Letters to the Editor
Olanzapine Augmentation of Fluoxetine
in the Treatment of Pathological Skin Picking
Dear Editor:
Pathological skin picking, also known as psychogenic excoriation, is characterized by excessive, stereotypic scratching or picking of normal skin or skin with minor irregularities; it leads to tissue damage and personal distress (1). Pathological skin picking is not given a formal diagnostic category in the DSM-IV, but it may be either a primary impulse-control disorder or a symptom of a mood, anxiety, or delusional disorder (2). Current literature suggests the possibility of a clinical and conceptual overlap with the impulse-control disorder trichotillomania (3). I describe the case of a geriatric patient whose pathological skin picking did not respond to various antidepressant agents, including serotonergic reuptake inhibitors, until a low dosage of olanzapine was added to her maintenance dosage of fluoxetine. Although there are case reports wherein olanzapine augmentation of fluoxetine decreased the repetitive behaviours of trichotillomania, this appears to be the first report of this combination’s dramatically improving pathological skin picking.
Case Report
Mrs A is white and aged 64 years. For the past decade, she has suffered from generalized anxiety disorder, dysthymic disorder (diagnosed according to DSM-IV criteria), and pathological skin picking. She had been followed by her primary care physician for 2 years before being referred for a psychiatric evaluation. Prior to her psychiatric evaluation, she had received adequate trials of amitriptyline and sertraline; she had also received a low dosage of a benzodiazepine (lorazepam, 1 mg twice daily). She showed modest improvement in her anxiety and depressive symptoms; however, she continued to engage in skin picking throughout the day and noted that it constituted approximately 2 to 3 hours of her total waking time.
At the time of her psychiatric evaluation, she noted that, unless a family member brought it to her attention, she was frequently unaware that she was excoriating her skin. Her scalp, the back of her neck, and her arms evidenced extensive and multiple sites of chronic excoriation that were a source of much embarrassment to her. She acknowledged that her skin picking was highly distressing but reiterated, “I don’t even know I’m doing it most of the time.” Behavioural strategies of self-monitoring and habit reversal did little to diminish the repetitive scratching activity.
To pharmacologically target the skin-picking behaviours, her sertraline was tapered and fluoxetine was initiated at 20 mg daily. Her anxiety and mood symptoms continued to be well controlled over a 12-week period, but the frequency of the interfering skin-picking behaviours was unaffected. Fluoxetine was increased to 40 mg daily and maintained at that dosage for an additional 4 weeks. The repetitive behaviours decreased slightly. Given olanzapine’s apparent effectiveness, when combined with fluoxetine, in controlling symptoms of trichotillomania (4,5), a trial of an olanzapine augmentation was performed. Olanzapine was initiated at 5 mg at night while the fluoxetine was maintained at 40 mg daily. After 2 weeks, Mrs A stated that the time given to skin picking had been reduced to about 30 minutes daily, and after 6 weeks, the behaviours were almost entirely extinguished, apart from occasional scratching of her forearm. She stated that she was much more aware of her impulse to pick at her skin and that she was able to exert a behavioural brake to the activity. She reported no significant change in her mood or anxiety symptoms since she began olanzapine augmentation. She also denied side effects to the combination treatment and continues to maintain a therapeutic response after 6 months.
In the literature, fluoxetine has been reported to be especially beneficial in reducing pathological skin-picking behaviours (6,7). With this particular patient, fluoxetine was quite effective in reducing mood and anxiety symptoms but of slight benefit in diminishing the psychogenic excoriation. To successfully treat trichotillomania, the literature clearly supports augmenting selective serotonin reuptake inhibitors, specifically fluoxetine, with olanzapine. Given the possible clinical similarities between trichotillomania and skin picking, as well as the antihistaminic and antiimpulsive properties of olanzapine (8), clinicians may find this augmentation strategy useful in treating individuals who present with this difficult-to-treat condition. This case suggests a possible role for olanzapine augmentation of fluoxetine in the treatment of individuals with comorbid mood and anxiety disorders who present with refractory skin picking.
References
1. Arnold LM, Auchenbach MB, McElroy SL. Psychogenic excoriation: clinical features, proposed diagnostic criteria and approaches to treatment. CNS Drugs 2001;15:351–9.
2. Grant JE, Phillips KA. Captive of the mirror: “I pick at my face all day, everyday.” Current Psychiatry 2003;2(12):45–52.
3. Lochner C, Simeon D, Niehaus DJ, Stein DJ. Trichotillomania and skin-picking: a phenomenolgical comparison. Depress Anxiety 2002:15(2):83–6.
4. Potenza MN, Wasylink S, Epperson CN, McDougle CJ. Olanzapine augmentation of fluoxetine in the treatement of trichotillomania. Am J Psychiatry 1998:155:1299–300.
5. Ashton AK. Olanzapine augmentation for trichotillomania. Am J Psychiatry 2001;158:1929–30.
6. Bloch MR, Elliott M, Thompson H, Koran LM. Fluoxetine in pathologic skin-picking: open-label and double-blind results. Psychosomatics 2001;42:314–9.
7. Simeon D, Stein DJ, Gross S, Islam N, Scmiedler J, Hollander E. A double-blind trial of fluoxetine in pathologic skin picking. J Clin Psychiatry 1997;58:341–7.
8. Garnis-Jones S, Collins S, Rosenthal D. Treatment of self-mutilation with olanzapine. J Cutan Med Surg 2000;4:161–3.
Richard C Christensen, MD, MA
Jacksonville, Florida
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