Skin Picking Disorder: What Does it Have to Do With OCD?
JJ Keeler
November 9, 2020
Dr. Dianne Stevenson
I am a Clinical Psychologist, with over 12 years experience working in private practice. I work with adults that are struggling with a range of mental health issues. These most commonly include OCD, anxiety, low mood, emotional dysregulation, trauma, relationship difficulties, and stress.
Skin Picking Disorder (sometimes called excoriation disorder or dermatillomania) isn’t always an illness; in fact, most people pick their skin from time to time, something done in an effort to remove a scab or ban a blemish (or some other perceived imperfection). Sometimes done because of nerves or boredom. Sometimes done for the heck of it.
But, on occasion, this behavior crosses the boundary of normal and becomes a full-blown disorder. It can cause bleeding, sores, infection, scarring, and invite more compulsive behavior. This is when it becomes problematic: When it’s done over and over again to the point of causing tissue damage, when it causes shame or interferes with life, or when it’s done as means to relieve anxiety.
But what does this have to do with OCD? After all, this is a blog dedicated to Obsessive Compulsive Disorder. Stay tuned!
Content
Why Do People Pick Their Skin?
Problematic skin picking might happen for a few different reasons. Some engage in it because they have a physical skin condition (like a scab); others may be withdrawing from drugs. However, often, people pick their skin compulsively as a way to regulate their thoughts. When this happens, they may be diagnosed with a skin picking disorder.
Exactly what this looks like depends on the individual. Some people may pick their faces while others pick their arms, legs, or hands (or some other part of the body). Some pick their skin with their fingers while others use tools, like scissors, tweezers, or their own teeth. Some may not engage in direct skin picking but instead scratch, rub, or repeatedly touch their skin.
People vary in what they do with their picked skin as well. Some throw it on the ground or discard it into a trash can. Some roll it up into little balls. Some may even eat it.
Who is at Risk for Skin Picking Disorder?
By some accounts, Skin Picking Disorder is relatively common, afflicting around 1 in 20 people. By others, it’s not as common, with only approximately 1.4% of the US population affected.
It occurs in both men and women but it’s more common in the latter, perhaps because women tend to feel more pressure to be beautiful and may pick at their perceived imperfections more than men. It may appear in either childhood or adulthood, but – commonly – it starts in puberty (around the age of 13-15).
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What are the Signs of a Skin Picking Disorder?
There are several signs that differentiate normal skin picking from the more severe disorder. These include:
- Skin picking that takes up a lot of time of the day
- Skin picking that causes tissue damage or scarring
- Skin picking that causes shame or embarrassment
- Skin picking that interferes with socializing, work, or other day-to-day activities (for example, you refuse to go to a school dance because of visible skin picking scars)
- Skin picking that causes distress
- Skin picking that can’t be explained by a dermatological condition or another condition
- Repeated attempts to stop that are unsuccessful
Skin Picking and Self-Mutilation
Skin picking, though it technically mutilates the skin, is not really a form of self-mutilation, which is the act of intentionally harming oneself in an effort to self-inflict punishment or distract oneself from painful emotions. Skin pickers, on the other hand, engage in their compulsions as an effort to relieve anxiety in a way that doesn’t intend to cause harm (though it does). This makes skin picking and self-mutilation generally separate problems.
Is Skin Picking OCD?
Skin picking isn’t exactly OCD, though the two conditions have a lot of overlap. For those who suffer from a skin picking disorder, the picking acts as a compulsion (something omnipresent in OCD). And people who engage in skin picking may do it to neutralize anxiety (the omnipresent motivation in OCD).
Some people do consider Skin Picking Disorder a “type of OCD” and use the terms interchangeably. But, according to the Diagnostic and Statistical Manual of Mental Disorders (the DSM-5), Skin Picking Disorder is classified under “Obsessive Compulsive and Related Disorders”, indicating that it has things in common with OCD that place it on the OCD spectrum. Essentially, it acts as a cousin to the traditional OCD mental illness.
OCD often accompanies Skin Picking Disorder (much like it often accompanies Body Dysmorphic Disorder) and those who pick their skin are more likely to have OCD than those who don’t. On the other hand, you can have a skin picking disorder without having OCD.
Skin picking may also appear in people who suffer from major depressive disorder, ADHD, and autism spectrum disorder (whether or not they have OCD).
Body-focused Repetitive Behaviors (BFRB)
Skin picking is considered a body-focused repetitive behavior (which some people with OCD experience). But it’s far from the only one. Other common BFRBs include:
Trichotillomania: This is known as the “hair pulling disorder” and is another illness classified under “Obsessive Compulsive and Related Disorders” (previously, it was classified as an impulse control disorder). People suffering from trichotillomania tend to compulsively pull hair from their scalp, eyebrows, eyelashes, and other parts of the body. Often this results in bald patches and some people (up to 20%) may also have a compulsion that forces them to swallow their hair.
Trichotillomania is accompanied by OCD and Skin Picking Disorder a great deal of the time. The latter accompanies it in 38% of cases.
Nail-Biting Disorder: Though a common nervous condition in the general public, nail biting can morph into a disorder too. When this happens, sufferers may bite their nails compulsively, biting past the nail bed and chewing on their cuticles. This results in soreness, bleeding, and – possibly – infection.
Miscellaneous Disorders: Other BFRBs that may present include cheek biting, lip biting, scab picking (or eating), nail picking, and self-grooming.
What Causes Skin Picking Disorder?
Why one person gets Skin Picking Disorder when another doesn’t remains to be seen. It’s believed that certain biological and environmental factors come into play (as they commonly do when dealing with mental disorders). Studies reveal a tendency for the disorder to run in immediate family members.
