Self-Injurious Skin Picking: Clinical Characteristics and Comorbidity
Abstract
BACKGROUND: Repetitive skin picking, a self-injurious behavior that may cause severe tissue damage, has received scant empirical attention. The authors examined the demographics, phenomenology, and associated psychopathology in a series of 31 subjects with this problem. METHOD: Subjects were administered the Structured Clinical Interview for DSM-IV for Axis I and Axis II disorders. They also completed several mood questionnaires and a new self-report inventory designed to assess phenomenology, triggers, cognitions, emotions, and consequences associated with skin picking. RESULTS: The mean age at onset on self-injurious skin picking was 15 years, and the mean duration of illness was 21 years. All subjects picked at more than one body area, and the most frequent sites of skin picking were pimples and scabs (87%). The most common comorbid Axis I diagnoses were obsessive-compulsive disorder (OCD; 52%), alcohol abuse/dependence (39%), and body dysmorphic disorder (32%). Forty-eight percent (N = 15) of the subjects met criteria for at least one mood disorder, and 65% (N = 20) for at least one anxiety disorder. The most common Axis II disorders were obsessive-compulsive personality disorder (48%) and borderline personality disorder (26%). CONCLUSION: Self-injurious skin picking is a severe and chronic psychiatric and dermatologic problem associated with high rates of psychiatric comorbidity. It may be conceptualized as a variant of OCD or impulse-control disorder with self-injurious features and may, in some cases, represent an attempt to regulate intense emotions.
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TTM and SPD are considered chronic disorders when not given adequate treatment.
“both TTM and SPD are considered chronic disorders when not given adequate treatment (Wilhelm et al., 1999; Christenson et al., 1991)”
From Internet-delivered acceptance-based behavior therapy for trichotillomania and skin-picking disorder in a psychiatric setting: A feasibility trial (2022) · cites this paper as Wilhelm et al., 1999
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“Uncontrolled clinical series suggest that BDD (Phillips et al 1993), hypochondriasis (Fallon et al 1993), pathologic skin picking (Arnold et al 1998; Wilhelm et al 1999), trichotillomania (Christenson et al 1991), kleptomania (McElroy et al 1991), and pathologic gambling (Linden et al 1986) are…”
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“Wilhelm and colleagues [94] reported rates of OCD around 52% in a sample of 31 patients with C–I skin picking (Table 2).”
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“…we wound healing, carving, self-hitting, needle sticking, and skin picking, are rarely a focus made no specific hypotheses regarding differences between the two groups. of research studies (for notable exceptions, see Keuthen et al., 2000; Neziroglu & Mancebo , 2001; Wilhelm et al., 1999 ).”
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“That women represented the vast majority of those with clinically significant skin picking is consistent with others (Arnold et al., 1998; Bohne et al., 2002; Hajcak et al., 2006; Lochner et al., 2002; Wilhelm et al., 1999), and may suggest a gender preponderance to this condition and/or be secondary to societal deman…”
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“In samples of 34, 122, and 31, respectively, research has demonstrated that skin picking may involve the use of fingers or tweezers and can occur on nearly all body surfaces but is most common on the face (Arnold et al., 1998; Bohne, Wilhelm, Keuthen, Baer, et al., 2002; Wilhelm et al., 1999).”
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“…regulation difficulties and emotion reactivity are associated with negative affect such as depression, anxiety and worry (e.g. Mennin, Heimberg, Turk, & Fresco, 2005; Nock et al., 2008), and as noted earlier people with PSP often have anxiety and depressive disorders (e.g. Wilhelm et al., 1999).”
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InfluentialSkin Picking in German Students
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“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].”
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“Mounting tension before picking and relief after excoriation have been reported and comorbid disorders from the compulsive-impulsive spectrum have been noted (Arnold et al., 1998; Wilhelm et al., 1999).”
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“Furthermore, patients responded to CBT although skin picking had been a chronic problem behavior for years and all patients had additional lifetime psychiatric diagnosis such as BDD or major depression.”
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“In a study of 31 patients with PSP, only 14 (45%) had ever sought treatment, and only six had ever received dermatologic treatment despite the infections and “deep craters” caused by their picking [10].”
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“Previous studies have suggested that OCD is associated with GDs (including PSP and trichotillomania) but not with other ICDs, such as pathologic gambling and kleptomania [24,35-46].”
