Materiały źródłowe

• #1 Excoriation disorder – Wikipedia

  https://en.wikipedia.org/wiki/Excoriation_disorder

  Excoriation disorder, more commonly known as dermatillomania, is a mental disorder on the obsessive-compulsive spectrum that is characterized by the repeated urge or impulse to pick at one’s own skin, to the extent that either psychological or physical damage is caused. The exact causes of this disorder are unclear but are believed to involve a combination of genetic, psychological, and environmental factors, including stress and underlying mental health conditions such as anxiety or obsessive-compulsive disorder (OCD). […] A common hypothesis is that excoriation disorder is often a coping mechanism to deal with elevated levels of turmoil, boredom, anxiety, or stress within the individual, and that the individual has an impaired stress response. […] There is limited knowledge regarding the neurobiology that drives excoriation disorder, and there have been few neuroimaging studies of those with excoriation disorder.

• #2 Skin picking disorder in a woman with polyarteritis nodosa. Case report | Revista Colombiana de Psiquiatría (English Edition)

  https://www.elsevier.es/en-revista-revista-colombiana-psiquiatria-english-edition–479-articulo-skin-picking-disorder-in-woman-S2530312019300487

  Excoriation (skin picking) disorder is included in the DSM-5 in the obsessive compulsive and related disorders category. It is defined as the recurrent urge to touch, scratch, scrape, scrub, rub, squeeze, bite or dig in the skin, leading to skin lesions. It is a rare disorder (1.4-5.4% of the population) and occurs mainly in women. […] Skin picking disorder, also known as dermatillomania, neurotic excoriation, psychogenic excoriation or excoriated acne, was described for the first time in 1875 by Erasmus Wilson, under the name skin picking. It was initially included in the classification as an impulse control disorder, but in the face of the emergence of neurobiological, epidemiological and clinical evidence, the DSM-5 has recently included it within the category of obsessive compulsive disorder and related disorders.

• #3

  https://www.termedia.pl/Exploring-skin-picking-disorder-aetiology-treatment-r-nand-future-directions,7,54674,1,1.html

  Overall, a multifactorial model incorporating genetic, neurobiological, and psychological factors is likely involved in the aetiology and pathophysiology of skin picking disorder. Understanding these underlying mechanisms is essential for the development of effective interventions and treatments that address the complex interplay of factors contributing to SPD.

• #4

  https://www.termedia.pl/Exploring-skin-picking-disorder-aetiology-treatment-r-nand-future-directions,7,54674,1,1.html

  There are numerous studies that suggest that genetic factors play an important role in the development of skin picking disorder (SPD). For example, research has indicated a familial aggregation of SPD, with higher rates of the disorder observed among first-degree relatives of sufferers in comparison to the general population. Studies of twins have provided further support for a genetic predisposition to SPD, with higher concordance rates observed among monozygotic compared to dizygotic twins. […] For this reason, certain candidate genes have been implicated in SPD, with a focus on genes involved in neurotransmitter regulation, impulse control, and emotional processing. For example, variations in genes encoding serotonin receptors, such as the serotonin transporter gene (SLC6A4), have been associated with impulsivity and compulsive behaviours, which are core features of SPD. Additionally, genes involved in the dopaminergic system, such as the dopamine D2 receptor gene (DRD2), have been implicated in reward processing and reinforcement, potentially contributing to the compulsive nature of skin picking behaviours.

• #5 Excoriation Disorder: Assessment, Diagnosis and Treatment – The Professional Counselor

  https://tpcjournal.nbcc.org/excoriation-disorder-assessment-diagnosis-and-treatment/

  Little is known about the etiology of excoriation disorder. Much of the current excoriation disorder research has been based on previous research conducted on trichotillomania. Excoriation disorder and trichotillomania are body-focused repetitive behaviors (BFRB) under the same DSM-5 classification, and the etiologies behind both disorders might be similar. Most theorists suggest that excoriation disorder is rooted in both biological and psychological factors. […] Biological factors related to excoriation disorder include genetic predispositions and neurological sensitivity to emotional stimuli, which result in emotional impulsivity and a need to self-soothe. In one study of 40 individuals who had excoriation disorder, 43% had a first-degree relative with the disorder. Specific genes (e.g., Hoxb8 and SAPAP3) have been identified as potential predictors of this disorder. In animal studies, mice with these genes engaged in excessive grooming to the point of skin lesions, behaviors similar to those of people who have excoriation disorder. Conversely, in another study, humans with the SAPAP3 gene only met criteria for excoriation disorder 20% of the time. It is important to note that genetics appear to play a role in the development of excoriation disorder, but other factors contribute to the disorder’s etiology and maintenance as well.

• #6 Excoriation Disorder: Assessment, Diagnosis and Treatment – The Professional Counselor

  https://tpcjournal.nbcc.org/excoriation-disorder-assessment-diagnosis-and-treatment/

  Little is known about the etiology of excoriation disorder. Much of the current excoriation disorder research has been based on previous research conducted on trichotillomania. Excoriation disorder and trichotillomania are body-focused repetitive behaviors (BFRB) under the same DSM-5 classification, and the etiologies behind both disorders might be similar. Most theorists suggest that excoriation disorder is rooted in both biological and psychological factors. […] Biological factors related to excoriation disorder include genetic predispositions and neurological sensitivity to emotional stimuli, which result in emotional impulsivity and a need to self-soothe. In one study of 40 individuals who had excoriation disorder, 43% had a first-degree relative with the disorder. Specific genes (e.g., Hoxb8 and SAPAP3) have been identified as potential predictors of this disorder. In animal studies, mice with these genes engaged in excessive grooming to the point of skin lesions, behaviors similar to those of people who have excoriation disorder. Conversely, in another study, humans with the SAPAP3 gene only met criteria for excoriation disorder 20% of the time. It is important to note that genetics appear to play a role in the development of excoriation disorder, but other factors contribute to the disorder’s etiology and maintenance as well.

• #7 Excoriation disorder – Wikipedia

  https://en.wikipedia.org/wiki/Excoriation_disorder

  There is significant evidence to suggest that skin picking disorders are due to inherited traits or genes. There have been multiple small studies with similar conclusions in regards to the SAPAP3 gene. Excessive grooming by mice has been observed by researchers after the deletion of the SAPAP3 gene. This observation led researchers to study the effects of the SAPAP3 gene on patients with trichotillomania, a disorder marked by the same behaviors directed at one’s own head and body hair. This study revealed a significant link between a single nucleotide polymorphism (SNP) within the SAPAP3 gene and trichotillomania.

• #8 Excoriation Disorder: Assessment, Diagnosis and Treatment – The Professional Counselor

  https://tpcjournal.nbcc.org/excoriation-disorder-assessment-diagnosis-and-treatment/

  Little is known about the etiology of excoriation disorder. Much of the current excoriation disorder research has been based on previous research conducted on trichotillomania. Excoriation disorder and trichotillomania are body-focused repetitive behaviors (BFRB) under the same DSM-5 classification, and the etiologies behind both disorders might be similar. Most theorists suggest that excoriation disorder is rooted in both biological and psychological factors. […] Biological factors related to excoriation disorder include genetic predispositions and neurological sensitivity to emotional stimuli, which result in emotional impulsivity and a need to self-soothe. In one study of 40 individuals who had excoriation disorder, 43% had a first-degree relative with the disorder. Specific genes (e.g., Hoxb8 and SAPAP3) have been identified as potential predictors of this disorder. In animal studies, mice with these genes engaged in excessive grooming to the point of skin lesions, behaviors similar to those of people who have excoriation disorder. Conversely, in another study, humans with the SAPAP3 gene only met criteria for excoriation disorder 20% of the time. It is important to note that genetics appear to play a role in the development of excoriation disorder, but other factors contribute to the disorder’s etiology and maintenance as well.

• #9

  https://www.termedia.pl/Exploring-skin-picking-disorder-aetiology-treatment-r-nand-future-directions,7,54674,1,1.html

  There are numerous studies that suggest that genetic factors play an important role in the development of skin picking disorder (SPD). For example, research has indicated a familial aggregation of SPD, with higher rates of the disorder observed among first-degree relatives of sufferers in comparison to the general population. Studies of twins have provided further support for a genetic predisposition to SPD, with higher concordance rates observed among monozygotic compared to dizygotic twins. […] For this reason, certain candidate genes have been implicated in SPD, with a focus on genes involved in neurotransmitter regulation, impulse control, and emotional processing. For example, variations in genes encoding serotonin receptors, such as the serotonin transporter gene (SLC6A4), have been associated with impulsivity and compulsive behaviours, which are core features of SPD. Additionally, genes involved in the dopaminergic system, such as the dopamine D2 receptor gene (DRD2), have been implicated in reward processing and reinforcement, potentially contributing to the compulsive nature of skin picking behaviours.

• #10 8 Myths (And Facts) About Excoriation (Skin Picking Disorder)

  https://www.therecoveryvillage.com/mental-health/excoriation/skin-picking-myths/

  The fact that skin picking disorder has been correlated with structural and functional brain changes strongly suggests a genetic component to the disorder. A study of twins demonstrated a strong heritable component to skin picking disorder, which accounted for about 40% of the disorder. The genes involved appear to affect the brain chemical (neurotransmitter) serotonin, which explains the obsessive-compulsive and anxiety-inducing nature of skin picking. […] So, although research is just beginning to uncover these factors, it is already apparent that skin picking is not simply a bad habit. Rather, it is a disorder caused by structural and physiological brain changes, genetics and environmental factors. […] Skin picking disorder is psychological impulse control and obsessive-compulsive disorder where the individual picks at normal skin. They are not picking because their skin is itchy or sore, or because the skin is bumpy or in any way abnormal. Rather, they are driven by anxiety that is only relieved by picking.

