What Is Excoriation Disorder?

June heralds the start of summer. While it is a time for relaxation and a time for vacation, many of us don’t slow down. Even if we take vacations, we often squeeze them into full schedules. Take this time of the year to slow down. Reassess what is important. Make the changes in your life. Now is that time that you often referred to when you said, “When I get some time”. That time won’t happen unless you take it. Now is the time.

In this June E-letter, we provide information about Excoriation Disorder, our Ask the Doc question is about fear of dogs, and our email of the month is about 6 Reasons Someone Wishes They Were You. We hope you find the enclosed information helpful. As always, we appreciate your questions and feedback.

Research Study. We are pleased to announce that we will be participating in a four month research study with Life Extension Institute assessing the effects of cognitive therapy, nutritional supplements, and medications on weight management in overweight individuals. Dr. Kimmel and Denise Champagne will be conducting cognitive therapy groups for a sample of 40 subjects who will be followed by three physicians. For more information, contact our administrative assistant, Jillian, at 954 755-2885.

Parent Education and Family Stabilization Course. For several months now, we have been offering the Parent Education and Family Stabilization Course. Sometimes referred to as the Divorce Class, it is required by the State of Florida for all parents divorcing or separating even if not legally married. We have provided this course many times and have designed it as a 4-hour, one-session presentation that focuses on ensuring that parents protect their children from the effects of divorce or separation by setting aside their differences and focusing on the children’s need for both parents in their lives. The course also provides information about divorce as loss, gives an overview of the Florida laws and statutes related to divorce and custody issues, and offers information on how children react to divorce based on their ages.  The course is offered live on a flexible schedule, based on the availability of those attending the course.  Please contact our Administrative Assistant, Jillian, at 954 755-2885 for additional information.

Low Cost Counseling. Denise Champagne, M.S., is offering low cost counseling as a mental health intern. She is currently seeing patients and is available to take on new patients. This allows those individuals who cannot afford treatment to obtain it and allows her to complete the required number of additional clinical hours for full licensure. If you or someone you know is in need of counseling but just cannot afford it, please call the office and ask for Denise. All treatment provided by Denise will be reviewed and supervised by Dr. Kimmel.

Testings. If you are concerned about your child’s school placement for the next school year, this would be a good time to have them evaluated. Recent questions from parents have ranged from should their child be retained to whether they are gifted to whether they have a disability that can qualify for accommodations at school. Our practice does different types of evaluations to help answer those questions and information about these evaluations can be found on our website. If you have more specific questions, please contact Dr. Kimmel who would be happy to answer them.

Qualified Supervisor. Dr. Joel Kimmel has been certified by the State of Florida to supervise mental health counselors seeking supervision to meet the licensing requirements. If you or anyone you know needs a qualified supervisor to meet these requirements, contact Dr. Kimmel for further information.

Our E-Letter this month focuses on Excoriation Disorder. This disorder is one of the new diagnoses added to the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) which is “the book” mental health practitioners use to diagnose behavioral health disorders. It is a controversial diagnosis as some people say that excoriation disorder is a symptom of a larger disorder or that it is only a habit that does not deserve its own category.  Others believe that it is a disorder in its own right and deserves its own category. Excoriation disorder refers to chronic skin picking and is viewed as an impulse control disorder and is related to obsessive compulsive disorder. It is most common among females ages 30 to 45.

Excoriation or compulsive skin picking often occurs around the face yet it can take place anywhere on a person’s body. Cuticles are often another frequented area. It is thought that stress and tension lead to an uncontrollable desire to scratch or pick at one’s skin. The act of picking can provide some relief up to a point where the picking becomes compulsive. The picking can target real or imagined skin blemishes and other imperfections. It can involve scratching, pulling, poking, squeezing and tearing of the skin. It is often done with fingernails although razors, teeth, tweezers, and pins are commonly used. The scratching can become so intense that it can lead to skin lesions and permanent tissue damage.

Excoriation can occur when a person feels anxious, excited, or bored and sometimes, they go into a trance-like state where they are involved in some other activity and do not realize they are picking until they recognize blood on their fingers. Some people report that they find the act of picking to be pleasurable and can spend hours picking their skin. However, excoriation can cause feelings of guilt, shame, and embarrassment. It can lead to low self-esteem, isolation, relationship problems, and workplace problems.

Compulsive skin pickers often have a co-existing disorder such as depression, anxiety, obsessive compulsive disorder, and substance abuse, especially cocaine. People on the Autism Spectrum and those who engage in self-injurious behaviors may also engage in excoriation. Certain medical conditions such as eczema, psoriasis, and lupus can also cause skin picking and need to be taken into consideration when making a diagnosis of Excoriation Disorder.

Treatments include medications such as antidepressants which have been effective in the treatment of OCD. Cognitive Behavioral Therapy, Mindfulness-Based CBT, Habit Reversal Training, and Group Therapy are also treatments that have been shown to be effective with a variety of disorders. Reports on blogs have indicated that often just talking to a therapist about skin picking behaviors alone have been helpful in eliminating these behaviors.

