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.
Research for effective evidence-based therapies continues for excoriation disorder with promising results.
While the cause and mechanisms of excoriation disorder remain elusive, it is considered a body-focused repetitive behavior within the spectrum of obsessive-compulsive disorders (OCD). The research on effective treatments for OCD spectrum disorders and body-focused repetitive behaviors is helpful in addition to the research findings specific to excoriation disorder.
When treating excoriation disorder, evidence-based practice suggests a combined approach of pharmacology and psychotherapy.
Treatment is based on the way a person experiences excoriation disorder. For those who suffer from automatic, unconscious picking, treatment focuses on creating awareness, identifying triggers for picking behaviors, managing the triggers, and making conscious efforts to choose behavior. Those who suffer from picking behaviors in response to stressors, treatment focuses on recognizing stressors and managing stressors as well as changing habits and thinking related to picking behavior thereby giving someone power over impulses.
How you care for your skin after you pick will determine how quickly and how well your skin heals. Neglecting these steps can result in extended healing time and damaged skin, including scabs, scarring, and permanent redness.
Habit reversal training for body-focused repetitive behaviors (BFRBs) includes improving awareness and self-monitoring, controlling stimuli, and creating competing responses. Stimulus control and competing responses sound very similar. This article will talk about what they are, how they are different, and how they work in tandem to reduce body-focused repetitive behaviors.
Stimulus control refers to managing external factors, usually in one’s environment, to influence behavior. For example, someone who picks at their skin may do so in a location at home that triggers it. An area such as a well-lit bathroom with a huge mirror and a lock on the door. The bright lighting and huge mirror draw attention to every little imperfection of the skin and whenever you walk in there, you lock the door, push your face as close to the mirror as possible, start picking, and before you know it, a couple of hours have gone by.
Stimulus control prompts you to consider that environment.
First, the big mirror. What things can be done to change the giant mirror so it doesn’t “pull you in?”
Competing responses are movements or activities that are incompatible with habitual or automatic behaviors. In simple terms, if your hands are not available to use for picking at your skin, you won’t pick at your skin. In addition, think of something that is the opposite of the behavior you want to replace. It should be something you can do for longer than a couple of minutes and will be more less unnoticeable by others. It may be something challenging that you do with your hands, or something easy to do that just keeps your hands occupied.
This video transcript talks about using your smart phone as a competing response.
Hi, welcome back to Talk Therapy Channel on YouTube.
I’m Tammy Fletcher, Licensed Marriage and Family Therapist in California, and today, my friend Scooter and I are going to be talking to you about iPhone apps that can help with skin picking and hair pulling.
If you were to ask people who suffer from excoriation disorder whether hormonal changes influence the severity of their picking, they would likely say yes. Research supports this anecdotal evidence in several ways. First, the onset of excoriation disorder tends to occur during puberty. This means, the first time symptoms of skin picking start during a major hormonal change in the body. In addition, a study of 1,471 women aged 10-60 found a relationship between hormonal changes and an increase in “focused” picking behavior (Flessner et al, 2009). These women, described picking behavior as more severe when hormones were changing throughout their lives.
Has anything like this happened to you?
The scientific explanations for this phenomenon abound, however, for those who suffer from skin picking in an automated way, passive or sedentary activities can be triggers.
In simple terms, the situations described above are mild forms of dissociation. Some people refer to this as “zoning out,” while more severe versions can be diagnosed as a disorder. Think of dissociation along a continuum with mild zoning out and inattention at the less serious end and Dissociative Identity Disorder on the severe end. Dissociation can be the brain’s way of taking a break and can be caused by traumatic events or simply boredom.
There are many therapeutic interventions to help an individual focus on what is important to them. Values are those things which someone prioritizes as valuable. They can be things, ideas, people or activities and people make decisions consistent with what is important to them. Values-based therapy starts by setting up new values or reviewing existing values. This happens before discussing the problem because every step of therapy afterwards will use values as the foundation for decision making and treatment planning.
Driving is a prime environment for skin picking behavior, but competing responses can help. People who pick their skin fall into two categories:
Driving is one of those activities that many people do alone and as a private place, or it can become automatic allowing one’s thoughts to wander.
In habit reversal therapy, before considering replacement behaviors, you learn to recognize circumstances and locations that trigger picking. For many people, driving is a frequent location. Once triggers and behavior patterns are recognized, you learn and develop strategies to disrupt the behaviors you want to change. One of the strategies for disrupting behaviors is the development of competing responses.
Skin picking disorder, more formally known as excoriation disorder, is considered to be a disorder related to obsessive-compulsive disorder, but not an obsessive-compulsive disorder in itself. Skin picking can also be a symptom of obsessive-compulsive disorder, so how does one tell the difference? First, we’ll talk about the basic diagnostic criteria for each disorder, then we’ll get more specific about how to tell the difference.
(Diagnostic criteria are taken from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition published by the American Psychiatric Association.)
1. OCD is marked by the presence of obsessions, compulsions, or both.
Obsession – Recurrent or persistent thoughts, urges, or images that are intrusive, unwanted, and cause significant anxiety or distress. A person attempts to ignore or suppress them or to neutralize them with some other thought or action. Actions usually take the form of compulsions.