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PSYCHOCUTANEOUS MEDICINE

Picking Apart the Picker: A Clinician’s Guide for Management of the Patient Presenting With Excoriations

Richard G. Fried, MD, PhD; Sidney Fried, PhD

Management of patients who “pick” at their skin “crazy pickers and scratchers.” Lack of a precise is often difficult. Etiologies and maintaining fac- diagnosis inevitably leads to both abandonment of tors can be unclear. Significant psychiatric over- scientific rigor and poorly focused patient manage- lay is often present, and the clinician is left with ment.1,2 Phillips and Taub3 have stated that the an overwhelming differential diagnosis and a term neurotic excoriations, “while useful in under- poorly focused treatment plan that can result in scoring the behavior’s psychiatric etiology, is a suboptimal clinical outcomes. The purpose of broad term used since 1875 that does not specify this paper is to provide a conceptual framework the underlying psychiatric disorder or have clear for the evaluation and treatment of patients pre- treatment implications.” Not all picking is moti- senting with excoriations. Ten diagnostic cate- vated by the same underlying factors. Phillips4 has gories are examined, and specific suggestions suggested that skin picking can be a manifestation for treatment are offered. of body dysmorphic disorder (BDD), while others have suggested that it may be related to obsessive- ll people manipulate their skin. We touch, compulsive disorder (OCD).5,6 Regardless of the rub, squeeze, scratch, and pick. Skin manip- underlying etiology, skin picking is common. A ulation can be initiated or maintained due Keuthen et al7 found that 78% of a nonclinical to cutaneous lesions or imperfections or may occur sampling of college students admitted to some in response to altered sensations in the skin. How- degree of skin picking. Further, 48% of the pickers ever, manipulation often occurs in the absence of reported noticeable skin damage.7 Thus, we pro- visual or tactile stimuli. Clinically relevant manip- pose that skin picking is ubiquitous and that pre- ulation (picking) is characterized by disfiguring cise treatment algorithms are essential for effective insult to the integument or by social, vocational, or patient management. intrapsychic morbidity (dysfunction) caused or Our goal is to provide a more useful conceptual- worsened by skin excoriation. Picked or excoriated ization and classification of patients presenting with skin is a common clinical presentation observed by excoriations. The authors assume that traditional the dermatologic, general medicine, and psychi- management strategies—such as occlusion, topical atric practitioner. If well-recognized organic etiolo- corticosteroids, mentholated compounds, tar prepa- gies have been ruled out, patients are often overtly rations, emollients, intralesional corticosteroids, or covertly diagnosed as “neurotic excoriators” or and cryosurgery—have been and will continue to be employed along with our psychocutaneous recom- mendations. Patients who pick their skin can be Accepted for publication October 17, 2002. thought of as belonging to one of the 10 general Dr. Richard Fried is from Thomas Jefferson University, groups of pickers we describe (Table 1). Philadelphia, Pennsylvania. Dr. Sidney Fried (deceased) was from the State University of New York, Farmingdale. The authors report no conflict of interest. General Considerations Reprints: Richard G. Fried, MD, PhD, 903 Floral Vale Blvd, When symptoms of anxiety, depression, OCD, or Yardley, PA 19067 (e-mail: [email protected]). are clinically evident, augmentation of

