Dr. Bob's Psychopharmacology Tips

Self excoriation

Date: Tue, 14 May 1996 19:59:10 -0400 (EDT)
From: Charles S Berlin <cberlin+@pitt.edu>
Subject: Self excoriation

The APA session on this topic focused generally on self excoriation, including various permutations of scratching and/or picking, usually with the finger nails, but sometimes with instruments. The point made at these presentations is that there is a very large differential diagnosis to consider here, both medically and psychologically, and therefore that very thorough evaluation needs to be done. Cases were presented of patients whose excoriations were considered to be entirely psychological, missing serious underlying medical illnesses, and vice versa. For those patients whose problems were definitely psychologically centered, this often was viewed as an obsessive-compulsive spectrum disorder, but other diagnoses, including body dysmorphic disorder, delusional disorders, and depression, were not uncommon. The treatment approaches varied a lot with the circumstances of the specific case. For some patients, good old-fashioned insight oriented psychotherapy was invaluable. Medications mentioned repeatedly were diphenhydramine (Benadryl) and doxepin ("the dermatologist's vitamin D") when pruritis was substantial, along with SSRIs and pimozide (Orap) (which I was interested to learn does differ in some ways from other common neuroleptics).

There was note that opiate antagonists may have promise, but none of the presenters had experience with this. There are a number of literature reports of the effectiveness of opiate antagonists for intractible pruritis (opiates can cause itchiness), so I would think that naltrexone might be worth a try in this circumstance, although I have not yet had the opportunity to do so, either.

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