• #11

  https://www.termedia.pl/Exploring-skin-picking-disorder-aetiology-treatment-r-nand-future-directions,7,54674,1,1.html

  While genetic factors contribute to individual susceptibility to SPD, the relationship between genetic predisposition and the influence of the environment remains crucial. To be more specific, environmental stressors, trauma, and learned behaviours may interact with genetic vulnerabilities to increase the likelihood of SPD developing. […] Neurobiological research has provided insights into the underlying neural circuits and neurotransmitter systems implicated in skin picking disorder. Functional neuroimaging studies show changes in brain regions responsible for impulse control, such as the prefrontal cortex and anterior cingulate cortex, among individuals with SPD. Dysfunction in these regions may contribute to difficulties in inhibiting urges to pick at the skin. […] Moreover, abnormalities in the dopaminergic and opioid systems have been identified in the pathophysiology of SPD. Dysregulation of dopamine signalling, particularly in reward-related brain regions such as the striatum, may contribute to the reinforcing properties of skin picking behaviours. Similarly, alterations in endogenous opioid release and sensitivity may underlie the pleasurable sensations experienced during skin picking, further reinforcing the behaviour.

• #12 White Matter Abnormalities in Skin Picking Disorder: A Diffusion Tensor Imaging Study | Neuropsychopharmacology

  https://www.nature.com/articles/npp2012241

  Skin picking disorder (SPD) is characterized by the repetitive and compulsive picking of skin, resulting in tissue damage. Neurocognitive findings in SPD implicate difficulty with response inhibition (suppression of pre-potent motor responses). This function is dependent on the integrity of the right frontal gyrus and the anterior cingulate cortices, and white-matter tracts connecting such neural nodes. It was hypothesized that SPD would be associated with reduced fractional anisotropy in regions implicated in top-down response suppression, particularly white-matter tracts in proximity of the bilateral anterior cingulate and right frontal (especially orbitofrontal and inferior frontal) cortices. […] These findings implicate disorganization of white-matter tracts involved in motor generation and suppression in the pathophysiology of SPD, findings remarkably similar to those previously reported in trichotillomania.

• #13 White Matter Abnormalities in Skin Picking Disorder: A Diffusion Tensor Imaging Study | Neuropsychopharmacology

  https://www.nature.com/articles/npp2012241

  The current data implicate disconnectivity in white-matter tracts connecting neural regions involved in motor generation and suppression. […] These findings add considerable support to the notion that in addition to the phenomenological and comorbid overlap between SPD and trichotillomania, these disorders likely share overlapping neurobiology. […] The key finding was that SPD was associated with reduced integrity of distributed white-matter tracts connecting the anterior cingulate cortices to other neural nodes bilaterally. […] The FA abnormalities in SPD appeared unrelated to the extent of disease severity as indexed by NEYBOCS scores. […] Future work should use diffusion tensor imaging in conjunction with functional imaging to explore the relationship between white-matter tract disorganization and dysfunction of particular nodes within the networks responsible for habit suppression.

• #14 White Matter Abnormalities in Skin Picking Disorder: A Diffusion Tensor Imaging Study | Neuropsychopharmacology

  https://www.nature.com/articles/npp2012241

  Skin picking disorder (SPD) is characterized by the repetitive and compulsive picking of skin, resulting in tissue damage. Neurocognitive findings in SPD implicate difficulty with response inhibition (suppression of pre-potent motor responses). This function is dependent on the integrity of the right frontal gyrus and the anterior cingulate cortices, and white-matter tracts connecting such neural nodes. It was hypothesized that SPD would be associated with reduced fractional anisotropy in regions implicated in top-down response suppression, particularly white-matter tracts in proximity of the bilateral anterior cingulate and right frontal (especially orbitofrontal and inferior frontal) cortices. […] These findings implicate disorganization of white-matter tracts involved in motor generation and suppression in the pathophysiology of SPD, findings remarkably similar to those previously reported in trichotillomania.

• #15 Skin picking disorder in a woman with polyarteritis nodosa. Case report | Revista Colombiana de Psiquiatría (English Edition)

  https://www.elsevier.es/en-revista-revista-colombiana-psiquiatria-english-edition–479-articulo-skin-picking-disorder-in-woman-S2530312019300487

  From a neurobiological perspective, common characteristics with trichotillomania have been found, such as higher density in the grey matter in the striatum, amygdala-hippocampal formation and in the convolution of the cingulum. Furthermore, disorganisation of the white matter tracts related to the interface of motor generation and suppression has also been found. […] With regard to pharmacological treatment, given the relationship described with obsessive-compulsive spectrum disorders, the use of selective serotonin reuptake inhibitors (SSRIs) is recommended. […] The most-studied non-pharmacological intervention is cognitive behavioural therapy. Habit reversal therapy or training (HRT) is designed to treat nervous habits and tics, in the circumstance that habits persist due to the response chain that is implemented in the face of limited awareness of the behaviour, the excessive practice of this behaviour and social tolerance towards them.

• #16 White Matter Abnormalities in Skin Picking Disorder: A Diffusion Tensor Imaging Study | Neuropsychopharmacology

  https://www.nature.com/articles/npp2012241

  The current data implicate disconnectivity in white-matter tracts connecting neural regions involved in motor generation and suppression. […] These findings add considerable support to the notion that in addition to the phenomenological and comorbid overlap between SPD and trichotillomania, these disorders likely share overlapping neurobiology. […] The key finding was that SPD was associated with reduced integrity of distributed white-matter tracts connecting the anterior cingulate cortices to other neural nodes bilaterally. […] The FA abnormalities in SPD appeared unrelated to the extent of disease severity as indexed by NEYBOCS scores. […] Future work should use diffusion tensor imaging in conjunction with functional imaging to explore the relationship between white-matter tract disorganization and dysfunction of particular nodes within the networks responsible for habit suppression.

• #17

  https://link.springer.com/article/10.1007/s12311-018-0957-y

  In general, limited knowledge exists regarding the underlying neuronal mechanisms of SPD. […] The present study followed up on this finding and investigated whether SPD patients also show reduced cerebellar volume. […] The current study used probabilistic ROI masks with a 50% threshold. Cerebellar masks were taken from the SUIT atlas. This resulted in ten cerebellar masks for each hemisphere and an additional mask for the vermis. […] The present study identified structural and functional cerebellar abnormalities in patients with skin-picking disorder (SPD). […] This observed cerebellar activity might reflect motor-related processes required for carrying out the tasks. […] Interestingly, although SPD patients were characterized by diminished overall cerebellar activation, they displayed increased activation of the left cerebellar crus I during skin picking vs. caressing when compared with controls.

• #18

  https://link.springer.com/article/10.1007/s12311-018-0957-y

  The present study identified a specific role of crus I for skin picking because patients scores on the focused picking scale (MIDAS) were positively associated with activation in this region. […] During skin picking, SPD patients showed enhanced coupling of the left crus I with the left inferior frontal gyrus. This region belongs to the ventrolateral prefrontal cortex (VLPFC), which is central for cognitive and affective control. […] It has been argued that emotional dysregulation is one core pathological mechanism in SPD. Skin-picking has been conceptualized as a maladaptive mechanism of affect control. […] The increased cerebellum-VLPFC coupling possibly reflects increasing efforts to exert more cognitive control to counter neuronal input from the cerebellum.

• #19 Excoriation (Skin-Picking) Disorder | Abnormal Psychology

  https://courses.lumenlearning.com/wm-abnormalpsych/chapter/excoriation-skin-picking-disorder/

  Excoriation disorder is an obsessive-compulsive spectrum disorder that is characterized by the repeated urge or impulse to pick at ones own skin to the extent that either psychological or physical damage is caused. […] A common hypothesis is that excoriation disorder is often a coping mechanism to deal with elevated levels of turmoil, arousal, or stress within the individual, and that the individual has an impaired stress response. […] Studies have shown a linkage between dopamine and the urge to pick. […] Thus, excoriation disorder could result from a dysfunction in the dopamine reward functions. […] There may be another neurological explanation for excoriation disorder: individuals with the condition have less motor-inhibitory control, but show no sign of difference in cognitive flexibility, when compared to individuals without the condition. […] The impairment of motor-inhibitory control is similar to the neurological conditions of those who have problems suppressing inappropriate behaviors, such as abusing methamphetamine.

• #20 Excoriation disorder – Wikipedia

  https://en.wikipedia.org/wiki/Excoriation_disorder

  Studies have shown a linkage between dopamine and the urge to pick. Drugs such as cocaine and methamphetamine, which increase the pharmacological effects of dopamine, have been shown to cause uncontrollable picking in users. […] Thus, excoriation disorder could result from a dysfunction in the dopamine reward functions. […] There may be another neurological explanation for excoriation disorder: individuals with the condition have less motor-inhibitory control, but show no sign of a difference in cognitive flexibility when compared to individuals without the condition. Motor-inhibitory control is a function of the right-lateralized frontostriatal circuit, which includes the right inferior frontal and bilateral anterior cingulate cortices. The impairment of motor-inhibitory control is similar to the neurological conditions of those who have problems suppressing inappropriate behaviors, and it has been suggested by at least one study that this may be similar to the mechanisms of substance use disorder.

