Stopping compulsive skin picking: the Carrot or the stick?

Tasneem Abrahams
Jul 25th, 2016

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Dermatillomania, also known as excoriation or skin picking is when a person compulsively picks away at their skin, leaving their skin marked with scars. People who have dermatillomania are driven to pick at their skin for different reasons. Some may pick their skin in times of stress or anxiety, starting with picking at acne, finding that it is pleasurable and may even relieve their anxiousness. Dematillomania is viewed as a coping mechanism that people engage in to cope with emotional or psychological distress that they cannot verbalise. The most commonly picked areas on the body tend to be the face, and the condition affects more women than men. People with dermatillomania can pick at their skin at different times during the day, or spend hours picking at one area with their fingers, or even with tweezers and needles. Excessive picking can result in sores, scars, complications, and even infections, and result in shame and guilt around this condition such to the extent that people who pick at their skin feel ashamed to ask for help.

Is dermatillomania an addiction or just a bad habit?

It is for this reason that dermatillomania, classified in the Diagnostic and Statistical Manual under obsessive compulsive and related disorders, is seen as a clinical compulsion or related to mental illnesses, and not just a bad habit.  Bad habits can be easily broken, but addictions take more time to resolve as it requires a shift in behaviour and thinking. Research has found that treating dermatillomania as a compulsion, using similar methods to substance abuse treatment, could prove to be successful. 

This is because similar behaviour that leads people to engage in substance abuse are seen in dermatillomania. The similarities between the two are that people who pick at their skin feel an uncontrollable urge to engage in the behavior. However, that seems to be where the similarities end, as an addiction is an activity the person develops a physiological or emotional dependency on and often while engaging in the behavior, do not have insight into the harmful effect at the time of engagement. Whereas in contrast, people with body-focused repetitive behaviors (BFRBs) such as compulsive skin picking, are aware it is harmful even while they are engaging in the behavior and want to stop, but seem to be unable to stop. Never the less in bosth instances, mere willpower alone is not enough to simply stop skin picking not stop an addictive behavior. Strategies need to be developed to address this condition, similar to how people with addictions need rehabilitation interventions to help them.

Positive vs negative reinforcement

There are a number of therapies used to address dermatillomania, as well as other forms of compulsive disorders, namely psychotherapy in which people talk about the underlying feelings and that may be contributing to their need for a coping mechanism, and cognitive behavioural therapy which looks at strategies to help people change how they think and act to help them understand why they pick at their skin, and how to stop it.

Within the cognitive behavioural therapy are strategies such as habit reversal therapy that helps people to change their automatic inclination to pick at their skin, and the positive and negative reinforcement approach, which takes behavioural psychology into account.

The positive and negative reinforcement approach takes the view that positive reinforcement resulting in the desired outcome, in this case no skin picking is rewarded. Negative reinforcement on the other hand, penalises the person for not achieving the desired outcome.

What is more effective - the carrot or the stick?

A person with dermatillomania could be encouraged through positive reinforcement to stop picking at their skin if they know there is a reward for not picking at her skin. This reward could be in the form of receiving a monetary reward or bonus points that could be converted into cash or something like getting to travel to a new destination for each time they don't pick at her skin. This method is often used as a behavior modification tool with children and teenagers and is commonly referred to as the reward system. With children the reward system could take the form of a sticker chart or a peg system, where the child receives a sticker or a peg for each pre-determined period of time he or she is able to abstain from picking. the child then works toward an end goal by building up enough rewards toward a bigger reward.

In contrast, if the child picks at their skin, they risk losing points for that day or do not get to do what they would have otherwise been rewarded with, and this is negative reinforcement at work. Theoretically these reinforcement strategies should result in the natural stopping of skin picking through an automatic response associated with the positive and negative aspects of the reinforcement strategies.

This type of behaviour reinforcement is known as operant conditioning, which focuses on positive or negative learning techniques to shape the desired behaviour in a situation. It is important to note that negative reinforcement in this case does not mean punishment, for punishment is associated with being punished for doing something you are not supposed to do. It is also a form of making small, incremental changes each day until the behaviours leading to the desired outcome - no skin picking - are learned and become natural, just like how one learns to brush teeth every night before going to bed.

The drawback of positive reinforcement is that research has shown that people can get too dependant on the rewards to an extent they have a hard time adjusting to normal day-to-day life when this rewards system is removed. This is known as developing an external locus of control. This is therefore not ideal for use with adults, but in children who have not yet developed the abstract thinking skills to reflect on why they are picking or how their thoughts and feelings influence each other and their behaviors, behavior modification my be very effective. Research has also shown that while negative reinforcement seems to be effective in the beginning in getting people to change their dermatillonia behaviors, long-term negative reinforcement does not help to stop the skin picking completely as it can become demotivating and further reinforce negative feelings often felt by skin pickers toward themselves.

A holistic approach

The trick in ensuring that positive and negative reinforcement strategies are successful, is to implement them in such a way that a good balance is struck such that one strategy is not favoured above the other. Again, it must be remembered that people respond differently to different stimuli and this needs to be taken into account when looking at ways to help people stop picking at their skin and break free of the wrong thinking around misperceptions they have about themselves that helps them to lead happier, more fulfilling lives. cognitive behavioral therapy has consitently been found to be the most effective form of treatment for body-focused repetitive behaviors. There are various modalities, some of which focus more of behavioral modification as in Habit Reversal Therapy, and others that focus more on acceptance of self and learning how to cope with negative emotions in more constuctive ways, such as in Acceptance Based Therapy. While not every treatment will have the same results for each person, the ksy to is look at the disorder holistically and treat each person individually based on their unique treatment needs.

Tasneem Abrahams

Tasneem is an Occupational Therapist, and a graduate of the TLC foundation for BFRBs professional training institute. Her experience in mental health includes working at Lentegeur Psychiatric hospital forensic unit (South Africa), Kingston Community Adult Learning Disability team (UK), Clinical Specialist for the Oasis Project Spelthorne Community Mental Health team (UK). Tasneem is a member of both the editorial team and the clinical staff on Skinpick, providing online therapy for people who suffer from excoriation (skin picking) disorder.

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