People who compulsively pick at their skin have different triggers and behavior patterns. Treatment attempts to identify the triggers and behavior patterns to create new, healthier behavior patterns. The assumption is that if the factors contributing to picking behaviors can be successfully addressed, then the behaviors will decrease or go away. For example, many people with skin picking disorder report picking more when they are stressed or anxious. In treatment then, the goal is to decrease stress and anxiety, and the picking behaviors will decrease as well. Then, there is the guilt, shame, anxiety, and stress that follow skin-picking episodes which sometimes trigger additional episodes. Therefore, a person’s ability to regulate emotions may impact skin picking behavior severity.
Keratosis Pilaris is a common skin disorder characterized by bumpy skin accompanied by redness. It tends to show up on the upper arms, legs, buttocks, and sometimes the face. Often described as “chicken skin” it is harmless, non-contagious, and cycles through periods of mild to severe outbreaks.
When the skin is dry, skin cells flake off, however, in people with Keratosis Pilaris, the small dry skin particles called keratin clump up in the openings of hair follicles. The redness that sometimes appears with the bumps results from the dilation of the small blood vessels under the skin. Everyone experiences the sloughing of dead skin cells, but medical science does not have an answer for why some people develop keratosis pilaris and why others do not. Some theories suggest it is a hereditary condition since it tends to run in families. Other theories suggest it is related to dry skin conditions and allergic inflammation conditions.
Skin picking disorder is a compulsive body-focused repetitive behavior with neurobiological similarities to attention deficit hyperactivity disorder (ADHD). Methylphenidate is a psychostimulant used to treat ADHD yet may also serve to trigger skin picking disorder.
People with skin picking disorder repeatedly pick, poke, squeeze or lance the skin resulting in injury and emotional distress. It is a compulsive act, and many people try to stop on their own but cannot. Researchers have discovered neurobiological mechanisms that contribute to skin picking disorder as well as physical reasons for worsening symptoms, but the exact biological mechanism remains unknown. For example, skin picking disorder appears to have a genetic link. People with a family history of the obsessive-compulsive disorder are more likely to develop to skin picking disorder. People with skin picking disorder are also more likely to have family members with other body-focused repetitive behaviors.
Excoriation disorder is a debilitating and traumatic mental health disorder that commonly begins at the onset of puberty. Young tweens are likely to experience their first episodes accompanied by fear, shame, embarrassment, and the desire to hide the habit and the physical evidence at all costs. Approximately 1.4%-5.4% of the population experiences the compulsion to pick at their skin which is triggered by a variety of things. Skin conditions such as eczema, rashes, itching, or acne often inspire skin picking, but emotional triggers such as stress, anxiety, depression, anger, boredom, and fatigue can trigger it as well. People who pick at their skin in a disordered way may start with something innocuous like picking at a scab, but then they cannot stop resulting in severe skin damage.
One of the questions asked of those who struggle with compulsive skin picking is, “doesn’t it hurt?” Despite all the research available on excoriation disorder, none examined the pain thresholds of people who compulsively pick at their skin, until recently.
Excoriation disorder is a body-focused repetitive behavior where people compulsively pick at their skin to the point of doing extensive damage. Sometimes picking starts to rid oneself of blemishes and imperfections, while other times it serves as a self-soothing behavior. The triggers are different for each person, and the cause is unknown. Most people spend a significant amount of time picking, sometimes hours per day. Also, many hours go into covering up wounds and caring for damaged skin. The stigma attached to this disorder leads to significant psychosocial impairment, and many with this disorder end up with co-occurring mental health problems.
Skin picking disorder is a chronic condition that lasts a lifetime, which means it never goes away completely. However, it is possible to live without picking, and many people do so successfully. People in recovery from skin picking disorder learn to manage the urges and behaviors similar to the way people with asthma learn to manage their condition. It takes awareness, perseverance, and resilience but even then relapse can happen.
The concept of relapse is most associated with addiction. The word itself connotes dread, fear, or failure. The dictionary definition does not inspire confidence either “suffer a deterioration after a period of improvement.” Contrast the definition of “lapse” which is to “pass gradually into an inferior state or condition.” How would you like refer to a setback?
Dermatologists are physicians who specialize in treating conditions of the skin. Skin picking disorder tends to result in visits to a dermatologist to help with problems from chronic skin damage. But how often do dermatologists recognize a compulsive body-focused repetitive behavior and refer to a patient to a therapist or psychiatrist for help?
When dermatologists are trained, they are made aware of the interconnectedness between the skin and the nervous system. Not only do some skins condition worsen during periods heightened nervous system activity such as stress and anxiety, but skin conditions often provide fuel to heighten the nervous system. In dermatology, the interconnection between the skin and the psychosocial dimension of skin conditions is referred to as psychocutaneous medicine (Gould, 2004). Despite receiving initial training, many dermatologists neglect the role psychology plays.
HabitAware uses technology to help people become more aware of the body-focused repetitive behaviors they want to change. The company recently applied for a patent for Keen, a wearable device that vibrates when your hand moves into a position to pick, pull, or bite.
First, it learns. Body-focused repetitive behaviors tend to have one thing in common. The use of the hands to bite, pull or pick and it usually starts with the dominant hand. Keen is a wearable device that senses movements and with the aid of a phone app, learns which movements are specific to the behavior for which you want to increase awareness. Next, it alerts. Once Keen learns your movements, it will alert you when you make movements that may be precursors to indesirable behaviors. It alerts you by sending a vibration through the wearable device. Allows you to make choices. Once you are made aware of the precursor movements, you can make a choice about what to do next. Do you follow through with the behavior? Or do you do something else with your hands?
The bacterial tenants of the skin exist in harmony with our bodies most of the time. Skin acts as a barrier, protecting our internal systems from the dangers of those bacteria and benefiting from that bacteria in ways we do not fully understand yet. If you compulsively pick at their skin, you risk disrupting the delicate balance resulting in potentially dangerous infections. Regular skin examinations can help reduce the risk of complications due to these skin infections. However, it must be noted that self skin-examination can also be a major trigger for picking for may compulsive skin pickers. In this instance it is best to have the skin examined by a medical professional such as a GP, dermatologist or nurse.
Excoriation disorder, or skin picking disorder, rarely occurs alone. There are many clinical correlates that when understood, help put the severity of skin picking symptoms in perspective enabling the development of more effective treatment plans.
The term “co-occurring disorders” refers to the existence of multiple mental health diagnoses experienced by one person at one time. Referring to correlates means anything that influences another thing in either a positive or negative direction. Many people who struggle with skin picking disorder will attest that they struggle with more than picking behaviors. The most common clinical correlates of skin picking disorder are obsessive-compulsive disorder, other body-focused repetitive behaviors, impulsivity, anxiety, depression, and shame. There are more issues that correlate with skin picking disorder, however, research seems to focus on these.