A case of body dysmorphic disorder with pathological skin-picking

Mimi MC Wong 黃美彰, Ka-lun Kong 江嘉麟, Pui-fai Pang 彭培輝

HK Pract 2024;46:24-27

Summary

Body dysmorphic disorder (BDD) is classified under obsessive-compulsive or related disorders. Some type of skin-picking behaviour occurs in patients with BDD and their co-occurrence results in a more severe clinical picture of skin-picking. BDD is more commonly encountered in primary care and dermatology practice than in psychiatric settings. It is important to screen patients with skin-picking for BDD and to screen for skin-picking in BDD patients. Management of BDD requires a combination of skin treatment, psychotherapy and psychopharmacological treatment.

摘要

身體畸型恐懼症是強迫症及相關障礙症的一種。可能 會出現摳皮這種行為。如果摳皮是由於擔心身體或皮膚不 正常，摳皮情況會較為嚴重。患有身體畸型恐懼症的病人 較少向精神科醫生求診，反而會向普通科或皮膚科醫生求 助。醫生需留意身體畸型恐懼症患者會否有摳皮行為，或 有摳皮行為的病人會否患有身體畸型恐懼症。治療方法包 括精神科藥物、心理治療及皮膚護理。

Introduction

Body dysmorphic disorder (BDD) is a distressing and difficult-to-treat condition characterised by a preoccupation with imagined or slight physical defects in appearance. It is viewed as an obsessive-compulsive spectrum disorder and reclassified under obsessivecompulsive or related disorders in DSM-V¹ and ICD- 11.² It is associated with a lower quality of life, stress, depression, anxiety, suicidal ideation and suicidal attempts.³ It has a prevalence of about 2% in the general population. Skin is the commonest location of the perceived defect.⁴ BDD appears to be common in dermatological patients with reported prevalence rates in the range of 4.9% to 36%.⁵ Skin-picking disorder is defined as repetitive picking of the skin to the point of causing tissue damage. The face is the most commonly reported site of picking, followed by hands, arms and legs. A variety of utensils such as tweezers and pins may be used. It is a recognised mental illness but it can also be a symptom of other psychiatric disorders, in particular BDD if they pick their skin in an attempt to improve the appearance of perceived skin flaws. Some type of skin-picking behaviour occurs in between 26% and 45% of patients with BDD and their co-occurrence results in a more severe clinical picture of skin-picking.⁶ We have encountered a patient with BDD and extreme skin-picking.

Case Presentation

This patient was a 65-year-old widow who was a retired boutique owner. Her husband passed away more than ten years ago. She had three grown up children who were supportive (Figure 1). One of them was living overseas while the other two would visit her regularly. She did not have much contact with her siblings. She was described as perfectionistic and cared about her appearance since she was young. She has developed a habit of trimming her eyebrow regularly with increasing frequency since 2018 which was after her retirement. She was preoccupied with picking white hairs from her eyebrows and even picking the skin of her upper eyelid with a tweezer resulting in an ulcer. Sutures were required in a private clinic for a chronic ulcer over her left upper eyelid. Her preoccupation with eyebrow trimming was not yet noticed and it persisted. She was brought to the Accident and Emergency Department in October 2019 and an ophthalmologist was consulted for the wound near her eyes. Magnetic resonance imaging with contrast of her orbit was done and a deep skin wound over the right upper eyelid was found. The right lacrimal gland was slightly thickened, likely related to inflammatory changes. Wound dressing and topical treatment were provided and she was followed up by an ophthalmologist. She was also referred to a consultation liaison psychiatric nurse for assessment. She was diagnosed with obsessivecompulsive disorder with skin-picking behaviour, and was referred to the psychiatric clinic and treated with two antidepressants (paroxetine and trazodone). Her children requested that she send them a photo of her face daily for their monitoring as she was living alone. She remained well until July 2021.

In July 2021, her children found various wounds on her feet, for which they brought her to a private hospital for a “check-up”. Psychiatric admission was arranged for her as the wounds were suspected to be self-inflicted and she was noted to be in a low mood. She admitted to regularly cutting her left big toe due to an ingrowing toenail. She denied hurting herself intentionally and claimed the slow healing was related to her diabetes mellitus. There was no more picking of her eyebrow or eyelid. Later, she revealed that she was distressed by her children's frequent monitoring of her wounds and the Covid pandemic. She stayed in the psychiatric ward for two weeks and was discharged home after observation. There was no change in her psychiatric diagnosis and management. She remained stable until early 2022.

In February 2022, there was skin-picking behaviour again over her right nasal wing resulting in erythema, a slit-like wound and yellowish discharge. She claimed that there was a pimple over her nose and she had to squeeze it and make it flat. She continued the picking and squeezing even though there was no more discharge. She would do it several times daily and even use a tweezer. She had refrained from meeting her friends due to this wound over her nose. But she felt better when she wore her mask to go out of her home. Her diagnosis was changed to body dysmorphic disorder during her psychiatric outpatient follow-up in view of her preoccupation with the perceived flaws in her physical appearance and repetitive skin picking behaviour which had resulted in clinically significant impairment. Her insight was poor at that time. An antipsychotic, quetiapine, was started for her. Her skin-picking further worsened and eventually, another psychiatric admission was arranged for her in May 2022. She did not exhibit further skin-picking behaviour after her admission. She reported being distressed by the idea of having a pustule over her nose which her children did not notice. She considered the pustule to be ugly and made her nose appear “big”. Her mood remained stable. Her antidepressants were changed to a combination of escitalopram and clomipramine. Psychological interventions were also arranged for her. She refused to continue her stay in the psychiatric ward after three weeks even though titration of clomipramine had not been completed as she believed she had recovered already. She was allowed for home discharge with acknowledgement of medical advice together with her children.