Even when people have a predisposition, other factors have a say. A person’s ability to withstand stress, their age, their family life, and their environment can all affect the disorder’s development. And, without a predisposition, people can still suffer from a skin picking disorder.
BFRBs are also common in certain animal species, such as primates, mice, and birds. Scientists believe the reasons for this are complex and they study them in an effort to learn more about their cause.
As previously mentioned, Skin Picking Disorder is often accompanied by specific mental illnesses and those mental illnesses can act as the cause. For example, someone who suffers from Contamination OCD may pick their skin as a way to “pick off” germs. Someone who suffers from Harm OCD, may pick their skin to neutralize a thought they have about strangling their little brother. Someone who suffers from Magical Thinking OCD may pick their skin in an attempt to neutralize the thought that a tornado will wipe out their town.
Skin picking is commonly seen in Body Dysmorphic Disorder (BDD), a condition classified under “Obsessive Compulsive and Related Disorders.” This condition is marked by an obsessive focus on personal appearance and a preoccupation with flaws. These flaws are typically minor and insignificant, such as a tiny blemish on the face that no one notices but the sufferer. Sometimes, no flaw exists at all and it is only imagined by the sufferer.
On occasion, a physical skin condition may trigger Skin Picking Disorder. For instance, a rash, an injury that causes a scab, a scrape, a cut, or a skin infection may cause someone to pick at that part of their skin. If they do it long enough, or find that it relieves anxiety, a cycle can develop.
Stress is another element that can lead to skin picking as people may pick more frequently during turbulent times as a way to regulate themselves. It’s no different from the person who bites their nails because they’re nervous. If they do it long enough, a habit develops. Others may engage in skin picking as a way to self-groom.
Normal versus Abnormal
However, the above can exist without turning into a full blown disorder. Just as it’s perfectly normal for an avid football fan to bite their nails as their team drives down the field in an attempt to win the game, it’s equally normal for a teenager to pick away a pimple on their nose. It’s when the skin picking (or nail biting, hair pulling, etc.) begins to interfere with the person’s life, causes distress, or feels like something the “have” to do that it becomes a disorder.
The Effects of Skin Picking Disorder
Skin picking has emotional, social, and physical ramifications. Some of these include:
- Shame, embarrassment, and secrecy
- Depression and anxiety
- An inability to maintain a normal social life, work life, school life, or home life
- Physical pain and sores
- Infection (in people with immunosuppression or heart conditions that put them at risk of endocarditis, this is especially risky)
- Scars and disfigurement (occasionally, these may be severe enough to necessitate skin grafts and surgery)
Treatment for Skin Picking Disorder
The treatment for Skin Picking Disorder depends on the cause (if known). For instance, if skin picking is the result of OCD, then treatment for OCD is crucial.
The treatment for skin picking has evolved and varied and included, in the past, treatments that weren’t especially helpful. Today, it’s better understood and some people benefit from Cognitive Behavioral Therapy (if the sufferer has OCD, CBT must be employed). Acceptance and Commitment Therapy (ACT) is used too (not only in Skin Picking Disorder but OCD as well).
Two techniques that are believed most helpful include Habit-Reversal Training (HRT) and Mindfulness-Based Cognitive Behavioral Therapy (CBT).
HRT involves tracking one’s picking through the use of skin picking logs. Writing down when the skin picking is more frequent helps the sufferer recognize patterns and increase their self-awareness. They may also use habit blockers, such as gloves. These can act as a barrier to a routine that has become rote.
In Mindfulness-Based CBT, the idea is to learn how to accept unwanted and unpleasant thoughts without overreacting (or reacting to them at all). The goal is to tolerate the urge to pick as this urge will lessen the more tolerance is applied.
This isn’t really a “rip the band aid off” method and rather involves increasing one’s tolerance. For example, the sufferer may be instructed to wait 24 hours before picking again, then 36 hours, then 48 hours, then 72 hours. Eventually, and hopefully, the urge becomes nonexistent and the sufferer realizes that picking is a choice rather than something they must engage in.
Of course, another part of treatment is learning how to regulate behavior without skin picking (as skin picking is self-soothing or anxiety-neutralizing). Sufferers are often instructed to discuss the underlying feelings they’re trying to get rid of (name it to tame it!) or write their feelings of angst and worry in a journal. This invites them to tolerate their feelings without the urge to pick their skin.
Medications
There are some medications that may prove beneficial too, including SSRIs (such as Zoloft, Paxil, and Prozac). This is especially true when OCD is involved.
Anti-seizure medications may be helpful in some cases (such as Lamictal) as may supplements (such as N-acetyl Cysteine). Naltrexone, a medication used to treat opioid addiction and alcoholism, may help as well.
Because of the overlap between skin picking and OCD, many of the clinics that treat OCD treat skin picking too. Unfortunately, not everyone seeks treatment as they see their behavior as a normal, nervous tic. But, if it interferes with your life or causes distress, treatment can make all the difference.
Even when seeking help, getting better doesn’t happen immediately and sufferers may experience slow and steady progress and possible setbacks along the way (as well as required vigilance). The key is to keep going.
References:
https://www.psychologytoday.com/us/conditions/dermatillomania-skin-picking
https://www.mhanational.org/conditions/excoriation-disorder-skin-picking-or-dermatillomania
https://emedicine.medscape.com/article/1122042-workup#c8
https://www.bfrb.org/trichophagia
https://www.sciencedirect.com/science/article/abs/pii/S0022399915000045
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