• #21 Excoriation Disorder DSM-5 698.4 (L98.1)

  https://www.theravive.com/therapedia/excoriation-disorder-dsm–5-698.4-(l98.1)

  Dopamine is felt to be involved in skin-picking, although there have as yet been no studies of brain imaging or function. […] In comparison to control subjects, excoriation disorder patients show impaired motor inhibitory control, which is mediated by a frontostriatal circuit that links the right inferior frontal cortex and both anterior cingulate gyri; the circuit is involved in the suppression of inappropriate behaviors, and such motor inhibition is impaired in methamphetamine users (Odlaug and Grant, 2010).

• #22

  https://www.termedia.pl/Exploring-skin-picking-disorder-aetiology-treatment-r-nand-future-directions,7,54674,1,1.html

  Additionally, alterations in the serotonin system have been witnessed in studies of SPD, given the involvement of serotonin in impulse control, mood regulation, and anxiety. Reduced serotonin levels or dysregulation of serotonin receptors may contribute to the compulsive and repetitive nature of skin picking behaviours. […] Psychological theories offer valuable insights into the development and continuation of skin picking disorder, highlighting the role of cognitive, emotional, and behavioural factors. Cognitive-behavioural models propose that maladaptive beliefs and cognitive biases contribute to the initiation and perpetuation of skin picking behaviours. For example, individuals with SPD may hold beliefs about the effectiveness of skin picking in relieving distress or achieving a sense of control, reinforcing the behaviour over time.

• #23 Use of Topiramate in Skin-Picking Disorder: A Pilot Study

  https://www.psychiatrist.com/pcc/topiramate-in-skin-picking-disorder/

  Topiramate modulation of -aminobutyric acid (GABA)-ergic neurotransmitters in addition to sodium and calcium channels has elicited interest that it might be a useful agent for treating skin-picking disorder. […] Multiple lines of evidence have suggested glutamatergic dysfunction in the pathophysiology of the obsessive-compulsive spectrum and efficacy of glutamatergic metabolites in the treatment of repetitive and compulsive disorders. […] Dysfunction in the dopamine reward pathway has also been speculated as a possible cause of skin picking since dopamine agonist drugs such as cocaine and methamphetamine have been associated with an uncontrollable urge to pick the skin among users. […] Topiramate (2,3:4,5-bis-O-[1-methylethylidene]–d-fructopyranose sulfamate) exerts inhibitory effects on neuronal excitability and enhances GABAergic neurotransmitters by increasing GABA-mediated chloride influx through GABAA receptors. […] Additional studies are needed to elucidate more clearly the basic mechanistic processes that underlie topiramate efficacy.

• #24

  https://link.springer.com/article/10.1007/s40263-019-00621-7

  Skin-picking disorder, also known as excoriation disorder or psychogenic skin excoriations, is an obsessive-compulsive and related disorder that is classified with other body-focused repetitive-behavior disorders in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). […] Various pharmacological interventions have also been described to treat this condition in case reports and open and controlled trials. Specific classes of agents implemented include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors, antipsychotics, and glutaminergic-modulating agents. SSRIs and N-acetylcysteine have been shown to be the most effective of the pharmacological interventions. […] A potential neurobiological underpinning of the efficacy of pharmacotherapy in impulse control disorders. […] Glutamate abnormalities in obsessive-compulsive disorder: neurobiology, pathophysiology and treatment. […] A selective review of glutamate pharmacological therapy in obsessive compulsive and related disorders. […] Glutamatergic agents for OCD and related disorders.

• #25 Excoriation disorder – Wikipedia

  https://en.wikipedia.org/wiki/Excoriation_disorder

  Studies have shown a linkage between dopamine and the urge to pick. Drugs such as cocaine and methamphetamine, which increase the pharmacological effects of dopamine, have been shown to cause uncontrollable picking in users. […] Thus, excoriation disorder could result from a dysfunction in the dopamine reward functions. […] There may be another neurological explanation for excoriation disorder: individuals with the condition have less motor-inhibitory control, but show no sign of a difference in cognitive flexibility when compared to individuals without the condition. Motor-inhibitory control is a function of the right-lateralized frontostriatal circuit, which includes the right inferior frontal and bilateral anterior cingulate cortices. The impairment of motor-inhibitory control is similar to the neurological conditions of those who have problems suppressing inappropriate behaviors, and it has been suggested by at least one study that this may be similar to the mechanisms of substance use disorder.

• #26 Excoriation disorder – Wikipedia

  https://en.wikipedia.org/wiki/Excoriation_disorder

  Studies have shown a linkage between dopamine and the urge to pick. Drugs such as cocaine and methamphetamine, which increase the pharmacological effects of dopamine, have been shown to cause uncontrollable picking in users. […] Thus, excoriation disorder could result from a dysfunction in the dopamine reward functions. […] There may be another neurological explanation for excoriation disorder: individuals with the condition have less motor-inhibitory control, but show no sign of a difference in cognitive flexibility when compared to individuals without the condition. Motor-inhibitory control is a function of the right-lateralized frontostriatal circuit, which includes the right inferior frontal and bilateral anterior cingulate cortices. The impairment of motor-inhibitory control is similar to the neurological conditions of those who have problems suppressing inappropriate behaviors, and it has been suggested by at least one study that this may be similar to the mechanisms of substance use disorder.

• #27 Excoriation (Skin-Picking) Disorder | Abnormal Psychology

  https://courses.lumenlearning.com/wm-abnormalpsych/chapter/excoriation-skin-picking-disorder/

  Excoriation disorder is an obsessive-compulsive spectrum disorder that is characterized by the repeated urge or impulse to pick at ones own skin to the extent that either psychological or physical damage is caused. […] A common hypothesis is that excoriation disorder is often a coping mechanism to deal with elevated levels of turmoil, arousal, or stress within the individual, and that the individual has an impaired stress response. […] Studies have shown a linkage between dopamine and the urge to pick. […] Thus, excoriation disorder could result from a dysfunction in the dopamine reward functions. […] There may be another neurological explanation for excoriation disorder: individuals with the condition have less motor-inhibitory control, but show no sign of difference in cognitive flexibility, when compared to individuals without the condition. […] The impairment of motor-inhibitory control is similar to the neurological conditions of those who have problems suppressing inappropriate behaviors, such as abusing methamphetamine.

• #28 Brain mechanisms for processing caress-like touch in skin-picking disorder

  https://pmc.ncbi.nlm.nih.gov/articles/PMC10786990/

  Skin-picking disorder (SPD) is characterized by repetitive touching and picking of ones skin. The picking is typically experienced as pleasant although this behavior leads to tissue damage. The present functional magnetic resonance imaging (fMRI) study investigated how individuals with SPD react to caress-like touch, which stimulates C-tactile afferents. […] Relative to healthy controls, patients with SPD showed greater activation in parietal regions (supramarginal/angular gyrus) during CT-optimal touch. Moreover, the deactivation of the middle/ inferior frontal cortex displayed by control participants was absent in the SPD group. […] The mentioned frontal and parietal brain regions are sources of attentional control. They are involved in integrating somatosensory information and switching attention between external/internal stimuli.

• #29 Brain mechanisms for processing caress-like touch in skin-picking disorder

  https://pmc.ncbi.nlm.nih.gov/articles/PMC10786990/

  Skin-picking disorder (SPD) is characterized by repetitive touching and picking of ones skin. The picking is typically experienced as pleasant although this behavior leads to tissue damage. The present functional magnetic resonance imaging (fMRI) study investigated how individuals with SPD react to caress-like touch, which stimulates C-tactile afferents. […] Relative to healthy controls, patients with SPD showed greater activation in parietal regions (supramarginal/angular gyrus) during CT-optimal touch. Moreover, the deactivation of the middle/ inferior frontal cortex displayed by control participants was absent in the SPD group. […] The mentioned frontal and parietal brain regions are sources of attentional control. They are involved in integrating somatosensory information and switching attention between external/internal stimuli.

• #30

  https://link.springer.com/article/10.1007/s12311-018-0957-y

  The present study identified a specific role of crus I for skin picking because patients scores on the focused picking scale (MIDAS) were positively associated with activation in this region. […] During skin picking, SPD patients showed enhanced coupling of the left crus I with the left inferior frontal gyrus. This region belongs to the ventrolateral prefrontal cortex (VLPFC), which is central for cognitive and affective control. […] It has been argued that emotional dysregulation is one core pathological mechanism in SPD. Skin-picking has been conceptualized as a maladaptive mechanism of affect control. […] The increased cerebellum-VLPFC coupling possibly reflects increasing efforts to exert more cognitive control to counter neuronal input from the cerebellum.

• #31

  https://www.termedia.pl/Exploring-skin-picking-disorder-aetiology-treatment-r-nand-future-directions,7,54674,1,1.html

  Additionally, alterations in the serotonin system have been witnessed in studies of SPD, given the involvement of serotonin in impulse control, mood regulation, and anxiety. Reduced serotonin levels or dysregulation of serotonin receptors may contribute to the compulsive and repetitive nature of skin picking behaviours. […] Psychological theories offer valuable insights into the development and continuation of skin picking disorder, highlighting the role of cognitive, emotional, and behavioural factors. Cognitive-behavioural models propose that maladaptive beliefs and cognitive biases contribute to the initiation and perpetuation of skin picking behaviours. For example, individuals with SPD may hold beliefs about the effectiveness of skin picking in relieving distress or achieving a sense of control, reinforcing the behaviour over time.