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traditional dermatologic treatments with psycho- therapeutic techniques and selected , Table 1. anxiolytic, and can greatly enhance therapeutic outcomes (Table 2). Categories of Pickers Traditional dermatologic therapies, including topi- cal and oral agents, occlusion, casting, and, in Angry extreme cases, hospitalization, remain the mainstay Anxious/depressed of treatment. Psychiatric referral is often not possi- ble because of patient resistance and insurance Body dysmorphic constraints. Thus, it is incumbent upon the derma- tologist or primary care physician to provide appro- Borderline priate treatment. When evaluating an anxious or Delusional depressed patient, the risk of suicide must always be considered and assessed. Appropriate psychiatric Guilty referral is mandatory if there is overt or implied Habit suicidal intent. The severity of excoriations and psy- chosocial impairment can be an indicator of the risk Narcissistic to the patient or others and of the urgency for treat- Obsessive compulsive ment. When psychiatric referral is necessary, it is often best to tell patients that the referral is to a Organic “skin emotion specialist” who understands the unique skin-emotion link. This euphemism is usually better accepted than traditional referral to a “shrink.” Table 2 lists various emotional states and the suggested psychotropic agents for their manage- aggressive manifestation of a patient’s anger. A ment. In general, treatment should be initiated at a classic example is the picker whose picking upsets low dosage unless the patient is severely agitated or or even infuriates the nonpicking partner or par- suicidally depressed (reasons for immediate psychi- ent. The passive indifference displayed by an ado- atric referral). This approach often can minimize lescent with acne excoriee who comes to a clinic unpleasant side effects that can lead to noncompli- accompanied by a distraught parent is a common ance. Dosing regimens should be titrated up at 2- to presentation. This form of emotional manipulation 3-week intervals until the desired therapeutic effect is typical, and the dynamics of the picking and its is achieved.8 role in the relationship are rarely evident to the Both recognized and idiosyncratic side effects picker. The clinician must realize that angry pick- are always possible. Thus, it is suggested that clini- ers may find the idea of relinquishing the picking cians become familiar with one or two agents in act to be frightening due to fear of their underlying each therapeutic class and begin incorporating impulses. The picking behavior often affords those agents into their practice. Clinicians who are patients a sense of control over both themselves uneasy with the concept of prescribing psychotropic and others. The excoriations of the angry picker agents must recall that the American Academy of often become functionally autonomous (a self- Dermatology Task Force on Psychocutaneous maintaining function independent of the initial Medicine endorses these medications and encour- eliciting factors) and may evolve into an obsessive- ages their use. compulsive pattern. The goal of treatment is to help patients reduce and more effectively dissipate The Angry Picker their anger while more effectively manipulating Picking can be a manifestation of conscious or sub- their environment in a less self-injurious fashion. conscious anger. The individual may “choose” to Concrete behavioral alternatives, aggressive exer- pick as an attempt to sublimate rageful or unac- cise, competitive sports such as kickboxing or ceptable impulses. Angry pickers can be passive karate, relaxation training, and insight-oriented and nonassertive in their demeanor and interac- psychotherapy can be helpful in decreasing the tions with others; however, their underlying anger picking of these patients. Concomitant use of is often expressed through sarcasm and passive selective reuptake inhibitors (SSRIs) or aggressiveness. These passive expressions and peri- anxiolytic medications can be helpful in treating odic outbursts of rage can be hints about pervasive underlying depression, agitation, and associated underlying anger. Picking also can be a passive- obsessive-compulsive components.

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Table 2. Selected Anxiolytic, Antidepressant, and Antipsychotic Medications for Management of Picking*

Acute Anxiety Benzodiazepines Alprazolam: 0.25–1 mg every 6–8 h PRN Clonazepam: 0.25–0.5 mg every 6–8 h PRN : 0.5 mg every 8 h PRN

Long-standing Anxiety Add concomitant nonbenzodiazepine 5–15 mg TID

Depression SSRIs—all can be activating or sedating; most can decrease libido : for depression, start at 10–20 mg QD, titrate to 40–60; for OCD, start at 60–80 mg : for depression, start at 25–50 mg QD, titrate to 100 mg (single or divided doses); for OCD, dose up to 200 mg QD : for depression, start at 10–20 mg QD; for OCD, start at 20–40 mg QD : for depression, start at 50 mg QD, titrate to 200 mg; for OCD, titrate to 200–300 mg QD : for depression, start at 10 mg QD, maximum 20 mg QD : for depression and anxiety, start at 75 mg QD, titrate to 300 mg if necessary : all can have sedating and anticholinergic effects : start at 10–25 mg HS, titrate to 75–100 mg QD (single or divided doses) : start at 25 mg HS, titrate to 75 mg HS

Psychosis or Severely Destructive Excoriations : start at 1.25–2.5 mg QD, titrate to 5 mg QD TID Pimozide: start at 1 mg HS, titrate to 6 mg HS : start at 1 mg HS, titrate to 2 mg HS : start at 0.5 mg QD, titrate to 2 mg QD

*PRN indicates as occasion requires; TID, 3 times daily; SSRIs, selective serotonin reuptake inhibitors; BID, 2 times daily; QD, every day; OCD, obsessive-compulsive disorder; HS, hour of sleep (bedtime).

