This is the first in (hopefully) a series of interviews about the skin picking disorder with leading researchers and academics in the field Jan 7, 2009
David: I first got to know your name from your website (http://grossbart.com), while searching for info about Dermatillomania online, a few years back. I noticed that you have a chapter in your book (SkinDeep:A New Mind/Body Program for Healthy Skin) that is dedicated to this disorder. Besides that, I found a few articles scattered around the internet about this disorder, but I couldn’t find one trustful resource that is dedicated to skin picking, so I decided to build one. At that time I didn’t have an idea about how many people actually suffer from it… actually this is one of the things I wanted to talk to you about – I’m not really sure how wide spread this disorder is, I mean what I see is only the online statistics, but I guess not everybody looks for it online, and not many really know the specifics of the terminology at all
Dr. Grossbart: Yeah that’s true, there are a few “labels” to it, but this disorder isn’t even included in the diagnostic manual. My hunch is that it’s a hidden epidemic. I think that there’s an enormous number of people out there (I won’t even begin to guess how many), it’s totally underreported, it’s not the kind of thing people are talking about at cocktail parties, and even in terms of the popular press I think there’s been a little bit of interest. I’ve actually tried to approach several magazines, and a few a articles had been published and it had some success, but in general there’s the “yuck” factor, people are kind of put off, it doesn’t seem to be an “official” disease, and I think we’ve got a lot of work to do. I think that the TLC (trichotillomania leaning center) – the fact that they are now involved with skin picking is a big plus. Other than that, if you don’t have an organization, if you don’t have the equivalent of the national cancer society or national psoriasis foundation, doing both publicity and lobbying for research funding, professional education and so on, it’s a problem.
David: yeah that’s exactly what I was trying to do. I mean, I’m not an organization, I’m just one person, and I researched this subject all by myself, consulting professionals here and there.. but I’m hoping that this site gives info to people and spreads the word as much as possible.
Dr Grossbart: Yeah I think it’s a terrific contribution and people need all the help they can get. I think more and more work gets done in the professional medical literature, and people are pushing to get it included in the diagnostic manual, but that’s not something that is going to be particularly useful to an individual who’s looking for help.
David: I think it resembles a “circle” , because if it gets into the diagnostic manual, and on the other end this disorder gets exposed in the media, then people will both know about the existence of this disorder, and will be able to get it diagnosed and get help
Dr Grossbart: Exactly, yes, one piece of momentum leads to another piece of momentum. I’ve had a number of people say “I didn’t know it was a real disorder, so I didn’t know I could get real help, I just thought I was weird”.
David: Would you say that most of the people who turn to you for help don’t know what they’re suffering from?
Dr Grossbart: Well, I get a lot of referrals from local dermatologists, where there has been a preliminary discussion with the dermatologist, so these people have some level of awareness. This includes also people who found me through my site, and did some reading on this subject. But there’s certainly a number of people who not really long ago didn’t know what they were dealing with. Another thing people will often say is “I feel it’s my own fault, I’m doing this to myself” therefore don’t feel they deserve serious help.
David: let me ask you the most important question there is (it’s even more important than the question “how to stop picking” in my opinion) - why is this happening? It is a total mystery to me. I mean it doesn’t seem to be just an ordinary disease, where you got some chemical imbalance or whatever, and it gets expressed in ways of lesions and sickness. it’s actually the “you do it to yourself” case, as your patients say
Dr Grossbart: Part of the problem is that there are a few paths that lead to this certain behavior, so I don’t think it’s a single thing. If you get 10 different people who are picking, there may be 5 different underlying patterns that are leading to it. I think there probably is some hereditary factor. They certainly have found some genetic links with hair pulling (Trichotillomania), so it would be not be a big leap to think that there may be some similar ones with picking. Dermatillomania is classically listed as an OCD spectrum disorder, but this doesn’t go along with some of the research going on, and some of the things I learned from my practice. Some patients do fit the OCD profile extremely well, others really do not. I think this again is telling us that there’s no a single path to get there.
David: Could you say that it’s mainly a “mind” problem, or is it mainly a “biological” problem?
Dr Grossbart: I think it’s both simultaneously. If somebody picks when they’re anxious, or picks when they’re depressed – well, those are biological events, AND psychological events. So I think it’s the old “mind-body” problem, and what’s real important in this case is to identify which one affects more, so that we can treat the problem
David: which brings us to the second question, which is about treatment: I know that some people recommend medications, and others recommend habit reversal training (HRT), from your experience which methods have proven most effective?