• #32 Excoriation Disorder: Assessment, Diagnosis and Treatment – The Professional Counselor

  https://tpcjournal.nbcc.org/excoriation-disorder-assessment-diagnosis-and-treatment/

  Another common theory regarding the onset and maintenance of excoriation disorder is that skin picking behaviors can help regulate emotions and can become a behaviorally-reinforced coping mechanism used to manage elevated levels of anxiety, stress and arousal. Individuals who skin pick often display elevated stress responses to normal stimuli, and skin picking appears to temporarily soothe such stress. Additionally, obsessive thoughts about skin imperfections and anxiety over not picking can be temporarily relieved by completing the behaviors. As such, there is a behavioral component in addition to the genetic and biological components of the disorder that must be considered when understanding the etiology, assessment, diagnosis and treatment of excoriation disorder.

• #33 Excoriation Disorder: Assessment, Diagnosis and Treatment – The Professional Counselor

  https://tpcjournal.nbcc.org/excoriation-disorder-assessment-diagnosis-and-treatment/

  In terms of psychological factors, skin picking behaviors help regulate uncomfortable emotions and can become a behaviorally-reinforced coping mechanism used to manage negative feelings. Some researchers suggest that excoriation disorder is rooted in higher levels of emotional impulsivity and that this characteristic supports and encourages the development of the disorder. Those with excoriation disorder experience obsessive thoughts about skin picking and engage in more impulsive, sensation-seeking behaviors (e.g., picking, rubbing) than those without the disorder. Those with excoriation disorder often have a greater difficulty with response inhibition and an increased difficulty suppressing an already initiated response as compared to control participants. For example, it might be more difficult for those with excoriation disorder to retract their hand if they already started reaching for an object to use to excoriate. This elevated level of impulsivity may be rooted in brain abnormalities; however, further research is necessary to clearly establish this connection.

• #34 Excoriation Disorder: Assessment, Diagnosis and Treatment – The Professional Counselor

  https://tpcjournal.nbcc.org/excoriation-disorder-assessment-diagnosis-and-treatment/

  Another common theory regarding the onset and maintenance of excoriation disorder is that skin picking behaviors can help regulate emotions and can become a behaviorally-reinforced coping mechanism used to manage elevated levels of anxiety, stress and arousal. Individuals who skin pick often display elevated stress responses to normal stimuli, and skin picking appears to temporarily soothe such stress. Additionally, obsessive thoughts about skin imperfections and anxiety over not picking can be temporarily relieved by completing the behaviors. As such, there is a behavioral component in addition to the genetic and biological components of the disorder that must be considered when understanding the etiology, assessment, diagnosis and treatment of excoriation disorder.

• #35 Excoriation Disorder: Assessment, Diagnosis and Treatment – The Professional Counselor

  https://tpcjournal.nbcc.org/excoriation-disorder-assessment-diagnosis-and-treatment/

  Another common theory regarding the onset and maintenance of excoriation disorder is that skin picking behaviors can help regulate emotions and can become a behaviorally-reinforced coping mechanism used to manage elevated levels of anxiety, stress and arousal. Individuals who skin pick often display elevated stress responses to normal stimuli, and skin picking appears to temporarily soothe such stress. Additionally, obsessive thoughts about skin imperfections and anxiety over not picking can be temporarily relieved by completing the behaviors. As such, there is a behavioral component in addition to the genetic and biological components of the disorder that must be considered when understanding the etiology, assessment, diagnosis and treatment of excoriation disorder.

• #36 Pathological Skin Picking: Phenomenology and Associations With Emotions, Self-Esteem, Body Image, and Subjective Physical Well-Being

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8549828/

  Literature suggests that skin picking often occurs in reaction to negative emotions as it usually provides short-term relief of tension, but during and after the skin picking episode, negative states like shame, guilt, and pain seem to increase. […] Overall, the findings suggest that individuals with PSP suffer from a lower self-esteem and experience body image disturbances independent of depressive symptoms. The association between skin damage and body image disturbances may be a first hint that PSP caused skin damage may contribute to body image disturbances. […] However, beyond that, the study cannot make any statement about the causality of this relationship. […] Overall, the results provide evidence of a strong association between PSP severity and body image disturbances and support the idea that body image problems, but also self-esteem are important aspects to include in therapeutic interventions.

• #37

  https://www.termedia.pl/Exploring-skin-picking-disorder-aetiology-treatment-r-nand-future-directions,7,54674,1,1.html

  Additionally, alterations in the serotonin system have been witnessed in studies of SPD, given the involvement of serotonin in impulse control, mood regulation, and anxiety. Reduced serotonin levels or dysregulation of serotonin receptors may contribute to the compulsive and repetitive nature of skin picking behaviours. […] Psychological theories offer valuable insights into the development and continuation of skin picking disorder, highlighting the role of cognitive, emotional, and behavioural factors. Cognitive-behavioural models propose that maladaptive beliefs and cognitive biases contribute to the initiation and perpetuation of skin picking behaviours. For example, individuals with SPD may hold beliefs about the effectiveness of skin picking in relieving distress or achieving a sense of control, reinforcing the behaviour over time.

• #38 Clinical Classification of Excoriation Disorder (skin picking disorder) | OCD-UK

  https://www.ocduk.org/related-disorders/skin-picking/clinical-classification-of-skin-picking/

  Excoriation disorder is characterized by recurrent picking of one’s own skin leading to skin lesions, accompanied by unsuccessful attempts to decrease or stop the behaviour. […] The essential feature of excoriation (skin-picking) disorder is recurrent picking at one’s own skin (Criterion A). […] Criterion C indicates that skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. […] Skin picking may also be preceded or accompanied by various emotional states. Skin picking may be triggered by feelings of anxiety or boredom, may be preceded by an increasing sense of tension (either immediately before picking the skin or when attempting to resist the urge to pick), and may lead to gratification, pleasure, or a sense of relief when the skin or scab has been picked. […] Excoriation disorder is more common in individuals with obsessive-compulsive disorder (OCD) and their first-degree family members than in the general population. […] Excoriation disorder is associated with distress as well as with social and occupational impairment.

• #39 Excoriation Disorder: Assessment, Diagnosis and Treatment – The Professional Counselor

  https://tpcjournal.nbcc.org/excoriation-disorder-assessment-diagnosis-and-treatment/

  In terms of psychological factors, skin picking behaviors help regulate uncomfortable emotions and can become a behaviorally-reinforced coping mechanism used to manage negative feelings. Some researchers suggest that excoriation disorder is rooted in higher levels of emotional impulsivity and that this characteristic supports and encourages the development of the disorder. Those with excoriation disorder experience obsessive thoughts about skin picking and engage in more impulsive, sensation-seeking behaviors (e.g., picking, rubbing) than those without the disorder. Those with excoriation disorder often have a greater difficulty with response inhibition and an increased difficulty suppressing an already initiated response as compared to control participants. For example, it might be more difficult for those with excoriation disorder to retract their hand if they already started reaching for an object to use to excoriate. This elevated level of impulsivity may be rooted in brain abnormalities; however, further research is necessary to clearly establish this connection.

• #40 Excoriation Disorder: Assessment, Diagnosis and Treatment – The Professional Counselor

  https://tpcjournal.nbcc.org/excoriation-disorder-assessment-diagnosis-and-treatment/

  In terms of psychological factors, skin picking behaviors help regulate uncomfortable emotions and can become a behaviorally-reinforced coping mechanism used to manage negative feelings. Some researchers suggest that excoriation disorder is rooted in higher levels of emotional impulsivity and that this characteristic supports and encourages the development of the disorder. Those with excoriation disorder experience obsessive thoughts about skin picking and engage in more impulsive, sensation-seeking behaviors (e.g., picking, rubbing) than those without the disorder. Those with excoriation disorder often have a greater difficulty with response inhibition and an increased difficulty suppressing an already initiated response as compared to control participants. For example, it might be more difficult for those with excoriation disorder to retract their hand if they already started reaching for an object to use to excoriate. This elevated level of impulsivity may be rooted in brain abnormalities; however, further research is necessary to clearly establish this connection.

• #41 Excoriation Disorder DSM-5 698.4 (L98.1)

  https://www.theravive.com/therapedia/excoriation-disorder-dsm–5-698.4-(l98.1)

  Obsessive picking at the skin has undoubtedly taken place for centuries, but the first formal description of acne excorie was published by Louis Brocq at the end of the 19th Century (Brocq, 1898). […] A growing consensus that skin excoriation could be the result of organic mental disorder (Misery et al., 2012) has led to the classification of skin picking with the obsessive-compulsive disorders. […] It has been suggested that skin-picking disorder is more like substance abuse than obsessive-compulsive disorder (Orlaug and Grant, 2010): excoriation disorder patients are disproportionately female, skin-picking is rarely driven by obsessive thoughts, many of the treatments for obsessions and compulsions do not help skin excoriation and many patients report that skin-picking is pleasurable.