The Anxious/Depressed Picker should be initiated by offering the patient insight Picking is common among anxious and depressed and hope. Anxiety and depressive disorders often patients. A review by Phillips and Taub3 suggested have an insidious onset, and symptoms are frequently that 88% of patients with major depression and 58% not recognized by the patient. Patients often of patients with anxiety disorders pick their skin. attribute symptoms to age, declining health, etc. The The clinical disfigurement that follows can lead to astute clinician can elucidate associated anxiety and exacerbation of the depression and anxiety state, depression by asking pertinent questions such as, with subsequent tendency toward more self-excoriation. “Are your feelings of tension, fatigue, or sadness Management of the anxious/depressed picker interfering with your ability to be happy or do the

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things you want or need to do?” Ask patients if they experience pleasurable sensations from activities Table 3. such as eating, exercising, and sex. Ask how they feel before and after they pick their skin. Patients often Common Signs and Symptoms of report increased levels of anxiety or depression that Depression and Anxiety are transiently decreased by their picking. Tell patients there are techniques and medica- Anxiety tions that can make them feel less stressed and happier. If there is no active suicidal or homicidal Gastrointestinal upset ideation of intent, offer patients referrals for stress management, biofeedback, cognitive behavioral or insight-oriented psychotherapy, or hypnosis. Cog- Jitteriness (tremulousness) nitive behavioral psychotherapy helps individuals Panic attacks identify and change self-defeating thoughts and perceptions that lead to negative emotional reac- Poor attention span tions and maladaptive behaviors. Helping patients Restlessness decrease their tendency to view life events as awful or catastrophic can decrease their anxiety and Tachycardia (palpitations) depression and lessen the urge to pick. Insight- oriented psychotherapy helps patients identify Depression emotions, thoughts, and behavior patterns and make Anhedonia (inability to experience pleasure) meaningful emotional and behavioral changes. The result is often decreased subjective stress, Blunted (constricted affect) improved insight into motivation for picking, and Decreased libido decreased urge to pick. Concomitant use of an appropriate psychotropic agent as an adjunct to Hyperphagia/hypophagia traditional dermatologic therapy can be useful. Table 3 lists the common signs and symptoms of Hypersomnia/hyposomnia anxiety and depression. Limited spontaneous verbalizations The Body Dysmorphic Picker Poor eye contact The body dysmorphic picker shares many similari- ties with the narcissistic picker. Both can present with extreme preoccupation with minimal cos- metic imperfection. However, body dysmorphic pickers often have greater distortions in their per- ception of their skin “defect” and carry a much with SSRIs.13 Also, both BDD and OCD often have higher rate of morbidity and mortality. These are repetitive behaviors that provide individuals with individuals preoccupied with a minimal or imag- immediate reduction in tension; however, the ined defect in appearance. Their exaggerated and behaviors and their sequelae often lead to even more distorted perceptions cause significant emotional severe rebound anxiety, depression, and persevera- distress and/or impairment in social, occupational, tion. Picking often occurs for extended periods (for or other important areas of functioning. Patients hours a day) in front of a mirror. People with BDD commonly present with exaggerated preoccupation have significant associated morbidity with a high with and excessive manipulation of acneform frequency of social or occupational impairment. lesions, telangiectasias, nevi, etc. Their preoccupa- Many become housebound, and psychiatric hospi- tion and skin manipulation can have devastating talizations and suicide attempts are not uncommon.4 emotional and functional consequences with sub- Treatment of individuals with BDD is difficult. stantial associated morbidity and mortality. Phillips Because there is frequently substantial impairment in et al3 and Koblenzer9 stated that BDD is a relatively functioning, as well as suicide potential, aggressive common disorder that often involves preoccupa- modalities are warranted. An SSRI and adjunctive tion with the skin. psychotherapy are essential and should be strongly Overlap between BDD and OCD may exist.9-12 recommended by the clinician. Use of a low-dose This claim is somewhat substantiated by the fact antipsychotic can be helpful. Vigilance that both disorders respond favorably to treatment should be maintained for signs of accelerating

