Practice Brief Showcase - By Matthew J. Paylo & Alison A. Zins

Excoriation disorder: A new diagnosis in the DSM-5

The ACA Center for Counseling starts to ensue as a result of your picking. to remove an imperfection such as Practice, Policy and Research is proud You become repulsed by your behaviors, , scabs or other irregularities until to offer Practice Briefs in which expert attempting to conceal your scars and the imperfection seems completely scholars in the counseling profession scabs with bandages or trying to cover obliterated, ultimately exacerbating the write brief, research-based summaries of your face with makeup. Furthermore, you imperfection. This type of skin picking best practices and empirically supported begin to realize that you are doing all of is called focused picking. With focused approaches related to a wide variety of this to yourself. picking, there is a building tension that concerns that counseling consumers bring leads up to the picking behaviors. Often, Excoriation disorder characteristics to counseling. Each Practice Brief is a few these individuals believe the only way Although this experience may seem pages in length and provides a variety of to relieve their urge is to engage in the foreign, odd or even outlandish, it counseling approaches and web-based picking compulsion, similar to acting on is an all too common occurrence for resources. a compulsion in OCD. Individuals who individuals with excoriation disorder A nontechnical overview of the ACA engage in this type of focused picking (ED). ED, a new diagnosis in the fifth Practice Brief on excoriation disorder tend to avoid intense emotions and may edition of the Diagnostic and Statistical is included in this article. The full pick as a means of relieving negative Manual of Mental Disorders (DSM-5), is Practice Brief — as well as many others emotions such as sadness, worry or . characterized by recurrent and excessive on a variety of topics — is available at Although some individuals with ED picking, scratching or rubbing of counseling.org/knowledge-center/center-for- are aware they are picking, others are normal skin. Also known as skin-picking counseling-practice-policy-and-research/ not. When picking occurs outside of disorder and dermatotillomania, ED falls practice-briefs. an individual’s level of awareness, the under the DSM-5 heading of obsessive- behavior is referred to as automatic u compulsive and related disorders picking. With automatic picking, Have you ever looked in the mirror because of its genetic and symptomatic individuals may pick while watching TV, and thought, “What is this on my connection with obsessive-compulsive reading or studying and may describe face?” Maybe it was a blemish, a slight disorder (OCD). Most people pick at their picking experience as being in a imperfection or even a pimple. You may their skin from time to time, but those trancelike state. have given it little conscious thought, yet with ED have an impulsive and persistent Individuals with ED may use their still started to pick at it ever so slightly. pattern of picking that progresses to the hands, mouths or even other objects such But what if you couldn’t stop those point of skin lesions and tissue damage. as tweezers or safety pins to pick multiple picking behaviors? Let’s say that you In most cases, these individuals feel areas on their bodies (for example, face, start to experience scars, scabs and even unable to stop, and these behaviors arms, hands, chest, legs and back). In excessive bleeding. Maybe you end up interfere significantly with their ability to some cases, individuals eventually need wasting large portions of your day picking function optimally. antibiotics to treat infections and surgery at your skin, finding it more difficult to It is important to note that individuals to treat severe wounds. Additionally, this stop each time. This progresses, and you with ED do not engage in picking population often experiences feelings start picking more frequently and with behaviors because of a skin condition such as loss of control, greater intensity. Now you pick when (for example, dry or itchy skin), drug or and regarding their behaviors. you’re anxious or angry — or sometimes alcohol withdrawal, or another medical Frequently, these individuals have failed for no reason at all. One thing is certain: condition. They engage in these behaviors repeatedly in their attempts to decrease or Once you start picking, you become in an attempt to remove a perceived stop these distressing behaviors. stuck in a trance. You don’t even realize imperfection either on or underneath Although individuals with ED often you’re doing it. their skin. In many cases, individuals with attempt to hide the physical evidence of At first, a sense of relief, or even ED will engage in picking with more skin picking (using bandages, clothing a “high,” may wash over you when frequency and intensity in response to and makeup) from significant others, you engage in picking behaviors. intense emotions. family members, friends and health Unfortunately, feelings of , These impulses or compulsions are professionals, these behaviors affect their embarrassment and shame flood you similar to those found in OCD. These social relationships and generally lead to afterward. Beyond that, physical pain impulses drive individuals with ED periods of isolation. In addition to social

