Decision Making and Skin Picking: Are They Related?

Dr. Dawn Ferrara
Feb 28th, 2022

Online test

Find out the severity of your symptoms with this free online test


Decisions…we make them every day. Sometimes, we’re fully aware of our decisions. We thoughtfully consider our options and choose our actions. Other times, though, we make decisions with barely an awareness, almost as if we’re running on autopilot, and just seem to end up where we are. If you’ve ever been driving and suddenly end up where you were headed, you know that feeling. You were making decisions (e.g., gas, brake, turn left, turn right, park) but were probably not acutely aware of every little thing you did as you drove. Sometimes that works out just fine. Other times, we’re left wondering, “Why did I do that?” “What was I thinking?” Even when we’re not fully aware of our decisions, we make them a million times a day.

What do decisions have to do with skin picking? Quite a lot actually.

If you or a loved one lives with a body focused repetitive behaviors (BFRBs) like skin picking, you’ve probably had the experience of someone asking why you do it and can’t you just stop? It’s frustrating for sure and there isn’t always a good answer. Skin picking is a complex behavior and there are layers of reasons why it happens.

Researchers have found that people with BFRBs like skin picking disorder (SPD) differ in how they process information. Neuropsychological studies have found that people with trichotillomania (TTM) or SPD have structural differences in their brains compared to people that don’t have one of these disorders. People with TTM and SPD also show differences in their cognitive functions. People with TTM show impairments in inhibitory control, spatial working memory, divided attention, visuospatial learning, and immediate visual memory. Studies into skin picking are more limited but people with SPD tend to have an impaired stop-signal inhibitory control that makes it hard for them to stop picking at their skin. In other words, people with SPD also have a harder time controlling their behavior or knowing when to stop (greater impairment of inhibitory control).

These differences don’t mean that people with BFRBs are somehow “broken”. It simply means that their brains seem to be structurally different and process information in ways that may make them more susceptible to developing a BFRB.

One area of cognitive functioning that has not been well-studied is that of decision making. Decision making is a key part of behavior and a necessary part of behavior change. Given what we know about the structural and cognitive differences in people with SPD, it seems logical that decision making would be an area to be considered. There has been some research related to decision making in people with TTM, but virtually none with people with SPD. A new study takes a closer look at the relationship between decision making, TTM, and SPD.

Understanding Decision Making

When describing decision making, cognitive researchers generally categorize decision making as either decision making under risk or decision making under uncertain situations.

Decision making under risk involves giving the person information about the outcomes of a task and the reward-punishment risks. The information is straightforward, and the person knows the likely outcomes and risk/reward.

Decision making under uncertain situations means that the person is given information that implies possible outcomes, so the reward-punishment risk is unclear. How a person interprets these types of tasks is highly dependent on how their brain processes and interpret information. These processes are thought to be related to both the brain’s structure and function.

Decision-making under uncertain situations has not been previously studied in people with TTM or SPD. Decision-making under uncertain situations is strongly associated with specific areas of the brain. Given what is known about structural brain and neurocognitive differences in people with TTM and SPD, it makes sense that decision-making could provide clues to understanding BFRBs.  

The Study

Researchers sought to explore decision making in people with TTM and SPD. A secondary objective was to explore possible differences between automatic and focused-type patterns of pulling/picking.

  • Automatic picking/pulling is an automatic behavior where the person is not aware of what they’re doing. It is sometimes described as “trance” behavior.
  • Focused picking/pulling occurs when the person is fully aware of and engaged in what they’re doing. This type of behavior is often seen in response to a specific trigger such as intense urges to feel a certain emotion either during or after the act or relieve an intense physical sensation such as itching. Once started, it is difficult to stop.

A third objective was to assess the relationship between decision making and impulsivity. The study used an established gambling-style decision making measurement tool that included decision making under uncertain situations.

The study found that decision making performance under uncertainty for people with SPD was similar to people without SPD. For people with TTM however, they demonstrated poor decision-making performance under uncertainty when compared with people who do not have TTM.