One week after her discharge from the psychiatric ward, she was found to have repeated skin-picking of her nose again, resulting in a 2cm x 3cm x 2cm deep ulcer on the right side of her nose complicated by awound infection. She was brought to the Accident and Emergency Department and was admitted to the Ear, Nose and Throat ward in June 2022. Debridement of the wound with skin suture was done and a course of intravenous antibiotics was administered (Figure 2). She was later transferred to the psychiatric ward for further treatment. She had a eight week stay in the psychiatric ward this time. She expressed frustrations towards previous treatments and initially tried to minimise the severity of her skin-picking problems. Clomipramine was further titrated up for her. She gradually became less evasive and showed improved insight towards her mental condition. After several psychotherapy sessions and family meetings, she recognised the need for treatment and agreed to stay until she had completed her treatment. She was treated with a combination of highdose clomipramine (100mg), escitalopram (20mg), and quetiapine (100mg) daily. The psychological interventions provided by the multidisciplinary team adopted a cognitive behavioural approach focusing on modifying her overvalued beliefs about her physical appearance, eliminating her self-picking behaviour, and enhancing alternative coping strategies and activity scheduling. She had good wound healing and was able to refrain from picking her skin (Figure 3). She agreed to attend the psychiatric day hospital and to live with her daughter after discharge for better supervision. She remained well when this case report was reviewed (April 2024).

Discussion

BDD is defined as a preoccupation with one or more perceived defects or flaws in one’s physical appearance that are not observable or appear slight to others. The individual has performed repetitive behaviours (e.g., mirror checking, excessive grooming, skin-picking, reassurance seeking) or mental acts (e.g., comparing their appearance with others) in response to the appearance concerned. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.¹ This case illustrates BDD with skin-picking could result in serious complications including open wounds and infections. Delay presentation is common as patients are evasive about their behaviour and will try to cover up their wounds. Inpatient psychiatric treatment and even compulsory admission may be needed for close supervision and protection of patients with poor insight. BDD is more commonly encountered in primary care and dermatology practice than in psychiatric settings. Its prevalence in patients with acne ranged between 9% and 15%.⁷ BDD is difficult to be noticed as patients do not expressly talk about their symptoms or concerns. This case report was written by the psychiatrists treating her in her last psychiatric admission to provide general practitioners and general dermatologists some insight into this medical condition. People with BDD may incur high costs to healthcare systems as they may repeatedly present for different ineffective interventions. They often become dissatisfied with therapies and claim that any given therapy has worsened their appearance. Unnecessary intervention and pathological skin-picking will induce harm to the patient. Recommended treatment for BDD includes high-dose selective serotonin reuptake inhibitors and clomipramine, psychoeducation and cognitive-behavioural therapy (CBT).⁸ CBT involved challenging of automatic negative thoughts about body image, learning of more flexible ways of thinking as well as alternative ways of handling urges or rituals and increasing engagement with healthy supports and activities. If symptoms persisted despite the use of the pharmacological treatment suggested, referral to psychiatrist would be indicated for multimodal and multi-disciplinary care.

Conclusion

When general practitioners and dermatologists encounter a patient with little objective signs of skin disease but with high suffering and co-morbid psychosocial complaints, BDD could be one of the differential diagnoses to explain the patient’s condition. It is important to screen patients with skin-picking for BDD and to screen for skin-picking in BDD patients.⁶ A combination of skin treatment, psychotherapy and psychopharmacological treatment may be warranted. However, this condition usually takes a recurring and chronic course so ongoing treatment and supervision are commonly needed.

Acknowledgment

There is no financial support and no conflict of interest.

References

1. American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Publishing, 2013.
2. World Health Organization. ICD-11 for Mortality and Morbidity Statistics. Available at: https://icd.who.int/browse11/l-m/en (version 02/2022).
3. Ross J & Gowers S. Body dysmorphic disorder. Advances in psychiatric treatment 2011;17(2):142-149.
4. Phillips KA. 2005a The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder (2nd edn). Oxford University Press; 2005a.
5. Herbst I & Jemec GBE. Body Dysmorphic Disorder in Dermatology: a Systematic Review. Psychiatric Quarterly 2020;91:1003–1010.
6. Grant JE, Redden SA, Leppink EW et al. Skin picking disorder with cooccurring body dysmorphic disorder. Body Image 2015;15: 44–48.
7. Marron SE, Miranda-Sivelo A, Tomas-Aragones L et al. Body dysmorphic disorder in patients with acne: a multicentre study. JEADV 2020; 34: 370–376.
8. Castlea D, Beilharzb F, Phillips KA, et al. Body dysmorphic disorder: a treatment synthesis and consensus on behalf of the International College of Obsessive-Compulsive Spectrum Disorders and the Obsessive Compulsive and Related Disorders Network of the European College of Neuropsychopharmacology. International Clinical Psychopharmacology 2021; 36:61–75.