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Ravindran, A. V., da Silva, T. L., Ravindran, L. N., Richter, M. A., & Rector, N. A. (2009) · The Canadian Journal of Psychiatry · doi:10.1177/070674370905400507 · Cited by 52 · see citing works
“Although not formally classified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, onychophagia (chronic nail biting) and psychogenic excoriation (compulsive skin picking) are considered impulse control disorders, given their phenomenological similarities and significant comorbidity with OC…”
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A latent profile analysis of age of onset in pathological skin picking
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Characteristics of 262 adults with skin picking disorder
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“Further, a subgroup of patients adopt skin picking as an emotion regulation strategy (Deckersbach, Wilhelm, Keuthen, Baer, & Jenike, 2002; Wilhelm et al., 1999) and the disorder has been associated with difficulties in emotion regulation (Snorrason et al.”
BackgroundMethodInfluentialSiddiqui, E., Naeem, S. S., Naqvi, H. A., & Ahmed, B. (2012) · BMC Research Notes · doi:10.1186/1756-0500-5-614 · Cited by 39 · see citing works
“Research suggests that skin picking occurs in people with a mean age of onset of around 15 years [9] but our study comprised of medical students aged 18 and above, with those indulging in skin picking ranging from 19–26 years with a mean of 22.”
BackgroundMaloney, E. A., Degenhardt, L. J., Darke, S. G., & Nelson, E. C. (2010) · Suicide and Life-Threatening Behavior · doi:10.1521/suli.2010.40.1.50 · Cited by 47 · see citing works
“A majority of studies have identified that self-mutilation begins during middle to late adolescence, with being single often identified as a risk factor (Favazza & Conterio, 1989; Pattison & Kahan, 1983; Suyemoto, 1998; Wilhelm et al., 1999).”
BackgroundBowes, L. E., & Alster, T. S. (2004) · Dermatologic Surgery · doi:10.1111/j.1524-4725.2004.30266.x · Cited by 46 · see citing works
“In two separate series of patients with psychogenic excoriations, the most common body site of skin picking was the face and/or areas with pimples and scabs.(8,9) Behavioral techniques such as ‘‘habit reversal’’ (a multicomponent program that consists of selfmonitoring, with recordation of scratching episodes and proc…”
BackgroundPsychodermatology of skin picking (excoriation disorder): A comprehensive review
Torales, J. C., Diáz, N. R., Barrios, I., Navarro, R. E., García, Ó., O’Higgins, M. G., Castaldelli-Maia, J. M., Ventriglio, A., & Jafferany, M. (2020) · Dermatologic Therapy · doi:10.1111/dth.13661 · Cited by 46 · see citing works
“Reasons for this may include a greater access to the consultation services by women(4) as well as the involvement of female sex hormones in the pathogenesis of such condition.(24,25) Clinically, ED shows notable heterogeneity and phenomenological complexity, accompanied by significant emotional and physical consequenc…”
BackgroundThe relationship of psychological trauma with trichotillomania and skin picking
Özten, E., Sayar, G., Eryılmaz, G., Kağan, G., Işık, S., & Karamustafalıoğlu, O. (2015) · Neuropsychiatric Disease and Treatment · doi:10.2147/ndt.s79554 · Cited by 42 · see citing works
“A secondary aim was to investigate the presence of dissociative symptoms with TTM or SP.”
BackgroundInfluentialObsessive-Compulsive Spectrum Disorder Symptoms in College Students
Sulkowski, M. L., Mariaskin, A., & Storch, E. A. (2011) · Journal of American College Health · doi:10.1080/07448481.2010.511365 · Cited by 44 · see citing works
Disgust, shame and the psychosocial impact of skin picking: Evidence from an online support forum
Anderson, S., & Clarke, V. (2019) · Journal of Health Psychology · doi:10.1177/1359105317700254 · Cited by 40 · see citing works
“, 2008), as well as lasting tissue damage and pitted scarring (Wilhelm et al., 1999).”
BackgroundTeng, E. J., Woods, D. W., Marcks, B. A., & Twohig, M. P. (2003) · Journal of Psychopathology and Behavioral Assessment · doi:10.1023/b:joba.0000007456.24198.e4 · Cited by 43 · see citing works
Skin Picking in Turkish Students
Çalıkuşu, C., Küçükgöncü, S., Tecer, Ö., et al. (2011) · Behavior Modification · doi:10.1177/0145445511420282 · Cited by 42 · see citing works
Mathew, A. S., Davine, T. P., Snorrason, Í., Houghton, D. C., Woods, D. W., & Lee, H. (2020) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2020.02.020 · Cited by 41 · see citing works
Gender in obsessive-compulsive disorder and obsessive-compulsive spectrum disorders
Löchner, C., & Stein, D. J. (2001) · Archives of Women s Mental Health · doi:10.1007/s007370170004 · Cited by 39 · see citing works
“has a number of clinical characteristics in common with TTM, is also more common in women (Arnold et al., 1998; Simeon et al., 1997; Wilhelm et al., 1999).”
