child & youth Mental Health Series
Today’s topic:
Speaker:
Dr. Erin Kelly
November 15, 2018 If you are connected by videoconference:
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Declaration Speaker does not plan to of conflict discuss unlabeled/ investigational uses of commercial product. Goals
• What is Excoriation Disorder? • How does it typically present? • Differential diagnoses? • Clinical Correlates? • Management?
Excoriation (Skin Picking) Disorder • Repetitive picking, rubbing, scratching, digging, or squeezing of skin, with or without instrumentation, resulting in visible tissue damage and impairment in functioning • Part of a group of disorders characterized by “self-grooming behaviour” in which hair, skin, nails are manipulated. “Body Focused Repetitive Behaviours” or BFRBs
Excoriation (Skin Picking) Disorder • Occasional picking at cuticles, acne, scabs, callouses, and other skin abnormalities is a very common human behaviour • Animals engage in BFRBs too! • Great apes, monkeys pull hair, overgroom, pick nits off themselves and others • Birds pull out feathers • Mice pull their own hair and others • Cats and dogs lick and bite, leaving injury and bald areas Excoriation (Skin Picking) Disorder • New diagnosis included in DSM–5 • New chapter of Obsessive-Compulsive and Related Disorders • Considered a “Body Focused Repetitive Behaviour” along with hair pulling, nail biting, nose picking, lip and cheek biting • DSM-5 lists Excoriation Disorder and Trichotillomania as clinically important as they are the most common BFRBs Excoriation (Skin Picking) Disorder Synonyms: dermatillomania psychogenic excoriation lichen simplex chronicus neurodermatitis neurotic excoriation acne excoriee DSM - 5 • Recurrent skin picking resulting in skin lesions • Repeated attempts to decrease or stop skin picking • The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning • The skin picking is not attributable to the physiologic effect of a substance (eg, cocaine) or another medical condition (eg, Scabies) • The skin picking is not better explained by symptoms of another mental disorder (eg, delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance as in Body Dysmorphic Disorder, stereotypes in stereotypic movement disorder, or intention to harm oneself in non- suicidal self-injury)
Genetic Predisposition?
• Higher number of BFRB’s in family members of those with trichotillomania compared to the general population • Higher concordance in identical twins vs. fraternal for trichotillomania • Temperament, environment, family stress factors also play a role
Prevalence
• Studies estimate 5% of the population engage in skin picking that would require clinical intervention • 4% in college students • 2% in dermatology clinics • Adolescent inpatients = 11.8% in one study. Goes unrecognized! • More common in females • Onset between 13-15 yrs Common Presentations
• Lesions of different sizes, extent, severity • All stages of healing may be present, with active lesions and/or post-inflammatory hypo- or hyperpigmentation • Appearance also depends on method (usually fingers/fingernails but can be teeth, tweezers, scissors, pins) • Deeper lesions = ulceration, infection, scarring, disfigurement Common Presentations
• Symmetrical distribution in hands reach • Most often face (nose, forehead, cheeks, chin) • Extensor surfaces of arms and/or legs • Scalp • Cuticles • Shoulders • Back • Perianal region • Scrotal area Common Presentations
• Target multiple body sites for extended periods of time • Target healthy and previously damaged skin
Common Presentations
• May begin with urge to manipulate small, benign lesions such as acne, insect bites, scab, inflammation, a wart, mole, or keratin plug • May start as manipulation of intact skin that is itchy, burning or in pain • Skin may be perfectly normal Common Presentations
• Episode of picking may last 6-10 minutes • May involve hours • Private activity that peaks in the evening • Context – sedentary - looking in mirror, talking on phone, bathing, lying in bed, watching TV, reading, etc. • Not conscious of the behaviour at times and other times very focused • May run hand over skin in search of perceived abnormality
Common Presentations
• Patients report an urge and tension/anxiety/distress that builds until they pick • Some report a desire to improve their skin and permission giving cognitions about how their skin should look/feel when they see/feel a bump, sore spot, pimple • “Just a habit” that is mindless • Derive pleasure Common Presentations
After picking behaviour may report:
• urge reduction • sense of relief/reduction of anxiety • sense of pleasure
Common Presentations
• shame and embarrassment • social isolation • cover up skin with make-up, clothing • avoid being seen without make-up, going to the beach/swimming, wearing shorts • avoid intimacy • time management issues due to amount of time it takes to conceal • avoid medical care Common Presentations
May need medical attention:
