Posted by noa on August 1, 2003, at 11:35:48
This is goign to be long. I appreciate the patience involved in reading through the post, if you make it to the end! : - )
The ultimate question will be about medication, but let me describe the problem in detail first, along with other types of interventions that apply.
I have dermatillomania (skin picking) which is considered to be an OCD spectrum disorder. I believe that I have had it since childhood, but that it is exacerbated by one or more of my meds. Two of my siblings also seem to have it, although I think in a much milder form.
I have been working on trying to understand this behavior more, and am noticing that it seems to have several facets for me. It is a compulsive behavior. It also feels neurological, kind of the way my med-induced akithisia feels, including the RLS-like kicking. It *feels* tic-like and is extremely difficult to suppress, and when I can suppress it, it comes out later in the day. On the other hand, there are times, when it also feels somewhat habit-like.
There seem to be two modes of this behavior for me. The primary mode is kind of absentmindedly scratching and picking at my scalp or face. This occurs when I am passively engaged in something (driving, watching tv, etc.). Often, I might not notice I'm doing it (although since I started working on addressing this problem in earnest, I have been noticing it within a few seconds of initiating it). In this mode, it feels neurological, tic-like, compulsive, impulsive, as well as habit-like at times. In this mode, it seems driven both by what my hand needs to be doing(like a repetetive movement or tic), and what my skin needs to feel (stimulation, self-soothing, etc.). In this mode, it can also be less absentminded, as well, in that I sometimes tune into what I am doing and how it feels. It is calming and stimulating at the same time. The stimulation is similar to what I feel if I grab a large fistful of hair and gently and slowly tug, the way some massage therapists do. I have also been able to recreate this sensation by using the sensory integration technique of brushing the skin. In the passive activity mode, it feels like the picking behavior is soothing. It also feels like it is providing sensory input because I'm feeling understimulated in the passive activity, but also calming and soothing to shut out feeling overstimulated by stress, etc.
The other mode is one that has developed in recent years (I have always had the skin picking although I think it is exacerbated by meds, but before a few years ago, it involved only the first mode described above). It involves standing in front of the mirror, inspecting my facial skin and picking at pores, pimples, bumps, etc.--any imperfection. Over time, this mode has worsened. Sometimes, I spend hours doing this, lost in a trance-like state. It is highly compulsive and what I've been able to tune into lately is that there is a corresponding obsessive thought (I hadn't really been aware of the OCD quality of it before a few weeks ago): total preoccupation with getting rid of all textural imperfections on my skin. So, it definitly feels compulsive, like the first mode, only much moreso and more OCD-like compulsive. Of course, as the behavior has worsened in recent years, more time is lost to it, it has become much more dissociative-like, and my skin has worsened from the effects of picking at it. My skin often looks broken out, or rashy or hivey, and has small lesions and scabs. I have constantly been trying to stop the behavior and know that the picking makes the skin worse, but haven't been able to stop. In recent weeks, I've been able to do this less frequently, and sometimes to stop myself sooner in the process, and I have been able to be less agressive about it, so the apparent skin damage has decreased somewhat. I have been able to start challenging the prevailing compulsive thinking that somehow I am going to clear up the acne and clogged pores by this behavior. So, even when I slip and go into the mirror trance mode, when I stop, I look at myself in the mirror and ask, "is what you just did really going to help?" and of course, the rational answer is always emphatically "No". I am hoping that repeating this cognitive challenge will help.
Whether this second mode (mirror mode) is calming like the other mode, is hard to say, and it doesn't feel like it gives the same kind of sensory input/stimulation that the other mode does. In some ways, it might be calming because of the pseudo-dissociative trance-like thing that happens. BUT, the mirror mode is more agitating, really. It feels a bit neurological but less so than the first mode, with the OCD energy becoming more primary. Often, the passive mode behavior leads to the mirror mode behavior when I start picking at my face instead of my scalp--and in that mode, it feels more neurological, and tic-like, compulsive and impulsive. What happens is that I might be touching my face at that point, and then start getting preoccupied with what I feel on my face, and then go to the bathroom mirror, where the more compulsive/OCD aspect seems to become the primary driving force. The more I stand there going after the pores, etc., the more preoccupied I think I feel and the more pulled into the compulsive repetition I feel. It is similar to the agitated addictive feeling I felt playing hours of minesweeper and freecell (during which I also would go into a pseudo-dissociative trance-like state and lose hours of time) before I deleted all my computer games. Both behaviors feel addictive but unsatisfying, where I feel compelled to keep repeating it over and over and over.
Strategies I'm working on include some cognitive behavioral strategies like the cognitive self talk challenge I described above, and Habit Reversal Training, which I am just beginning to learn about. It basically involves substituting an alternative action that is incompatible with the disordered behavior. So, I bought a stress ball that I use it a lot in the car, but also at other times. It is interesting that I find that when I have the stress ball in my hand, my restless, anxious energy become much more apparent to the outside world---I get really fidgetty with the stress ball. But it feels good, not agitating. It is just that I usually hold all that energy in, except for the dermatillomania behaviors, and sometimes when I can get impulsively hyperverbal with people, and when I stop suppressing the akithisia and allow my leg-bouncing and other restless movements to come out.
So, now for the med questions. I have started reading about neurotransmitters and their effects on repetetive movements and self-grooming behaviors in animals. Mostly, the studies show that such behaviors can be induced or increased by administering dopamine agonists, although there seems to be a difference between D1 agonists and D2 agonists. My recall is shaky at the moment, but I think in one study the D1 agonists were induced the sterotypy but not the D2 agonists. At some point, I can post the references for anyone who is interested. Another study showed that wasp venom, which is similar to dopamine, induced a sustained period of ultra-repetitive grooming in a stung cockroach, followed by what seems like catatonia, and the authors created a similar effect (hyper grooming follwed by catatonia-like state) in the cockroach by administering a substance that causes the release of massive amounts of the cockroach's neurotransmitters until they are depleted.
I have also read a lot about how OCD spectrum problems and compulsive behaviors are successfully treated by SSRIs.
I have not found support for my idea that the serotonin-induced motor activation I do have could explain the dermatillomania.
I have read things that support the idea that stims incrase anxiety and OCD symptoms.
I was hoping it was the Effexor and not the Adderall, but it is looking like the stimulant may be the main problem.
I discussed this with my pdoc, who thinks it is the stim.
I need to try to stop caffeine intake and see if that helps at all. I also need to exercise more consistently. When I do, I notice the akithisia energy getting released somewhat, and I wonder if that would help with this problem.
My question is: what are your experiences with stims, anxiety and OCD? Has anyone found stims to increase OCD behaviors? I have heard this is so, but I would like to hear first person accounts from folks here at babble, and any other insights y'all might have.
If you've made it this far in your reading, I cannot thank you enough!!
poster:noa
thread:247350
URL: http://www.dr-bob.org/babble/20030728/msgs/247350.html