalp, abdomen, chest, and extremities such as the fingernails, cuticles, and toenails.\u00a0Most patients with excoriation disorder report having a primary area of the body that they focus their picking on, but they will often move to other areas of the body to allow their primary picking area to heal.\u00a0Individuals with excoriation disorder vary in their picking behavior; some do it briefly multiple times a day while others can do one picking session that can last for hours.\u00a0The most common way to pick is to use the fingers although a significant minority of people use tools such as tweezers or needles.<\/p>\n<p>Skin picking often occurs as a result of some other triggering cause.\u00a0Some common triggers are feeling or examining irregularities on the skin and feeling anxious or other negative feelings.<\/p>\n<p>Complications arising from excoriation disorder include infection at the site of picking, tissue damage, and\u00a0sepsis. Damage from picking can be so severe as to require\u00a0skin grafting. Severe picking can cause\u00a0epidermal abscesses. Severe cases of excoriation disorder can cause life-threatening injuries. For example, in one reported case, a female picked a hole through the bridge of her nose, which required surgery to fix, and a 48-year-old female picked through the skin on her neck exposing the\u00a0carotid artery. Pain in the neck or back can arise due to prolonged bent-over positions while engaging in the behavior. Besides physical injuries, excoriation disorder can cause severe physical scarring and disfigurement.<\/p>\n<div style=\"width: 230px\" class=\"wp-caption alignleft\"><a class=\"image\" href=\"https:\/\/en.wikipedia.org\/wiki\/File:Excoriation_disorder_affecting_face.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"thumbimage\" src=\"https:\/\/upload.wikimedia.org\/wikipedia\/en\/thumb\/2\/25\/Excoriation_disorder_affecting_face.jpg\/220px-Excoriation_disorder_affecting_face.jpg\" alt=\"https:\/\/en.wikipedia.org\/wiki\/Excoriation_disorder\" width=\"220\" height=\"165\" \/><\/a><\/p>\n<p class=\"wp-caption-text\"><strong>Figure 2<\/strong>. Compulsive picking of face using nail pliers and tweezers.<\/p>\n<\/div>\n<div class=\"thumbcaption\">\n<div class=\"magnify\"><span style=\"font-size: 1rem; text-align: initial;\">Excoriation disorder can cause feelings of intense helplessness,\u00a0guilt,\u00a0shame, and\u00a0embarrassment\u00a0in individuals, and this greatly increases the risk of self-harm.\u00a0Studies have shown that excoriation disorder presented\u00a0suicidal ideation\u00a0in 12% of individuals with this condition,\u00a0suicide attempts\u00a0in 11.5% of individuals with this condition, and psychiatric hospitalizations in 15% of individuals with this condition.<\/span><\/div>\n<\/div>\n<div><\/div>\n<h2>Causes<\/h2>\n<p>There have been many different theories regarding the causes of excoriation disorder including biological and environmental factors. A common hypothesis is that excoriation disorder is often a coping mechanism to deal with elevated levels of turmoil, arousal, or stress within the individual, and that the individual has an impaired stress response.<sup id=\"cite_ref-Odlaug_3-7\" class=\"reference\"><\/sup>\u00a0A review of behavioral studies found support in this hypothesis in that skin picking appears to be maintained by automatic reinforcement within the individual. In contrast to neurological theories, there are some\u00a0psychologists\u00a0who believe that picking behavior can be a result of repressed rage felt toward\u00a0authoritarian\u00a0parents.\u00a0A similar theory holds that overbearing parents can cause the behavior to develop in their children.