- Infection - Open wounds - Scarring/Disfigurement - Needing skin grafts Is Skin Picking Self-Harm? • Body Focused Repetitive Behaviours are separate and distinct from self-injurious behaviours • Skin picking not intended to cause physical pain as in cutting or other self-injurious behaviour in order to distract from emotional pain • Skin picking not significantly associated with interpersonal difficulties, Borderline Personality Disorder, past trauma, self-harm (lower rates than general population) • Skin picking is correlated with other BFRB’s like trichotillomania • Skin picking is akin to “self-soothing” not “self-harm” Differential Diagnoses
Primary skin conditions: Atopic Dermatitis Psoriasis Scabies Bullous Pemphigoid Systemic Illness w/ pruritus: Uremia Cholestasis and primary biliary cholangitis Differential Diagnosis
Systemic Illness w/ pruritus cont’d:
Polycythemia vera Lymphoma Solid tumors Hyperthyroidism Iron deficiency HIV Differential Diagnosis
Substance/Medication induced pruritus:
Cocaine – itch during withdrawal, delusional parasitosis Methamphetamine – “meth mites”, delusional parasitosis Methylphenidate – infrequent side effect of pruritus
Differential Diagnosis
Other Psychocutaneous syndromes:
Dermatitis artifacta Delusional infestation Body Dysmorphic Disorder Nail picking disorder (onychotillomania) Pachydermodactyly (superficial digital fibromatosis) Clinical Correlates
• Grant and Chamberlain (2017) • First large study of clinical variables and relationship to illness severity in 125 adults aged 18-65 with SPD. • Mean age of SPD onset reported was 12.9 years. • Most picked skin from multiple sites Clinical Correlates
• Used semi-structured interview (SCID), HAM-A, HAM-D, Skin Picking Symptom Assessment Scale (SP-SAS), Sheehan Disability Scale (SDS), Barratt Impulsivity Scale, Eysenck Impulsiveness Questionnaire (EIQ), measures for cognitive flexibility, Stop Signal Task for motor inhibition • Increased severity of SPD associated with higher impulsivity, higher state anxiety/depression, having a current anxiety disorder, having a lifetime history of substance use disorder
Comorbidities - Adults • OCD • Learning Disorders • Depression • Eating Disorders • Bipolar Disorder • Alcohol use Disorder • Other BFRB disorders such as Trichotillomania, onychophagia • Feature of Prader-Willi Syndrome Children and Youth
• Odlaug and Grant (2007) examined clinical characteristics and psychiatric comorbidity in 40 participants aged 17-65, comparing childhood-onset (before age 10) to later onset • Severity = time spent picking per day, intensity and frequency of thoughts and urges to pick, and social and occupational functioning. Children and Youth
• Age of onset = time picking began, even if it didn’t meet full criteria • Semi-Structured Interview SCID-I for comorbidities • Severity – Clinical Global Impression Scale (CGI), Yale-Brown Obsessive Compulsive Scale Modified for Neurotic Excoriation (NE-YBOCS), Sheehan Disability Scale Children and Youth
• Looked at lifetime rates and family history of impulse control disorders • Childhood onset group was 7 years younger at diagnosis • Those with childhood onset were less likely to pick with conscious awareness of their behaviour. • They were not aware of their behaviour until they started to bleed or someone pointed it out to them Children and Youth
• Childhood onset = less likely to have taken medication • Only 4 participants sought treatment, however • All 4 received medication • Psychotherapy –HRT (one participant), hypnosis (one participant) • Childhood onset more likely to describe trigger as “feel of the skin” Children and Youth
• Childhood onset reported onset at 5.6 yrs but not seeking treatment until 31.3 yrs (lag of 25.7 yrs) • Adult onset reported onset at 20.3 yrs, presenting for treatment at 38 yrs (lag time of 17.7 yrs) • Comorbidity was common in sample (42.5%) but less prevalent in childhood sample (31.6 %) vs. later onset (52.4%) Children and Youth
• Most common co-occurring disorders among childhood onset were mood disorders • Family history data was not different between groups • 55.6% of childhood onset participants had at least one first degree relative with a grooming disorder vs. 52.4% Children and Youth
• Those with childhood onset were less likely to pick with full conscious awareness of their behaviour, were more likely to wait considerable time before seeking any treatment, and were less likely to seek medication treatment • Childhood onset was not associated with a more severe form of illness or more comorbidity Children and Youth • Childhood onset was not associated with greater social or occupational impairment at a later age but is associated with less awareness of the behaviour • Perhaps more awareness of urges and impulses in childhood would lead to earlier treatment • Perhaps more awareness on the part of parents/clinicians would lead to earlier treatment Treatment Guidelines
• Involvement of Family Physician or Dermatologist in order to rule-out a primary skin disorder or co-existing skin disorder • Rule-out substance or medication induced pruritus (cocaine, methamphetamine, methyphenidate) • Co-management usually needed Treatment Guidelines
• Psychotherapy – most evidence • Psychopharmacology
• Self-Help App = Skinpick (Dermatillomania Journal) Psychotherapy Treatment of choice for BFRBs is CBT based.
