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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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“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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McKay, D., & Andover, M. S. (2011) · Behavior Modification · doi:10.1177/0145445511417707 · Cited by 26
“, 1995), whereas pleasurable feelings and lack of control associated with the behavior are suggestive of impulsivity (Wilhelm et al., 1999).”
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“…high rates of psychiatric comorbidity, including disorders such as OCD, eating disorders, trichotillomania, obsessive–compulsive personality disorder, borderline personality disorder and, in particular, body dysmorphic disorder (Phillips and Taub, 1995; Arnold et al., 1998; Wilhelm et al., 1999).”
BackgroundExamination of Gender in Pathologic Grooming Behaviors
Grant, J. E., & Christenson, G. (2007) · Psychiatric Quarterly · doi:10.1007/s11126-007-9045-z · Cited by 24
“For example, comorbid anxiety disorders, other than OCD, have been reported in 13–15% of individuals with TTM [24, 25] and up to 23% of individuals with PSP [12].”
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“To our knowledge, there are no group-design clinical studies of youth with SPD. Findings regarding comorbidity in adults with SPD have been mixed, suggesting elevated rates of major depressive disorder (MDD), obsessive-compulsive disorder (OCD), GAD, TTM, nail biting, and substance use [21–24 ].”
Self-citationEarly maladaptive schemas as common and specific predictors of skin picking subtypes
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Self‐Injurious Skin Picking: Clinical Characteristics, Assessment Methods, and Treatment Modalities
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“Finally, one study reported increased rates of trichotillomania and borderline personality disorder, suggesting a link between self-injurious skin picking and disorders of impulse control and emotion regulation (Wilhelm et al., 1999).”
BackgroundResultInfluentialSelf-citationThe role of emotion regulation in body-focused repetitive behaviours
Roberts, S., O'Connor, K., Aardema, F., Bélanger, C., & Courchesne, C. (2016) · Cognitive Behaviour Therapy · doi:10.1017/s1754470x16000039 · Cited by 23
“All three behaviours are performed primarily when individuals are alone or are not engaged interpersonally (Christenson et al. 1991; Wilhelm & Margraf, 1993; Wilhelm et al. 1999).”
BackgroundExpression of Anger and Alexithymia in Patients with Psychogenic Excoriation: A Preliminary Report
Çalıkuşu, C., Yücel, B., Polat, A., et al. (2002) · The International Journal of Psychiatry in Medicine · doi:10.2190/22lb-hl0u-cpjp-wn6a · Cited by 22
“Further research on PE is also needed to investigate cognitive-behavioral therapy that targets emotion-modulation skills [31].”
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Skin Picking as a Form of Self-Injurious Behavior
Neziroglu, F. A., & Mancebo, M. C. (2001) · Psychiatric Annals · doi:10.3928/0048-5713-20010901-07 · Cited by 20
Help-seeking attitudes and experiences in individuals affected by skin picking
Gallinat, C., Moessner, M., Haenssle, H. A., Winkler, J. K., Backenstraß, M., & Bauer, S. (2019) · Journal of Obsessive-Compulsive and Related Disorders · doi:10.1016/j.jocrd.2019.100483 · Cited by 21
Body focused repetitive behaviors among Salvadorian youth: Incidence and clinical correlates
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Predictors of Comorbid Obsessive-Compulsive Disorder and Skin-Picking Disorder in Trichotillomania
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Self-citationSkin picking and sleep disturbances: Relationship to anxiety and need for research
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“Additionally, individuals with PE have high incidence of comorbid anxiety disorders [Arnold et al., 2001; Calikusu et al., 2003; Wilhelm et al., 1999].”
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“Many individuals with SPD report that the behavior began with the onset of a dermatological condition such as acne (Wilhelm et al., 1999), but the picking continues even after the dermatological condition clears.”
