Skin Picking from Patients' Perspectives
“Usually, I'm not even aware that I've been picking my skin until after it is over…I sit down in front of the TV and it usually just starts with touching my feet. Then I feel a rough patch or a little piece of skin that feels “extra“ and without really thinking about it, I pull it off and pick at the skin until it feels smooth again. I continue watching TV and zone out. Then, usually something breaks the “spell“ like my mom or brother coming into the room. I look at my foot and notice that it looks all red and raw. I'm now embarrassed to go swimming, wear sandals, or do anything where other people will see my feet and what I've done to them…yet I can't seem to stop this nightly ritual.“
“I now notice that I usually pick when I feeling really overwhelmed…when I'm behind a few reports at work and I feel like my boss is breathing down my neck. When I get home, I have trouble letting go of the day. I should have accomplished more…where did all the time go…I'll need to work even harder tomorrow to catch up. I start feeling jittery and nervous as I'm sitting on my sofa reviewing my day. The only thing that helps me let go is when I am able to move my focus to my skin. It starts innocently enough…I'm thinking about my day as I'm touching my face and feeling how smooth it is. Then, I'll come across a blemish, something that feels wrong and upsets the smoothness of my face. I scratch at it with my fingers until it feels smoother, this can take a while because sometimes one pick makes it rougher and a few more picks are needed to make it smooth. Once this is accomplished, my fingers trail on to the next part of my face. Another bump. Smooth it out. It hurts but also feels good. Like a search and destroy mission. My day fades away…“.
It is unknown what causes skin picking. However, like other psychological difficulties, it is likely due to a combination of many factors, including biological as well as life experience and stressors.
To date, there has been very little research into “neurotic excoriation“ or skin picking. Skin picking is currently not classified as a separate disorder in its own right but is rather classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as an Impulse Control Disorder, Not Otherwise Specified. Trichotillomania (i.e., hair pulling) is also currently classified as an impulse control disorder, and skin picking appears to have many features in common with this disorder as well as with Obsessive-Compulsive Disorder.
Most people pick their skin when they are alone. Some people appear to be more aware of their picking whereas others seem to do it completely automatically. People can pick the skin anywhere on their bodies but the most common areas tend to be the face, upper back, and chest. Frequently, people primarily pick blemishes, pimples, bumps, blackheads, or any sores. Some people report that in the moment it feels good to pick and they have a sense of relief when they are picking, but, afterward, most people are very distressed at the damage they have done to their skin. People will usually try to hide the damage that they have done to their skin from others.
Frequently, it is often necessary to have a professional evaluation to determine if skin picking is the result of an impulse control problem or is simply a symptom of another problem like Body Dysmorphic Disorder or Obsessive-Compulsive Disorder.
As previously indicated, the treatment for skin picking will depend on if it is the result of an impulse control problem, Body Dysmorphic Disorder, or Obsessive-Compulsive Disorder. Obviously, if the causes of the skin picking are due to BDD or OCD, treatment is implemented for those disorders (please see sections on this website for these disorders). However, if the skin picking is an impulse control problem, the treatment of choice is usually very similar to what is implemented for those with trichotillomania (i.e., hair pulling - also an impulse control disorder).
Both medications as well as Cognitive-Behavioral Therapy (CBT) seem to be effective for skin picking. Generally, selective serotonin reuptake inhibitors (SSRIs) are tried first, but then other drug classes (such as tricyclics or dopamine blockers) or combinations of medications might be tried to find the ideal medication. People respond very differently to each medication, so it is unfortunately a trial-and-error process to find the right medication or medications.
For most people with skin picking, a combination of medications and CBT are often necessary to help them fight the urges to pick. However, if a person prefers one treatment to another, it is usually permissible to try out the one treatment alone, but, if that is ineffective, to then augment the current treatment (whether that is medications or CBT) by adding the other treatment.
CBT for skin picking involves several steps - with the most integral one being the steps of “habit reversal“. In habit reversal, the first step is typically awareness training. This is a fancy term for the individual being taught how to monitor their behaviors. This is frequently very helpful in determining which situations a person is most likely to pick, what environmental or emotional triggers may initiate picking, and what types of situations produce the strongest urge to pick. Frequently, people find that they pick in some situations that they were not really aware of or they are surprised to find that their picking is limited to just a few types of situations. Sometimes, this basic intervention is successful in helping people substantially reduce their skin picking.
In addition, people with skin picking are also taught how to monitor the steps in their “behavioral chain“ - in other words, learning what the first behavior is that leads to skin picking. For example, someone might notice that the thing that first triggers their picking is a feeling of frustration, which then leads to leaning their head on their hand, then feeling their face, and eventually leads to picking a blemish that is found.
Once they are aware of when the picking occurs, individuals are then taught a competing response. In other words, they are taught how to engage in another behavior that prevents them from picking their skin. They are taught to engage in this response until the urge to do the picking decreases. For example, if the urge to pick arises when they are in bed at night reading a book, they are taught the competing response of gripping the edges of the book hard until the urge passes. Different competing behavioral responses can be designated for different situations.
In addition, many people with impulses to pick find learning relaxation techniques to be very helpful. Techniques such as breathing retraining and progressive muscle relaxation often help to control the distressing emotions and general stress level that led to the picking in the first place. When real stressors exist, it is often helpful to engage in problem solving techniques to explore additional ways of better coping with these life stressors. In addition, using techniques to analyze daily thoughts and stresses are often a very helpful adjunct to habit reversal - these techniques help people better deal with the stresses of life so that they are less likely to resort to skin picking to help relieve any stresses that occur in the future.
In addition, it is often helpful for people to write a list of all the ways in which skin picking has caused them any inconvenience or embarrassment and to keep this list with them. Many people also find that rewards help to keep them motivated with treatment. First, rewards are given for successfully reducing and then eliminating skin picking.