A Preliminary Analysis of the Phenomenology of Skin-picking in Prader-Willi Syndrome
Morgan, J. R., Storch, E. A., Woods, D. W., Bodzin, D. K., Lewin, A. B., & Murphy, T. K. (2010) · Child Psychiatry & Human Development · doi:10.1007/s10578-010-0180-7 · Cited by 39 · see citing works
Gallinat, C., Moessner, M., Haenssle, H. A., Winkler, J. K., Backenstrass, M., & Bauer, S. (2019) · Journal of Medical Internet Research · doi:10.2196/15011 · Cited by 38 · see citing works
“In light of the substantial psychosocial impairment and risk for chronicity [2,11], the need for affected individuals to receive timely professional treatment is evident.”
InfluentialNutritional up-regulation of serotonin paradoxically induces compulsive behavior.
Dufour, B., Adeola, O., Cheng, H.-W., Donkin, S., Klein, J. D., Pajor, E., & Garner, J. (2010) · Nutritional neuroscience · doi:10.1179/147683010x12611460764688 · Cited by 36 · see citing works
Skin picking in a non-clinical sample of young Polish adults. Prevalence and characteristics
Prochwicz, K., Kałużna-Wielobób, A., & Kłosowska, J. (2016) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2016.08.013 · Cited by 38 · see citing works
“Most of the participants in our study picked with fingernails or fingers, which were reported to be the most commonly used instruments for picking the skin in previous studies of clinical [3,12,21] and non-clinical groups [1,8,9].”
BackgroundMethodResultEvidence-Based Psychosocial Treatments for Pediatric Body-Focused Repetitive Behavior Disorders
Woods, D. W., & Houghton, D. (2016) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374416.2015.1055860 · Cited by 32 · see citing works
“Other BFRBDs can result in repetitive strain injuries, dental malocclusions, permanent scarring, infections, and excessive bleeding (Bohne et al., 2005; Jones, Swearer, & Friman, 1997; Silva & da Fonseca, 2003; Snorrason & Woods, 2014; Wilhelm et al., 1999).”
BackgroundResultArbabi, M., Farnia, V., Balighi, K., Mohammadi, M. R., Nejatisafa, A., Yazdchi, K., Golestan, B., & Darvish, F. (2008) · DOAJ (DOAJ: Directory of Open Access Journals) · Cited by 36 · see citing works
Phillips, K. A., & Crino, R. D. (2001) · Current Opinion in Psychiatry · doi:10.1097/00001504-200103000-00003 · Cited by 35 · see citing works
Epidemiology and Comorbidities of Excoriation Disorder: A Retrospective Case-Control Study
Kwon, C. D., Sutaria, N. H., Khanna, R., Almazan, E., Williams, K. A., Kim, N., Elmariah, S. B., & Kwatra, S. G. (2020) · Journal of Clinical Medicine · doi:10.3390/jcm9092703 · Cited by 32 · see citing works
“To date, few studies address the epidemiology, health comorbidities, and clinical outcomes of patients with ED, posing challenges to the diagnosis and treatment of ED [2,5,12,13].”
BackgroundThe Skin Picking Impact Scale: Factor structure, validity and development of a short version
Snorrason, Í., Ólafsson, R. P., Flessner, C. A., Keuthen, N. J., Franklin, M. E., & Woods, D. W. (2013) · Scandinavian Journal of Psychology · doi:10.1111/sjop.12057 · Cited by 32 · see citing works
Self-citationCapriotti, M. R., Ely, L. J., Snorrason, I., & Woods, D. W. (2015) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2014.01.008 · Cited by 29 · see citing works
“Additionally, some studies have found high rates of personality disorders, especially obsessive-compulsive and borderline personality disorders among treatment-seeking individuals with ExD (Lochner, Simeon, Niehaus, & Stein, 2002; Wilhelm et al., 1999).”
