Excoriation: When Skin Picking Is a Mental Health Issue

Shoulder and torso view of a person scratching their arm. The person is wearing a magenta top and has shoulder-length hair.Do you feel compelled to remove flakes of dead skin from your nose? Do you have a hard time keeping your hands off pimples and blackheads? What about those random bumps on your arm that arise unexpectedly? For people diagnosed with excoriation disorder, skin picking is a common response to these and other generally harmless skin irritants.

According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, excoriation—which falls under the umbrella of obsessive compulsion—is characterized by recurrent skin picking resulting in some sort of skin lesion; repeated attempts to stop the picking; potential impairment or distress over the picking; and an inability to attribute the skin picking to a medical condition, substance abuse, or another mental health diagnosis. Like hair pulling and nail biting, research suggests that excoriation may be a body-focused repetitive behavior (BFRB).

Most people who pick can typically find multiple sites on their body to pick, squeeze, or scratch. It is often a search-and-find mission using fingernails or some other designated instrument. The result of the picking can be inflamed, red, and sometimes bloody skin. When scabs develop, they may represent another reason to pick.

People who pick their skin often are ashamed and feel the need to conceal excoriation through the use of makeup, extra clothing, or hats. The shame may add to the distress they feel regarding their appearance or their behavior toward their body. Often, there is an undercurrent of perfectionism with BFRBs, especially skin picking, and a deeply held belief that any imperfections must be eliminated.

Often, therapy will address underlying feelings and emotions that fuel the behavior, exploration of triggers that affect when and where the person picks, and soothing strategies to deescalate compulsive behaviors.

Would you be surprised to know that more than 75% of people diagnosed with excoriation are female? It is estimated that excoriation affects 1.4% of the general population, although many experts think the number may be higher. Most often, the condition begins at the onset of puberty and becomes chronic over time.

Skin picking may be triggered by tension, stress, or boredom and often has a compulsive element to it, meaning the person cannot stop themselves from picking and feels compelled to either relieve uncomfortable feelings or respond to minor skin irritations. Most often it occurs without full awareness of the behavior and when the person is alone. While reading, studying, on the phone, or watching television are all common scenarios for excoriation to occur. Many people spend up to one hour per day picking or resisting the urge to pick. Often, another person has noticed and mentioned the behavior.

Treatment for skin picking is often found in cognitive behavioral therapy, dialectical behavior therapy, rational emotive behavioral therapy, or acceptance and commitment therapy facilitated by a licensed mental health provider. Often, therapy will address underlying feelings and emotions that fuel the behavior, exploration of triggers that affect when and where the person picks, and soothing strategies to deescalate compulsive behaviors.

Those with BFRBs may also find relief with tactile and meditative strategies. Tactile replacements may be helpful in providing substitute relief and can include bubble-wrap popping, fidget toys, cooking, working with clay, painting, or even using a piece of ribbon as a soothing instrument to wrap, rip, and stroke. Meditative behaviors such as yoga, cleaning, walking, or listening to music can also be effective in soothing the urge to pick.

Although excoriation is a complicated and often distressing behavior, it is manageable with professional treatment and replacement behaviors.

References:

  1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author.
  2. OCD & Related Disorders Program. (n.d.). Excoriation. Retrieved from https://mghocd.org/clinical-services/excoriation/

© Copyright 2016 GoodTherapy.org. All rights reserved. Permission to publish granted by Angela Avery, MA, LPC, NCC, therapist in Clarkston, Michigan

The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the preceding article can be directed to the author or posted as a comment below.

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  • Beth

    Beth

    August 2nd, 2016 at 11:54 AM

    How would it ever not be considered a mental illness?

  • Eve

    Eve

    August 3rd, 2016 at 7:39 AM

    I would like to know is this is related to hair pulling. I have a niece who pulls out her own hair and her parents are worried sick about it.

  • Donna

    Donna

    August 6th, 2016 at 1:13 PM

    Yes Eve, hair pulling (trichotillomania) is a body focused repetitive behavior (BFRB). Tell your niece’s parents to stop worrying and to get her in with a skilled therapist with specialized training in treating BFRB’s Thanks for asking the question! Early intervention makes a world of difference.

  • Corrine

    Corrine

    August 4th, 2016 at 4:57 AM

    Omg I’ve been doing a lot of skin picking and hiding it out of shame , I actually thought I was going mad but to read this article has helped me.I am a suffer from depression and anxiety all my life but has reached a high over the last two years.

  • blakely

    blakely

    August 4th, 2016 at 11:14 AM

    I am not at all surprised to read that this is something that mainly impacts females. I think that we are just naturally prone to looking for imperfections and trying to uncover ways to remove those from all facets of our lives. I think that this is probably just one of those ways that this manifests.

  • AndrewA

    AndrewA

    August 6th, 2016 at 11:31 AM

    My sister started doing this as a teenager and she is now 30 and even though she has sought help and got treatment I can assure you that the compulsion is still there, especially when she gets into a situation that does not feel comfortable to her. I feel so bad for her because she knows that she causes sores and sometimes people can be so mean and stop and stare but i swear I still think that there are times when she doesn’t even realize what she’s doing.

  • Stacy

    Stacy

    December 8th, 2017 at 3:32 PM

    It helps a tremendous amount when you join communities of people with the same problem like reddit.com/r/Skinpicking/ , trust me

  • Paul

    Paul

    August 8th, 2016 at 4:30 PM

    I understand that this is a compulsion that can’t always be controlled, but wow, there are so many dangerous germs and bacteria that you could contract as a result that this would be all it took for me to stop doing this immediately. If you just think about all of the germs that you could be introducing into your body by doing this…

  • Heidi

    Heidi

    February 7th, 2017 at 8:38 PM

    My dad had been picking since my mom died. He’s already been hospitalized for an infection he got by picking an ingrown toenail that first became infected and then became cellulitis. His doctor just tells him to stop and doesn’t back me up when I suggest a geriatric psychiatrist. It’s gotten worse as his thin has gotten thinner as he’s aged. I try to distract him with alternatives like applying bandaids and cream to his very dry skin. But latelely he’s been drawing blood to the point that all his bedding has blood all over and I throw a shirt a week away. Is leaving the blood on his blanket a bad idea as long as I keep it clean so he can see what he’s doing? He thinks psychiatrists are all quacks and won’t go so I’m at a loss there. Help!

  • Victoria G.

    Victoria G.

    October 13th, 2017 at 3:42 AM

    I wouldnt suggest leaving the blood on the sheets for me this increases a weird gratification. I pick sores on my head that I have created myself due to continous picking at skin. I find that I like to see the bits i pick off, put them on black backgrounds to make them stand out, the bigger the better. The worst is when one feels so painful and satisfying only to find out it was tiny

    This is all very disgusting I know

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