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Near-Fatal Skin Picking From Delusional Body Dysmorphic Disorder Responsive to Fluvoxamine

Received September 17, 1996; revised September 25, 1997; accepted May 21, 1997. From the Psychiatric Neuroscience Program, Massachusetts General Hospital–East CNY–9, Harvard Medical School, Charlestown, Massachusetts; and Butler Hospital and the Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, Rhode Island. Address correspondence and reprint requests to Dr. O'Sullivan, Massachusetts General Hospital, Department of Psychiatry, Bldg. 149, 13th Street, Charlestown, MA 02129.

Key Words: Body Dysmorphic Disorder • Fluvoxamine • Dermatologic Conditions

Skin picking as a manifestation of psychopathology, while an underrecognized problem, is receiving increased attention in the medical and psychiatric literature.^1–4 Sometimes described as neurotic excoriations, skin picking is a relatively frequent manifestation of body dysmorphic disorder (BDD), a distressing or impairing preoccupation with a minimal or nonexistent defect in one's appearance.^4,5 Skin picking also occurs in other psychiatric disorders, including trichotillomania⁶ and obsessive-compulsive disorder (OCD),⁷ as well as various medical and developmental conditions.^1,2 Morbidity may be considerable, including psychological distress, skin infections, scarring, and surgical intervention.⁷ Many of these patients first present for treatment to a primary care physician, dermatologist, or surgeon, rather than a psychiatrist.⁸ We report a case of severe skin picking attributable to delusional BDD, which resulted in considerable medical morbidity and a nearly fatal outcome. To our knowledge, this is the first report of decreased skin picking in delusional BDD with fluvoxamine.

Case Report

Consultation for skin picking was requested by a primary care physician for a 48-year-old, married, white female accountant. Skin picking developed at age 44, when the patient began to pick at her skin, particularly her face, legs, and arms, for 2 to 4 hours a day. Her focus was on perceived skin irregularities, described as pimples and "bumps," which she thought about for many hours a day and tried to eradicate by picking. Several dermatologic consultations had been obtained for treatment of numerous skin wounds and infections due to picking, and nonpsychiatric etiologies were eliminated in the course of her evaluations. The patient eventually required several medical hospitalizations for treatment and surgical revision of nonhealing wounds.

Previous diagnoses were neurotic excoriations and OCD, with secondary factitious lesions. Past psychiatric treatment had consisted of family therapy and supportive psychotherapy for issues related to self-esteem, which did not diminish the patient's BDD symptoms. Treatment with sertraline, up to 100 mg/day for 3 months, improved her mood but did not decrease the picking behavior. However, subsequent treatment with fluvoxamine (50 mg/day) diminished the picking behavior to some degree.

Despite the patient's partial improvement with psychiatric treatment, she reported feeling that "everything wasn't out" of her skin after removal of a small occlusion cyst (which was unrelated to the picking behavior). She persisted in picking at the wound, which eventually healed. Subsequently, she became obsessively preoccupied with a skin irregularity in her neck, which she described as a "pimple"; this led to an episode of severe skin picking, initially with her fingernails and then with tweezers. Over a 3-hour period, the patient picked through her dermis, subcutaneous tissue, and musculature with a tweezer, resulting in a deep neck wound that exposed her carotid artery. The patient's husband reported that she appeared to have a "bullet hole" in her neck and brought her to medical attention, where her deep wound was cleaned, packed, and sutured.

Upon consultation, the patient presented as a cooperative, articulate, intelligent woman with a healing left-neck wound and numerous leg, arm, and facial scars from picking. On the Structured Clinical Interview for DSM-IV, she had past diagnoses of alcohol dependence in remission, OCD manifested by counting and fear of harm, and recurrent unipolar depression. The patient's family history was notable for alcoholism in both parents and two brothers. The skin picking was the patient's greatest concern, in part because she felt that the physicians she had seen did not understand that her picking was a means to improve a defect—to "make it [skin imperfections] go away"—not to harm herself. She was delusional concerning the appearance of her skin imperfections, as manifested by the absolute conviction and certainty with which she held the belief about her skin abnormalities. She had absolutely no insight and could not acknowledge the possibility that her perception of her skin imperfection was perhaps exaggerated or that she was overly sensitive to normal skin irregularities. For example, she would point to an area of facial skin that she would describe as "having something wrong," that is, there was something in the skin making it irregular and abnormal. Objective evaluation of her skin did not reveal any distinct abnormalities, save for areas of scarring from picking. Irregularities were perceived by the patient in nonscarred areas. The patient otherwise had no evidence of thought disorder or psychosis.

The patient's fluvoxamine was increased to 300 mg/day, which resulted in further lessening of her picking, to the point that it occurred only 20 minutes a day. The patient also found it easier to resist checking mirrors for skin defects, and she was less preoccupied with the appearance of her skin. Her improvement was maintained, and she was then referred for behavioral treatment to treat her remaining symptoms but was seen only once. Despite her improvement, the patient terminated pharmacologic and behavioral treatment because of reported logistical constraints.

Discussion

This case merits attention for several reasons. First, it demonstrates that skin picking secondary to BDD can be very severe, even life-threatening. As a result of using tweezers in an attempt to remove a perceived defect from her skin, the patient nearly lacerated her carotid artery. Her internist and surgeon reported that had her wound been slightly more lateral, it would likely have been fatal.

