Olanzapine Augmentation of Fluoxetine in the Treatment of Pathological Skin Picking

Abstract

Dear Editor: Pathological skin picking, also known as psychogenic excoriation, is characterized by excessive, Stereotypie 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). 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 while 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 scrtraline; she had also received a low dosage of a bcnzodiazepine (lorazcpam, 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 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 strategics 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. …