• #42 Pathological Skin Picking: Phenomenology and Associations With Emotions, Self-Esteem, Body Image, and Subjective Physical Well-Being

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8549828/

  Pathological skin picking (PSP) refers to the repetitive manipulation of the skin causing wounds, scars, emotional distress, and social impairment. Skin picking disorder was first recognized as a distinct disorder in the DSM-5 and is still understudied in terms of phenomenology, etiology, and associated consequences. […] The results suggest that boredom, bodily tension and strong negative feelings often precede PSP episodes. During the episode most individuals seem to experience a loss of control, trance and positive feelings. After the PSP episode, shame, guilt, anger and anger toward themselves are most prominent. […] The results indicate that PSP severity is associated with a negative body image and low self-esteem, and suggest that it may be warranted to consider these aspects in the development of future interventions for PSP.

• #43 Pathological Skin Picking: Phenomenology and Associations With Emotions, Self-Esteem, Body Image, and Subjective Physical Well-Being

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8549828/

  Pathological skin picking (PSP) refers to the repetitive manipulation of the skin causing wounds, scars, emotional distress, and social impairment. Skin picking disorder was first recognized as a distinct disorder in the DSM-5 and is still understudied in terms of phenomenology, etiology, and associated consequences. […] The results suggest that boredom, bodily tension and strong negative feelings often precede PSP episodes. During the episode most individuals seem to experience a loss of control, trance and positive feelings. After the PSP episode, shame, guilt, anger and anger toward themselves are most prominent. […] The results indicate that PSP severity is associated with a negative body image and low self-esteem, and suggest that it may be warranted to consider these aspects in the development of future interventions for PSP.

• #44 Brain mechanisms for processing caress-like touch in skin-picking disorder

  https://pmc.ncbi.nlm.nih.gov/articles/PMC10786990/

  The observed abnormalities in the attentional control network encompassed changes in localized activity (SMG, ANG, MFG, IFG), as well as connectivity (MFG-SMG; ANG-SMG). These findings illustrate that neural correlates of altered touch processing in SPD can be found both at the level of individual brain regions as well as a network level. […] The SPD group reported a greater urge to pick their skin while being gently touched and gave lower valence ratings than the control group. Moreover, an unusual correlation pattern emerged in the SPD group: greater insula activity was associated with less positive valence ratings for touch.

• #45

  https://www.termedia.pl/Exploring-skin-picking-disorder-aetiology-treatment-r-nand-future-directions,7,54674,1,1.html

  While genetic factors contribute to individual susceptibility to SPD, the relationship between genetic predisposition and the influence of the environment remains crucial. To be more specific, environmental stressors, trauma, and learned behaviours may interact with genetic vulnerabilities to increase the likelihood of SPD developing. […] Neurobiological research has provided insights into the underlying neural circuits and neurotransmitter systems implicated in skin picking disorder. Functional neuroimaging studies show changes in brain regions responsible for impulse control, such as the prefrontal cortex and anterior cingulate cortex, among individuals with SPD. Dysfunction in these regions may contribute to difficulties in inhibiting urges to pick at the skin. […] Moreover, abnormalities in the dopaminergic and opioid systems have been identified in the pathophysiology of SPD. Dysregulation of dopamine signalling, particularly in reward-related brain regions such as the striatum, may contribute to the reinforcing properties of skin picking behaviours. Similarly, alterations in endogenous opioid release and sensitivity may underlie the pleasurable sensations experienced during skin picking, further reinforcing the behaviour.

• #46

  https://www.termedia.pl/Exploring-skin-picking-disorder-aetiology-treatment-r-nand-future-directions,7,54674,1,1.html

  While genetic factors contribute to individual susceptibility to SPD, the relationship between genetic predisposition and the influence of the environment remains crucial. To be more specific, environmental stressors, trauma, and learned behaviours may interact with genetic vulnerabilities to increase the likelihood of SPD developing. […] Neurobiological research has provided insights into the underlying neural circuits and neurotransmitter systems implicated in skin picking disorder. Functional neuroimaging studies show changes in brain regions responsible for impulse control, such as the prefrontal cortex and anterior cingulate cortex, among individuals with SPD. Dysfunction in these regions may contribute to difficulties in inhibiting urges to pick at the skin. […] Moreover, abnormalities in the dopaminergic and opioid systems have been identified in the pathophysiology of SPD. Dysregulation of dopamine signalling, particularly in reward-related brain regions such as the striatum, may contribute to the reinforcing properties of skin picking behaviours. Similarly, alterations in endogenous opioid release and sensitivity may underlie the pleasurable sensations experienced during skin picking, further reinforcing the behaviour.

• #47 Excoriation Disorder/ Dermatillomania/ Skin-picking Disorder: Symptoms, Causes, and Treatment – Los Angeles Outpatient Center

  https://laopcenter.com/mental-health/disorder/skin-picking/

  Biological factors are the factors that directly influence the development of excoriation disorder. These factors include genetics, neuroimaging, and neurotransmitter abnormalities. According to Okan Ibilolu A et al.s 2016 study A Case of Skin Picking Disorder of a Patient with a History of Childhood Abuse, published in the Archives of Neuropsychiatry Journal, individuals with a family history of excoriation disorder are more likely to develop the disorder themselves. […] Psychological factors refer to the mental and emotional aspects that may contribute to the development of excoriation disorder. These include underlying mental health issues such as anxiety, OCD, or depression, as reviewed by Murayama Ks 2020 study titled Impacts of Stressful Life Events and Traumatic Experiences on Onset of Obsessive-Compulsive Disorder, published in the Front Psychiatry Journal, traumatic experiences or stressful life events trigger the onset of excoriation disorder in some individuals. […] Therefore, combining these factors plays a role in the development of excoriation disorder. It is essential to understand that this disorder is not caused by personal weakness or character flaws but rather by a complex interplay of biological, psychological, and environmental factors.

• #48 Skin picking disorder – NHS

  https://www.nhs.uk/mental-health/conditions/skin-picking-disorder/

  Skin picking disorder is related to obsessive compulsive disorder, where the person cannot stop themselves carrying out a particular action. […] It can be triggered by: boredom, stress or anxiety, negative emotions, such as guilt or shame, skin conditions, such as acne or eczema, other blemishes that the person wants to get rid of (these may not be noticeable to other people). […] It’s sometimes called a body-focused repetitive behaviour and is similar to repetitive hair pulling disorder (trichotillomania). […] It’s also related to other obsessive compulsive disorders, such as body dysmorphic disorder, where the person is excessively preoccupied with their appearance. […] People with skin picking disorder often also have other obsessive compulsive disorders. These may require their own assessment and treatment.

• #49 Clinical Classification of Excoriation Disorder (skin picking disorder) | OCD-UK

  https://www.ocduk.org/related-disorders/skin-picking/clinical-classification-of-skin-picking/

  Excoriation disorder is characterized by recurrent picking of one’s own skin leading to skin lesions, accompanied by unsuccessful attempts to decrease or stop the behaviour. […] The essential feature of excoriation (skin-picking) disorder is recurrent picking at one’s own skin (Criterion A). […] Criterion C indicates that skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. […] Skin picking may also be preceded or accompanied by various emotional states. Skin picking may be triggered by feelings of anxiety or boredom, may be preceded by an increasing sense of tension (either immediately before picking the skin or when attempting to resist the urge to pick), and may lead to gratification, pleasure, or a sense of relief when the skin or scab has been picked. […] Excoriation disorder is more common in individuals with obsessive-compulsive disorder (OCD) and their first-degree family members than in the general population. […] Excoriation disorder is associated with distress as well as with social and occupational impairment.

• #50 Dermatillomania (Skin Picking) | Psychology Today

  https://www.psychologytoday.com/us/conditions/dermatillomania-skin-picking

  There may be a genetic component to excoriation disorder, since some people appear to have an inherited tendency to BFRBs such as skin picking and hair pulling, as well as higher-than-average rates of mood and anxiety disorders in first-degree relatives. […] Most experts believe that BFRBs are to some extent genetic; the disorders tend to run in families, and twin studies have suggested an inherited component. However, genes are likely only one potential cause of BFRBs, including excoriation disorder/dermatillomania. Other factors such as stress levels, family environment, and temperament are thought to play a role as well. […] Anxiety disorders often co-occur with dermatillomania, and episodes of anxiety whether they constitute a diagnosable disorder or not are a common trigger of skin-picking episodes.

• #51 Assessing and Treating Excoriation Disorder (Skin Picking)

  https://www.blueprint.ai/blog/assessing-and-treating-excoriation-disorder-skin-picking

  Excoriation disorder, also known as skin-picking disorder or dermatillomania, is a mental health condition that often goes overlooked and deserves more focus in clinical training. […] Although little is known about the exact cause of excoriation disorder, much of the current research has been based on previous research conducted on trichotillomania (hair-pulling disorder) Let’s examine the key elements that contribute to current theories about the onset and maintenance of this condition: […] Research suggests a genetic component to excoriation disorder, with studies indicating higher prevalence among first-degree relatives. Additionally, neurotransmitter imbalances, particularly in the dopamine system, may contribute to the compulsive nature of skin picking. […] It’s important to note that excoriation disorder often appears alongside other mental health conditions, such as anxiety disorders, mood disorders, and body dysmorphic disorder (BDD). The presence of these comorbidities can complicate the clinical picture and require a comprehensive treatment approach that addresses both the skin-picking behaviors and the underlying psychological factors.