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depression or suicidal ideation and appropriate refer- meditation, and biofeedback also can be helpful. ral to a psychiatric professional should be made. Borderline pickers can become moderately bizarre, even delusional, under stressful situations. During The Borderline Picker acutely agitated states, anxiolytic and antipsy- The borderline picker is characterized by enormous chotic medications may be necessary. These affective instability, chronic feelings of emptiness, patients will continually demand novel therapies boredom, and unhappiness. Poor judgment and lim- and will invariably find your therapeutic offerings ited impulse control further define these individuals, ineffective. Long-term psychotherapy is advocated and their picking is often only one of many self- when possible for effective treatment of this severe injurious activities that highlight their present and characterologic disorder. past behaviors. Clues to the borderline picker may include scars from suicide attempts, cigarette burns, The Delusional Picker or self-inflicted wounds. These self-destructive acts The picking behavior of the delusional picker is, by are performed in response to anger or anxiety or as definition, motivated by a rigidly held belief that is an attempt to “feel something.” The borderline not based on reality. The delusional belief can be picker often has a history of or drug abuse limited to skin infestation or skin defect and interpersonal relationships that were marred by (monosymptomatic hypochondriacal delusion). In excessive lability (ie, vicious verbal and physical contrast, the delusional belief can be part of a more fighting). The work history of these individuals is pervasive with many other mis- often unstable, and relationships with previous perceptions of reality. Delusions of parasitosis physicians are commonly described as unsatisfactory. (monosymptomatic hypochondriacal psychosis) is Initial therapeutic encounters with these patients the classic example of a circumscribed delusional may be unusually pleasant for the physician (exces- system. These patients rigidly maintain a belief of sive praise and overly ingratiating statements offered infestation with an insect or parasite, and their pick- by the patient). However, the physician inevitably ing is an attempt to eradicate or modify the infesta- becomes a target of the patient’s anger and disap- tion. They are otherwise without active delusional pointment when clinical success is not immediate ideation. These delusional pickers often respond and complete. Borderline pickers often violate the favorably to treatment with pimozide,11 and recent boundaries of the doctor-patient relationship and data suggest possible favorable responses to treat- have exaggerated expectations of physician avail- ment with olanzapine and risperidone.14 Patients ability and duration of visits. with more generalized delusional systems are in need Treatment of the borderline picker is often diffi- of standard antipsychotic medication and often cult and unsuccessful because of their predisposition require periodic psychiatric hospitalization. It is to ongoing self-injurious behavior, poor judgment, important that the clinician avoid challenging the and poor impulse control. The underlying chronic patient’s delusional beliefs. Disputing the patient’s depression experienced by these patients can be ideas and attempting to force reality-based percep- somewhat ameliorated by the use of antidepressant tions on the patient will jeopardize the therapeutic medications, and the anxiety and chronic agitation alliance. In fact, it may even be dangerous if the of borderline pickers can be somewhat responsive to physician is perceived as a threat within the anxiolytic medications. Benzodiazepine anxiolytics patient’s delusional system. Accepting the patient’s can be problematic because there is frequently a delusional beliefs as real and important will yield the high potential for addiction or abuse. Narcissistic greatest chance of a safe and effective alliance. If the preoccupation is frequently common and can be delusional belief is circumscribed, as in the patient useful as a starting point to engage the patient in with delusions of parasitosis, treatment with treatment. Statements such as “I don’t want to see pimozide or olanzapine may be helpful. More gener- you become scarred” or “I am fearful that your alized delusional disorders usually require standard picking will lead to permanent scars” can be help- psychiatric referral. ful. Initially, offer patients quick-fix therapies such as topical steroids, mentholated compounds, topi- The Guilty Picker cal , and moisturizers. Concrete Guilt is a subjective experience of emotional discom- alternative behaviors such as deep breathing exer- fort that is encountered by all individuals with a cises, gentle slapping of lesions, application of cold conscience. A basic fear of retribution occurs when packs, and palm or finger pressure on lesions can individuals perceive their thoughts or deeds as be helpful distraction methods. More formal inter- wrong, impure, or evil at either a conscious or uncon- vention such as progressive muscle relaxation, scious level. Guilt can be a facilitative motivator for