While the severity of skin picking secondary to BDD, and the associated medical morbidity, have received little mention in the literature, we are aware of several other patients with BDD-related skin picking who required emergency surgery. Two were women with BDD who picked at minimal facial blemishes for several hours a day; on several occasions they picked their skin so severely and deeply that they required sutures on an emergency basis (Phillips KA, unpublished observations, 1997). In another case of which we are aware, a male patient with BDD picked through his facial artery, lost a large amount of blood, and required emergency surgery. Damage may be considerable because of the unrelenting intensely driven nature of the behavior, which in severe cases can occur for up to 12 hours a day.⁴ In addition, some patients cause severe skin damage by picking with implements such as tweezers, needles, pins, razor blades, staple removers, or knives.⁴

This case also illustrates that the diagnosis of BDD can easily be missed and emphasizes the need for careful differential diagnosis of skin picking. The term "neurotic excoriations" is excessively broad and lacks treatment implications. This differential should instead include several conditions whose behavioral expression involves recurrent picking at skin, including delusional parasitosis, self-mutilatory conditions, tic disorders, and habit disorders. Whereas persons with BDD pick at their skin to improve its appearance, those with parasitosis may pick to remove a perceived infestation. In contrast, self-mutilation typically derives from a desire to relieve anxiety or psychic pain, and sometimes from a conscious plan to harm oneself; the behavior often is accompanied by other self-destructive behaviors. Sensory intrusions, as opposed to the beliefs about appearance that characterize BDD, generally stimulate skin picking in tic disorders. Skin picking in habit disorders lacks the cognitive component of a preoccupation with a defect in appearance. Although skin picking is often included within the rubric of OCD, the presence of skin picking alone is generally insufficient to merit a diagnosis of OCD. The aforementioned conditions can overlap in their presentation and phenomenology, and clearly differentiating among them is sometimes difficult.

In the case we present, the patient was diagnosed as having OCD with a factitious component, but her skin picking derived from BDD—that is, a preoccupation with a perceived defect in appearance, which she was trying to eradicate by picking. The patient's belief was delusional, as she was completely convinced that her view of her skin defects was accurate. She was absolutely certain and could not be dissuaded from the belief, without the possibility of a doubt or possible exaggeration on her part, that there were very noticeable defects in her skin. Although physical examination revealed areas of scarring at old picking sites, her facial skin was otherwise uniform and normal appearing. Because she was unable to acknowledge that her view of her skin might be distorted, her belief was considered a delusion rather than an overvalued idea.

Diagnostically, according to DSM-IV criteria, the patient fulfilled criteria for both BDD and delusional disorder, somatic type (delusional BDD may be "double coded" as both BDD and delusional disorder). Although there remains significant debate about the diagnostic boundaries of poor insight, overvalued ideas, and delusions, empirical data on delusional and nondelusional phenomenology of BDD from a large series⁹ suggest that delusional and nondelusional BDD may not be clearly distinct disorders but may instead constitute the same disorder, spanning a continuum of insight.

As a result of her delusional beliefs and misdiagnosis, the patient felt misunderstood by her treaters. While her clinicians made great efforts to be helpful, their misunderstanding of the delusional nature of her skin preoccupation—and the fact that her behavior was not factitious in nature, or intended to cause mutilation—may have limited the efficacy of their interventions.

This case is consistent with uncontrolled studies suggesting that BDD may improve with serotonin reuptake inhibitors (SRIs).^8–15 Delusional BDD appears to also respond to SRIs.^8,9,15 Available data, while limited, suggest that SRIs may also be effective for "compulsive" skin picking secondary to OCD^7,13,14 or to BDD,⁴ which is consistent with reports of improvement with SRIs in feather picking in birds¹⁶ and repetitive paw licking in dogs¹⁷—animal behaviors with similarities to skin picking. Why the patient did not respond to sertraline is not clear, although the treatment trial may have been inadequate because the dose was not raised above 100 mg/day. Another possible explanation is that for any given patient, one SRI may be more effective than another.⁸

Whether behavior therapy would have been additionally helpful for this patient is unknown. Preliminary data suggest that exposure and response prevention may be effective for BDD,^18,19 but it is unclear whether these strategies can be used successfully when the patient is delusional and the associated behaviors are not sufficiently ego-dystonic.

This case underscores the need for clinicians to inquire about BDD symptoms in patients who pick their skin. Some of these patients have a belief of delusional intensity about the "ugliness" of the defect and the need to remove it by repetitive-driven behaviors such as skin picking. Well-intentioned attempts to reassure the patient that the perceived defects are minimal or nonexistent, as well as simple instructions to stop the picking behavior, are unlikely to be effective. These people constitute a challenging group of patients who are probably best treated with a combination of dermatologic treatment (to heal and minimize skin damage due to picking) and psychiatric treatment (to decrease the severe preoccupation and picking behavior). While available data suggest that the SRIs are promising for these patients, further studies of pharmacologic and cognitive–behavioral treatment strategies are needed to clarify what constitutes optimal treatment for skin picking in patients with delusional BDD.

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