• #52 Skin Picking Disorder Test (Dermatillomania)

  https://peachtreewellnessmh.com/online-mental-health-assessments/skin-picking-disorder-test/

  Genetic Predisposition: Family studies indicate a potential hereditary component, with higher rates of skin picking and related disorders among first-degree relatives of affected individuals. This suggests a genetic vulnerability that may increase risk when combined with environmental triggers. […] Psychological Factors: Perfectionism, anxiety sensitivity, and body-focused awareness often underlie picking behaviors. Many individuals report that skin picking temporarily reduces negative emotions, creating a reinforcement cycle that strengthens the behavior pattern over time. The disorder may function as a maladaptive self-soothing mechanism or emotion regulation strategy. […] Comorbid Conditions: Excoriation Disorder frequently co-occurs with other mental health conditions, including anxiety disorders, depression, OCD, body dysmorphic disorder, and trichotillomania. These conditions may share underlying mechanisms and can exacerbate skin picking behaviors.

• #53 SciELO Brazil – A skin-picking disorder case report: a psychopathological explanation A skin-picking disorder case report: a psychopathological explanation

  https://www.scielo.br/j/jbpsiq/a/483STJ4WyQhJr5St4Bdcd3B/

  Skin picking disorder (SPD) is characterized by repetitive and compulsive picking of skin, leading to tissue damage. […] Although documented in medical literature since the 19th century, only recently changed from being considered a residual diagnosis related to impulse control to a listed diagnosis in the range of the obsessive-compulsive disorders. […] SPD is often a diagnosis of exclusion, and the differential diagnosis of self-inflicted skin lesions can be separated between purely medical aetiologies, purely psychiatric aetiologies and a combination of both. […] Possible medical sequelae include infections, lesions, scarring, and serious physical disfigurement. […] Psychiatric comorbidity comprise different disorders such as depression, anxiety, substance abuse, mood disorders, OCD and trichotillomania.

• #54 Is Skin Picking Disorder Related to OCD? (Excoriation Explained) – Therapy & Counseling for OCD & Eating Disorders

  https://kimberleyquinlan-lmft.com/ocd-and-skin-picking/

  Research figures highlight that 28% of those with BDD also have excoriation or skin-picking disorder. […] The urge to pick may be an obsessive-compulsive behavior but it is not, in isolation, a symptom of OCD. […] While people with dermatillomania may not want to stop picking their skin, they don’t like the consequences of doing so and they feel very controlled by these urges. […] It’s because it can be psychologically and emotionally difficult to manage day-to-day life. […] Both OCD and excoriation disorder together or separately can be treated effectively. […] As with OCD, CBT has been shown to be effective at treating excoriation disorder by helping to change how their relationship and response to stressful or overly emotional situations. More specifically, a technique called habit reversal training is used to help identify what causes these urges and develop alternative, less harmful behaviors.

• #55 Skin Picking Disorder Test (Dermatillomania)

  https://peachtreewellnessmh.com/online-mental-health-assessments/skin-picking-disorder-test/

  Genetic Predisposition: Family studies indicate a potential hereditary component, with higher rates of skin picking and related disorders among first-degree relatives of affected individuals. This suggests a genetic vulnerability that may increase risk when combined with environmental triggers. […] Psychological Factors: Perfectionism, anxiety sensitivity, and body-focused awareness often underlie picking behaviors. Many individuals report that skin picking temporarily reduces negative emotions, creating a reinforcement cycle that strengthens the behavior pattern over time. The disorder may function as a maladaptive self-soothing mechanism or emotion regulation strategy. […] Comorbid Conditions: Excoriation Disorder frequently co-occurs with other mental health conditions, including anxiety disorders, depression, OCD, body dysmorphic disorder, and trichotillomania. These conditions may share underlying mechanisms and can exacerbate skin picking behaviors.

• #56 Skin Picking | Excoriation | BFRB

  https://www.bfrb.org/skin-picking

  Skin picking disorder is currently classified as Obsessive-Compulsive and Related Disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). […] Due to the nature of skin picking, it is important to consider whether the behavior is characteristic of excoriation disorder or whether it is better accounted for by another psychiatric disorder which warrants treatment. […] Comprehensive evaluation and accurate diagnosis is important in determining an appropriate treatment plan. […] Medical complications as a result of skin picking disorder are not uncommon. Infection, which may require medical treatment, scabbing, open wounds, discoloration, scarring, or disfigurement are possible consequences of chronic skin picking behavior.

• #57 SciELO Brazil – A skin-picking disorder case report: a psychopathological explanation A skin-picking disorder case report: a psychopathological explanation

  https://www.scielo.br/j/jbpsiq/a/483STJ4WyQhJr5St4Bdcd3B/

  Skin picking disorder (SPD) is characterized by repetitive and compulsive picking of skin, leading to tissue damage. […] Although documented in medical literature since the 19th century, only recently changed from being considered a residual diagnosis related to impulse control to a listed diagnosis in the range of the obsessive-compulsive disorders. […] SPD is often a diagnosis of exclusion, and the differential diagnosis of self-inflicted skin lesions can be separated between purely medical aetiologies, purely psychiatric aetiologies and a combination of both. […] Possible medical sequelae include infections, lesions, scarring, and serious physical disfigurement. […] Psychiatric comorbidity comprise different disorders such as depression, anxiety, substance abuse, mood disorders, OCD and trichotillomania.

• #58 8 Myths (And Facts) About Excoriation (Skin Picking Disorder)

  https://www.therecoveryvillage.com/mental-health/excoriation/skin-picking-myths/

  It is the picking that causes skin problems, not skin problems that cause the picking. […] Skin picking disorder is a serious impediment to good mental health and normal life function, and is associated with a number of other serious conditions. […] Skin picking disorder has been associated with some serious issues, such as low self-esteem, depression, anxiety, poor body image, poor general health, poor sleep (due to picking), and decreased immune function. […] The most effective way to address excoriation disorder is to start with a comprehensive assessment to identify the underlying causes (such as past traumas, etc.) and any co-occurring disorders (such as depression and substance use disorders). Treatment involves designing a personalized holistic treatment program that addresses the underlying and co-occurring problems, especially the obsessive-compulsive and anxiety components of the disorder. […] Psychological therapy with techniques such as cognitive behavioral therapy (CBT), and pharmacological therapy with anti-depressant/anti-anxiety medications such as SSRIs, are the mainstays of treating excoriation.

• #59 Pathological Skin Picking: Phenomenology and Associations With Emotions, Self-Esteem, Body Image, and Subjective Physical Well-Being

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8549828/

  Pathological skin picking (PSP) refers to the repetitive manipulation of the skin causing wounds, scars, emotional distress, and social impairment. Skin picking disorder was first recognized as a distinct disorder in the DSM-5 and is still understudied in terms of phenomenology, etiology, and associated consequences. […] The results suggest that boredom, bodily tension and strong negative feelings often precede PSP episodes. During the episode most individuals seem to experience a loss of control, trance and positive feelings. After the PSP episode, shame, guilt, anger and anger toward themselves are most prominent. […] The results indicate that PSP severity is associated with a negative body image and low self-esteem, and suggest that it may be warranted to consider these aspects in the development of future interventions for PSP.

• #60 Pathological Skin Picking: Phenomenology and Associations With Emotions, Self-Esteem, Body Image, and Subjective Physical Well-Being

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8549828/

  Literature suggests that skin picking often occurs in reaction to negative emotions as it usually provides short-term relief of tension, but during and after the skin picking episode, negative states like shame, guilt, and pain seem to increase. […] Overall, the findings suggest that individuals with PSP suffer from a lower self-esteem and experience body image disturbances independent of depressive symptoms. The association between skin damage and body image disturbances may be a first hint that PSP caused skin damage may contribute to body image disturbances. […] However, beyond that, the study cannot make any statement about the causality of this relationship. […] Overall, the results provide evidence of a strong association between PSP severity and body image disturbances and support the idea that body image problems, but also self-esteem are important aspects to include in therapeutic interventions.

• #61 Excoriation (skin-picking) disorder: a systematic review of treatment | NDT

  https://www.dovepress.com/excoriation-skin-picking-disorder-a-systematic-review-of-treatment-opt-peer-reviewed-fulltext-article-NDT

  Excoriation (skin-picking) disorder (ED), also known as dermatillomania, psychogenic excoriation, or neurotic excoriation, is characterized by recurrent picking of skin, leading to skin lesions and significant distress or functional impairment. […] In terms of treatment, there is a paucity of data. Nevertheless, management currently relies on a comprehensive psychiatric examination, behavioral therapy, and medication. […] A significant benefit for nonpharmacological treatments, such as cognitive-behavioral therapy (CBT) and habit reversal therapy (HRT), in ED has been suggested. […] Cognitive-behavioral interventions for ED may also be useful when presented in a self-help format that patients access themselves. […] In the last decade or two, the efficacy and tolerability of a number of pharmacological agents have been tested in ED, with studies including selective serotonin reuptake inhibitors (SSRIs), lamotrigine, glutamatergic agents such as N-acetyl cysteine (NAC) and riluzole, and opioid antagonists such as naltrexone. […] SSRIs have been a mainstay of pharmacotherapy, but there is now evidence from a RCT that NAC should also be considered as a potential intervention.

