The disorder excoriation Compulsive (DEC) , also called “Skin Picking” in English and “dermatillomania” in Italian, is a clinical condition characterized by a constant stuzzicamento skin that causes skin lesions, and repeated attempts to curb such behavior, according the APA (American Psychiatric Association) lines of 2013.
Although this disorder appeared in the history of psychiatry as early as the late 1800s, it found a precise definition only recently, when according to the DSM-5 manual, also in 2013, it was included among the Obsessive-Compulsive Spectrum Disorders .
DEC is a very disabling psychological disorder: those who suffer from it, in fact, torment their skin in various ways: pinching, rubbing, scratching, tearing often in an attempt to eliminate real or rather imaginary skin imperfections present on their skin (eg moles, pimples, blackheads, scabs, etc.), with the consequence of causing even serious wounds and abrasions, which can lead to infections and scars.
Subjects scratch with their fingernails, but are capable of tormenting the skin even with tweezers, scissors, needles, or even their teeth. The affected area is usually the face, but the arms, chest, shoulders, hands, lips and scalp can also be attacked.
Discomfort can begin at any age, from pre-adolescence to old age, with a prevalence for women.
The person who suffers from it spends many hours of his day inspecting his skin, with or without the mirror, and obviously leaves out daily appointments such as study, work and social contacts.
These individuals then try in every way to disguise the marks left by their “torture” with make-up and clothes, as the feeling that accompanies them is always that of shame, embarrassment, guilt; thus they will avoid public places such as swimming pools, beaches, gyms where they would have to undress and make their bruises public.
The difference with what can be considered common behavior is the inability to control the urge to torment the skin and not be able to stop.
This practice, in fact, becomes pathological when it assumes the character of a compulsion, that is when the subject is unable to refrain from implementing the behavior, when it is repeated over time, with an ever greater intensity and, therefore, begins to cause skin alterations. evident and / or permanent. In these cases, dermatillomania also has obvious social, relational and working consequences.
Usually this disorder is put into practice after experiencing very stressful and anxious situations: the most common onset is following stressful life events, both unexpected such as bereavement, dismissal, separation, or even planned, eg. births, marriage, removals, etc.
The exact causes are still unknown, but many hypotheses have been formulated, supported by early scientific confirmations, ranging from genetic, hereditary factors to neurological ones and unexpressed anger.
Similar features to Obsessive-Compulsive Disorder (OCD), to Body Dysmorphic Disorder and the Trichotillomania , often found in their comorbidity with these disorders. Some American research has also looked for possible correlations with hormonal cycle fluctuations, but with controversial results.
The emotions that precede this behavior are usually anxiety, boredom, excitement, fear, and it is noted that the episodes are characterized by an increase in emotional tension. Often this behavior is performed by the subject in a “trance-like” state and also has a calming effect.
Therefore, we can hypothesize two main functions of DEC: the function of regulating emotions (like other self-injurious behaviors, it makes negative ones vanish) or as a sort of “reward”, as it relaxes and is estranging, similar to other disorders of the deficit behavior control, eg: gambling , internet addiction , binge eating , etc.
The question of genetic predisposition is still 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, Family comorbidity with the disorders obsessive-compulsive spectrum .
The treatment of choice is cognitive behavioral therapy . The primary goal is behavior modification, to stop 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 triggering cause and does not notice that some events cause this impulse. The program consists, precisely, in making her aware of these uncomfortable situations that trigger the response and, therefore, learning to implement alternative behaviors and to cope with emotions. Self-control and stress management skills are taught, along with adequate cognitive restructuring of negative thoughts.
The model to explain how the disorder works and is maintained takes into consideration some elements, such as:
– conditioned stimuli , both internal and external to the subject, which have the ability to activate the implementation of the behavior; vary from individual to individual: for example particular emotional states (anxiety, anger, tension, boredom, loneliness, etc.), negative thoughts / beliefs (“I must have perfect skin”, “if I have pimples everyone will make fun of me”, etc.), being in particular environments / contexts (bedroom, bathroom, in front of the mirror, etc.), carrying out certain sedentary activities (reading, studying, telephoning, etc.), particular moments of the day, being alone in home, having certain tools at hand (tweezers, scissors, etc.), visual and / or tactile stimuli (pimples, freckles, scabs, skin reliefs, etc.);
– preparatory behaviors , 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 looking for their own goals of picking, etc.);
– the actual behaviors of DEC may vary depending on what is actually done on the target (tapping, scratching, squeezing, digging, etc.), what result you try to achieve (remove a scab, eliminate pus, bring out a black point, etc.), the overall duration of the episode (from a few seconds to many hours). What is done with cuticles, scabs, skin flaps, etc. is very complex and particular, also depending on the severity of the disorder (if, perhaps, it is comorbid with other psychiatric pathologies): some patients simply throw them away, others observe them, study them, pass them through their fingers and sometimes reach keep them and collect them;
– the consequences of the behavior(they can be reinforcing or aversive), the immediate sensation that is often felt is of pleasure, therefore a pleasant emotional consequence, such as a true psychic gratification, which acts as a positive reinforcement on the disorder and contributes to its maintenance, going to develop a real addiction. Other times, it can have a distracting effect, relieving stress, boredom, unwanted thoughts and emotions (eg “I go into a trance and forget about my problems for a while”). Some subjects explain it as a kind of mental “enchantment”. In some cases, it is driven by the pursuit of perfection (eg achieving symmetry between the eyebrows or obtaining smooth skin, etc.), in fact one of the reasons that maintain DEC is perfectionism: these patients can spend hours in front of the mirror examining their face closely for imperfections, in an attempt to eliminate them and achieve the much desired perfection. Paradoxically, after a “treatment” of this kind, it looks aesthetically much worse than before; all of this intensifies negative emotions such as guilt, shame or anxiety, which can, in turn, trigger subsequent episodes, creating a vicious circle.
The cognitive-behavioral therapy seeks its own, in essence, to change thoughts, emotions and behaviors that precede the “picking”, to go to act, subsequently, on the consequences that maintain and perpetuate this disorder.
In particular, Habit Reversal Training is very useful in DEC cases. It consists of 3 phases: implementation of awareness, implementation of the competitive response and social support.
The first requires the patient to learn to monitor and describe skin picking behaviors, also recognizing previous and consequent thoughts, emotions and situations (e.g. alarm bells). Often, in fact, the action occurs unconsciously, without full knowledge of the chain of events that ultimately produces the damage.
The second phase consists in learning to implement a different behavior, which prevents the habitual and harmful one. This behavior, called “competitive response”, is emitted for a minute, as soon as he realizes that he is tormenting his skin or feels the first alarm bell. A common example is to have the patient bend his arms or have him stretch his arms at his sides, lightly clenching his fists. Whatever you decide to do, it is important that the action is: physically incompatible with harmful behavior, practicable in almost all situations, imperceptible to others and acceptable to the subject.
The final stage involves hiring a person for social support: this can be a friend, family member, partner, etc. who are asked to point out his behavior to the patient, with the aim of helping him to be more aware and kindly reminding him to practice the competitive response.