Dr Grossbart: Well, what I tell people is that it’s a very stubborn disease. You’ve got to come at it with a number of ways simultaneously, it’s sort of shotgun approach. Typically people will have tried one thing or another, it would have worked for a little while and stop, so they throw it away, or it works a little but not enough and they throw it away… I think that if you can find 10 things that work 10 percent then you’re there. I’m very big at pulling out as many resources as possible, let people try them, and build their own toolbox. In general, as for medication (and I don’t prescribe it myself) it seems to certainly help some people, and doesn’t seem to help others. The statistical studies on medication are not that impressive. So if somebody wants to try it, if they’ve got underlying depressive issues or anxiety issues it might be helped by medication. Often times it does help with the depression / anxiety, but not with the picking. So, medication should be on the list, but with real reservations. I think HRT is a vital component, and I kind of giggle [giggles] because I’ve been dong HRT before there was HRT, before the label existed, and I think it’s a vital and essential part of the toolbox, but again I don’t think any one thing is going to be the answer. A number of CBT techniques are very useful, but for a lot of people there’s a real need to look at the feelings underneath, and at the personal history that’s getting played out. One thing that I’ve seen perhaps more often than any other pattern is when people who pick on themselves have been in one sense or another picked on growing up. It may have been in the school yard, but more typically it’s a critical or perfectionist parent, or in some cases physically or sexually abusive parent, or sibling. This type of pressuring behavior can start the pattern of picking, as what starts on the outside then becomes incorporated on the inside as the person becomes brainwashed to this critical, picky point of view on themselves. I think that this type of understanding, which is basically psychotherapy, has been extremely useful. On the other hand, some of the very mechanical behavioral techniques (putting bandages on your fingers, or putting a tiny light bulb in the bathroom on the bathroom mirror so that you can’t do the scrutinizing) and other things that just break the pattern, are extremely useful as well.
David: have any of your patients stopped picking 100% and forever?
Dr Grossbart: Oh, absolutely! Yeah, I’ve had people who have got to the point that it [picking] is history, it’s not like they’re fighting it successfully inch by inch, but they’ve really turned the corner and don’t even think about it. I recall one girl I was just curious, I called her about 6 months after treatment just to find out what’s going, and she said :”yeah yeah I’m glad you called, I actually forgot all about it and that I ever used to do it!”. That is realistic for some people. Roughly a third of the people are able to do some complete or nearly complete turnaround. About a third get improvement, get more tools to use, but it’s an ongoing struggle. And about a third of the people I see don’t show any improvement and don’t get value form therapy.
David: I think I recall seeing in the article you’ve previously sent me that one of the methods that effectively treats Dermatillomania is Hypnosis?
Dr Grossbart: Yes, that’s an interesting one, and one that there are a lot fewer people that are trained at, and really understand it and do it. I actually did a couple of hypnosis workshops at the TLC conference in Chicago. It’s something you don’t read about as much, and it isn’t a standard. A substantial majority of people with picking problems go into a trance state as they pick. People often think they’re picking for 5 minutes, and then they realize they’d been picking for half an hour or more. During this time they are in this kind of state of focused concentration, either conscious or unconscious, as they pick. What that is telling us is that they are already in the hypnotic realm, but they are not taking control over that tendency of going into a trance state. They’re not using it as an asset, they are using it for “negative” hypnosis. But in fact people who are prone to the negative version, are also more adept at the positive version, cause it’s basically the same “pipeline” but with different contents. So I routinely teach people how to do hypnosis, or particularly self hypnosis with tapes, that people do between sessions, and if people are overseas or in other parts of the country, they are able to record a tape over the phone, and that’s an extremely useful part of the treatment.
David: So, how does it work? What is on these tapes?
Dr Grossbart: Well, part of it is going into a relaxed state, part of it is using hypnosis in conjunction with a version of HRT, with the idea that habits are neither conscious nor unconscious, but somewhere in between. Hypnosis just seems to let us talk to that [unconscious] part of the brain. So some of it is about going into this state of conscious concentration, and then using it to observe what sorts of emotional states are triggering the picking, to use it to enhance the HRT and then if there are family dynamics underlying issues that you need to stay more conscious of, to reinforce that as well. So that if there is [for example] an abusive parent in the past, to really bring home the idea that each time you decide to pick or not pick it’s like you’re voting for yourself or you’re voting for a dictatorial regime that’s hurtful to you. Hypnosis has been used around problems like smoking, weight control and a range of medical disorders, so it’s a question of really adapting these techniques to picking.
David: Dr Grossbart, thanks a lot for your time, I’ve got a lot more to ask, but we’ll save it to another time.
Dr Grossbart: You’re welcome, I enjoyed talking to you and will gladly do this again in the future.