Dissociation and Skin Picking: The State-Trait Connection

Skin picking disorder (SPD) (also known as dermatillomania or excoriation disorder) is a body-focused repetitive behavior (BFRB) characterized by repetitive picking at the skin resulting in injury to the skin tissues, distress, and impaired psychosocial functioning. People living with SPD feel unable to resist the urges to pick, despite repeated attempts to reduce or stop picking.

One of the things we know about pathological skin picking is that it is highly heterogenous. People experience it in different ways. Picking behaviors may include repetitive touching, rubbing, scratching, picking at, or digging into the skin. The focus of picking may be on healthy skin or existing scabs, lesions, pimples, or other blemishes. Picking can occur anywhere on the body. The most common areas tend to be the face, arms or hands.

There are two primary types of skin picking:

Focused picking is intentional and occurs within one’s awareness:

• Picking is in response to an urge
• Triggered by stress, anxiety, boredom, or tension
• Physical sensation precedes picking, such as tingling, discomfort, or an itch
• May begin with a goal of correcting a skin imperfection
• After picking, a person may feel relieved or pleasure, but the urge to pick returns

Automatic picking occurs outside of one’s awareness:

• Picking occurs without being aware of the behavior
• Tends to occur in response to boredom or lack of attention or focus
• Often described as being in a “trance”

It is estimated that about 68% of people with skin picking disorder experience these trance-like episodes of dissociation. In these skin picking trances, the person becomes completely absorbed in the experience of picking. They may become so engrossed in the picking that they may be completely unaware of what’s happening around them. They may not even realize that they are picking until the episode is over and they see the results. This dissociation is also seen in people with other BFRBs like trichotillomania and with OCD.

Some people who pick engage in both automatic and focused picking behaviors. The transitions tend to be blended with picking beginning automatically and unconsciously then coming into awareness as it progresses. This phenomenon has led to questions whether these are two distinct types of picking or rather a reflection of degrees of severity.

Are some people just more susceptible to dissociation? In other words, is this dissociation due to a state or a trait?

Dissociation and Traits vs States

Traits are patterns of thinking, feeling, and behaving that are unique to each individual. These traits generalize across situations and tend to remain fixed and stable across time. A personality trait is a common example of a trait. For example, introversion is a trait of personality that tends to be stable over time.

States are patterns of thinking, feeling, and behaving in a specific situation at a given moment in time. Unlike traits, they vary across time and situations you find yourself in. Your mood at any given moment would be an example of a state. Your mood will change over time and in response to your experiences.

Dissociation is a disruption or disconnection in the normal integration of one’s consciousness, memory, perceptions, emotions, behaviors, and sense of self. It’s a phenomenon that is associated with a number of disorders, but dissociation happens in everyday life too. If you’ve ever gotten completely “lost” in a book or movie, you may have experienced mild dissociation. But back to states and traits…

• Dissociative states are transient, brief episodes of dissociation that can last a few moments or a few hours. They are a response to what’s happening in the moment.
• Dissociative traits are integral components of personality that reflect a general tendency towards dissociation. They are stable across time and settings.

States, Traits and Skin Picking

So, what about the dissociation that people experience when picking? Is it state or trait driven?  A lot of research has focused on trait dissociation and picking but not so much on state dissociation. In what is thought to be the first of its kind, a new study takes an innovative look at the role of state- and trait dissociation in skin picking behavior and what it might mean for informing treatment.

The study found that about two-thirds of participants experienced episodes of state dissociation and varying degrees of awareness during picking episodes. Feeling like they were on “automatic pilot” or “blanked out” and changes in time perception were common. About 20% of participants were found to be high in trait dissociation.

Interestingly, the researchers found that dissociative symptoms experienced while picking were more closely associated with the focused type of picking rather than the expected automatic type. Trait dissociation was associated with both focused and automatic picking. They noted that they were not able to draw any conclusions about distinct subtypes of picking that can be differentiated based on the degree of awareness and intentionality.

While the study was small and more research is needed, the findings suggest that both state and trait dissociation play a role in skin picking. It may be less of an “either-or” and more of a “both-and”.

Both trait and state dissociation were significantly associated with skin picking-related impairment. The study authors advocate for early assessment and consideration of dissociative behaviors in the treatment planning process. Dissociation can impede the emotional learning process that is a necessary part of psychotherapy as well as adversely affect treatment outcomes. Awareness and understanding of the role of dissociation can help to inform treatment.

References

1. Gallinat, C., Stürmlinger, L. L., Schaber, S., & Bauer, S. (2021). Pathological skin picking: Phenomenology and associations with emotions, self-esteem, body image, and subjective physical well-being. Frontiers in Psychiatry, 12. https://www.frontiersin.org/articles/10.3389/fpsyt.2021.732717/full

2. Schmitt, M., Blum, G.S. (2020). State/Trait Interactions. In: Zeigler-Hill, V., Shackelford, T.K. (eds) Encyclopedia of Personality and Individual Differences. Springer, Cham. https://link.springer.com/referenceworkentry/10.1007/978-3-319-24612-3_1922

3. Dissociative disorders. (n.d.). DSM Library. https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x08_Dissociative_Disorders

4. Spitzer, C., Lübke, L., Müller, S., Conrad, R., & Gallinat, C. (2023). State and trait dissociation in pathological skin picking. European Journal of Trauma & Dissociation, 7(1), 100317. https://www.sciencedirect.com/science/article/abs/pii/S2468749923000066