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.