Recovery from pathological skin picking and dermatodaxia using a revised decoupling protocol

Pathological skin picking (PSP) is characterized by repetitive scratching, biting, and picking of the skin. The disorder is subsumed under the section "obsessive-compulsive and related disorders" in the DSM-5. A related body-focused repetitive disorder, which has received less empirical attention so far, is dermatophagia or dermatodaxia (eating or biting/gnawing of the skin). Habit reversal training (HRT) is regarded as the treatment of choice demonstrating improvement at a medium effect size relative to control conditions.

The present case report describes a 50-year-old man with a lifetime history of PSP and dermatodaxia of the fingertips who stopped excessive nail-biting approximately 10 years ago using a treatment method known as decoupling. Yet, his PSP and dermatodaxia remained treatment-refractory after treatment with both decoupling (conventional protocol) and HRT.

Using a revised protocol of decoupling, the man was able to fully stop PSP and dermatodaxia; only the tendency to fidget nervously with his hands remained. The case report describes the revised protocol. Scores on the Skin Picking Scale Revised (SPS-R) dropped from 15 to 0.

The revised decoupling protocol is an easy to use technique that holds promise in this underdiagnosed and undertreated condition. Yet, rigorous randomized controlled studies are needed to ascertain its efficacy.