doxepin, clomipramine, naltrexone, pimozide, and olanzapine. Small studies of fluoxetine, an SSRI, in treating excoriation disorder showed that the drug reduced certain aspects of skin picking compared with a placebo, but full remission was not observed. One small study of patients with excoriation disorder treated with citalopram, another SSRI, showed that those who took the drug significantly reduced their scores on the Yale –Brown Obsessive Compulsive Scale compared with a placebo, but that there was no significant decrease on the visual-analog scale of picking behavior. While there have been no human studies of opioid antagonists for the treatment of excoriation disorder, there have been studies showing that these products can reduce self-chewing in dogs with acral lick, which some have proposed is a good animal model for body-focused repetitive behavior. Furthermore, case reports support the use of these opioid antagonists to treat excoriation disorder. Opioid antagonists work by affecting dopamine circuitry, thereby decreasing the pleasurable effects of picking. Another class of possible pharmacological treatments is glutamatergic agents such as N-acetyl cysteine (NAC). These products have shown some ability to reduce other problematic behaviors such as cocaine addiction and trichotillomania. Some case studies and some small studies of NAC have shown a decrease in picking by treatment with NAC compared with placebo. Excoriation disorder and trichotillomania have been treated with inositol. Topiramate, an anti-epileptic drug, has been used to treat excoriation disorder; in a small study of individuals with Prader–Willi syndrome, it was found to reduce skin picking. Psychological treatment Treatments include cognitive-behavioral therapy, acceptance-enhanced behavior therapy, and acceptance and commitment therapy (ACT). Several studies have shown that habit reversal training associated with awareness training reduces skin-picking behavior in those individuals with excoriation disorder that do not have psychological problems. Habit reversal training includes awareness enhancement and competing response training. For example, in one study the competing response training required participants to make a closed fist for one minute instead of picking or in response to a condition that usually provokes picking behavior. In a recent study of participants (n = 113) diagnosed with ED, less than 50% followed through with an appointment to Psychiatry. In an absence of longitudinal data which follows patients with Psychiatric referrals as a result of ED, little is known for the reasons patients do not follow through with the referral, or what more is needed to ensure access to care. Overall, less than 25% of