Elsevier

General Hospital Psychiatry

Volume 28, Issue 6, November–December 2006, Pages 487-493
General Hospital Psychiatry

Psychiatric–Medical Comorbidity
Pathological skin picking in individuals with body dysmorphic disorder

https://doi.org/10.1016/j.genhosppsych.2006.08.009Get rights and content

Abstract

Objective

The objective of this study was to examine the prevalence and clinical correlates of pathological skin picking (PSP) in a large sample of individuals with body dysmorphic disorder (BDD).

Method

One hundred seventy-six individuals with BDD (71.0% women; mean age, 32.5±12.3 years) were assessed with respect to comorbidity, BDD severity, delusionality (insight), quality of life and social/occupational functioning, using reliable and valid measures. All variables were compared in BDD subjects with and without lifetime PSP.

Results

About 44.9% of subjects reported lifetime PSP, and 36.9% reported current PSP secondary to BDD. BDD subjects with PSP were more likely to be female, to have skin preoccupations, to have comorbid trichotillomania or a personality disorder, to camouflage with makeup and to seek and receive nonpsychiatric (e.g., dermatological) treatment for their skin preoccupations.

Conclusion

There is a high prevalence of PSP among individuals with BDD, and clinicians should be aware of the clinical correlates of this problematic behavior.

Introduction

Pathological skin picking (PSP) is a complex behavior characterized by repetitive, ritualistic or impulsive picking of otherwise normal skin [1]. Although described in the medical literature for over a century, PSP remains a poorly understood psychiatric problem and often goes undiagnosed and untreated [2], [3]. Complicating the picture is the fact that some degree of skin picking appears to be normal. In fact, most people pick at their hands or face, to a limited extent, at various times in their lives [4]. Pathology exists in the focus, duration and extent of the behavior, as well as in the reasons for picking, associated emotions and resulting problems [5]. Individuals with PSP report thoughts of picking or impulses to pick that are irresistible, intrusive and/or senseless [1]. These thoughts, impulses or behaviors also cause marked distress and significantly interfere with other activities [1]. Unlike normal picking behavior, PSP is recurrent and may result in noticeable skin damage [1], [6]. Some patients, using sharp implements such as needles or razor blades, pick through major blood vessels (e.g., facial or carotid arteries), which can require emergency medical treatment and can even be life-threatening [7].

The prevalence of PSP in the general population is not known. Studies have shown, however, that 2% of dermatology patients and 3.8% of college students suffer from PSP [1], [4]. Interpretation of these prevalence rates is complicated by the fact that PSP may be a symptom of several conditions: obsessive–compulsive disorder (OCD; picking to remove contaminants) [1], genetic disorders such as Prader–Willi syndrome [8] or delusional disorders such as delusions of parasitosis (picking to remove imagined parasites) [9].

PSP may also be a symptom of body dysmorphic disorder (BDD) — a distressing or impairing preoccupation with an imagined or a slight defect in one's appearance [10]. Although BDD has been consistently described for more than a century [11], PSP was identified as a BDD symptom only recently [10]. In the present study, PSP specifically refers to picking secondary to BDD. The purpose of PSP in BDD is to improve the appearance of the skin by attempting to remove or minimize nonexistent or slight imperfections in appearance (e.g., perceived scars, pimples or bumps) [7]. In a previously reported study of 123 individuals with BDD, 26.8% (n=33) met criteria for PSP secondary to BDD [7].

The aims of the current study were to assess the prevalence of PSP among a more broadly ascertained group of individuals with BDD and to examine previously unstudied questions such as the relationship of PSP to certain comorbid disorders and whether individuals who pick differ from those who do not pick on standard measures of depression, social anxiety, functioning and quality of life. In addition, although the standard pharmacological treatment for BDD is serotonin reuptake inhibitors (SRIs), there are only sparse data regarding any type of treatment for PSP [6]. Another aim of this study, therefore, was to assess what types of treatment individuals with BDD and PSP sought and their subjective responses to these interventions.

Section snippets

Subjects

One hundred seventy-six individuals who met current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for BDD agreed to participate in a naturalistic prospective study of the course of BDD. This report includes only data from intake (baseline) assessment. Study inclusion criteria were as follows: (a) a diagnosis of DSM-IV BDD or its delusional variant; (b) age of ≥12 years; and (c) ability to be interviewed in person. The only exclusion criterion was the

Results

Of the 176 subjects with current BDD, 44.9% (n=79) reported lifetime PSP secondary to BDD and 36.9% (n=65) reported current PSP secondary to BDD. BDD subjects with PSP were more likely than those who did not pick to be female (82.3% vs. 17.7%; P=.003). There were no significant differences on any other demographic variables (Table 1).

In terms of clinical characteristics (Table 2), all BDD subjects with PSP reported being excessively preoccupied with the appearance of their skin and were more

Discussion

In this study, we determined the prevalence of PSP in 176 individuals with current DSM-IV BDD. To our knowledge, this is the largest and most broadly ascertained sample of individuals with BDD to have been studied. Because the current sample was ascertained from a wide variety of sources and because one third was not currently receiving mental health treatment, these results may be broadly generalizable. Of BDD subjects in this study, 44.9% had lifetime PSP and 36.9% had current PSP. The

Acknowledgments

This study was supported by a grant from the National Institute of Mental Health (R01 MH60241) to Dr. Phillips.

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