18 | ct.counseling.org | June 2015 impairment, those who have this disorder to engage in high-risk behaviors for highly comorbid with OCD and other often experience academic or vocational pleasure-seeking purposes and without body-focused repetitive behaviors such as difficulties because the time spent picking regard to the possible consequences. . In addition, ED is often distracts them from their academic or The pleasure an individual experiences comorbid with anxiety disorders, mood professional responsibilities. during a picking episode is usually disorders, impulse-control disorders and followed with embarrassment, guilt or substance-related disorders. Development and course shame, as is the case with most impulse- When diagnosing ED, counselors More frequently diagnosed in females, control disorders. This phenomenon can need to differentiate the behavior from ED often develops in adolescence but may occur with both focused and automatic nonsuicidal self-injury (NSSI). Whereas not be discovered until later in adulthood individuals with NSSI are typically (typically in a person’s 30s or 40s). Many picking because both types can provide motivated by intense, negative thoughts individuals with ED keep their behaviors instant gratification. Individuals with about themselves, the world or their secret and suffer quietly because of ED may engage in both types of picking future, individuals with ED are more embarrassment, guilt or shame. simultaneously or at different times fixated on or obsessed with the removal of In most cases, the onset of ED within the same development or course of unwanted imperfections. symptoms aligns with the onset of the disorder. puberty. Individuals with ED typically Individuals with ED experience a Treatment spend large amounts of time (several broad range of effects on functioning. Individuals with ED generally hours a day) engaging in picking These may include social impairment, demonstrate some insight into their behaviors and report their picking as such as embarrassment caused by behavior and usually want to stop being worse at night. Although some visible lesions that may lead to isolation picking. Often, they identify large periods individuals experience dormant periods or avoidance of activities in which of time dedicated to picking, thinking throughout their lives, most skin-picking skin lesions could be exposed, and about picking or trying to resist picking behaviors remain chronic if untreated. occupational impairment caused by urges. However, frequent attempts to ED has genetic and psychological excessive time spent picking, resulting in reduce or resist picking urges have failed, influences. ED is more common in the neglect of job duties. Finally, lowered thus requiring counseling treatment. individuals who have also been diagnosed self-esteem may occur because of skin As is the case with most with OCD or have family members disfiguration or scarring, and intense disorders, the sooner an individual with diagnosed with OCD or ED. The frustration resulting from an inability to ED engages in treatment — preferably psychological aspect of ED involves stop picking can lead to before having these symptoms for more these individuals having higher levels of or suicide attempts. Individuals with than a year — the higher the likelihood emotional impulsivity and sensation- ED typically spend a great deal of time of recovery. However, because ED is often seeking behaviors than does the general concealing their self-inflicted wounds overlooked by counselors, clients and population. and use cosmetic products, bandages or society in general, many individuals are As previously stated, ED is a new clothing to avoid questions regarding the unaware that help is even available. disorder classified under obsessive- origins of their wounds. Because of the lack of publicity compulsive and related disorders in the Unfortunately, ED is often overlooked about this disorder, more research on DSM-5. OCD is often characterized by by counselors or overshadowed by its treatment is necessary. Even so, it is the engagement in compulsive behaviors comorbid diagnoses. This is due in part important for counselors to be mindful in an attempt to reduce uncomfortable to ED’s recent addition to the DSM-5, its of this diagnosis and familiar with feelings such as anxiety. These similarities and with other treatment options so that clients who characteristics are the same for focused disorders, the lack of publicity surrounding suffer from ED can find relief. Cognitive picking. On the other hand, lack of ED and the shame and secrecy associated behavior therapy (CBT), acceptance impulse control is defined by a tendency with the disorder. In general, ED is and commitment therapy (ACT), habit