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prosocial behavior or, in contrast, it can be a perva- of the habit picker. The picking of the habit picker sive destructive force that leads to intrapsychic mis- is usually milder and more anatomically localized in ery and self-punitive behavior. The compulsive hand comparison with those patients with more severe washing described in Shakespeare’s Macbeth may be psychopathology or classic neurotic excoriations. conceptualized within our framework as the guilty The overall functional status of these patients is usu- washer. The fearful, guilt-ridden individual may pick ally very good. Sometimes they simply need insight incessantly as a self-punitive gesture or as an attempt and awareness and can respond extremely well to to rid oneself of impurity or infection. The guilt and behavior modification incorporated with alternative accompanying fear may be reality-based, as in the behaviors as well as hypnosis. Simple occlusion, top- individual who engages in an extramarital affair and ical and intralesional corticosteroids, topical anti- is fearful that he or she has contracted a sexually histamines (doxepin), mentholated compounds, and transmitted disease. More often, the guilt is in topical preparations all can be helpful. response to minimal behavioral indiscretions or Excoriations of the habit picker can evolve into an unacceptable thoughts or fantasies. The guilt is often obsessive-compulsive pattern; therefore, in chronic buttressed by cultural and religious beliefs regarding resistant cases, the use of an SSRI may be helpful. retribution, which can cause individuals to ruminate, perseverate, and repeatedly excoriate. Excoriated The Narcissistic Picker lichen simplex chronicus of the scrotum or pruritus The narcissistic picker self-excoriates because of an ani may be symptoms of persistent guilt and fear of inability to accept imperfection. These individuals retribution for unacceptable thoughts or acts in are by definition self-preoccupied and can spend patients presenting with these conditions. long periods of time seated in front of a mirror study- Supportive clinicians who appropriately edu- ing their real, minimal, or imagined imperfections. cate their patients can often assuage some of the They pick as an attempt to rid themselves of an guilt of these individuals and thus allow them to intolerable mar on an otherwise perfect picture. minimize ongoing self-punitive behavior. Appro- Narcissistic patients are often impossible to please priate diagnostic tests for conditions such as because they crave and demand perfection and con- chlamydia, syphilis, gonorrhea, and human immu- stant attention. Their insatiable appetite for atten- nodeficiency virus should be performed if patient tion, recognition, and perfection leads them to history or clinical suspicion warrant. Gentle reas- numerous cosmetic, medical, and surgical specialists surance and humor can often allay anxiety for in search of the unattainable. They are frequently these patients and provide them with perspective. bitter and angry because of inadequate attention Patients who pick incessantly because of fantasies from loved ones and imperfect therapeutic outcomes of an extramarital affair can often be reassured that rendered by healthcare professionals. Primary or sec- this is a common fantasy for which there is no pun- ondary depression and OCD are not uncommon. ishment. Offering concrete alternative behaviors Treatment of the narcissistic picker is a long and can be helpful. If substantial guilt is still present, often unsuccessful endeavor. It is common for the short-term cognitive behavioral psychotherapy, physician to feel drained or exploited after repeated insight-oriented psychotherapy, SSRIs, and anxi- contact with a narcissistic patient. Clinicians olytic medications all can be helpful in treating should be aware of the intense subjective discom- associated depression, anxiety, and obsessive- fort experienced by these patients and should avoid compulsive symptoms. minimizing the importance of the patient’s per- ceived imperfections. Emotional support and tact- The Habit Picker ful attempts to provide reality-based objective All individuals develop mechanisms and techniques assessment of the imperfections are a starting point to dissipate anxiety. In contrast to the obsessive- of therapy. Avoidance of overly aggressive medical compulsive picker, the habit picker has no associ- and surgical therapies is strongly advised because ated obsessions or compulsive ritualistic behaviors. they will inevitably fall short of the patient’s The habit picker probably stumbles upon a simple expectations. It may be helpful to treat concomi- behavior to reduce underlying anxiety. For some, tant depression, anxiety, and possible obsessive- hair twirling may be effective, while for others, rock- compulsive patterns by using SSRIs and anxiolytic ing, rubbing, eating, smoking, or masturbating may medications. Cosmetic camouflage may be helpful be their chosen methods. The nail picker who pre- in allowing patients to not focus on the imperfec- sents with median nail dystrophy or the patient with tion as their treatment progresses. Concomitant scalp lesions who presents with small excoriated psychotherapy is often desirable if the patient will nodules on the posterior scalp are classic examples accept the recommendation.

