What are the strengths and weaknesses of the DSM‑5‑TR (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision) and ICD‑11 (International Classification of Diseases, Eleventh Revision) in diagnosing Excoriation (Skin‑Picking) Disorder?

Comparative Strengths and Weaknesses of DSM-5-TR and ICD-11 for Diagnosing Excoriation Disorder

Both DSM-5-TR and ICD-11 provide robust diagnostic frameworks for Excoriation Disorder with nearly identical core criteria, but DSM-5-TR offers superior clinical granularity through its insight specifiers and time-burden thresholds, while ICD-11's strength lies in its broader contextual placement within an expanded obsessive-compulsive spectrum that includes conditions absent from DSM-5-TR. 1, 2

Shared Strengths Across Both Systems

Recognition as Independent Diagnosis

• Both classification systems formally recognize excoriation disorder as a distinct psychiatric entity within the Obsessive-Compulsive and Related Disorders chapter, representing a major advancement from DSM-IV and ICD-10 where the condition lacked independent diagnostic status. 1, 2
• This formal recognition enables evidence-based treatment selection, particularly cognitive-behavioral therapy with habit-reversal training as first-line intervention and SSRIs or N-acetylcysteine as second-line pharmacotherapy. 2, 3

Core Diagnostic Criteria Alignment

• Both systems define the disorder identically: recurrent skin picking leading to skin lesions, accompanied by repeated unsuccessful attempts to decrease or stop the behavior. 1, 2
• Both require clinically significant distress or functional impairment, which appropriately distinguishes pathological picking from normal grooming behaviors. 1, 2
• Both include exclusion criteria ensuring the picking is not better explained by another mental disorder (such as body dysmorphic disorder), substance effects, or medical conditions. 1, 2

Differential Diagnosis Framework

• Both systems emphasize that excoriation disorder picking is not primarily motivated by appearance concerns, which is the critical distinction from body dysmorphic disorder where picking attempts to "fix" perceived defects. 1, 2, 4
• This motivational distinction is clinically essential because body dysmorphic disorder and excoriation disorder require different treatment approaches despite superficially similar picking behaviors. 1, 4

DSM-5-TR Specific Strengths

Insight Specifiers

• DSM-5-TR provides three insight specifiers that ICD-11 lacks: (1) good or fair insight (recognizing beliefs are probably not true), (2) poor insight (thinking beliefs are probably true), and (3) absent insight/delusional beliefs (completely convinced beliefs are true). 1
• These specifiers prevent misdiagnosis of patients with absent insight as having a primary psychotic disorder, ensuring appropriate treatment rather than erroneous antipsychotic monotherapy. 1
• The insight dimension guides treatment intensity and helps predict treatment response, as patients with poor insight may require augmented interventions. 1

Time-Burden Threshold

• DSM-5-TR explicitly states that symptoms are typically time-consuming (often >1 hour per day), providing clinicians with a concrete threshold for assessing severity. 2
• This quantitative benchmark assists in differentiating pathological picking from subclinical behaviors, though it is not an absolute requirement for diagnosis. 2

Tic-Related Specifier

• DSM-5-TR includes a tic-related specifier denoting individuals with current or past tic disorder, reflecting evidence that patients with comorbid tics differ in phenomenology and psychobiology. 1
• This specifier is relevant for appreciating the relationship between excoriation disorder and Tourette syndrome, and may guide tailored evaluation and management. 1

DSM-5-TR Specific Weaknesses

Narrower Contextual Framework

• DSM-5-TR's Obsessive-Compulsive and Related Disorders chapter excludes Tourette syndrome, hypochondriasis, and olfactory reference disorder, which limits the conceptual understanding of shared pathophysiology across the broader spectrum. 1, 2
• This narrower grouping may reduce clinician awareness of phenomenological overlap with conditions like Tourette syndrome, despite the inclusion of the tic-related specifier. 1

ICD-11 Specific Strengths

Expanded Diagnostic Context

• ICD-11's Obsessive-Compulsive and Related Disorders chapter includes 21 disorder groupings (versus 11 in prior versions), incorporating Tourette syndrome, hypochondriasis, and olfactory reference disorder alongside excoriation disorder. 1, 2
• This broader classification emphasizes shared etiology, pathophysiology, and phenomenology among body-focused repetitive behavior disorders, potentially enhancing diagnostic pattern recognition. 2