BackgroundInfluentialHarries, M. D., Chamberlain, S. R., Redden, S. A., Odlaug, B. L., Blum, A. W., & Grant, J. E. (2017) · Psychiatry Research Neuroimaging · doi:10.1016/j.pscychresns.2017.09.006 · Cited by 30 · see citing works
Selles, R. R., Buissonnière-Ariza, V. L., McBride, N. M., Dammann, J. E., Whiteside, S. P. H., & Storch, E. A. (2017) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2017.11.001 · Cited by 30 · see citing works
‘Wanting’ and ‘liking’ skin picking: A validation of the Skin Picking Reward Scale
Snorrason, Í., Ólafsson, R. P., Houghton, D. C., Woods, D. W., & Lee, H. (2015) · Journal of Behavioral Addictions · doi:10.1556/2006.4.2015.033 · Cited by 30 · see citing works
“When appropriate, we controlled for general levels of stress, anxiety and depression (DASS-21), because previous research indicated that skin picking behaviors can be in fl uenced by negative affect (e.g., Wilhelm et al., 1999).”
MethodPrevalence and predictors of hair pulling disorder and excoriation disorder in Tourette syndrome
Greenberg, E., Tung, E. S., Gauvin, C. A., Osiecki, L., Yang, K. G., Curley, E., Essa, A., Illmann, C., Sandor, P., Dion, Y., et al. (2017) · European Child & Adolescent Psychiatry · doi:10.1007/s00787-017-1074-z · Cited by 29 · see citing works
“As in HPD, SPD is also believed to affect more women than men [12].”
BackgroundSelf-citationThe psychiatric profile of patients with psychogenic excoriation
Mutasim, D. F., & Adams, B. B. (2009) · Journal of the American Academy of Dermatology · doi:10.1016/j.jaad.2009.03.038 · Cited by 28 · see citing works
Pozza, A., Giaquinta, N., & Dèttore, D. (2016) · Neuropsychiatric Disease and Treatment · doi:10.2147/ndt.s109162 · Cited by 28 · see citing works
“The hypothesis that there would be two different subtypes of SP, with phenomenological and functional characteristics similar to those of the subtypes of trichotillomania, is based on clinical observation and studies that suggest a strong association between SP and trichotillomania.(14,15) The validation study(9) was…”
MethodAbramowitz, J. S. (2017) · Behavior Therapy · doi:10.1016/j.beth.2017.06.002 · Cited by 28 · see citing works
Krooks, J., Weatherall, A., & Holland, P. (2018) · Journal of dermatological treatment (Print) · doi:10.1080/09546634.2017.1395389 · Cited by 21 · see citing works
“Additionally, sequelae include academic, occupational, and psychosocial impairment and increased levels of sadness, anxiety, anger, and guilt (90,94,101,102).”
BackgroundInfluentialBody-focused repetitive behaviors and the dermatology patient
Sampaio, D. G., & Grant, J. E. (2018) · Clinics in Dermatology · doi:10.1016/j.clindermatol.2018.08.004 · Cited by 28 · see citing works
- Authors
- Wilhelm, S., Keuthen, N. J., Deckersbach, T., Engelhard, I. M., Forker, A. E., Baer, L., O'Sullivan, R. L., & Jenike, M. A.
- Affiliations
- Harvard University (US)
- Venue
- The Journal of Clinical Psychiatry
- Publisher
- Physicians Postgraduate Press, Inc
- Published
- 1999-07-15
- Volume
- 60
- Issue
- 7
- Pages
- 454-459
- ISSN
- 0160-6689 (ISSN-L)
- OpenAlex
- W1972662442
- Cited by
- 252
- References
- 0
- Citations by year
- 2026: 1 · 2025: 5 · 2024: 9 · 2023: 8 · 2022: 11 · 2021: 9 · 2020: 12 · 2019: 12 · 2018: 8 · 2017: 22 · 2016: 11 · 2015: 14 · 2014: 5 · 2013: 11 · 2012: 15
- FWCI
- 10.85
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Journal of Clinical Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Obsessive-Compulsive Spectrum Disorders
- Social Sciences › Psychology › Clinical Psychology › Body Image and Dysmorphia Studies
- Health Sciences › Medicine › Psychiatry and Mental health › Psychosomatic Disorders and Their Treatments
- Keywords
- dermatillomania, obsessive-compulsive disorder, psychiatric comorbidity, obsessive-compulsive personality disorder, borderline personality disorder, impulse control disorders, mood disorders, anxiety disorders, body dysmorphic disorder, alcohol abuse, emotion regulation, phenomenology
- MeSH terms
- Adolescent, Adult, Alcoholism, Anxiety Disorders, Mental Disorders, Female, Humans, Disruptive, Impulse Control, and Conduct Disorders, Male, Middle Aged, Obsessive-Compulsive Disorder, Personality Disorders, Personality Inventory, Psychiatric Status Rating Scales, Skin, Skin Diseases, Somatoform Disorders, Comorbidity, Self-Injurious Behavior, Stereotypic Movement Disorder, Mood Disorders
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