We offer the following information on Excoriation Disorder:

• Excoriation disorder or dermatillomania is often referred to as compulsive skin-picking
• It is common among people who have obsessive-compulsive disorder and mood disorders as well as people on the Autism Spectrum
• Prevalence estimates vary from 1.4% to 5.4% in the general population and is much more common in females
• It involves repetitive picking, scratching, pulling, poking, squeezing, twisting, or tearing of skin blemishes or marks in an attempt to remove imperfections
• It can start with an irresistible urge to scratch, often brought on by anxiety or stress, which provides some relief but the scabbing compels further picking
• Excessive scratching can leave lesions that look like long abrasions in the skin
• Individuals with excoriation disorder can pick at normal skin variations such as freckles, moles, scabs, sores, and other skin defects
• Instruments used to pick include fingernails, tweezers, teeth, razor blades, and pins
• The most commonly picked area is the face although the arms, legs, back, gums, lips, shoulders, scalp, fingernails, toenails, and cuticles are other common areas
• Medical conditions that can cause scratching and skin picking include eczema, psoriasis, diabetes, and lupus which need to be ruled out for a diagnosis of excoriation
• In addition to physical damage to the skin, secondary effects include embarrassment, impaired social functioning, strained relationships, low self esteem, and isolation
• Excoriation Disorder has a high rate of co-occurrence with depression, anxiety, substance abuse, obsessive-compulsive disorder and body dysmorphic disorder
• Excoriation is often thought to be a coping mechanism used to deal with high levels of stress and anxiety in people who have no other effective means of coping
• People with excoriation disorder often go into a trance-like state where they become obsessed with their real or imagined skin imperfections
• Excoriation behavior can become so conditioned that people often don’t realize they are picking while participating in another activity until they see blood on their fingers
• Treatments include medications, cognitive behavior therapy, habit reversal therapy, mindfulness therapy, and group therapyExcoriation Disorder is now included in the DSM V; the Diagnostic and Statistical Manual of Mental Disorders, and is recognized as a controversial diagnosis

• If you pick, keep your hands busy with another activity when you feel the urge to pick and try to distract yourself
• Try to hold off the urge for as long as you can and the urge may pass
• Use lotions and crèmes to keep your skin moist and smooth
• Use anti-bacterial soap or an antiseptic cleanser to keep your skin free from blemishes
• Practice relaxation exercises and positive self-talk
• Throw out all tools including tweezers and razors that may be used for skin picking
• Consult a dermatologist for medical treatment
• Seek professional help if you are unable to stop picking your skin as speaking with a cognitive behavioral therapist can be extremely helpful

BZ writes: My 8 year old son has a fear of dogs. Whenever we are outside and he sees a dog, he wants to run inside the house. If we are in the mall, he starts to cry. It doesn’t matter if the dog is big or small. We think having a pet would be good for him. What can we do?

Dr. Jimmy Kaikobad replies: For your son, the best approach toward fear is an indirect strategy that gently chips away at it until its power is neutralized. It appears that he may have a phobia of dogs. And, all phobias are rooted in irrational beliefs. To change those beliefs, you approach them in small graduated “baby steps”. Do not inflame your son’s fears by either forcing him to confront a dog or make statements that might question himself or his courage. Challenge his irrational beliefs while starting an incremental desensitization program such as the following:

1. Show him photographs of boys his age having a very good time hugging and romping with dogs. Simultaneously, ask him things such as: wouldn’t it be fun for him to have a friend all his own to play with too?
2. See if you and your son can watch shows that depict the joy a dog brings into a child and family’s life and how they become an inseparable part of the family. Two shows that are excellent for this purpose are Too Cute and the Dog Whisperer. They are on television and YouTube. Ask your son how he feels after watching such shows and if his feelings have changed a little toward dogs. Also impress upon him how much fun the kids in the shows are having and he could too.
3. Consult a dog trainer, a pet behavior therapist, a good veterinarian, or a kennel to gradually expose him to a gentle friendly dog. They are in the business of promoting pet and human contact and they have trained staff that you can also consult with to see what they recommend in terms of alleviating your son’s fear.
4. Gradually expose your son at a safe distance to a friendly dog while calming him and asking him to take deep breaths.
5. Ask your son to repeat to himself that he can keep himself calm as you gradually bring the dog closer.
6. Continue this process until your son is comfortable in the presence of a dog.

Remember at no time have your son confront a dog on his own or without the help of a trained professional. If a dog is unfriendly or gets scared, it might growl or nip at your son. This may not only exacerbate your son’s fear but may also prove dangerous.

We would like to thank Roberta G. for the following email:

6 Reasons Someone Wishes They Were You

How often do you pause to appreciate your life? Even when life is far from perfect, it’s important to keep things in perspective. Many people in this world wish they had what you have. Here’s why:

1. You are educated enough to read this. If you’re reading this, you have something brilliant to be thankful for. It’s called an education. Believe it or not, there are roughly 774 million people in the world who don’t have this ability. That’s a significant percentage of the human population.
2. You are reasonably healthy. In other words, if you got sick today you could recover. Never underestimate the gift of your health. It’s the greatest wealth you will ever own. It’s the foundation for every chance at happiness and success life has to offer. Your body is the only place you will truly ever live.The secret to good health for both the mind and body is to live in the present moment openly and earnestly, to eat lightly, breathe deeply, exercise daily, cultivate happiness through acceptance, and maintain a general interest in whatever it is you spend the majority of your time doing.
3. You have the freedom to choose. If you often worry about what you’re going to do with your life – your career, your family, the next step, etc., be grateful. All details aside, this means you have ambition, passion, drive, and the freedom to make your own decisions.
4. You have enough wealth to live comfortably. You didn’t go to sleep hungry last night. You awoke this morning with a roof over your head. You had a choice of what clothes to wear. You have access to clean drinking water and electricity. You are online right now.
5. You have a home. Home isn’t a physical structure, or a specific location on a map. Home is wherever the people you love are, whenever you’re with them – even if your encounter is virtual. It’s not a defined place, but a space in your heart and mind that builds upon itself like little bricks being stacked to create something stable that you take with you for your entire life, wherever you may go.
6. You still have a chance. Time is precious. Everything you know is ending. Not yet, but soon enough. What you must decide is what you want to do with the time you have left.