Simplified Diagnostic Language

• ICD-11's definition is more concise and accessible for non-psychiatric specialists (dermatologists, primary care physicians) who often encounter these patients first. 1, 2
• The streamlined criteria may facilitate earlier recognition in non-psychiatric settings where patients typically present for skin lesions rather than psychiatric symptoms. 5

ICD-11 Specific Weaknesses

Absence of Insight Specifiers

• ICD-11 does not include insight specifiers, which represents a significant clinical limitation given that approximately 10-15% of patients with obsessive-compulsive spectrum disorders have absent insight. 1
• Without insight specifiers, ICD-11 provides less guidance for distinguishing excoriation disorder with delusional beliefs from primary psychotic disorders. 1

Lack of Quantitative Severity Markers

• ICD-11 does not specify time-burden thresholds or other quantitative severity markers, potentially reducing diagnostic consistency across clinicians. 2
• The absence of concrete benchmarks may lead to overdiagnosis of subclinical picking behaviors or underdiagnosis of severe cases that don't meet implicit severity assumptions. 2

No Tic-Related Specifier

• ICD-11 omits the tic-related specifier despite including Tourette syndrome in the same diagnostic chapter, missing an opportunity to highlight this clinically relevant subtype. 1

Common Pitfalls in Both Systems

Differential Diagnosis Complexity

• Both systems require clinicians to distinguish excoriation disorder from skin picking in body dysmorphic disorder, OCD (where picking may occur to remove contamination), and depression (where picking lacks the compulsive quality), but neither provides detailed algorithmic guidance for ambiguous presentations. 1
• Comorbidity is common (approximately 70% of patients have at least one additional diagnosis), and both systems' hierarchical exclusion criteria can be difficult to apply when multiple conditions coexist. 1

Limited Guidance on Developmental Considerations

• Neither system provides age-specific diagnostic modifications despite evidence that excoriation disorder commonly begins in adolescence with variable presentations across developmental stages. 6, 7
• The lack of pediatric-specific criteria may lead to underdiagnosis in younger populations where insight and ability to articulate motivations differ from adults. 1

Insufficient Attention to Body Location Patterns

• Both systems ignore emerging evidence that patients who primarily pick different body locations (face versus fingers versus torso) display divergent clinical characteristics and may require tailored interventions. 7
• This omission may result in one-size-fits-all treatment approaches when personalized strategies based on picking patterns would be more effective. 7

Clinical Recommendations for Navigating System Differences

When Using DSM-5-TR

• Always assess and document insight level using the three-tier specifier system, as this directly impacts treatment planning and prognosis. 1
• Evaluate for current or past tic disorders and document the tic-related specifier when present, as this may indicate need for specialized assessment. 1
• Use the >1 hour/day threshold as a guideline but not an absolute requirement, recognizing that severe impairment can occur with shorter durations if picking is highly focused or causes significant tissue damage. 2

When Using ICD-11

• Manually assess insight level despite the absence of formal specifiers, documenting degree of conviction about picking-related beliefs to guide treatment selection. 1
• Leverage ICD-11's broader diagnostic context by systematically screening for Tourette syndrome, hypochondriasis, and olfactory reference disorder in patients with excoriation disorder. 1
• Establish local protocols for quantifying time burden and functional impairment to compensate for ICD-11's lack of specific thresholds. 2

Universal Best Practices

• Systematically assess picking frequency, duration, and body location patterns using structured tools like the Diagnostic Interview for Skin Picking Problems (DISP), as these variables predict treatment response. 7
• Screen for suicidality at every visit, as approximately 25-50% of patients with body-focused repetitive behaviors report self-harm or suicide attempts. 1, 3
• Evaluate for comorbid depression, anxiety disorders, and eating disorders, which occur in the majority of patients and require integrated treatment. 1
• Distinguish excoriation disorder from stimulant-induced picking in patients receiving ADHD medications, as dose reduction or medication holidays may be warranted. 3