Compulsive Excision Disorder (DEC): Skin Picking, Dermatillomania

By Cristiano Antonino Last updated Jun 16, 2023

Compulsive Excision Disorder (DEC), also called ‘Skin Picking’ and ‘dermatillomania’, is a clinical condition characterised by constant picking at the skin causing skin lesions, and repeated attempts to curb this behaviour, according to the 2013 APA (American Psychiatric Association) guidelines

The history of Skin Picking, or dermatillomania

Although this disorder appeared in the history of psychiatry as early as the late 1800s, it only recently found a precise definition when it was included among Obsessive-Compulsive Spectrum Disorders according to the DSM-5 manual in 2013.

DEC is a very disabling psychological disorder: sufferers torment their skin in a variety of ways: pinching, rubbing, scratching, tearing themselves often in an attempt to eliminate real or rather imaginary skin imperfections on their skin (e.g. moles, pimples, blackheads, scabs, etc.), resulting in serious wounds and abrasions that can lead to infections and scarring.

Subjects scratch themselves with their nails, but are also capable of marring their skin with tweezers, scissors, needles, or even with their teeth. The affected part is usually the face, but arms, chest, shoulders, hands, lips and scalp can also be prey to attacks.

The discomfort can begin at any age, from pre-adolescence to old age, with a prevalence for the female sex.

The sufferer spends many hours of their day inspecting their skin, with or without a mirror, and obviously neglects daily appointments such as study, work and social contacts.

These individuals then try, in every way possible, to camouflage the marks left by their ‘tortures’ with make-up and clothes, since the feeling that accompanies them is always one of shame, embarrassment and guilt; they will thus avoid public places such as swimming pools, beaches, gyms where they would necessarily have to undress and make their excoriations public.

The difference with what may be considered common behaviour is the inability to control the impulse to torment one’s skin and the inability to stop.

This practice, in fact, becomes pathological when it takes on the character of a compulsion, i.e. when the subject is unable to refrain from carrying out the behaviour, when it is repeated over time, with increasing intensity and, therefore, begins to cause evident and/or permanent skin changes. In these cases, dermatillomania also has obvious social, relational and work consequences.

Usually this disorder is triggered after experiencing very stressful and anxiety-provoking situations: the most common onset is following stressful life events, whether unexpected, such as bereavements, dismissals, separations, or even planned, e.g. births, weddings, moving house, etc.

The precise causes are still unknown, but many hypotheses have been formulated, supported by initial scientific confirmation, ranging from genetic, hereditary to neurological factors and unexpressed anger.

It has similar characteristics to Obsessive-Compulsive Disorder (OCD), Body Dysmorphism Disorder and Trichotillomania, and is often found in comorbidity with these disorders. Some American research has also looked for possible correlations with fluctuations in the hormonal cycle, but with controversial results.

The emotions that precede this behaviour are usually anxiety, boredom, excitement, fear, and episodes are characterised by increased emotional tension. Often this behaviour is enacted by the subject in a ‘trance-like’ state and also has a calming effect.

Two main functions of DEC (Compulsive Excision Disorder, or ‘Skin Picking’ and ‘dermatillomania’) can be hypothesised

The function of regulating emotions (like other self-harming behaviours, it makes the negative ones go away) or as a sort of ‘reward’, as it relaxes and is alienating, similar to other behavioural control deficit disorders, e.g. gambling, internet addiction, binge eating, etc.

The question of genetic predisposition is however controversial. Some studies have shown the presence of dermatillomania (between 19 and 45%) among first-degree relatives of patients suffering from the disorder, others have found, as already mentioned, familial comorbidity with obsessive-compulsive spectrum disorders.

The treatment of choice is cognitive behavioural therapy.

The primary goal is behavioural modification, in order to interrupt the skin lesions as soon as possible.

Skin pinching is considered a learned response, conditioned by a specific situation.

The person is almost always unaware of the trigger and does not realise that certain events provoke this impulse.

The programme consists, precisely, in making the person aware of these uncomfortable situations that trigger the response and, therefore, learn how to implement alternative behaviour and cope with emotions.