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The Obsessive-Compulsive Picker Table 4. OCD is characterized by intrusive, obsessive thoughts accompanied by or leading to compulsive, Organic Etiologies Associated With ritualistic acts. The thoughts and behaviors often Skin Excoriations lead to psychosocial impairment and/or dermato- logic problems. Common clinical presentations Dermatologic Conditions include acne excoriee, excoriated lichen simplex chronicus, and neurotic excoriations. Affected indi- Acne/folliculitis viduals report increased tension and anxiety preced- Dermatitis herpetiformis ing performance of the ritualistic act, which is temporarily reduced by performance of the act. Eczema When the act is detrimental or disfiguring, it is common for individuals to experience increased agi- Infestation tation and anguish. This emotional discomfort can Lichen planus lead to additional picking and perpetuation of the cycle. The picking of patients with OCD may be a Psoriasis manifestation of a single compulsive act or may be Urticaria only one of several compulsions. There may be other ritualistic acts, including checking, cleaning, and Systemic Conditions rubbing. The need for treatment is determined by the degree to which the obsessions or compulsions Amyloid tumor disfigure or scar the skin or interfere with the psy- Carcinoid chosocial functioning of patients. Successful treatment is directed at decreasing the Diabetes compulsive urge and empowering patients to better Drug reactions control their picking behavior. The practitioner should recognize that asking patients to relinquish Hepatic disease the compulsive act can arouse tremendous subjec- Hodgkin’s disease tive anxiety because the picking has evolved as a maladaptive but important method to decrease anx- Human immunodeficiency virus iety and maintain control. Bearing this in mind, treatment of the obsessive-compulsive picker must Lupus be initiated with gentle support and a clear message Multiple sclerosis to patients that they may maintain control. First- line treatment should be an SSRI. Clinicians should Polycythemia vera introduce the medication with the suggestion that it Renal disease will help patients increase control over their picking behavior. Explain that the medicine will decrease Sjögren syndrome the intensity of the urge to pick and the associated emotional subjective discomfort. Once the urge to Neuropsychiatric Conditions pick has been lessened, patients are often better able Alcohol, , other substance intoxication to embrace and develop alternative behaviors. Offer concrete alternative behaviors such as deep breath- Alzheimer disease ing, relaxation training (available in audiotape form Parkinson disease in local bookstores), imagery techniques (such as relaxing scenes, healing healthy skin, sunlight, Pervasive developmental disorder soothing sensations), squeezing of fists, application of pressure, cold compresses, and application of med- Prader-Willi syndrome ications. Concomitant cognitive behavioral or sup- Stereotypic movement disorders portive psychotherapy is often helpful. Behavior modification techniques often are used to enable patients to break conditioned stimulus-response emotional and behavioral associations (eg, picking while in traffic, watching television, in front of the bathroom mirror). Dermatologic therapies including