BackgroundHair Pulling Behavior Reported by African American and Non-African American College Students
McCarley, N. G., Spirrison, C. L., & Ceminsky, J. L. (2002) · Journal of Psychopathology and Behavioral Assessment · doi:10.1023/a:1016099015437 · Cited by 18
“The questionnaire was a modified and condensed version of an inventory originally used by Wilhelm et al. (1999). Six questions concerned hair-related behavior.”
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“…disorders including BDD (Perugi et al., 1997; Gunstad and Phillips, 2003), health anxiety (Barsky et al., 1992; Jaisoorya et al., 2003; Abramowitz et al., 2006), trichotillomania (King et al., 1995; Fontenelle et al., 2005), and pathological skin picking (Wilhelm et al., 1999; Cullen et al., 2001).”
Psychotropic and neurotropic agents in dermatology: unapproved uses, dosages, or indications
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Ricketts, E., Snorrason, I., Rozenman, M., Colwell, C., McCracken, J., & Piacentini, J. (2017) · Journal of Obsessive-Compulsive and Related Disorders · doi:10.1016/j.jocrd.2017.01.006 · Cited by 14
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“, minor sores), 61% reported infections due to skin picking, and in 45% skin picking left “deep craters” in the skin (Wilhelm et al., 1999).”
BackgroundAydın, E. P., Demirci, H., Beğenen, A. G., Kenar, J. G., Altunay, İ. K., Özer, Ö. A., & Karamustafalioglu, K. O. (2022) · The European Journal of Psychiatry · doi:10.1016/j.ejpsy.2021.11.001 · Cited by 14
The problem with picking: Permittance, escape and shame in problematic skin picking
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“Physical damage may include scarring, bleeding and infection (Tucker et al., 2011; Wilhelm et al., 1999), sometimes requiring antibiotic treatment (Odlaug & Grant, 2008b) or surgery (Arnold et al.”
BackgroundInfluentialPrevalence and clinical characteristics of skin picking among adults with skin disease symptoms
Dixon, L. J., & Snorrason, Í. (2019) · Journal of Obsessive-Compulsive and Related Disorders · doi:10.1016/j.jocrd.2019.100454 · Cited by 15
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“Previous studies have shown skin picking disorder often starts in adolescence (2,3,23); thus, research should pay attention to those who may be unable to stop picking, even if their skin improves.”
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Yeh, A. H., Taylor, S. J., Thordarson, D. S., & Corcoran, K. (2003) · Cognitive Behaviour Therapy · doi:10.1080/16506070302323 · Cited by 13
“These results are encouraging, particularly because OCD (and the spectrum disorders) are often chronic in the absence of treatment (American Psychiatric Association [APA], 2000; Neziroglu et al., 1999; Wilhelm et al., 1999).”
BackgroundResultOliveira, E. C. B., Fitzpatrick, C. L., Kim, H. S. A., Gulassa, D. C. R., Amaral, R., Cristiana, N. D. M., Hayashiuchi, A. Y., McGrath, D. S., & Tavares, H. (2019) · Psychiatry Research · doi:10.1016/j.psychres.2019.112518 · Cited by 12
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Dermatillomania: A Case Report and Literature Review
Malayala, S. V., Rehman, H., & Vasireddy, D. (2021) · Cureus · doi:10.7759/cureus.12932 · Cited by 12
“Several psychiatric co-morbidities have been found to be associated with skin picking leading to self-injury such as obsessive compulsive disorder (OCD), alcohol abuse or dependence, body dysmorphic disorder, mood disorder, anxiety disorder, borderline personality disorder and obsessive compulsive personality disorder…”
BackgroundCognitive dysfunction in childhood-onset pathologic skin picking
Grant, J. E., Odlaug, B. L., & Chamberlain, S. R. (2012) · Journal of Obsessive-Compulsive and Related Disorders · doi:10.1016/j.jocrd.2012.01.002 · Cited by 11
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“Pick” wisely: An approach to diagnosis and management of pathologic skin picking
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Body Focused Repetitive Behaviors (BFRBs) and Personality Features
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“Skin picking can occur anywhere on the body, and patients often pick multiple body areas [15,16].”