June 2015 | Counseling Today | 19 reversal training (HRT) and medication behavior for the picking behavior. that the client establishes with the aid of all appear to be effective strategies for Ultimately, after clients implement these the counselor. aiding this population. strategies, CBT involves preparation and Finally, medication is another effective When using CBT, counselors help strategies for overcoming future urges and measure used in the treatment of ED. clients to identify, challenge and modify reducing the likelihood of relapse. Selective serotonin reuptake inhibitors their distorted and dysfunctional thoughts ACT is another approach to apply (SSRIs) such as , fluvoxamine related to their skin-picking behaviors. when working with individuals with ED. and escitalopram are often used in the The first step usually consists of gathering ACT integrates acceptance, mindfulness treatment of ED. This may be because information about the nature of the and behavioral change strategies into SSRIs have been shown to be effective in skin-picking behaviors (for example, counseling treatment. In early stages of treating OCD and related disorders such frequency, location of picking, intensity the counseling process, counselors help as trichotillomania. However, although and antecedents) and then exploring clients to distinguish between urges to SSRIs are effective for some clients, the psychoeducational component of pick and actual picking behaviors. Once these medications have demonstrated the development and maintenance of this distinction is made, counselors inconsistent effects across individuals. unwanted behaviors. can then explore clients’ past attempts In addition to SSRIs, clients with ED Second, counselors highlight the to control, resist and diminish picking may also respond to anticonvulsant automatic thoughts associated with behaviors. These clients often believe medications such as lamotrigine. these picking behaviors. For example, that they cannot tolerate the tension Regardless of the medication used, a client might express that because of a leading to picking behaviors and engage stand-alone medication is generally heated encounter with another employee, in picking as a means to relieve these not as effective as medication used in she should have the right to engage in uncomfortable urges and emotions. But conjunction with counseling treatments. picking behaviors. Furthermore, this this proves to be only an immediate, Counselors and other mental health client may express that relaxation is impulsive solution because their urges professionals are instrumental in not possible without engaging in skin- ultimately return. Through mindfulness- advocating for the increased awareness picking behaviors (the client uses it as a based techniques, ACT challenges clients of ED, diagnosing the disorder when coping mechanism). A counselor can aid to instead embrace these unpleasant necessary and providing effective this client by testing the validity of her emotions by noticing their emotional counseling treatment to address maladaptive thoughts and attempting response, attempting to tolerate these clients’ difficulties. Although relapse is to replace them with more adaptive emotions in the present and ultimately always a concern, through the use of a thoughts. For example, after the client’s engaging in more adaptive behaviors. comprehensive approach to treatment, belief is challenged, she may consider that HRT, another approach to use when many individuals with ED lead more even when she is highly upset, perhaps it working with this population, begins adaptive and productive lives. u is OK to feel that way and she can handle with awareness training. This involves it. She may also conclude that after she describing the picking behaviors Matthew J. Paylo, a licensed picks, she feels horrible about herself, but (frequency, intensity, duration) and the professional clinical counselor after she takes a run on the treadmill, she specific situations that lead up to the supervisor, is an associate feels significantly better about herself. behaviors. In essence, HRT is an approach professor at Youngstown State In addition to addressing thoughts that increases clients’ awareness of their University. In addition to having and emotions, CBT also addresses the behaviors, develops alternative responses, numerous publications on various behaviors themselves. Three types of reinforces those responses and generalizes clinical topics to his credit, he behavioral interventions useful with these new behaviors to alternative has more than 10 years of clinical clients struggling with ED are preventive situations. For example, a competing experience. In his most recent measures, activity replacement and relapse response needs to be versatile and ready in book, Treating Those With Mental Disorders, which he co-authored prevention. Counselors can assist clients a host of client situations. A client might with Victoria E. Kress, he addresses by implementing preventive measures decide to clench his fist for two complete the diagnosis and treatment of such as gloves, wraps or bandages to minutes each time an urge arises. After excoriation disorder. hinder and deter their ability to engage in two minutes, the client can assess if he skin-picking behaviors. These measures has other alternatives. If not, he can Alison A. Zins is a graduate can also reinforce clients’ abilities to clench his fist for another two minutes. student at Youngstown State tolerate urges or serve as a distraction until This is done until his urges either are University. She has written and urges decrease. Activity replacement helps more manageable or fully dissipate. presented on various clinical clients to consider other, more adaptive, The flexibility and availability of this topics and is currently working as behaviors when their urges ensue. For alternative behavior is extremely accessible an intern at an outpatient mental example, when a client feels the urge to and practical. It is important to have health facility. pick, he could consult a predetermined, clients reinforce their adaptive behaviors practiced list of alternative behaviors (for by rewarding themselves when they use Letters to the editor: example, cleaning, exercising or calling a these behaviors. This can be done through [email protected] friend) and substitute a more productive a token economy or contingency contract

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