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topical and intralesional corticosteroids, occlusion, treatment recommendations that will lead to better topical or oral antibiotics, mentholated compounds, therapeutic outcomes. tar preparations, topical lidocaine creams, and topi- cal therapies may be helpful as well. REFERENCES Newer topical immunosuppressant agents such as 1. Fried RG. Evaluation and treatment of “psychogenic” pimecrolimus and tacrolimus may be useful if recal- pruritus and self-excoriation. J Am Acad Dermatol. citrant pruritus is present. Nighttime use of a tri- 1994;30:993-999. cyclic antidepressant may be helpful if there is 2. Koblenzer CS. Cutaneous manifestations of psychiatric dis- associated sleep impairment or nocturnal itching. ease that commonly present to the dermatologist: diagnosis and treatment. Int J Psychiatry Med. 1992;22:47-63. The Organic Picker 3. Phillips KA, Taub SL. Skin picking as a symptom of body Many organic states lead patients to excoriate. The dysmorphic disorder. Psychopharmacol Bull. 1995;31:279-288. excoriation of the organic picker may be in response 4. Phillips KA. Body dysmorphic disorder: clinical features in to itch or other cutaneous dysesthesia or to part of a drug treatment. CNS Drugs. 1995;3:30-40. more complex motoric manifestation of another 5. Gupta MA, Gupta AK. Fluoxetine is an effective treat- syndrome. Table 4 lists a number of common derma- ment for neurotic excoriations: case report. Cutis. tologic, systemic, and neuropsychiatric conditions 1993;51:386-387. that can lead patients to excoriate their skin. 6. Stein DJ, Hutt CS, Spitz JL. Compulsive picking and obses- If the underlying organic state is treatable, com- sive-compulsive disorder. Psychosomatics. 1993;34:177-181. plete eradication of associated cutaneous sensations 7. Keuthen NJ, Deckersbach T, Wilhelm S, et al. Repetitive (if present) and self-excoriation may be possible. skin-picking in a student population and comparison with a Identification of reproducible patterns of excoria- sample of self-injurious skin-pickers. Psychosomatics. tion can help in both diagnosis and treatment. 2000;41:210-215. 8. Koblenzer CS. Psychotropic drugs in dermatology. In: Conclusion James MD, Cockerell CJ, Dzubow LM, et al, eds. Advances Substantial overlap exists between the 10 groups of in Dermatology. Vol 15. St. Louis, Mo: Mosby Publishing; pickers. Clearly, many patients do not fit neatly 2000:183-201. into one of the described categories, and definitive 9. Koblenzer CS. The dysmorphic syndrome. Fitzpatrick’s J placement within a given group may be difficult. Clin Dermatology. March-April 1994;14-19. Despite these shortcomings, we believe that it is 10. Koblenzer CS. Dermatology and conditions related to helpful to conceptually categorize the patient who obsessive-compulsive disorder [letter]. J Am Acad Dermatol. stands before you with active excoriations into one 1992;27:1033-1035. of these groups so that rational treatment planning 11. Koo J. Psychodermatology: a practical manual for clini- may take place. Akin to the patient presenting cians. Curr Probl Dermatol. 1995;7:204-232. with fever of unknown origin, algorithms and cate- 12. McElroy SL, Hudson JI, Phillips KA, et al. Clinical and gorization can be helpful in approaching these theoretical implications of a possible link between patients in an organized fashion. The degree to obsessive-compulsive and impulse control disorders. which any practicing clinician wishes to venture Depression. 1993;1:121-132. into psychodermatology certainly varies. We main- 13. Phillips KA, Gunderson CG, Mallya G, et al. A compar- tain that all clinicians should practice a significant ison study of body dysmorphic disorder and obsessive- amount of psychodermatology by conveying empa- compulsive disorder. J Clin Psychiatry. 1998;59:568-575. thy and hope for patients. Further, the burden of 14. Garnis-Jones S. Management of patients with delusions of comprehensive medical and emotional care is most parasitosis. Presented at: Association for Psychocutaneous often placed on the nonpsychiatrist. It is hoped Medicine of North America Annual Meeting; March 10- that this conceptual framework will provide useful 15, 2000; San Francisco, Calif.

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