• #62 Excoriation (Skin Picking) Disorder – Center for OCD and Related Disorders

  https://mghocd.org/excoriation/

  The most distinguishing symptom of Excoriation (Skin Picking) Disorder (SPD) is the recurrent picking of one’s skin resulting in noticeable skin damage. […] SPD shares many features with other body-focused repetitive behaviors, such as trichotillomania (hair pulling disorder) or pathological nail biting. […] Research exploring the efficacy of psychopharmacological interventions in the treatment of skin picking disorder is limited and few randomized control trials exist. […] While the mechanism of action in skin picking is not well understood, it has been postulated that the SSRIs may reduce skin picking by targeting triggers like anxiety or depression. […] Dr. Keuthen has extensive research experience studying skin picking. She developed several self-report scales to assess picking severity and impact, studied the efficacy of medication treatment for skin picking and documented prevalence rates for this disorder. […] Our mission involves the provision of state-of-the-art, empirically-based treatments for skin picking symptoms and the alleviation of suffering.

• #63

  https://link.springer.com/article/10.1007/s40263-019-00621-7

  Skin-picking disorder, also known as excoriation disorder or psychogenic skin excoriations, is an obsessive-compulsive and related disorder that is classified with other body-focused repetitive-behavior disorders in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). […] Various pharmacological interventions have also been described to treat this condition in case reports and open and controlled trials. Specific classes of agents implemented include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors, antipsychotics, and glutaminergic-modulating agents. SSRIs and N-acetylcysteine have been shown to be the most effective of the pharmacological interventions. […] A potential neurobiological underpinning of the efficacy of pharmacotherapy in impulse control disorders. […] Glutamate abnormalities in obsessive-compulsive disorder: neurobiology, pathophysiology and treatment. […] A selective review of glutamate pharmacological therapy in obsessive compulsive and related disorders. […] Glutamatergic agents for OCD and related disorders.

• #64 Antioxidant Therapies for Ulcerative Dermatitis: A Potential Model for Skin Picking Disorder | PLOS One

  https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0132092

  Skin Picking Disorder affects 4% of the general population, with serious quality of life impacts, and potentially life threatening complications. […] We have proposed mouse Ulcerative Dermatitis as a model for human Skin Picking Disorder based on similar epidemiology, behavior, and its comorbidity and mechanistic overlap with hair pulling (trichotillomania). […] These findings lend additional support for mouse Ulcerative Dermatitis as a model of Skin Picking Disorder and also support oxidative stress and glutathione synthesis as the mechanism of action for these compounds. […] Although the mode of action is unclear, trichotillomania and Skin Picking Disorder both respond to N-Acetylcysteine (NAC). […] Ongoing work in our lab suggests a primary role for oxidative stress in barbering and UD.

• #65 Use of Topiramate in Skin-Picking Disorder: A Pilot Study

  https://www.psychiatrist.com/pcc/topiramate-in-skin-picking-disorder/

  Topiramate modulation of -aminobutyric acid (GABA)-ergic neurotransmitters in addition to sodium and calcium channels has elicited interest that it might be a useful agent for treating skin-picking disorder. […] Multiple lines of evidence have suggested glutamatergic dysfunction in the pathophysiology of the obsessive-compulsive spectrum and efficacy of glutamatergic metabolites in the treatment of repetitive and compulsive disorders. […] Dysfunction in the dopamine reward pathway has also been speculated as a possible cause of skin picking since dopamine agonist drugs such as cocaine and methamphetamine have been associated with an uncontrollable urge to pick the skin among users. […] Topiramate (2,3:4,5-bis-O-[1-methylethylidene]–d-fructopyranose sulfamate) exerts inhibitory effects on neuronal excitability and enhances GABAergic neurotransmitters by increasing GABA-mediated chloride influx through GABAA receptors. […] Additional studies are needed to elucidate more clearly the basic mechanistic processes that underlie topiramate efficacy.

• #66 Skin Picking Disorder (Dermatillomania)

  https://www.mentalhealth.com/library/dermatillomania

  Presence of anxiety or stress – Skin picking is used by some people to cope with stressful situations. […] Experiencing negative emotions – Emotions like shame and guilt are uncomfortable to deal with, so some people might cope with these emotions by picking at their skin. […] Presence of OCD – OCD and skin picking disorder often co-occur. Hair-pulling, or trichotillomania, often co-occurs as well. […] Additionally, skin picking might be more common in people with conditions like eczema or acne. This specific type of excoriation disorder is known as acne excoriée and is far more common in women than men (as is dermatillomania as a whole). […] As previously mentioned, research indicates that skin picking disorder might be caused by an imbalance of serotonin in the brain. As a result, selective serotonin reuptake inhibitors (SSRIs) like fluoxetine, escitalopram, and fluvoxamine might be prescribed to help patients manage their symptoms.

• #67 Skin Picking Disorder (Dermatillomania)

  https://www.mentalhealth.com/library/dermatillomania

  In particular, SSRIs help reduce obsessions and compulsions, which can help mitigate skin picking behaviors. […] Another class of medications that might be prescribed to treat this condition is anticonvulsants. Anti-seizure medications like lamotrigine have shown promise for treating skin picking disorder. […] Cognitive behavioral therapy is the most common treatment for skin picking disorder. CBT is a short-term therapy that focuses on a primary problem. During treatment, you and your therapist work to identify maladaptive patterns of thinking that lead to undesirable behavior, in this case, skin picking. […] As with most mental health conditions, treating skin picking disorder is often most effective when therapy and medications are combined.

• #68 Assessing and Treating Excoriation Disorder (Skin Picking)

  https://www.blueprint.ai/blog/assessing-and-treating-excoriation-disorder-skin-picking

  The act of picking might offer temporary relief or a feeling of control, reinforcing the behavior over time. In some cases, skin picking becomes an automatic response to tension or discomfort, occurring almost unconsciously. […] Treating excoriation disorder involves addressing the psychological, behavioral, and emotional factors contributing to the condition. A combination of evidence-based therapies, medication, and self-help strategies can effectively reduce skin-picking behaviors and improve overall well-being. […] Cognitive behavioral therapy (CBT) serves as the main psychological intervention for excoriation disorder. CBT focuses on identifying and modifying the thoughts, beliefs, and behaviors that perpetuate skin picking. […] Dialectical behavior therapy (DBT) also offers an effective treatment approach for excoriation disorder. DBT emphasizes emotion regulation, distress tolerance, and mindfulness skills to help individuals manage the intense emotions and impulsivity associated with skin picking.

• #69 Skin-Picking Disorder Is Even Harder to Manage During the Coronavirus Pandemic | SELF

  https://www.self.com/story/skin-picking-disorder-coronavirus

  Experts arent sure why some people develop dermatillomania and others dont, though there does seem to be a genetic component, Santner says. […] According to the TLC Foundation, other diagnostic criteria for skin-picking disorder include repeated attempts to stop picking, picking intensely enough that it causes damage to the skin, and the symptoms not having another cause, like substance use or a different mental health disorder. […] A specific form of cognitive behavioral therapy called habit reversal training (HRT) is a mainstay of treatment. […] Theres also a type of treatment known as the comprehensive behavioral (ComB) model, where people use the term SCAMP (Sensory, Cognitive, Affective, Motor, Place) to understand what makes them pick and find strategies to stoplike using a fidget toy or journaling for anxiety. […] Experts arent yet sure enough of the neurological mechanisms involved with BFRBs to know the best medication to treat them overall.

• #70 Assessing and Treating Excoriation Disorder (Skin Picking)

  https://www.blueprint.ai/blog/assessing-and-treating-excoriation-disorder-skin-picking

  The act of picking might offer temporary relief or a feeling of control, reinforcing the behavior over time. In some cases, skin picking becomes an automatic response to tension or discomfort, occurring almost unconsciously. […] Treating excoriation disorder involves addressing the psychological, behavioral, and emotional factors contributing to the condition. A combination of evidence-based therapies, medication, and self-help strategies can effectively reduce skin-picking behaviors and improve overall well-being. […] Cognitive behavioral therapy (CBT) serves as the main psychological intervention for excoriation disorder. CBT focuses on identifying and modifying the thoughts, beliefs, and behaviors that perpetuate skin picking. […] Dialectical behavior therapy (DBT) also offers an effective treatment approach for excoriation disorder. DBT emphasizes emotion regulation, distress tolerance, and mindfulness skills to help individuals manage the intense emotions and impulsivity associated with skin picking.

• #71 Assessing and Treating Excoriation Disorder (Skin Picking)

  https://www.blueprint.ai/blog/assessing-and-treating-excoriation-disorder-skin-picking

  Alternative therapies can complement traditional treatment approaches for excoriation disorder. Mindfulness-based stress reduction (MBSR) and acceptance and commitment therapy (ACT) teach individuals to observe their thoughts and emotions without judgment, promoting a greater sense of self-awareness and acceptance.

• #72

  https://www.termedia.pl/Exploring-skin-picking-disorder-aetiology-treatment-r-nand-future-directions,7,54674,1,1.html

  Overall, a multifactorial model incorporating genetic, neurobiological, and psychological factors is likely involved in the aetiology and pathophysiology of skin picking disorder. Understanding these underlying mechanisms is essential for the development of effective interventions and treatments that address the complex interplay of factors contributing to SPD.

• #73 Skin Picking Disorder Test (Dermatillomania)

  https://peachtreewellnessmh.com/online-mental-health-assessments/skin-picking-disorder-test/

  Understanding the multifaceted nature of Excoriation Disorder is essential for developing comprehensive treatment approaches. […] At Peachtree Wellness Solutions, we recognize that each individual’s experience with skin picking is unique, influenced by their specific combination of biological vulnerabilities, psychological factors, and environmental circumstances. […] This understanding informs our mental health treatment programs aimed at addressing not just the picking behaviors but the underlying factors that maintain them.

