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Habitual scratching: a skin-damaging behaviour
As a psychodermatologist, I am a psychiatrist and I work with dermatologists. Sometimes I explain, especially about atopic eczema, that while a dermatologist deals more with the itching, as a psychiatrist I am more focused on the scratching.
Itch can have emotional causes - it is then called psychogenic pruritus - but scratching is one of a range of potentially problematic skin-damaging behaviours, some common and minor, some not so common, and more worrying:
- Nail biting [onychophagia] Nails get bitten, chewed and eaten, sometimes together with the skin around them. As a habit, it is especially associated with emotional arousal, as in “nail biting situations”.
- Hair pulling [trichotillomania] The hair of the scalp, the face and the rest of the body gets fiddled with, chewed, eaten and pulled out. It is also as a habit associated with certain mental states. We talk of “tearing hair out” when we talk of upset and frustration.
- Skin picking [neurotic excoriation; dermotillomania] Sometimes complicating acne [acne excoriée] but often a longstanding nervous habit, often linked to worrying - we talk of “worrying the skin”.
- Habitual scratching As such, not yet a diagnosis in dermatology. Another body focused repetitive behaviour [BFRB] - also an impulse control disorder [ICD]- and linked to a number of dermatological syndromes, including lichen simplex, neurodermatitis and chronic atopic eczema - where the resulting thickening of the skin is called lichenification.
- Occult self-mutilation Dermatitis artefacta, a factitious dermatosis, is caused by self-damaging behaviour that is not disclosed, but is eventually suspected from the appearance of the skin.
- Skin cutting At the extreme end of the skin-damaging behaviours. Skin cutting is a form of Deliberate Self Harm [DSH] associated with psychiatric disorders, not dermatological diagnoses. It may be openly disclosed: the results are obvious, but may be concealed by clothing.
Habit reversal is used in treating nail biting, hair pulling, skin picking and habitual scratching in atopic eczema.
Dr Christopher Bridgett