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Section 24
Anxiety: Skin Picking and Sleep Disturbance

Question 24 | Answer Booklet | Table of Contents | Printable Page

Pathological excoriation (PE), also referred to as ‘‘neurotic excoriation’’ or skin picking, is a syndrome that has received little attention in the scientific literature. Patients with this disorder will touch, squeeze, or pick at an area of their skin repeatedly, often causing bleeding, infection, or scarring of the skin. PE is fairly common among patients seen by dermatologists as nearly 2% of dermatology clinic patients have been reported to compulsively pick their skin.

Patients with skin problems often report anxiety and patients with primary anxiety disorders frequently report poor sleep quality. Additionally, individuals with PE have high incidence of comorbid anxiety disorders. However, the sleep quality in individuals with PE is not known. As part of a larger study investigating the prevalence of anxiety and impulse disorders in skin picking patients, we evaluated the subjective sleep of patients with pathological excoriation. Our preliminary observations indicate that patients with pathological excoriations have high rates of subjective sleep disturbance and anxiety, which can lead to significant work and social dysfunction.

Subjects and Methods
Three study groups were recruited. Ten patients with pathological excoriation (PE-DERM) were recruited from an ambulatory dermatology clinic. These patients were diagnosed by a board-certified dermatologist (A.M.). A comparison group of 10 patients with primary dermatological complaints but without PE (NonPE-DERM) were recruited from the same clinic.

Sleep related complaints were neither an inclusion nor an exclusion criterion. A third group of sex-matched and age-comparable healthy control subjects with no current or past history of any sleep or psychiatric disorder were recruited through a newspaper advertisement.

None of the subjects in the healthy control group voluntarily reported any evidence of skin problems, including pruritis, during the administration of the Structured Clinical Interview for DSM-IV (SCID-I); however, these subjects were not formally examined by a dermatologist to rule out PE or other primary skin diseases.  All subjects completed the Pittsburgh Sleep Quality Index (PSQI), which consists of 19 self-rated questions designed to assess sleep quality in the preceding month. These 19 items are grouped into 7 component scores; each is weighted equally on a 0 to 3 scale. The seven component scores are then totaled to provide a global PSQI score, which has a range of 0 to 21, with higher scores indicating worse sleep quality. PSQI has been shown to be a valid and reliable instrument to assess subjective sleep quality. We took the global score as an index of sleep quality in our study.

The subjects also completed two measures of anxiety: the State and Trait Anxiety Inventory (STAI) and a modified version of the Zung Anxiety Scale. All subjects were administered the Perceived Stress Scale (PSS) and the Work and Social Disability subscale of the Sheehan Disability Inventory (SDI-4). In addition the subjects with dermatological complaints, with or without PE, completed a self-rated questionnaire developed by two of the authors (L.S. and T.W.U.; instrument will be provided upon request) to assess skin-picking habits.

Subjects in the three groups did not differ in gender distribution or age.  Patients with dermatological complaints have significantly higher PSQIglobal, Spielberger state, Zung, PSS, and SDI-4 scores compared to healthy controls. Within the dermatological group there were no differences on any variable between the PE-DERM versus NonPE-DERM patients.

However, compared with the NonPE-DERM group, those patients with PE scored higher on every outcome measure and there was a trend (P ¼.072) toward increased trait anxiety in those with pathological excoriations. In fact, a power analysis indicated that sample sizes of only 20 subjects in each of the DERM subgroups would be needed to demonstrate statistically significant group differences on measures of state anxiety and trait anxiety. Moreover, skin picking patients, as identified by the presence of pathological excoriations during dermatological examinations, were the only patients to have significantly and consistently elevated scores on measures of sleep disturbance, perceived stress, and all measures of anxiety.

There were no significant associations between ratings of subjective sleep quality and ratings of anxiety in either the healthy controls or in the dermatological patients without pathological excoriations.

In contrast, in patients with pathological excoriations, there were highly significant and positive correlations between ratings of poor subjective sleep and ratings of anxiety on the Spielberger State and Zung but not Spielberger Trait anxiety scales.

Our preliminary findings indicate that patients seeking consultation in a private dermatology practice have high rates of poor quality sleep as measured by the widely used and previously validated Pittsburgh Sleep Quality Index (PSQI). Sleep problems were not voluntarily offered by the participants but were identified only after scores on the PSQI were evaluated as part of a larger battery of psychometric instruments in a study originally designed to investigate anxiety in patients with pathological excoriations. Sixty percent of the dermatological patients compared with ten percent of the normal controls had PSQI-global scores above the standard cutoff (i.e., 45) for identifying individuals with poor sleep quality. Our findings raise the possibility that patients with dermatological complaints, particularly ‘‘skin-pickers’’, may privately suffer from clinically significant sleep problems and may be candidates for clinical polysomnography.  Particularly noteworthy is the subgroup of patients with pathological excoriations, 50% of whom had PSQI scores above 10.

None of the patients in this study were evaluated by polysomnography and the relationship between skin problems and objective sleep indices will be the focus of future research by our laboratory. Of interest is the possible association between skin-picking behaviors and sleep and sleep deprivation. Almost all of the individuals in this study were aware of their skin picking or scratching behaviors, although some individuals with skin-picking behaviors are unable to recall picking their skin despite the presence of lesions.  Whether physical excoriations are in part or whole a sleep-related injury in a subset of individuals must be determined in the future.

That patients seeking treatment for skin problems in a private dermatology practice have high degrees of distress and comorbid anxiety is not an unexpected finding. Our observations, in a preliminary exploratory study, suggest that a subgroup of dermatology patients with skin picking behaviors, as evidenced by pathological excoriations, may be particularly anxious. Our skin-picking patients reported high levels of anxiety and distress on several rating scales of anxiety, including those, which target both ‘‘psychological’’ (i.e., state anxiety) and ‘‘physiological’’ (i.e., Zung) manifestations of anxiety.

While the subgroup of dermatological patients with skin-picking behaviors reported the greatest problems with anxiety and sleep disturbances, our study was not designed to examine the cause-effect relationships among these factors. Anxiety and subjective stress can cause poor sleep and poor subjective quality of sleep may lead to anxiety and higher perceived stress. Therefore, it is possible that higher anxiety levels in the skin-picking patients may predispose to poor sleep or that poor sleep may contribute to anxiety in these patients. It is also possible that a common underlying biological factor contributes to both increased anxiety and sleep problems in the skin-picking patients. There appeared to be positive association between sleep disturbances and the degree of work and social disability in the dermatological patients as a group; however, only those with pathological excoriations reported that their problems markedly or radically changed or prevented normal work or social activities (20% of skin pickers).

Taken together, our findings suggest that patients with pathological excoriations tend to be anxious and complain of more severe sleep disturbances than nonskin picking dermatological patients. In some cases, patients with pathological excoriations may develop severe work and social disability. Our exploratory findings in a small but controlled study underscore the need for a larger study to investigate the phenomenology, course of illness, sleep physiology, and treatment of patients with skin picking and related neurodermatological syndromes.
- Singareddy R, Moin, Ali, Spurlock, Lisa, Merritt-Davis, Orlena, Uhde, Thomas W. Depression And Anxiety, 2003.
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #10
The preceding section contained information about anxiety: skin picking and sleep disturbance.  Write three case study examples regarding how you might use the content of this section in your practice.

Taken together, what did Singareddy’s findings suggest about patients with pathological excoriations? Record the letter of the correct answer the Answer Booklet.

Answer Booklet for this course
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The article above contains foundational information. Articles below contain optional updates.
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