Postpartum-onset and childhood sexual trauma in a patient with skin picking disorder: a case report

ABSTRACT Women are at risk for the development of psychiatric disorders, particularly depression and psychosis in the postpartum period. Few studies have examined anxiety disorders or obsessive-compulsive and related disorders during pregnancy and the postpartum period. The individuals with skin-picking disorder (SPD) frequently have childhood history of sexual abuse. To best of our knowledge, there is no report in literature on postpartum-onset SPD to date. We here report a case of SPD initially presented a postpartum onset and exacerbated following a sexual trauma long years after her delivery. She had no previous history of trauma or psychiatric diagnoses. Pregnancy and sexual trauma seem to be associated with occurrence and relapsing of SPD in this case.


Introduction
Skin-picking disorder (SPD) is known as repetitive and compulsive picking of skin which may lead to tissue damage [1]. Due to phenomenological and neurobiological similarities with obsessive-compulsive disorder (OCD), SPD has recently been classified under obsessive-compulsive and related disorders title in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [2]. Subjects with SPD display more OCD and other OC spectrum disorders compared to ones without SPD [3]. Stress, anxiety, boredom, feelings of tiredness or anger have been found to be possible triggers for SPD [4,5]. Subjective difficulties in emotion regulation might predict picking behavior independent from depression and anxiety [6].
Various reports demonstrated that individuals SPD had a high frequency of previous traumatic events and a history of sexual abuse in childhood [7,8]. Recently, a longer duration of trichotillomania or skin picking was found to be related to a decreased severity of posttraumatic stress symptoms. The authors suggested that the patients coped with intrusive thoughts related to trauma through trichotillomania or skin-picking symptoms [2].
Women are at a great risk for the development of several psychiatric disorders in the pregnancy and lactation periods. Although most of the studies have examined depression or psychoses during these periods, only a few studies have examined anxiety disorders or OCD-related disorders occurring at pregnancy and the postpartum periods. Some of the studies demonstrated that anxiety disorders were common among postpartum women. It was reported that nearly 8.5% of postpartum women experienced at least one anxiety disorder [9]. The most frequent anxiety disorders during pregnancy and postpartum periods were OCD and generalized anxiety disorder [10,11]. Previously, trichotillomania, another OCDrelated disorder was reported to be associated with premenstrual period. The influence of pregnancy on trichotillomania was less clear [12]. The rate of OCD patients who reported an association between pregnancy/lactation and the onset of illness were significantly higher than the patients with trichotillomania.
Although the relationship of SPD with sexual trauma is previously known, to our best knowledge, there is no report on postpartum-onset SPD to date. We here report a case of SPD initially presented a postpartum-onset and exacerbated following a sexual trauma long years after her delivery.

Case
A 43-year-old, married female presented to the Psychiatry Department Outpatient Clinic with the complaints of excessive picking of skin of the fingers, forearms, abdomen and legs which firstly occurred within the first month of her first delivery twelve years ago. She reported that she experienced some rape-related posttraumatic stress disorder (PTSD) symptoms such as flashbacks, hyperarousal, hypervigilance, nightmares, and reexperiencing traumatic event since three years. Along the next ten years following her delivery, despite several attempts for psychiatric treatments, no significant improvement was observed in her picking behavior. Additionally, her SP exacerbated after a sexual assault three years ago. She failed to decrease or stop skin picking resulting in skin lesions. She reported feeling an intense sense of loss of control and tension prior to SP. She also reported experiencing relief a majority of the time. She had no dermatological or infectious etiologies of the SP. Dermatological consultation and laboratory investigations of thyroid, liver, and kidney functions were normal. We could not obtain her skin biopsy since she refused it to be done. She had also no past history of any OCDrelated disorders or impulse control disorders (ICD). She had not previously used any substance or other medications which might cause SP behavior. She reported that she had severe conflicts during childhood and adolescence with her father who had rigid and authoritarian temperament characteristics. Her pregnancy was planned and she prepared herself well for her baby. Prior to her pregnancy, she did not experience any physical or sexual abuse. In the inpatient unit, on the basis of current psychiatric examination, she received the diagnoses of SPD, PTSD, and major depressive disorder. Initially, 50 mg/day of sertraline and 50 mg/day of lamotrigine were started and both drugs were increased to 100 mg/day one week later.

Discussion
To the best of our knowledge, this is the first report describing a case of postpartum-onset SPD. This case had no previous history of trauma or psychiatric diagnoses. An experience of rape caused an exacerbation of ongoing SPD.
There are different etiological theories for SPD which have been previously proposed. As it is already explained for postpartum OCD [13], the occurrence of SPD in the postpartum period may also indicate an interaction between the rapidly changing reproductive hormones in postpartum women. The extreme fluctuations in these hormones may be linked to the acute onset of SPD during the postpartum period. SPD may also be considered a result of unconsciously motivated repetitive behavior [3]. Increases in picking behavior in these subjects might be related with an inability to tolerate stress [14]. Psychodynamic theorists reported that suppressed anger towards authoritarian parents is exhibited through self-destructive acts such as picking behaviors to defend themselves against that authority [15]. Domineering and demanding parents have been linked with picking behavior onset in children [16]. Marital conflicts, early-life or recent deaths of loved ones, and unwanted pregnancies have also been reported to be associated with symptom onset [17]. We supposed that a newborn baby in our case revived unconsciously the repressed rage towards her father and aggressive impulses of unmet needs of her childhood. For SPD patients with a history of PTSD and childhood abuse, the causes of psychogenic excoriations can be related to picking as a means of resolving stress or as noted, to some underlying psychopathology [18,19]. PTSD symptoms reduce with the prolonged SPD duration. As in our case, sexual trauma and PTSD can lead to a need for skin picking as a maladaptive coping strategy [19]. As previously noted [20], SP symptoms might have helped our patient to cope with intrusive thoughts related to trauma. Future prospective research is necessary to clarify prevalence of SPD or other OCD-related or ICD during pregnancy and the postpartum period and to identify subgroups of postpartum women who may be particularly vulnerable to development of these disorders.

Disclosure statement
No potential conflict of interest was reported by the authors.