Self-control and stress management skills are taught, together with an appropriate cognitive restructuring of negative thoughts.

To explain how the disorder works and is maintained, the model takes into consideration certain elements, such as:

– conditioned stimuli, both internal and external to the subject, which have the capacity to activate the implementation of the behaviour; they vary from individual to individual: e.g. particular emotional states (anxiety, anger, tension, boredom, loneliness, etc.), negative thoughts/beliefs, being in particular environments/contexts (bedroom, bathroom, in front of the mirror, etc.), performing certain sedentary activities (reading, studying, telephoning, etc.), particular times of day, being alone in the house, having certain tools (tweezers, scissors, etc.), having certain tools at hand (tweezers, scissors, etc.), being in the home, being in the hands of the person. ), carrying out certain sedentary activities (reading, studying, telephoning, etc.), particular times of the day, being alone in the house, having certain tools (tweezers, scissors, etc.), visual and/or tactile stimuli (pimples, freckles, scabs, skin relief, etc.);

– the preparatory behaviours, as many subjects develop a particular routine to carry out this activity (they may involve going to a private place, preparing the tools, choosing a particular area of the body to pinch, visually or tactilely searching for their picking targets, etc.);

– the actual behaviours of DEC, may vary depending on what one actually does on the target (tapping, scratching, squeezing, digging, etc.), what result one is trying to achieve (removing a scab, removing pus, bringing out a black spot, etc.), the overall duration of the episode (from a few seconds to many hours). What one does with cuticles, scabs, flaps of skin, etc. is very complex and particular, also depending on the severity of the disorder (if, perhaps, it is co-morbid with other psychiatric pathologies): some patients simply throw them away, others observe them, study them, run them through their fingers and sometimes go so far as to keep and collect them;

– the consequences of the behaviour (they may be reinforcing or aversive), the immediate feeling one experiences is often one of pleasure, thus a pleasant emotional consequence, like a real psychic gratification, which acts as positive reinforcement on the disorder and contributes to its maintenance, leading to the development of a real addiction. At other times, it can have a distracting effect, providing relief from stress, boredom, unwanted emotions and thoughts (e.g. ‘I go into a trance and forget my problems for a while’). Some subjects explain it as a kind of mental ‘enchantment’. In some cases, it is driven by the quest for perfection (e.g. achieving symmetry between the eyebrows or obtaining smooth skin, etc.). In fact, one of the motivations that keeps the DEC going is perfectionism: these patients may stand for hours in front of the mirror closely examining their face in search of imperfections, in an attempt to eliminate them and achieve the longed-for perfection.

Paradoxically, after such a ‘treatment’, one appears aesthetically much worse than before; all this intensifies negative emotions such as guilt, shame or anxiety, which can, in turn, trigger subsequent episodes, creating a vicious circle.

Cognitive-behavioural therapy seeks precisely, in essence, to modify the thoughts, emotions and behaviours that precede ‘picking’, in order to subsequently act on the consequences that maintain and perpetuate this disorder.

In particular, Habit Reversal Training is very useful in cases of DEC

It consists of 3 phases: awareness implementation, competitive response implementation and social support.

The first involves the patient learning to monitor and describe skin picking behaviour, also recognising previous (i.e. alarm bells) and subsequent thoughts, emotions and situations. Often, in fact, the action occurs unconsciously, without full knowledge of the chain of events that eventually produces the damage.

The second phase consists in learning to implement a different behaviour, which prevents the habitual and harmful one. This behaviour, known as the ‘competitive response’, is emitted for a minute, as soon as he realises that he is being tormented or feels the first alarm bell. A common example is making the patient fold his arms or extend his arms along his sides, clenching his fists slightly. Whatever one decides to do, it is important that the action is: physically incompatible with the harmful behaviour, practicable in almost all situations, imperceptible to others and acceptable to the subject.

The final phase involves engaging a person for social support: this may be a friend, family member, partner, etc., who is asked to point out the patient’s behaviour, with the aim of helping him/her to be more aware and gently reminding him/her to practise the competitive response.

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