Alexithymia and Skin Picking: What’s the Connection?

Dr. Dawn Ferrara
Oct 25th, 2022

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Body-focused repetitive disorders (BFRBs) like skin picking and hair pulling are characterized by repetitive behaviors that cause injury to the body such as skin lesions or hair loss. The resulting damage impacts emotional well-being, and self-esteem, leading to difficulties in interpersonal functioning.  

While not completely understood, it is thought that for people with BFRB’s, like skin picking, their ability to regulate their emotions effectively is impaired. Known as emotional dysregulation (ED), it is the inability to respond to and manage emotions in healthy ways. ED involves the repeated use of maladaptive strategies (e.g., skin picking) as a way to regulate emotions. Those strategies may alleviate the distress in the short term, but they ultimately result in further emotional and physiological distress or contribute to physical, personal, or psychosocial distress. Over time, it becomes a repetitive pattern.

Emotional dysregulation can be influenced by a number of things including certain personality characteristics. In fact, personality traits have been associated with picking and pulling styles and may be predictors of BFRBs like skin picking.

Alexithymia might be a trait you’ve not heard of before but it’s one that researchers think may be a key player. A new study takes a closer look at this lesser-known personality trait and just how it might be related to skin picking.

What Is Alexithymia and Why Is It Important to BFRBs?

Alexithymia is a personality trait characterized by an externally oriented cognitive style.  People with alexithymia can have difficulty recognizing or expressing what they’re feeling. It is also associated with difficulties in emotional regulation.

Studies have found that people with BFRBs like skin-picking and hair pulling (TTM) have higher rates of alexithymia than people who do not have the disorder, and in some cases, may even be related to the severity of the BFRB.

We also learn to recognize and understand emotions by interacting with others. Being able to interpret facial expressions and other cues helps us to interpret what someone is feeling and adjust our behaviors accordingly. It’s part of forming healthy connections with others. How we do that relies on something known as the mirror neuron system. Mirror neurons are a complex system of brain cells that respond in the same ways when we do something and when we see someone else do the same thing. For example, when you see someone laughing, the mirror neurons you have for laughing fire, allowing you recognize the feelings and sensations associated with laughing. Why is this important to understanding skin picking?

Alexithymia and difficulties with facial emotional recognition (FER) have been found in other disorders including obsessive-compulsive disorder. BFRBs are classified as OCD-related disorders. While research has found an association between alexithymia and BFRBs like skin picking and TTM, there have been no studies looking at FER. Do people with skin picking or TTM have problems with FER as well?

In what is thought to be the first study of its kind, researchers found several key indicators that suggest FER may be a problem associated with BFRBs, especially skin picking:

  • Poor total FER accuracy and higher alexithymia were present for both skin picking and TTM
  • Difficulty identifying feelings, difficulty describing feelings, and alexithymia were higher for both skin picking and TTM
  • Participants with skin picking were significantly less accurate with recognizing disgusted (negative) facial expressions and total FER. Interestingly, there was no difference in FER between the TTM and healthy control group.

What do these findings mean? The researchers suggest that while skin picking is not the same as OCD, it may be more closely related to OCD than other BFRBs. The more common compulsive (focused) subtype and the difficulty in recognizing disgusted facial expressions, which is similar to OCD, may be specific to skin picking.

The Takeaway

This study is thought to be the first to explore the connections between alexithymia, facial emotional recognition and BFRBs skin picking and hair pulling. It seems to support that while BFRBs share a number of similarities, there are unique differences that can impact treatment.

Understanding the relationships between alexithymia, social cognition and emotional recognition may help to guide the treatment and therapeutic options for people living with skin picking and other BFRBs. While more research is needed, studies like this add to the understanding of skin picking and shine a light on the importance of finding individualized, effective treatments.


1. Alexander, J. R., Houghton, D. C., Bauer, C. C., Lench, H. C., & Woods, D. W. (2018). Emotion regulation deficits in persons with body-focused repetitive behavior disorders. Journal of affective disorders, 227, 463–470.

2. Prochwicz, K., Kłosowska, J., & Kałużna-Wielobób, A. (2018). The relationship between emotion regulation strategies, personality traits and skin picking behaviours in a non-clinical sample of Polish adults. Psychiatry research, 264, 67–75.

3. Aydin, E. P., Demirci, H., Begenen, A. G., Kenar, J. G., Altunay, I. K., Ozer, O. A., & Karamustafalioglu, K. O. (2022). Facial emotion recognition difficulties may be specific to skin picking disorder but could also be related to the presence of alexithymia in trichotillomania. The European Journal of Psychiatry, 36(2), 130-136.

4. Science Direct. (n.d.). Alexithymia - An Overview. Retrieved from,et%20al.%2C%201976)

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 Psychiatry, 41(3), 238-245.

6. Rufer M, Bamert T, Klaghofer R, Moritz S, Schilling L, Weidt S. Trichotillomania and emotion regulation: is symptom severity related to alexithymia? Psychiatry Res. 2014;218(1−2):161−5.

7. Perry, S. (n.d.). Mirror neurons. Retrieved from

8. Roh, D., Kim, W. J., & Kim, C. H. (2011). Alexithymia in obsessive-compulsive disorder: clinical correlates and symptom dimensions. The Journal of nervous and mental disease, 199(9), 690–695.

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.

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