<\/p>\n<p>Clinical studies have posited that there is a strong link between traumatic childhood events and excoriation disorder. Those with self-injurious disorders of the skin are found to also frequently report childhood sexual abuse. While attempting to produce diagnostic criteria for excoriation disorder, researchers conversed with 10 patients with the disorder and found that a majority reported personal problems before the picking began, and four reported on abuse they suffered in childhood or adolescence.<a class=\"footnote\" title=\"Yal\u00e7in M, Tellio\u011flu E, Yildirim DU, Savrun BM, \u00d6zmen M, Aydemir EH (December 2015). &quot;Psychiatric Features in Neurotic Excoriation Patients: The Role of Childhood Trauma&quot;. Noro Psikiyatri Arsivi. 52 (4): 336\u2013341. doi:10.5152\/npa.2015.9902. PMC 5353104. PMID 28360736\" id=\"return-footnote-294-1\" href=\"#footnote-294-1\" aria-label=\"Footnote 1\"><sup class=\"footnote\">[1]<\/sup><\/a><\/p>\n<h3><span id=\"Neurological\" class=\"mw-headline\">Neurological<\/span><\/h3>\n<p>Studies have shown a linkage between\u00a0dopamine\u00a0and the urge to pick. Drugs such as\u00a0cocaine\u00a0and\u00a0methamphetamine, which increase the pharmacological effects of dopamine, have been shown to cause uncontrollable picking in users. Central nervous system stimulants may create the sensation of\u00a0<strong>formication<\/strong>, which feels like something is crawling on or under the skin.\u00a0Thus, excoriation disorder could result from a dysfunction in the dopamine reward functions.<\/p>\n<div id=\"attachment_4488\" style=\"width: 310px\" class=\"wp-caption alignright\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-4488\" class=\"wp-image-4488 size-medium\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/5351\/2020\/07\/17183157\/MRI_anterior_cingulate-300x229.png\" alt=\"MRI slice with highlighting indicating location of the anterior cingulate cortex, which is towards the front of the head, in the middle, close to the limbic system.\" width=\"300\" height=\"229\" \/><\/p>\n<p id=\"caption-attachment-4488\" class=\"wp-caption-text\"><strong>Figure 3<\/strong>. The\u00a0anterior cingulate cortex, part of the right-lateralized frontostriatal circuit, is shown here. We know that it plays a role in motor-inhibitory control and may be associated with excoriation disorder.<\/p>\n<\/div>\n<p>There may be another neurological explanation for excoriation disorder: individuals with the condition have less motor-inhibitory control, but show no sign of difference in\u00a0cognitive flexibility, when compared to individuals without the condition. Motor-inhibitory control is a function of the right-lateralized\u00a0frontostriatal circuit, which includes the right inferior frontal and bilateral\u00a0anterior cingulate cortices. The impairment of motor-inhibitory control is similar to the neurological conditions of those who have problems suppressing inappropriate behaviors, such as abusing methamphetamine.<\/p>\n<h3>Epidemiology<\/h3>\n<p>The prevalence of excoriation disorder is not well understood. Estimates of prevalence of the condition range from 1.4 to 5.4% in the general population. One U.S. telephone survey found that 16.6% of respondents &#8220;picked their skin to the point of noticeable tissue damage&#8221; and that 1.4% would qualify as meeting the requirements of excoriation disorder.\u00a0Another community survey found a rate of 5.4% had excoriation disorder. A survey of college students found a rate of 4%.<a class=\"footnote\" title=\"Odlaug BL, Grant JE (September 2010). &quot;Pathologic skin picking&quot;. The American Journal of Drug and Alcohol Abuse. 36 (5): 296\u2013303. doi:10.3109\/00952991003747543. PMID 20575652\" id=\"return-footnote-294-2\" href=\"#footnote-294-2\" aria-label=\"Footnote 2\"><sup class=\"footnote\">[2]<\/sup><\/a>\u00a0One study found that among non-disabled adults, 63% of individuals engaged in some form of skin picking and 5.4% engaged in serious skin picking.