Home > Dermatillomania (Skin-Picking Disorder) > What the DSM-5 Says About: Excoriation (Skin-Picking) Disorder
  • Dermatillomania
  • Skin Picking Disorder
  • Chronic Skin Picking
  • Compulsive Skin Picking
  • Neurotic Excoriation
  • Acne Excoriee
  • Pathological Skin Picking
  • Pyschogenic Excoriation

All these different names for one disorder, and the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, brought on yet another, calling it Excoriation (Skin-Picking) Disorder. Although it’s not defined in the DSM-5, I wanted to first highlight what “excoriation” or to excoriate, means.dsm5

Most online definitions I find point to it meaning that skin is worn away, such as by chafing, but I have also found definitions that talk about tearing the skin away and even flaying. Interestingly, before the DSM-5, most definitions I found for excoriate had to do with scratching away the skin, which I felt was largely inaccurate for skin picking disorder, but I don’t see many, if any, of those definitions now. I wonder if these imprecise and scattered definitions of the word are why the editors of the DSM-5 chose to call it Excoriation (Skin-Picking) Disorder as opposed to simply Excoriation Disorder, to avoid confusion as to what the action actually is.

Whatever the reason or reasons for choosing this name for what the community typically calls dermatillomania, this is the first time it is appearing definitively in the DSM at all. Despite any controversy and beyond the difficult wait for it to finally be acknowledged, it’s finally there, and this is what the DSM-5 has to say about it so far.

To begin, here is the outlined Diagnostic Criteria for Excoriation (Skin-Picking) Disorder:

  1. Recurrent skin picking resulting in skin lesions.
  2. Repeated attempts to decrease or stop skin picking.
  3. The skin picking causes clinically significant distress or impairment in social, occupation, or other important areas of functioning.
  4. The skin picking is not attributable to the psychological effects of a substance (e.g., cocaine) or another medical condition (e.g., scabies).
  5. The skin picking is not better explained by symptoms of another mental disorder (e.g., delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in body-dysmorphic disorder, stereotypes in stereotypic movement disorder, or intention to harm oneself in non-suicidal self-injury).

Considering how many pickers are often judged as being drug users, it’s both a great and important that the DSM-5 acknowledges and emphasizes that the picking and the disorder as a whole are separate from drug use and is not drug induced. Equally important is for it to acknowledge that the disorder is not Body-Dysmorphic Disorder, although the difference is still a little muddy (in my opinion) based off of the letter “E” description alone.

According to the DSM-5, about 1.4% (“or somewhat higher”) of people have this disorder, with the vast majority being female. Excoriation disorder spans across many ages, with the most common starting point being puberty, which is likely because of acne or another skin condition. The face, arms and hands are often the go-to areas for pickers, but the DSM-5 does also note that picking can occur anywhere on the body. The targets for skin pickers include healthy skin, minor imperfections, pimples, callouses and old picking scabs, which can be picked at with fingernails (most common) or even tools like tweezers or pins. Picking can occur in short spurts throughout the day or for prolonged sessions.

Like with others BFRBs, there is a ritualistic nature to skin picking, which can involve the skin or the scabs. Some have particular kinds of scabs that they search for to pick and after picking, some “examine, play with, or mouth or swallow the skin.” Some people even pick the skin of other people. Overall, picking can be focused or automatic—meaning that sometimes it is a conscious effort whereas other times it is more absent-minded—and sometimes people have a mix of both types of behaviours. These are the rituals that the DSM-5 lists, but there are likely more that haven’t been noted yet.

A tricky topic, or maybe potentially embarrassing topic, with skin picking is how a person feels doing it. It can also be confusing to figure out any of the emotions with this disorder. The DSM-5 says that the picking is typically “preceded or accompanied by various emotions states,” such as anxiety or boredom. There is also a sense of tensions that can be felt before, during or while resisting picking, which is often alleviated after the picking. “[G]ratification, pleasure, or a sense of relief” are within the possible range of emotions after the behaviour has been completed, which is often embarrassing for people to admit, although the DSM-5 doesn’t acknowledge that bit. Really the only embarrassment the DSM-5 mentions is when it comes to the distress people feel about their picking, specifying that distress means feelings such as “loss of control, embarrassment, and shame.”

The majority of consequences that the DSM-5 talks about are functional, meaning the effect on a person’s everyday life. People avoid social situations, public situations and many times even work or school. It can also make studying for school a difficult task. However, there are medical consequences too, such as “tissue damage, scarring, and infection and [it] can be life threatening.” Infections frequently require “antibiotic treatment” and “on occasion it may require surgery.” An apparently rare physical consequence is synovitis of the wrists, which, as it says on the internet, is the inflammation of a membrane in the wrist called the synovial, and is similar to carpel tunnel and tendonitis. Other physical consequences are not listed.

Excoriation disorder is usually accompanied by other mental disorders, such as obsessive compulsive disorder, trichotillomania and major depressive disorder. This is called co-morbidity.

Like with the section on trichotillomania, there is a part of the section on excoriation that I disagree with, don’t understand, and which is not explained in the text. “Most individuals with Excoriation Disorder admit to skin picking.” Personally, that seems like a ridiculous statement considering how many people feel alone, shameful and don’t know anyone else does it, not to mention that it took so long for it to be entered into the DSM. Clearly people have been and continue to hide, and there are very few people I know that openly admit to skin picking. I really wish the editors had written more concerning this part.

In the end, thought, for it first official categorization in the DSM-5, what the editors and medical professionals have collected so far as information is pretty decent and fairly thorough. I feel there is a lot to still be learned and discovered about skin picking since this is the first time it’s really being looked at or taken seriously. The disorder, to them, is still in its infancy, and probably as it is able to recognized in more patients, more will be learned from each individual case. The fact that skin picking is in the DSM-5 at all is a big deal for those of us with the disorder seeking treatment, and so this entry is a great step in the right direction.

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What the DSM-5 Says About: