Mr. Tran is a 72 year-old Asian American man presenting with numerous excoriations limited to the extensor aspects of the forearms. Upon questioning, the patient stated that there were “slivers” of foreign materials imbedded in his skin, and he insists that they must be taken out, or else “my [his] skin will not work normally.” His mental preoccupation with said slivers had been going on for about 3 years, corroborated by chronic scars running down both of his forearms. Past medical history was remarkable for controlled hypertension and dyslipidemia, with no previous psychiatric history.

X-ray evaluation and skin biopsies showed no foreign materials. However, the patient dismissed these negative results, claiming that the slivers could not be visualized using X-rays and “are too deep to reach with the skin biopsy probes.” After much convincing on your part, he agreed to undergo empirical treatment with pimozide. Pimozide dosage was gradually titrated from a 1 mg/day to 3 mg/day; as a result, he experienced noticeable symptomatic relief. The patient happily reported spending less time trying to remove the foreign objects from his skin and more time on leisurely activities compared with before starting pimozide, and he incurred no extrapyramidal side effects during the trial period. After several months of taking pimozide at the 3 mg/day dose, he was slowly taken off the medication because his mental preoccupation and excoriating behavior had stopped.