Excoriation disorder

[forchinet121]

I don’t have much experience with this, are there mainstays of treatment? I researched acetylcysteine as an option do you guys start at 600 mg and go up? Any other insights for this condition?

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[Fan_of_Meehl]

If you live in a major metropolitan area with a PhD/PsyD doctoral training program they may have an anxiety disorders specialty clinic and may offer CBT protocol treatments for such things as OCD and excoriation disorder. I think cognitive restructuring and exposure/ response prevention would be mainstay elements and I think there is some literature on this.

 

[Sushirolls]

Risperdal

lower severity I've had response with lotions and/or gloves.

 

[hamstergang]

My understanding is that the existing literature most supports treating this like you would OCD. So that means therapy and SSRIs primarily. Augmenting with an antipsychotic or with NAC is also reasonable when needed.

 

[SubzDoc]

I recommend methamphetamine abstinence for this problem although I don't get very much traction with that recommendation.

There was a link in psychnews today about this, although I suspect OP has already seen this, hence the topic:
Double-Blind Placebo-Controlled Study of Memantine in Trichotillomania and Skin-Picking Disorder
https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.20220737

 

[Celexa]

Therapy therapy therapy. Specialized cbt if you have somewhere you can refer. Agree with usually treating like ocd in terms of pharmacology.

However, if the the excoriation is secondary to delusions (ie delusional parasitosis or morgellons) then you want to treat with antipsychotics. Whatever one you can coax the pt into taking. And agree with the poster above re: stimulants--if they're taking stimulants (prescription OR illicit), it's unlikely to improve without stopping that.

 

[allantois]

I had a patient whose eyebrow picking was better on Adderall than off it

 

[Merovinge]

NAC comes in 500 or 600mg depending on the manufacturer.

I typically start with 500-600mg QHS for a week then BID. If tolerated at next visit would go to 1000-1200mg BID.

While the effect size is small at best, but a little boost from a very safe intervention is always nice. It is also the current best option (among a sea of terrible options) for cannabis use disorders at the same dosing.

 

[WisNeuro]

Few options, ExRP, HRT, and soem ACT. Woods & Twohig would be my go to for comprehensive treatment protocols. Good RCTs that I can personally attest to.

Trichotillomania

Trichotillomania (TTM) is a complex disorder that is difficult to treat as few effective therapeutic options exist. Behavior therapy has the greatest empirical support, but the number of mental health providers familiar with TTM and its treatment is quite small. This manual was written as a...

global.oup.com

Trichotillomania

Trichotillomania (TTM) is a complex disorder that is difficult to treat as few effective therapeutic options exist. Behavior therapy has the greatest empirical support, but the number of mental health providers familiar with TTM and its treatment is quite small. This manual was written as a...

global.oup.com

Trichotillomania: Therapist Guide

Trichotillomania (TTM) is a complex disorder that is difficult to treat and few effective therapeutic options exist.

global.oup.com

 

[clausewitz2]

Can go up to 2 grams per day with the NAC, usually this is not tolerated due to nausea. Small studies support lamotrigine as a hail mary. Generally not an area where meds are terribly effective. You get more bang for your buck trying to sort out exactly when and where the episodes happen to begin the work of identifying triggers/the urges preceding the behavior.

Had no idea about the ACT-enhanced approach, will have to look into this.

 

[tr]

I feel like most of my excoriation disorder patients see a partial improvement from SSRI, about half get additional benefit from NAC, and between that and behavioral modifications to minimize precipitants/overall improvement when stressors are lower, most people end up in a range where they still have some mild excoriation going on but it isn't harming them, altering their appearance or creating functional impairment.

I almost never see it go away totally, but it gets to a manageable range.

 

[annoyedpsychiatrist]

ive used high dose prozac before. ive also used clomipramine.

 

[allantois]

I've never seen anyone with excoriation disorder and no other psychiatric comorbidity.. I find that treating the other issue to be the most helpful with excoriation disorder. I have also found risperidone helpful in kids.

 

[mistafab]

It depends on source/patient. If the patient has added delusional components then the management is different than if it is pure skin picking. Also, as pointed out above, stimulants will tend to make both worse so they are important to address.

 

[MedMan80]

Habit reversal therapy

 

[clausewitz2]

Habit reversal therapy

What did you think was meant up thread by HRT?

 

[Merovinge]

What did you think was meant up thread by HRT?

Humongous rectal transplant of course...

 

[MedMan80]

What did you think was meant up thread by HRT?

hormone replacement tx

 

[smalltownpsych]

Some of my patients with this clearly have OCD and others it is more of an anxiety based habit similar to fingernail chewing. The first needs ERP and can be much more difficult to treat, the second is more responsive to implementing more adaptive coping strategies for other life stressors and less focus on the specific behavior. If they are on adderall, might want to lower the dose a bit. 😉