Psychogenic excoriation Clinical description

Psychogenic excoriation (also called neurotic excoriation, pathological or compulsive skin picking, and dermatotillomania) is excessive scratching, picking, gouging, or squeezing of the skin sometimes in response to an itch or other skin sensation or to remove a lesion on the skin (for example acné excor/é).(353 and 37) Most patients use fingernails to excoriate the skin, but the teeth and instruments (for example tweezers, nail files, pins, or knives) are also used. Psychogenic excoriation causes substantial distress in patients, with most experiencing functional impairment and many reporting medical complications, some severe enough to warrant surgery.

Although not recognized as a distinct DSM-IV or ICD-10 disorder, psychogenic excoriation resembles an impulse control disorder in that patients often find themselves acting automatically and sometimes experience an increase in tension prior to scratching with transient relief or pleasure immediately afterwards. It also has compulsive features, in that it is repetitive, ritualistic, anxiety reducing, often resisted, and egodystonic. Moreover, some patients describe obsessions about an irregularity on the skin or preoccupations with having smooth skin.

In a recent study of the phenomenology of a group of 34 adults with psychogenic excoriation, (36> 27 (79 per cent) met DSM-IV criteria for impulse control disorder not otherwise specified. Many of these patients also had either body dysmorphic disorder ( n = 11) or obsessive-compulsive disorder (n = 4). Only symptoms in a minority of patients (n = 2) met criteria for obsessive-compulsive disorder alone. Moreover, 29 (85 per cent) subjects reported skin sensations related to the excoriation, most commonly, idiopathic pruritus. Fourteen (41 per cent) subjects reported primary pruritus (i.e. pruritus that occurred prior to any excoriation) and met criteria for undifferentiated somatoform disorder.

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