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Effectiveness of fluoxetine in the treatment of skin-picking
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Decision-making performance in Trichotillomania and skin picking disorder
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Psychometric properties of the excoriation (skin‐picking disorder) dimensional scale
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An unusual complication of dermatillomania
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“The repetitive, excoriation nature of picking in severe cases may even warrant skin grafting (6,7).”
BackgroundPhysical and Social Impairment in Persons With Repetitive Behavior Disorders
Woods, D. W., Friman, P. C., & Teng, E. J. (2007) · Springer eBooks · doi:10.1007/978-0-387-45944-8_3 · Cited by 8
Skin picking in patients with obesity: Associations with impulsiveness and self‐harm
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Pediatric skin picking disorder: A review of management
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Obsessive–compulsive spectrum and disorders of the skin
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A typology of heroin-dependent patients based on their history of self-injurious behaviours
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“Scab-picking has been considered a grooming concern, of a compulsive nature which leads to tension reduction in stressful situations (Dell'Osso et al., 2006; Stein et al., 1993; Wilhelm et al., 1999).”
BackgroundSelf-inflicted skin lesions: a review of the terminology.
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Kłosowska, J., Antosz‐Rekucka, R., Kałużna-Wielobób, A., & Prochwicz, K. (2021) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2021.698543 · Cited by 8
Zwangs- und verwandte Störungen im Licht der neuen DSM-5 Kriterien
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Self-citationGroup Therapy for Excoriation Disorder: Psychodrama versus Support Therapy
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Patterns of Skin Picking in Skin Picking Disorder: Ecological Momentary Assessment Study
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Obsessive-Compulsive and Related Disorders
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“Im letzteren Fall beschreiben Betroffene teils einen tranceartigen Zustand, der mehrere Minuten bis zu Stunden anhalten kann und häufig mit einem empfundenen Kontrollverlust einhergeht (Wilhelm et al. 1999).”
BackgroundHeightened Sense of Incompleteness in Excoriation (Skin-Picking) Disorder
Ricketts, E. J., Snorrason, Í., Mathew, A. S., Sigurvinsdóttir, E., Ólafsson, R. P., Woods, D. W., & Lee, H. (2021) · Cognitive Therapy and Research · doi:10.1007/s10608-020-10201-5 · Cited by 5
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Negative Affectivity Moderates the Relationship between Attentional Control and Focused Skin Picking
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Introduction to the Special Issue on Repetitive Behavior Problems
Woods, D. W. (2002) · Behavior Modification · doi:10.1177/0145445502026003001 · Cited by 5
“Similar results are seen in persons with oral-digital habits (e.g., Friman, McPherson, Warzak, & Evans, 1993; Joubert, 1993; Wells, Haines, & Williams, 1998) and skin picking (Wilhelm et al., 1999).”
ResultMetacognitive functions of patients with trichotillomania and skin picking disorder
Demirci, H. (2022) · Dusunen Adam The Journal of Psychiatry and Neurological Sciences · doi:10.14744/dajpns.2022.00189 · Cited by 5
The Pictorial is Neurodivergent: A Case for More Fidgets and Fewer Fixes
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“Picking at your own skin compulsively (dermatillomania) is considered to be a self-harming, body-focused repetitive behavior [60], accompanied by a different set of diagnoses, treatments, and social judgements.”
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Should there be a category: “grooming disorders?”
