Mental Health Series Todays topic: Speaker: Dr. Erin Kelly November - - PowerPoint PPT Presentation

Today’s topic: Speaker:

• Dr. Erin Kelly

child & youth

Mental Health Series

November 15, 2018

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Declaration

• f conflict

Speaker has nothing to disclose with regard to commercial support. Speaker does not plan to 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
• n phone, bathing, lying in bed, watching TV,

reading, etc.

• Not conscious of the behaviour at times and
• ther 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

• f 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

• f 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).

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