<a class=\"footnote\" title=\"Lang R, Didden R, Machalicek W, Rispoli M, Sigafoos J, Lancioni G, Mulloy A, Regester A, Pierce N, Kang S (2010). &quot;Behavioral treatment of chronic skin-picking in individuals with developmental disabilities: a systematic review&quot;. Research in Developmental Disabilities. 31 (2): 304\u201315. doi:10.1016\/j.ridd.2009.10.017. PMID 19963341\" id=\"return-footnote-294-3\" href=\"#footnote-294-3\" aria-label=\"Footnote 3\"><sup class=\"footnote\">[3]<\/sup><\/a>\u00a0Lastly, a survey of dermatology patients found that 2% suffered from excoriation disorder.\u00a0Excoriation disorder is statistically more common in females than in males.<\/p>\n<p>In some patients, excoriation disorder begins with the onset of\u00a0acne\u00a0in adolescence, but the compulsion continues even after the acne has gone away. Skin conditions such as keratosis pilaris, psoriasis, and eczema can also provoke the behavior. In patients with acne, the grooming of the skin is disproportionate to the severity of the acne.\u00a0Certain stressful events including marital conflicts, deaths of friends or family, and unwanted pregnancies have been linked to the onset of the condition.\u00a0If excoriation disorder does not occur during adolescence, another common age of onset is between the ages of 30 to 45.\u00a0Additionally, many cases of excoriation disorder have been documented to begin in children under the age of 10. One small survey of patients with excoriation disorder found that 47.5% of them had an early onset of excoriation disorder that began before age 10.\u00a0Traumatic childhood events may initiate the behavior.<\/p>\n<h2>Coborbidity<\/h2>\n<p>Excoriation disorder has a high rate of\u00a0comorbidity\u00a0with other psychiatric conditions, especially with mood and anxiety disorders.\u00a0One survey of patients with excoriation disorder found that 38% also had alcohol- or drug-abuse problems.\u00a0Studies have shown the following rates of psychiatric conditions found in patients with excoriation disorder:\u00a0trichotillomania\u00a0(38.3%),\u00a0substance abuse\u00a0(38%),\u00a0major depressive disorder\u00a0(approximately 31.7% to 58.1%),\u00a0anxiety disorders\u00a0(approximately 23% to 56%),\u00a0OCD (approximately 16.7% to 68%), and\u00a0body dysmorphic disorder\u00a0(approximately 26.8% to 44.9%).\u00a0There are also higher rates of excoriation disorder in patients in psychiatric facilities; a study of adolescent psychiatric inpatients found that excoriation disorder was present in 11.8% of patients.\u00a0It is also present at high rates with some other conditions: 44.9% of patients with\u00a0body dysmorphic disorder\u00a0also have excoriation disorder; 8.9% of patients with OCD have excoriation disorder; and 8.3% of patients with trichotillomania have excoriation disorder.<\/p>\n<p>Excoriation disorder has been the subject of several episodes of\u00a0<em>Obsessed<strong>,<\/strong><\/em> a television documentary series that focuses on treatment of anxiety disorders. Skin picking is shown as a symptom of Nina Sayers&#8217; anxiety and OCD in the movie\u00a0<i>Black Swan<\/i>.<\/p>\n<div class=\"textbox key-takeaways\">\n<h3>Key Takeaways: Excoriation Disorder<\/h3>\n<p><iframe loading=\"lazy\" title=\"Excoriation Disorder\" src=\"https:\/\/lumenlearning.h5p.com\/content\/1291225604668309728\/embed\" width=\"1088\" height=\"694\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><script src=\"https:\/\/lumenlearning.h5p.com\/js\/h5p-resizer.js\" charset=\"UTF-8\"><\/script><\/p>\n<\/div>\n<div class=\"textbox exercises\">\n<h3>Link to Learning<\/h3>\n<p><a href=\"https:\/\/www.youtube.com\/watch?v=mlt3o6dnGqA\" target=\"_blank\" rel=\"noopener\">Watch this Ted talk by artist Liz Atkin<\/a> and listen to her tell her own story of struggle and recovery in dealing with excoriation disorder.