MHM Magazine

34 | MENTAL HEALTH MATTERS | Issue 1 | 2022 MHM CAN SPD BE TREATED AND IF SO, HOW? The severity of skin-picking ranges from mild to severe; in subclinical cases, interventions are not needed, whereas when diagnostic criteria for SPD are met, treatment is usually indicated. Individuals with SPD don’t commonly seek treatment, however. Reasons for not seeking help include embarrassment, shame or the belief that the condition is just a “bad habit” and that they should just stop doing it. The few pickers that seek treatment often present to a general practitioner or a dermatologist, where the true reason for the skin lesions or skin “problems” may still be kept hidden. Individuals with SPD may only get to a psychiatrist or a psychologist if they’re specifically referred. All treatment starts with a comprehensive diagnostic and clinical assessment to identify the potential underlying causes (e.g., history of traumatic experiences) and any comorbid disorders (e.g., depression and alcohol and/or substance use disorders). Once diagnosed, psychoeducation is the next step, during which accurate information on the condition and its treatment is provided. A recent systematic review that provided readers with an up-to-date view of current treatment options for SPD, indicated that various randomised controlled trials on SPD have now been published, with current management options including behavioural therapy (habit reversal or acceptance-enhanced behaviour therapy), and medication (SSRIs or N-acetyl cysteine). Non-pharmacological (behavioral) treatment Cognitive-behavioral therapy (CBT) and habit reversal therapy (HRT), has been suggested as first-line treatment for SPD. CBT for SPD involves cognitive restructuring and also includes behavioural interventions such as HRT. HRT has previously been used to treat a variety of repetitive behaviour problems such as trichotillomania, and entails awareness training and competing response training. Awareness training includes elements such as self-monitoring, with the aim of bringing greater attention to skin-picking behaviours to increase self-control. Once there is a good awareness of skin- picking behavior, the next step is to develop a competing response. In competing response training, the patient is taught how to substitute skin-picking with an incompatible action (e.g., fist clenching). Another type of CBT, i.e., Acceptance and Commitment Therapy (ACT), has also been investigated in SPD. ACT promotes the acceptance of negative thoughts and feelings as part of the human experience (“acceptance”) and encourages thinking of ways to respond to these negative thoughts and emotions in a way that is congruent with personal values and goals (“commitment”) and not to engage" in destructive behaviours such as skin-picking. Cognitive-behavioural interventions for SPD may also be useful when presented in a self-help format. Of note is that individuals whose skin-picking is primarily “automatic”, may benefit more from HRT, whereas individuals whose skin-picking is primarily “focused”, may benefit more from CBT or ACT. Individuals with “mixed” picking, i.e., who demonstrate both “focused” and “automatic” skin- picking behaviours, may benefit from a combination of HRT and other techniques, such as CBT and ACT. Pharmacotherapy Relatively recently, the efficacy and tolerability of a number of pharmacological agents have been tested in patients with SPD. These include selective serotonin reuptake inhibitors (SSRIs), lamotrigine, glutamatergic agents such as N-acetyl cysteine (NAC), and opioid antagonists such as naltrexone. A number of SSRIs have shown promise as a way to reduce skin- picking behaviour in SPD; these include fluoxetine, fluvoxamine, escitalopram and sertraline. Trials to test the efficacy of lamotrigine (an anti-epileptic agent) in SPD have not rendered consistent data. There currently is increased interest in the use of glutamatergic agents in OCRDs such as SPD. NAC is a nutraceutical agent that modulates the glutamatergic and neuroinflammatory systems, and its potential benefit in SPD has been suggested by case reports. Similarly, the efficacy of opioid antagonists is supported by case reports only. Augmentation strategies have also been investigated but existing data consists of a few case studies which provided support for augmentation of SSRIs with atypical and typical antipsychotic agents. Alternative interventions There are several alternative interventions for SPD that have been proposed for treatment of SPD. These alternatives include, for example, yoga, aerobic exercise, acupuncture, and hypnosis, either as monotherapy or as an adjunct to psychotherapy and/ or pharmacotherapy. To my knowledge, no randomized controlled trials (RCTs) with these methods have been conducted yet. Combined treatment There are no RCTs that have investigated the efficacy of combinations of psychotherapy and pharmacotherapy in SPD yet. However, it’s well-known that in psychiatric conditions, a combination of treatments works best. For example, pharmacotherapy can assist in making other treatments, such as psychotherapy, more effective. CONCLUSIONS It may well be asked what the clinical utility is of inclusion of a condition in the official diagnostic manuals. In the case of SPD, inclusion and delineation of SPD in DSM has likely lead to increased awareness of the condition, more research, and will ultimately result in treatment advances. At the moment, the evidence base on SPD is still relatively sparce, but there seems to be good evidence for the benefit of behavioural treatments. SSRIs have been the cornerstone of pharmacotherapy, but evidence also points to the potential use of NAC in patients with SPD. There is a need for consensus on the optimal symptom severity measures, and for additional controlled trials designs. In the interim, there is also a need to improve accessibility to efficacious treatments. References available upon request