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Psychodermatology and Psychocutaneous Disease
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Phenomenology of Excoriation (Skin Picking) Disorder
Hallion, L. S., Tung, E. S., & Keuthen, N. J. (2017) · doi:10.1002/9781118890233.ch45 · Cited by 4
Self-citationDesfossés-Vallée, S., Leclerc, J. B., Blanchet, P. J., O’Connor, K. P., & Lavoie, M. E. (2024) · Journal of Clinical Medicine · doi:10.3390/jcm13092489 · Cited by 3
“…di ff ered for TS (F [7,17] = 8.24, p 0.001, power = 0.999, η 2 partial = 0.772), BFRB (F [7,9] = 10.70, p 0.001, power = 0.997, η 2 partial = 0.893), OCD (F [7,11] = 9.69, p 0.001, power = 0.998, η 2 partial = 0.860) and controls (F [7,52] = 31.58, p < 0.001, power = 1, η 2 partial = 0.810).”
BackgroundInfluentialSkin picking disorder in a woman with polyarteritis nodosa. Case report
Aranda, M., Suárez, G. M., Henao, A. M., & Lugo, G. F. O. (2019) · Revista Colombiana de Psiquiatría (English ed ) · doi:10.1016/j.rcpeng.2018.03.008 · Cited by 3
Phenomenology and therapeutic options for dermatotillomania
Arnold, L. M. (2002) · Expert Review of Neurotherapeutics · doi:10.1586/14737175.2.5.725 · Cited by 3
Psychiatric Characteristics and Quality of Life in Patients with Pathologic Skin Picking
Nejatisafa, A., Mohammadi, M. R., Balighi, K., et al. (2008) · DOAJ (DOAJ: Directory of Open Access Journals) · Cited by 3
Signal detection in pathological skin picking. Findings from non – clinical sample
Prochwicz, K., Kałużna-Wielobób, A., & Starowicz–Filip, A. (2013) · Archives of Psychiatry and Psychotherapy · doi:10.12740/app/17837 · Cited by 3
Obsessive-Compulsive Related Disorders
Breet, E., & Löchner, C. (2015) · Springer eBooks · doi:10.1007/978-3-319-13060-6_5 · Cited by 4
Obsessive-Compulsive and Related Disorders
Dougherty, D. D., Wilhelm, S., & Jenike, M. A. (2019) · American Psychiatric Association Publishing eBooks · doi:10.1176/appi.books.9781615371501.lr14 · Cited by 4
Self-citationFricke, S. (2013) · Zeitschrift für Psychiatrie Psychologie und Psychotherapie · doi:10.1024/1661-4747/a000156 · Cited by 3
Body‐Focused Repetitive Behavior
Conelea, C. A., Frank, H., & Walther, M. R. (2017) · doi:10.1002/9781118877142.ch21 · Cited by 3
Haut und Psychosomatik – Psychodermatologie heute
Gieler, U., Gieler, T., Peters, E. M. J., & Linder, D. (2020) · JDDG Journal der Deutschen Dermatologischen Gesellschaft · doi:10.1111/ddg.14328_g · Cited by 2
Skin Picking Disorder: A Canadian Retrospective Study of 83 Patients
Deschênes, L., & Veillette, H. (2025) · Journal of Cutaneous Medicine and Surgery · doi:10.1177/12034754241303119 · Cited by 2
“28-31 The incidence of these psychiatric comorbidities varies greatly in studies.”
InfluentialReddy, V. D., Myers, B. A., Chan, S. Y., Brownstone, N. D., Thibodeaux, Q. G., & Koo, J. Y. M. (2020) · Journal of Dermatological Treatment · doi:10.1080/09546634.2020.1832190 · Cited by 2
“Self-injurious skin picking can co-occur with BPD, with one cohort study finding that 26% of patients with repetitive skin picking also have concomitant BPD (13).”
BackgroundTreatment of Severe Excoriation Disorder With Mirtazapine: A Case Report
Keshtkarjahromi, M., Mariscal, J., Dempsey, K. R., & Tonarelli, S. B. (2021) · Clinical Neuropharmacology · doi:10.1097/wnf.0000000000000467 · Cited by 3
“Usually, the course of this disorder is chronic with fluctuations and frequent periods of exacerbation.(6) The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) has recently included ED under the category of obsessive-compulsive and related disorders.”
Background
Metadata
- 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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