People with SPD and the control group tended to be risk avoidant. People with TTM tended to make more risky decision choices. Compared to people with SPD, they tended to opt for the immediate reward without thinking about later consequences.

Regarding focused vs. automatic styles, people who identified with the focused type of picking and pulling tended to show impairments in decision making. These findings are compatible with the focused type of behavior. A focused style is more deliberate and targeted. There is awareness of the behavior but continue anyway. Subjects in the focused-type group knew they were making risky choices and did so anyway.  

Interestingly, impulsivity was not found to be related to the decision-making performance of participants with either TTM or SPD. This finding suggests that attention does not affect decision-making performance.

What the Results Mean for Skin Picking

The notion of skin picking as just being a choice that one can start or stop at will is not supported by these findings and does not fully explain the behavior. Decision-making, especially under uncertain situations, does not differ between people with SPD and those who do not have the disorder. In fact, they tend to be risk avoidant. For people with TTM, decision-making does seem to be impaired. Impulsivity was also not found to influence in decision making, at least in the focused-type behavior, for neither SPD nor TTM. There are clearly other factors influencing decision making in skin picking behavior.

These results suggest that while neural circuitry is important to consider, it is also important to address the cognitive factors that play a role in decision making. For example, research has found difficulties with emotional regulation in people with SPD.

Assessing cognitive issues in clinical evaluation may lend additional information that can translate into more individualized treatment planning. Treatments should include both behavioral and cognitive elements to address behavioral change as well as aspects of emotional regulation and decision making.

Researchers have only touched the surface of how neurocognitive functioning influences behaviors like skin picking. Much more work needs to be done but each new piece of information brings researchers one step closer to finding treatments that can alleviate symptoms and improve quality of life.



1. TLC Foundation for BFRBs. (n.d.). Learn about BFRBs. The TLC Foundation for BFRBs.

2. Chamberlain, S. R., Blackwell, A. D., Fineberg, N. A., Robbins, T. W., & Sahakian, B. J. (2005). The neuropsychology of obsessive-compulsive disorder: The importance of failures in cognitive and behavioural inhibition as candidate endophenotypic markers. Neuroscience & Biobehavioral Reviews, 29(3), 399–419.

2. Grant, J. E., Leppink, E., & Chamberlain, S. (2015). Body focused repetitive behavior disorders and perceived stress: Clinical and cognitive associations. Journal of Obsessive-Compulsive and Related Disorders, 5, 82–86.

3. Demirci, H., Aydın, E. P., Kenar, J. G., Özer, Ö. A., & Karamustafalıoğlu, K. O. (2021). Decision-making performance in trichotillomania and skin picking disorder. Journal of Obsessive-Compulsive and Related Disorders31, 100688.

4. Clark, L., Cools, R., & Robbins, T. (2004). The neuropsychology of ventral prefrontal cortex: Decision-making and reversal learning. Brain and Cognition55(1), 41-53.

5. Snorrason, Í., Smári, J., & Ólafsson, R. P. (2010). Emotion regulation in pathological skin picking: Findings from a non-treatment seeking sample. Journal of Behavior Therapy and Experimental Psychiatry41(3), 238-245.





Dr. Dawn Ferrara


With over 25 years of clinical practice, Dawn brings experience, education and a passion for educating others about mental health issues to her writing. She holds a Master’s Degree in Marriage and Family Counseling, a Doctorate in Psychology and is a Board-Certified Telemental Health Provider. Practicing as a Licensed Professional Counselor and Licensed Marriage and Family Therapist, Dawn worked with teens and adults, specializing in anxiety disorders, work-life issues, and family therapy. Living in Hurricane Alley, she also has a special interest and training in disaster and critical incident response. She now writes full-time, exclusively in the mental health area, and provides consulting services for other mental health professionals. When she’s not working, you’ll find her in the gym or walking her Black Lab, Riley.

Online test

Find out the severity of your symptoms with this free online test


Start your journey with SkinPick

Take control of your life and find freedom from skin picking through professional therapy and evidence-based behavioral techniques.

Start Now