A 35-year-old male presents to the office for transfer of care. The client has a previous diagnosis of anxiety. During the interview, multiple red areas are noted to his arms. The client denies substance abuse, tactile hallucinations, or recent infestation. The client states he feels embarrassed about the scabs. He tries to stop but finds himself picking when he is nervous or bored. What is the client's most likely diagnosis?

Choice A reason: Hoarding disorder involves a persistent difficulty discarding or parting with possessions, regardless of their actual value, leading to a cluttered living space. There is no clinical connection between hoarding behaviors and the physical act of skin picking described by the client in this scenario. Choice B reason: Trichotillomania is the repetitive pulling out of one's hair (scalp, eyebrows, etc.), leading to hair loss. While it is in the same DSM-5 category of "Obsessive-Compulsive and Related Disorders," the client specifically describes picking at his skin to the point of scabbing, which defines excoriation rather than hair pulling. Choice C reason: Body dysmorphic disorder (BDD) involves a preoccupation with one or more perceived defects or flaws in physical appearance that are not observable to others. While some individuals with BDD may pick at their skin to "fix" a perceived flaw, the primary motivation in this case is anxiety or boredom, which is more characteristic of excoriation disorder. Choice D reason: Excoriation (skin-picking) disorder is characterized by recurrent skin picking resulting in skin lesions, repeated attempts to stop the behavior, and significant distress or impairment. The client’s description of picking his arms when nervous or bored, combined with the presence of scabs and a desire to stop, perfectly meets the diagnostic criteria for this disorder.