Diagnosis of Excoriation (Skin picking) Disorder

Excoriation Disorder has recently been included in the DSM-5 as a full disorder with criteria summarized as follows:

  • • Picking of the skin which results in wounds to the skin
  • • The person endorses trying to either cut back or stop picking
  • • The patient experiences distress as a result of skin picking or some aspect of social, work, or other area of functioning is impaired
  • • Drug use (such as amphetamine or cocaine) or a medical condition is not the cause of the skin picking
  • • Another mental health condition (such as picking to improve one’s appearance or a perceived defect as seen in Body Dysmorphic Disorder, delusions or hallucinations, stereotypies, or international self-harm) is not the main prompt for skin picking

Although most people pick at their skin at some time, the above criteria differentiate typical and common picking from Excoriation Disorder. Most people who pick at their cuticles from time to time, for example, do not feel distressed by it and are not impaired due to the skin picking.

There are several questions that a clinician may use to assess the diagnostic criteria and to derive information regarding the picking behavior.

“Can you tell me why you pick?” This will help to rule out dermatological conditions and some psychiatric conditions.

“Can you control your picking?” or “Do you have urges to pick that are difficult for you to control?” Intense urges or tension or anxiety prior to actually engaging in the picking behavior are common in Excoriation Disorder and can potentially help in directing the patient for appropriate treatment.

“Are there activities or others things in your life that you avoid due to your picking?” Many patients will endorse not socializing with friends, refusing to wear short sleeves or shorts in the summer due to their scarring, or not dating because of their skin picking. It is reassuring for the patient to be able to tell someone about how picking affects their everyday life since many patients have been unable or unwilling to talk to someone about their picking before.

“At what time(s) in the day do you pick? For example, are you around other people or by yourself; do you pick most while driving or at home watching TV, etc.?”

“Do you have any triggers to your picking? For example, do you pick when you are tired, stressed, angry, sad, etc.?”

These questions can be beneficial when developing a behavioral therapy for the patient.

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