Diagnosis of Nervous Skin Picking
Nervous skin picking is diagnosed as Excoriation Disorder (also called Skin Picking Disorder or Dermatillomania), which is classified under Obsessive-Compulsive and Related Disorders in the DSM-5. 1, 2
Diagnostic Criteria
The diagnosis requires all of the following features 2, 3:
- Recurrent skin picking that leads to visible skin lesions 2
- Repeated unsuccessful attempts to decrease or stop the picking behavior 2
- Significant distress or functional impairment in social, occupational, or other important areas 2
- Not primarily motivated by appearance concerns (which would instead suggest body dysmorphic disorder) 2, 4
Key Distinguishing Features
What It Is NOT:
The picking behavior must not be better explained by 4:
- Body Dysmorphic Disorder (BDD): In BDD, picking is specifically driven by attempts to improve the appearance of perceived skin defects, whereas in excoriation disorder, picking represents compulsive behavior that may provide temporary relief or occur during boredom/anxiety states 4
- Dermatological conditions causing pruritus 3
- Effects of substances or medications (note: stimulants like methylphenidate can cause or worsen skin picking) 1, 5
Clinical Presentation:
Patients typically present with 3, 6:
- Multiple body sites affected, most commonly upper extremities 6
- Excoriations as the most frequent lesion type 6
- Bimodal age distribution with onset commonly in adolescence or adulthood 3, 6
- Female predominance across studies 3
Associated Psychiatric Comorbidities
Excoriation disorder frequently co-occurs with 3, 7, 6:
- Obsessive-compulsive disorder 7
- Anxiety disorders 7
- Mood disorders 3
- Personality disorders (19.2% in one large cohort) 6
- Substance-related disorders (16.8%) 6
- Approximately 50% report self-harm related to appearance concerns 1, 2
Critical Diagnostic Pitfall
Do not confuse the terminology: The older terms "psychogenic excoriations" or "neurotic excoriations" have been replaced by the formal DSM-5 diagnosis of Excoriation Disorder 3, 7. This reflects the reclassification as an obsessive-compulsive spectrum disorder rather than a purely psychogenic condition 3.