Dermatilomania (excoriation disorder): symptoms and causes

Excoriation disorder, also known as dermatilomania, consists of scratching and tearing parts of the skin, usually due to intense feelings of anxiety.

In this article we will describe symptoms, causes and treatment of dermatillomania; In relation to this last aspect, we will focus on the habit reversal technique.

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What is dermatilomania?

Dermatillomania is a psychological disorder characterized by a intense and frequent urge to pinch, scratch, or tear off parts of one's skin. The DSM-5 introduces it under the nomenclature "Excoriation disorder" within the category of obsessive-compulsive disorder and other related, which also includes the trichotillomania.

According to this diagnostic manual, excoriation disorder is defined as the habit of scratching the skin in a compulsive and repetitive way until causing injuries. These can be considerable and there is a significant risk of infections occurring in damaged regions.

Despite the fact that most experts point out

the closeness between dermatilomania and obsessive-compulsive disorders, Odlaug and Grant (2010) state that it is more similar to addictions because the act of pinching or scratching the skin involves pleasant emotions. In contrast, in compulsive disorders, rituals are aimed at reducing anxiety.

This disorder was first described in 1875 by Erasmus Wilson, who referred to it as "neurotic excoriations." Soon after, in 1898, Louis-Anne-Jean Brocq described several similar cases in teenage girls with acne. Despite the multiple references in the literature, until DSM-5, dermatillomania had not been officially recognized.

• Related article: "Obsessive-Compulsive Disorder (OCD): what is it and how does it manifest?"

Symptoms and main signs

Scientific literature reveals that feelings of anxiety and emotional tension trigger the episodes of dermatilomania. These are usually directed to a part of the skin where the person perceives some type of imperfection, such as a pimple or peeling.

The face is the most common target of injuries, although they also frequently occur on the back, on the chest, scalp or extremities, especially nails and tips of the fingers. Usually abrasions are carried out with the fingers, although sometimes the mouth or instruments such as needles are used.

These episodes can occur repeatedly during daily life, but it is also possible that it occurs only one a day with a very high duration and intensity. In general, people with dermatillomania focus on only one part of the body, except when it is severely damaged.

Dermatilomania can cause serious alterations in the skin, mainly damage to the affected tissues, development of pustules and infections that sometimes even reach the blood (septicemia). Excoriation can also scar or disfigure the skin, increasing strong feelings of shame and guilt in people with dermatillomania.

Causes of this disorder

Motivations for episodes of dermatillomania vary from person to person. However, a widely accepted hypothesis is that physiological activation, and in particular that derived from psychosocial stress, triggers excoriation behaviors, which have an anxiolytic functionality.

While in obsessive-compulsive profiles dermatilomania is usually associated with the perception of skin contamination, in others more close to body dysmorphic disorder, the purpose of these behaviors has to do with the attempt to eliminate imperfections physical.

A relationship has been found between dermatillomania and increased levels of dopamine, involved in motor control, in the reward brain system and in the development of addictions. The excessive presence of this neurotransmitter, which occurs when consuming substances such as cocaine, seems to promote excoriation.

On the other hand, it has been proposed that this disorder could have its biological basis in the frontostriate motor circuit, which connects the regions of the frontal lobe on which cognitive functions depend with the basal ganglia, essential for movements automatic.

• Related article: "Dopamine: 7 essential functions of this neurotransmitter"

Psychological treatment: habit reversal

As with other disorders related to physical and motor habits, including tics, onychophagia, trichotillomania, stuttering or temporomandibular syndrome, dermatilomania can be managed through Azrin and Nunn's habit reversal technique (1973), which is part of cognitive-behavioral therapy.

This procedure consists of several steps. In the first place, training is carried out to promote the detection of excoriation behaviors, which in many cases are automatic, as well as the stimuli that precede them, mainly the sensations of tension emotional.

Then a response is practiced that is incompatible with the negative habit to execute it when the impulse appears to, in this case, scratch the skin; this new behavior must become a habit to replace the excoriation. An example could be to clench your fists to prevent your fingers from touching your body.

The rest of the components of the Azrin and Nunn program consist of applying contingent reinforcement to the absence of galling (contingency management), teaching techniques of relaxation to the client to decrease the anxiety that triggers the episodes, and finally to systematically generalize the skills to the context of everyday life.

Bibliographic references:

• Azrin, N. H. & Nunn, R. G. (1973). Habit-reversal: a method of eliminating nervous habits and tics. Behavior Research and Therapy, 11 (4): 619–28.

• Dell'Osso, B., Altamura, A. C., Allen, A., Marazziti, D. & Hollander, E. (2006). Epidemiologic and clinical updates on impulse control disorders: a critical review. European Archives of Psychiatry and Clinical Neurosciences, 256 (8): 464–75.

• Odlaug, B. L. & Grant, J. AND. (2010). Pathologic skin picking. American Journal of Drug and Alcohol Abuse, 36 (5): 296–303.