1. Habit Reversal Training (HRT) 2. Comprehensive Behavioural Therapy (ComB)
The following can be used to bolster HRT and ComB
• Acceptance and Commitment Therapy (ACT) • DBT (some evidence in Trichotillomania) Psychotherapy
• General initial goal is to improve awareness, insight, motivation
• HRT – Awareness training, Competing Response Training, Social Support
• ComB – Assessment and Self-Monitoring, Choosing Individualized Strategies, Internal and External Triggers
Psychopharmacology
• Neurotransmitters glutamate, GABA, serotonin, dopamine may all be involved in BFRB • SSRIs, TCAs commonly prescribed if a medication is needed • Atypical Antipsychotics, esp. if delusional component • N-Acetylcysteine (NAC) • Inositol • Naltrexone Psychopharmacology
• SSRIs and TCAs have been found to be helpful in OCD and Trichotillomania but have had mixed results in Excoriation Disorder • Only evaluated for Excoriation Disorder in a limited number of clinical trials and case series with adults N-Acetylcysteine (NAC)
- Amino acid derivative, antioxidant -modulates glutamatergic, neurotropic, and inflammatory pathways -Appears to restore extracellular glutamate concentration in the nucleus accumbens -Also alters dopamine release -Used alone or as an augmentation strategy N-Acetylcysteine (NAC)
- Provisional studies indicate potential use for NAC in many psychiatric illnesses, including ASD and addictions - Evidence in OCD, Trichotillomania and Skin Picking in adults but no evidence it is better than placebo for Trichotillomania in youth. - No studies currently for Skin Picking in youth.
Summary
• Excoriation (Skin Picking) Disorder often begins in adolescence and results in significant impairment in psychosocial functioning • It is associated with secrecy, shame, isolation, psychiatric comorbidity • Can have medical complications such as infection, scarring, disfigurement • Often goes undiagnosed and untreated despite the availability of a multidisciplinary approach
Summary
• Rule out a primary skin disorder • Start with psychotherapy, particularly HRT • May need medication and in most cases this means an SSRI • More treatment studies in Children and Youth are needed Helpful Websites & References • TLC Foundation for Body-Focused Repetitive Behaviors - www.bfrb.org • Uptodate.com, ementalhealth.ca • Diagnostic and Statistical Manual of Mental Disorders (DSM-5) • Grant JE, Chamberlain SR. Clinical correlates of symptom severity in skin picking disorder. Comprehensive Psychiatry 78 (2017) 25-30.
Helpful Websites and References • Odlaug BL, Grant JE. Childhood-onset pathologic skin picking: clinical characteristics and psychiatric comorbidity. Comprehensive Psychiatry 48 (2007) 388-393. • Grant JE, Williams KA, Potenza MN. Impulse control disorders in adolescent psychiatric inpatients: co-occurring disorders and sex differences. Journal of Clinical Psychiatry 68 (2007) 1584-1592. Helpful Websites and References • Grant JE, et al. N-Acetylcysteine in the treatment of Excoriation Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2016 May 1; 73 (5): 490-496. • Dean O, Giorlando F, Berk M. N- Acetylcysteine in psychiatry: Current therapeutic evidence and potential mechanisms of action. J Psychiatry Neurosci. 2011 Mar; 36(2): 78-86. Helpful Websites and References • Bloch MH et al. N-Acetylcysteine in the treatment of pediatric trichotillomania: A randomized, double-blind, placebo controlled add-on trial. J Am Acad Child Adolesc Psychiatry. 2013 Mar; 52(3): 231-240. • Naveed S et al. Use of N-Acetylcysteine in Psychiatric Conditions among Children and Adolescents: A Scoping Review. Cureus. 2017 Nov; 9(11). Questions or Comments?
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