How has the diagnostic classification of Excoriation (Skin‑Picking) Disorder evolved across DSM‑III, DSM‑III‑TR, DSM‑IV, DSM‑5, DSM‑5‑TR, ICD‑10, and ICD‑11?

Evolution of Excoriation (Skin-Picking) Disorder Across DSM and ICD Classifications

Major Classification Shift: From Non-Existent to Independent Diagnosis

Excoriation disorder was formally recognized as a distinct psychiatric diagnosis only in DSM-5 (2013) and ICD-11 (2022), representing a fundamental shift from its previous absence or subsumption under other diagnostic categories. 1

DSM-III and DSM-III-TR (1980-2000)

• Excoriation disorder did not exist as a distinct diagnosis in DSM-III or DSM-III-TR. 2
• Pathological skin-picking was documented in medical literature since the 19th century but lacked formal psychiatric classification. 2
• When clinically significant, skin-picking behaviors were typically coded under "Impulse Control Disorder Not Otherwise Specified" or considered a symptom of other conditions. 3

DSM-IV and DSM-IV-TR (1994-2013)

• No distinct diagnostic category for excoriation disorder existed in DSM-IV or DSM-IV-TR. 2
• Pathological skin-picking remained unclassified as an independent entity, despite growing clinical recognition. 2
• Clinicians continued to use residual categories or diagnose comorbid conditions (OCD, anxiety disorders) when skin-picking was present. 3

DSM-5 (2013): The Landmark Change

• DSM-5 established excoriation disorder as an independent diagnosis within the newly created "Obsessive-Compulsive and Related Disorders" chapter, moving away from anxiety disorders and impulse control disorders. 1
• This new chapter groups excoriation disorder alongside body dysmorphic disorder, trichotillomania (hair-pulling), hoarding disorder, and OCD itself. 1

DSM-5 Diagnostic Criteria

• Recurrent skin picking leading to skin lesions is the core feature. 4
• Repeated unsuccessful attempts to decrease or stop the behavior must be documented. 4
• Significant distress or functional impairment is required for diagnosis. 5
• Not primarily motivated by appearance concerns (which would indicate body dysmorphic disorder instead). 5
• Time-consuming symptoms (typically >1 hour per day) are characteristic, though not an absolute threshold. 1
• The behavior cannot be better explained by another mental disorder, substance effects, or medical condition. 1

DSM-5-TR (2022)

• DSM-5-TR maintained the diagnostic criteria and classification structure established in DSM-5 without substantive changes to excoriation disorder. 1
• The disorder remains in the Obsessive-Compulsive and Related Disorders chapter with the same core diagnostic features. 1

ICD-10 (1990-2022)

• ICD-10 did not recognize excoriation disorder as a distinct diagnostic entity. 4
• The Mental and Behavioral Disorders chapter contained only 11 disorder groupings, and skin-picking disorder was omitted entirely. 1
• Clinicians had to use non-specific codes such as "Other habit and impulse disorders" (F63.8) or "Other specified disorders of adult personality and behavior" (F68.8). 4

ICD-11 (2022-Present): Harmonization with DSM-5

• ICD-11 introduced excoriation disorder as an independent diagnosis, mirroring DSM-5's classification. 4
• The WHO created a new "Obsessive-Compulsive and Related Disorders" chapter, expanding from 11 to 21 disorder groupings. 1

ICD-11 Definition

• "Characterized by recurrent picking of one's skin leading to skin lesions, accompanied by unsuccessful attempts to decrease or stop the behavior." 4
• This definition aligns closely with DSM-5 criteria, reflecting the WHO and American Psychiatric Association's explicit goal to harmonize classification systems. 4

ICD-11 Chapter Differences

• ICD-11's Obsessive-Compulsive and Related Disorders chapter additionally includes Tourette syndrome, hypochondriasis, and olfactory reference disorder, which are not in DSM-5's corresponding chapter. 1
• Both systems emphasize the shared etiology, pathophysiology, and phenomenology among these body-focused repetitive behavior disorders. 4

Clinical Implications of Classification Changes

Diagnostic Clarity

• The formal recognition in DSM-5 and ICD-11 has increased clinical awareness, research funding, and treatment development for what was previously an under-recognized condition. 2
• Clinicians can now assign a specific diagnosis rather than using residual categories, improving epidemiological tracking and insurance reimbursement. 2

Differential Diagnosis Refinement

• The distinction from body dysmorphic disorder is critical: in excoriation disorder, picking is not primarily driven by appearance concerns, whereas in skin-centered BDD, picking attempts to "fix" perceived defects. 5, 6
• The classification alongside trichotillomania acknowledges these as related body-focused repetitive behaviors with similar treatment approaches. 2

Treatment Framework

• Recognition as an obsessive-compulsive spectrum disorder guides evidence-based treatment selection: cognitive-behavioral therapy with habit reversal training is first-line, with SSRIs or N-acetylcysteine as second-line pharmacotherapy. 5, 7
• The formal diagnostic criteria (>1 hour/day, functional impairment) help clinicians distinguish pathological picking requiring intervention from normal grooming behaviors. 1

Summary of Evolution

Classification System	Status of Excoriation Disorder
DSM-III/III-TR	Not recognized; coded under NOS categories
DSM-IV/IV-TR	Not recognized; coded under NOS categories
DSM-5 (2013)	Independent diagnosis in OC-Related Disorders chapter
DSM-5-TR (2022)	Maintained DSM-5 classification unchanged
ICD-10	Not recognized; non-specific codes used
ICD-11 (2022)	Independent diagnosis in OC-Related Disorders chapter

4, 1, 2