<\/p>\n<\/div>\n<div class=\"textbox tryit\">\n<h3>Try It<\/h3>\n<p>\t<iframe id=\"assessment_practice_e2c89f68-dada-4c43-b2d1-83f181010631\" class=\"resizable\" src=\"https:\/\/assess.lumenlearning.com\/practice\/e2c89f68-dada-4c43-b2d1-83f181010631?iframe_resize_id=assessment_practice_id_e2c89f68-dada-4c43-b2d1-83f181010631\" frameborder=\"0\" style=\"border:none;width:100%;height:100%;min-height:300px;\"><br \/>\n\t<\/iframe><\/p>\n<\/div>\n<div class=\"textbox learning-objectives\">\n<h3>Glossary<\/h3>\n<p><b>excoriation disorder: <\/b>an obsessive-compulsive spectrum\u00a0disorder\u00a0that is characterized by the repeated urge or impulse to pick at one&#8217;s own skin to the extent that either psychological or physical damage is caused<\/p>\n<p><strong>formication: <\/strong>the sensation of something that is crawling on or under the skin<\/p>\n<\/div>\n\n\t\t\t <section class=\"citations-section\" role=\"contentinfo\">\n\t\t\t <h3>Candela Citations<\/h3>\n\t\t\t\t\t <div>\n\t\t\t\t\t\t <div id=\"citation-list-294\">\n\t\t\t\t\t\t\t <div class=\"licensing\"><div class=\"license-attribution-dropdown-subheading\">CC licensed content, Original<\/div><ul class=\"citation-list\"><li>Modification, adaptation, and original content. <strong>Authored by<\/strong>: Christina Hicks for Lumen Learning. <strong>Provided by<\/strong>: Lumen Learning. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><\/ul><div class=\"license-attribution-dropdown-subheading\">CC licensed content, Shared previously<\/div><ul class=\"citation-list\"><li>Excoriation Disorder. <strong>Provided by<\/strong>: Wikimedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/en.wikipedia.org\/wiki\/Excoriation_disorder\">https:\/\/en.wikipedia.org\/wiki\/Excoriation_disorder<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><li>RI slice with highlighting indicating location of the anterior cingulate cortex. <strong>Authored by<\/strong>: Geoff B Hall. <strong>Provided by<\/strong>: Wikimedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/en.wikipedia.org\/wiki\/Anterior_cingulate_cortex#\/media\/File:MRI_anterior_cingulate.png\">https:\/\/en.wikipedia.org\/wiki\/Anterior_cingulate_cortex#\/media\/File:MRI_anterior_cingulate.png<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/about\/cc0\">CC0: No Rights Reserved<\/a><\/em><\/li><\/ul><div class=\"license-attribution-dropdown-subheading\">All rights reserved content<\/div><ul class=\"citation-list\"><li>Body focused repetitive disorders (trichotillomania &amp; excoriation). <strong>Provided by<\/strong>: Osmosis. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/www.youtube.com\/watch?v=jFxoT3coHas\">https:\/\/www.youtube.com\/watch?v=jFxoT3coHas<\/a>. <strong>License<\/strong>: <em>Other<\/em>. <strong>License Terms<\/strong>: Standard YouTube License<\/li><li>What it&#039;s like to have a skin-picking disorder. <strong>Provided by<\/strong>: Newsy. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/www.youtube.com\/watch?v=5WYpRZbF1Jg\">https:\/\/www.youtube.com\/watch?v=5WYpRZbF1Jg<\/a>. <strong>License<\/strong>: <em>Other<\/em>. <strong>License Terms<\/strong>: Standard YouTube License<\/li><\/ul><\/div>\n\t\t\t\t\t\t <\/div>\n\t\t\t\t\t <\/div>\n\t\t\t <\/section><hr class=\"before-footnotes clear\" \/><div class=\"footnotes\"><ol><li id=\"footnote-294-1\">Yal\u00e7in M, Tellio\u011flu E, Yildirim DU, Savrun BM, \u00d6zmen M, Aydemir EH (December 2015). \"Psychiatric Features in Neurotic Excoriation Patients: The Role of Childhood Trauma\". Noro Psikiyatri Arsivi. 