• #74

  https://www.termedia.pl/Exploring-skin-picking-disorder-aetiology-treatment-r-nand-future-directions,7,54674,1,1.html

  Overall, a multifactorial model incorporating genetic, neurobiological, and psychological factors is likely involved in the aetiology and pathophysiology of skin picking disorder. Understanding these underlying mechanisms is essential for the development of effective interventions and treatments that address the complex interplay of factors contributing to SPD.

• #75 White Matter Abnormalities in Skin Picking Disorder: A Diffusion Tensor Imaging Study | Neuropsychopharmacology

  https://www.nature.com/articles/npp2012241

  The current data implicate disconnectivity in white-matter tracts connecting neural regions involved in motor generation and suppression. […] These findings add considerable support to the notion that in addition to the phenomenological and comorbid overlap between SPD and trichotillomania, these disorders likely share overlapping neurobiology. […] The key finding was that SPD was associated with reduced integrity of distributed white-matter tracts connecting the anterior cingulate cortices to other neural nodes bilaterally. […] The FA abnormalities in SPD appeared unrelated to the extent of disease severity as indexed by NEYBOCS scores. […] Future work should use diffusion tensor imaging in conjunction with functional imaging to explore the relationship between white-matter tract disorganization and dysfunction of particular nodes within the networks responsible for habit suppression.

• #76

  https://www.termedia.pl/Exploring-skin-picking-disorder-aetiology-treatment-r-nand-future-directions,7,54674,1,1.html

  Additionally, alterations in the serotonin system have been witnessed in studies of SPD, given the involvement of serotonin in impulse control, mood regulation, and anxiety. Reduced serotonin levels or dysregulation of serotonin receptors may contribute to the compulsive and repetitive nature of skin picking behaviours. […] Psychological theories offer valuable insights into the development and continuation of skin picking disorder, highlighting the role of cognitive, emotional, and behavioural factors. Cognitive-behavioural models propose that maladaptive beliefs and cognitive biases contribute to the initiation and perpetuation of skin picking behaviours. For example, individuals with SPD may hold beliefs about the effectiveness of skin picking in relieving distress or achieving a sense of control, reinforcing the behaviour over time.

• #77 Excoriation disorder – Wikipedia

  https://en.wikipedia.org/wiki/Excoriation_disorder

  Studies have shown a linkage between dopamine and the urge to pick. Drugs such as cocaine and methamphetamine, which increase the pharmacological effects of dopamine, have been shown to cause uncontrollable picking in users. […] Thus, excoriation disorder could result from a dysfunction in the dopamine reward functions. […] There may be another neurological explanation for excoriation disorder: individuals with the condition have less motor-inhibitory control, but show no sign of a difference in cognitive flexibility when compared to individuals without the condition. Motor-inhibitory control is a function of the right-lateralized frontostriatal circuit, which includes the right inferior frontal and bilateral anterior cingulate cortices. The impairment of motor-inhibitory control is similar to the neurological conditions of those who have problems suppressing inappropriate behaviors, and it has been suggested by at least one study that this may be similar to the mechanisms of substance use disorder.

• #78 Brain mechanisms for processing caress-like touch in skin-picking disorder

  https://pmc.ncbi.nlm.nih.gov/articles/PMC10786990/

  Skin-picking disorder (SPD) is characterized by repetitive touching and picking of ones skin. The picking is typically experienced as pleasant although this behavior leads to tissue damage. The present functional magnetic resonance imaging (fMRI) study investigated how individuals with SPD react to caress-like touch, which stimulates C-tactile afferents. […] Relative to healthy controls, patients with SPD showed greater activation in parietal regions (supramarginal/angular gyrus) during CT-optimal touch. Moreover, the deactivation of the middle/ inferior frontal cortex displayed by control participants was absent in the SPD group. […] The mentioned frontal and parietal brain regions are sources of attentional control. They are involved in integrating somatosensory information and switching attention between external/internal stimuli.

• #79

  https://link.springer.com/article/10.1007/s12311-018-0957-y

  The present study identified a specific role of crus I for skin picking because patients scores on the focused picking scale (MIDAS) were positively associated with activation in this region. […] During skin picking, SPD patients showed enhanced coupling of the left crus I with the left inferior frontal gyrus. This region belongs to the ventrolateral prefrontal cortex (VLPFC), which is central for cognitive and affective control. […] It has been argued that emotional dysregulation is one core pathological mechanism in SPD. Skin-picking has been conceptualized as a maladaptive mechanism of affect control. […] The increased cerebellum-VLPFC coupling possibly reflects increasing efforts to exert more cognitive control to counter neuronal input from the cerebellum.

• #80 Excoriation Disorder: Assessment, Diagnosis and Treatment – The Professional Counselor

  https://tpcjournal.nbcc.org/excoriation-disorder-assessment-diagnosis-and-treatment/

  Another common theory regarding the onset and maintenance of excoriation disorder is that skin picking behaviors can help regulate emotions and can become a behaviorally-reinforced coping mechanism used to manage elevated levels of anxiety, stress and arousal. Individuals who skin pick often display elevated stress responses to normal stimuli, and skin picking appears to temporarily soothe such stress. Additionally, obsessive thoughts about skin imperfections and anxiety over not picking can be temporarily relieved by completing the behaviors. As such, there is a behavioral component in addition to the genetic and biological components of the disorder that must be considered when understanding the etiology, assessment, diagnosis and treatment of excoriation disorder.

• #81

  https://www.termedia.pl/Exploring-skin-picking-disorder-aetiology-treatment-r-nand-future-directions,7,54674,1,1.html

  Additionally, alterations in the serotonin system have been witnessed in studies of SPD, given the involvement of serotonin in impulse control, mood regulation, and anxiety. Reduced serotonin levels or dysregulation of serotonin receptors may contribute to the compulsive and repetitive nature of skin picking behaviours. […] Psychological theories offer valuable insights into the development and continuation of skin picking disorder, highlighting the role of cognitive, emotional, and behavioural factors. Cognitive-behavioural models propose that maladaptive beliefs and cognitive biases contribute to the initiation and perpetuation of skin picking behaviours. For example, individuals with SPD may hold beliefs about the effectiveness of skin picking in relieving distress or achieving a sense of control, reinforcing the behaviour over time.

• #82 Excoriation Disorder: Assessment, Diagnosis and Treatment – The Professional Counselor

  https://tpcjournal.nbcc.org/excoriation-disorder-assessment-diagnosis-and-treatment/

  In terms of psychological factors, skin picking behaviors help regulate uncomfortable emotions and can become a behaviorally-reinforced coping mechanism used to manage negative feelings. Some researchers suggest that excoriation disorder is rooted in higher levels of emotional impulsivity and that this characteristic supports and encourages the development of the disorder. Those with excoriation disorder experience obsessive thoughts about skin picking and engage in more impulsive, sensation-seeking behaviors (e.g., picking, rubbing) than those without the disorder. Those with excoriation disorder often have a greater difficulty with response inhibition and an increased difficulty suppressing an already initiated response as compared to control participants. For example, it might be more difficult for those with excoriation disorder to retract their hand if they already started reaching for an object to use to excoriate. This elevated level of impulsivity may be rooted in brain abnormalities; however, further research is necessary to clearly establish this connection.

• #83 Pathological Skin Picking: Phenomenology and Associations With Emotions, Self-Esteem, Body Image, and Subjective Physical Well-Being

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8549828/

  Pathological skin picking (PSP) refers to the repetitive manipulation of the skin causing wounds, scars, emotional distress, and social impairment. Skin picking disorder was first recognized as a distinct disorder in the DSM-5 and is still understudied in terms of phenomenology, etiology, and associated consequences. […] The results suggest that boredom, bodily tension and strong negative feelings often precede PSP episodes. During the episode most individuals seem to experience a loss of control, trance and positive feelings. After the PSP episode, shame, guilt, anger and anger toward themselves are most prominent. […] The results indicate that PSP severity is associated with a negative body image and low self-esteem, and suggest that it may be warranted to consider these aspects in the development of future interventions for PSP.

• #84

  https://www.termedia.pl/Exploring-skin-picking-disorder-aetiology-treatment-r-nand-future-directions,7,54674,1,1.html

  Overall, a multifactorial model incorporating genetic, neurobiological, and psychological factors is likely involved in the aetiology and pathophysiology of skin picking disorder. Understanding these underlying mechanisms is essential for the development of effective interventions and treatments that address the complex interplay of factors contributing to SPD.

• #85

  https://link.springer.com/article/10.1007/s12311-018-0957-y

  The present study identified a specific role of crus I for skin picking because patients scores on the focused picking scale (MIDAS) were positively associated with activation in this region. […] During skin picking, SPD patients showed enhanced coupling of the left crus I with the left inferior frontal gyrus. This region belongs to the ventrolateral prefrontal cortex (VLPFC), which is central for cognitive and affective control. […] It has been argued that emotional dysregulation is one core pathological mechanism in SPD. Skin-picking has been conceptualized as a maladaptive mechanism of affect control. […] The increased cerebellum-VLPFC coupling possibly reflects increasing efforts to exert more cognitive control to counter neuronal input from the cerebellum.

Zobacz więcej