What are the treatment guidelines for chronic skin picking in an outpatient psychiatric setting for a patient with Attention Deficit Hyperactivity Disorder (ADHD), Bipolar II, Borderline Personality Disorder (BPD), and Obsessive-Compulsive Disorder (OCD)?

Treatment of Skin Picking in a Patient with Multiple Psychiatric Comorbidities

Habit reversal therapy is the first-line treatment for skin picking in patients with multiple psychiatric comorbidities, including ADHD, Bipolar II, BPD, and OCD. 1

Understanding Skin Picking in the Context of Multiple Diagnoses

Skin picking (excoriation disorder) in this patient must be understood within the complex interplay of their multiple diagnoses:

• OCD relationship: Skin picking may be related to OCD symptoms but differs in that skin picking in excoriation disorder is not primarily driven by appearance improvement, unlike in Body Dysmorphic Disorder (BDD) 1
• Bipolar II considerations: Mood episodes may exacerbate skin picking behaviors
• ADHD impact: Impulsivity from ADHD may contribute to difficulty controlling picking behaviors
• BPD factors: Emotional dysregulation can trigger or worsen skin picking episodes

First-Line Treatment: Habit Reversal Therapy

Habit reversal therapy should be initiated first and includes:

1. Awareness training - helping the patient recognize triggers and early warning signs of picking behavior
2. Development of competing responses - teaching the patient to engage in behaviors incompatible with picking (e.g., making a fist, holding an object) 1
3. Stimulus control - modifying the environment to reduce picking opportunities

Cognitive-Behavioral Approaches

Add cognitive-behavioral elements to address underlying factors:

• Cognitive restructuring to challenge maladaptive thoughts related to skin picking
• Behavioral experiments to test negative beliefs about stopping the behavior 1
• Attention training to develop greater attentional control and reduce self-focused attention 1

Pharmacological Management

Medication management should address both the skin picking and underlying conditions:

1. For OCD/skin picking: SSRIs at higher doses than typically used for depression may help reduce picking behaviors 1, 2

   • Consider that higher SSRI doses are associated with greater efficacy but also higher dropout rates due to side effects 1

2. For Bipolar II: Prioritize mood stabilization before addressing other symptoms

   • Mood stabilizers should be the foundation of treatment 3
   • Be cautious with SSRIs due to risk of treatment-emergent mania, which is higher in patients with comorbid OCD-bipolar disorder (86% vs 40% in those without OCD) 4

3. For ADHD: Consider stimulant or non-stimulant options only after mood stabilization

   • In comorbid ADHD-BD, treat BD episodes first 5, 6, 7
   • Non-stimulants may be preferred if there are concerns about stimulants triggering mania 5

Treatment Algorithm

1. Initial phase:

   • Begin habit reversal therapy
   • Ensure mood stabilization is adequate (for Bipolar II)
   • Address any acute OCD symptoms with ERP techniques

2. Intermediate phase:

   • Add cognitive components to habit reversal therapy
   • Consider SSRI addition if picking behaviors persist after mood is stabilized
   • Monitor closely for treatment-emergent mania

3. Maintenance phase:

   • Monthly booster sessions of habit reversal therapy for 3-6 months 1
   • Continue mood stabilizers long-term
   • Address ADHD symptoms once mood and picking behaviors are better controlled

Monitoring and Follow-up

• Track frequency and intensity of skin picking episodes using a daily log
• Monitor for signs of mood destabilization
• Assess for suicidality regularly, as patients with comorbid OCD-BD have higher rates of anxiety and impulse control disorders 4

Common Pitfalls to Avoid

• Treating ADHD before stabilizing mood - this can precipitate mania in bipolar patients
• Focusing only on skin picking without addressing underlying disorders - treatment must be comprehensive
• Inadequate medication trials - ensure sufficient duration at therapeutic doses
• Neglecting psychotherapy components - medication alone is rarely sufficient for skin picking

Special Considerations

• Family involvement is crucial, particularly to address any accommodation of symptoms 2
• Relapse prevention planning should include identifying triggers and early warning signs
• Consider more intensive treatment approaches if standard outpatient treatment is insufficient 1