52 (4): 336\u2013341. doi:10.5152\/npa.2015.9902. PMC 5353104. PMID 28360736 <a href=\"#return-footnote-294-1\" class=\"return-footnote\" aria-label=\"Return to footnote 1\">&crarr;<\/a><\/li><li id=\"footnote-294-2\">Odlaug BL, Grant JE (September 2010). \"Pathologic skin picking\". The American Journal of Drug and Alcohol Abuse. 36 (5): 296\u2013303. doi:10.3109\/00952991003747543. PMID 20575652 <a href=\"#return-footnote-294-2\" class=\"return-footnote\" aria-label=\"Return to footnote 2\">&crarr;<\/a><\/li><li id=\"footnote-294-3\">Lang R, Didden R, Machalicek W, Rispoli M, Sigafoos J, Lancioni G, Mulloy A, Regester A, Pierce N, Kang S (2010). \"Behavioral treatment of chronic skin-picking in individuals with developmental disabilities: a systematic review\". Research in Developmental Disabilities. 31 (2): 304\u201315. doi:10.1016\/j.ridd.2009.10.017. PMID 19963341 <a href=\"#return-footnote-294-3\" class=\"return-footnote\" aria-label=\"Return to footnote 3\">&crarr;<\/a><\/li><\/ol><\/div>","protected":false},"author":29,"menu_order":7,"template":"","meta":{"_candela_citation":"[{\"type\":\"cc\",\"description\":\"Excoriation Disorder\",\"author\":\"\",\"organization\":\"Wikimedia\",\"url\":\"https:\/\/en.wikipedia.org\/wiki\/Excoriation_disorder\",\"project\":\"\",\"license\":\"cc-by-sa\",\"license_terms\":\"\"},{\"type\":\"copyrighted_video\",\"description\":\"Body focused repetitive disorders (trichotillomania & excoriation)\",\"author\":\"\",\"organization\":\"Osmosis\",\"url\":\"https:\/\/www.youtube.com\/watch?v=jFxoT3coHas\",\"project\":\"\",\"license\":\"other\",\"license_terms\":\"Standard YouTube License\"},{\"type\":\"copyrighted_video\",\"description\":\"What it\\'s like to have a skin-picking disorder\",\"author\":\"\",\"organization\":\"Newsy\",\"url\":\"https:\/\/www.youtube.com\/watch?v=5WYpRZbF1Jg\",\"project\":\"\",\"license\":\"other\",\"license_terms\":\"Standard YouTube License\"},{\"type\":\"original\",\"description\":\"Modification, adaptation, and original content\",\"author\":\"Christina Hicks for Lumen Learning\",\"organization\":\"Lumen Learning\",\"url\":\"\",\"project\":\"\",\"license\":\"cc-by-sa\",\"license_terms\":\"\"},{\"type\":\"cc\",\"description\":\"RI slice with highlighting indicating location of the anterior cingulate cortex\",\"author\":\"Geoff B Hall\",\"organization\":\"Wikimedia\",\"url\":\"https:\/\/en.wikipedia.org\/wiki\/Anterior_cingulate_cortex#\/media\/File:MRI_anterior_cingulate.png\",\"project\":\"\",\"license\":\"cc0\",\"license_terms\":\"\"}]","CANDELA_OUTCOMES_GUID":"1dd622ed-ebe5-4b58-a366-1f97d25d8e06, f31cf0ec-3a89-43c5-9a3b-232c070b7a34","pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-294","chapter","type-chapter","status-publish","hentry"],"part":138,"_links":{"self":[{"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/pressbooks\/v2\/chapters\/294","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/wp\/v2\/users\/29"}],"version-history":[{"count":29,"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/pressbooks\/v2\/chapters\/294\/revisions"}],"predecessor-version":[{"id":7623,"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/pressbooks\/v2\/chapters\/294\/revisions\/7623"}],"part":[{"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/pressbooks\/v2\/parts\/138"}],"metadata":[{"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/pressbooks\/v2\/chapters\/294\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/wp\/v2\/media?parent=294"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/pressbooks\/v2\/chapter-type?post=294"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/wp\/v2\/contributor?post=294"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/wp\/v2\/license?post=294"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}