Compulsive skin-picking refers to excessive scratching, picking, gouging, lancing, digging, rubbing or squeezing of normal skin or skin with minor surface irregularities. It’s known by a variety of different names, such as ‘pathological skin-picking’ or ‘psychogenic excoriation’. It can cause significant distress and disability and may lead to visible disfigurement and chronic infections.
Compulsive skin-picking (CSP) is a fairly common feature of body dysmorphic disorder (BDD). It is sometimes a symptom of obsessive compulsive disorder (OCD) – for example when there is a desire to get rid of contamination under the skin. It is also a feature of borderline personality disorder when it is a form of self-harm.
People who pick their skin usually have healthy skin or minimal acne. They target pimples, scabs, mosquito bites, ‘large’ pores, ‘bumps’, ‘small black dots’, ‘white dots’, ‘ugly things’, ‘cysts’ or apparent imperfections or dirt, pus or ‘impurities’ from under their skin. More often than not, individuals with CSP have healthy skin, or at least they had healthy skin until they picked. If you have CSP then you might be using your fingernails to pick, pinch or squeeze your skin. You might use utensils such as tweezers, needles, pins, razor blades, staple removers, or knives to pick. The damage caused by skin-picking ranges from red patches, swelling, blisters, denuded areas and crusts to cuts and scars.
Sites chosen for picking are those that you can reach with your hands. The face is the most frequent site for picking. Other popular areas include the back, neck, scalp, ears, chest, cuticles, hands, arms and legs. It may lead to marked scarring, infections and visible disfigurement on the skin. You are likely to avoid activities that involve letting others see damaged skin such as intimacy, sexual activity or sports. You might be trying to camouflage yourself with cosmetics, clothing or bandages to cover the damage on your skin. We understand that most people are extremely ashamed of their picking and don’t want to do it. Some people become housebound or suicidal because of their picking.
Skin-picking tends to occur in the evenings and, for women, either pre-menstrually or during menstruation. The most common trigger is standing in front of a mirror or touching your skin when you are alone at home. Other triggers include a feeling of itchiness under your skin, or a sensation of something underneath the surface of the skin.
Physical complications of skin-picking can include bleeding, infections, ulcers, permanent discolouration, and scarring that is disfiguring. This in turn leads to further scabs or imperfections, which become a further target for skin-picking, creating a vicious circle. The complications can require dermatological treatment for which you should seek advice. If inflammation is a problem then dermatological treatment can help (e.g. hydrocortisone) or Eurax cream (hydrocortisone and crotamiton) and decrease the sensation of itching. Dry skin should be moisturized regularly (e.g. using Eucerin). Don’t be ashamed to reveal you have a problem with picking – doctors are used to seeing such problems. If, for some reason, they do not seem to understand, you should think about seeing a different doctor.
In addition to skin-picking, people often have other repetitive behaviors such as nail-biting, hair-pulling (trichotillomania), lip-biting, knuckle-cracking, cheek-chewing or body-rocking. These are all habit disorders which can be treated in a similar way to skin-picking. Research into skin-picking is limited but the recommended treatment consists of a type of behavior therapy called self-monitoring and habit reversal, which we describe below.
QUESTIONNAIRE 11.1: UNDERSTANDING THE PROBLEM OF SKIN-PICKING
The first step in overcoming skin-picking is to have a good understanding of the problem.
1. How old I was when I first started skin-picking?
2. How old I was when skin-picking first became a problem?
3. What was happening at the time my skin-picking started (e.g. acne or a stressful event)?
4. Which areas of my body do I tend to pick?
5. What do I target for picking (e.g. pimples, scabs, mosquito bites, scars, healthy skin)? Has this varied over time?
6. What methods have I used to pick (e.g. fingers or fingernails, scratching, squeezing, razors, picking, digging or lancing with pins, tweezers)?
7. What are the typical times of day when I pick and how long does each episode last for?
8. Why do I want to stop picking now? Am I ready to stop?
If you are ambivalent about stopping, you might find it helpful to do a cost–benefit analysis? What are the costs and benefits of stopping? What are the costs and benefits of continuing to pick?
A blank version of this form can be found in Appendix 2, page 392, for further cost-benefit analyses.
Like many other sufferers, you might feel ashamed of your excessive skin-picking, thinking that you are odd or a freak, which is likely to make you quite secretive about it. Perhaps you even have a parent, friend, or partner who has already been quite critical of your skin-picking and this further increases your desire not to get caught. This can lead to a destructive cycle in which more of your attention gets focused upon hiding your skin-picking than on overcoming it. To help combat your shame, you need to begin by taking a self-accepting and compassionate attitude towards yourself for having the problem. No matter how alarmed someone else might be about your picking, remember that you are in good company and that it is a recognized problem. With calm determination, you can overcome skin-picking, especially if you can detach from unkind and critical thinking about having the problem.
This section asks you to describe in as much detail as possible the chain or sequence of events that lead up to picking. There are two types of triggers – the events immediately before you start picking and events that make the picking easier or harder to do.
Two types of triggers usually occur before picking – those that are external (i.e. generated outside of you) or those that are internal (i.e. generated inside you). Examples of external triggers include different:
• Settings (e.g. being alone in front of your bathroom mirror, putting on make-up, driving, planning to go out socially and coming out of the shower, being up late at night on a computer).
• Implements (e.g. the presence of a mirror or a pair of tweezers).
• Visual triggers (e.g. ‘looking in a mirror and seeing a scab’).
Examples of internal triggers include:
• Emotional states. Any emotional state can be a trigger for picking or pulling but the most common are being bored, lonely, empty, hurt, or anxious.
• Tactile sensations (e.g. ‘feeling a bump on your skin with your fingers’ or ‘feeling a tingling sensation on your skin’).
• Physical sensations at the site (e.g. an itch, irritation, burning under your skin, or feeling greasy).
• Thoughts. A specific intrusive thought or rumination or image (e.g. ‘my skin is dirty and disgusting and has pus under it, I have to get it out. Maybe the pus has been pushed inwards, or maybe it is just swelling up in preparation for a spot appearing but hasn’t formed yet.’)
We want you to describe in as much detail as possible the chain or sequence of events that lead up to your pick, e.g. ‘I come home feeling tired, I start to think about my skin, I then feel for bumps with my fingers, I go to the bathroom and look for imperfections in the mirror. I see a mark’ or ‘I start doing my homework in my bedroom, I’m feeling bit bored, and I get a tingling sensation on my skin, I have a thought – that sensation means there is something that shouldn’t be there and my hand goes up to my face’.
Describe in as much detail as possible your particular chain of events. There may be several different scenarios you need to describe. If so, continue on another sheet.
How aware are you of the triggers before you start picking or during your actual picking? Is the picking done ‘on auto-pilot’ (where you have little awareness of what you are doing)? Or is it planned? Or is it a mixture of the two?
The next step is to identify the things that make it easier or harder for you to pick. Examples of external triggers are being with someone or not having a pair of tweezers. Both of these make it harder to pick. However, having a drink might make it easier it to pick. Examples of internal triggers that make it easier include certain postures such as ‘holding my hand near my face’. Thoughts that make picking easier include ‘I deserve this pick’.
What makes your picking easier to do?
What makes your picking harder to do?
Next, write down a detailed description of your actual picking in sequence. There are usually three different stages:
• In the preparatory stage, you might go to a specific place, find your implements, choose a site on the body, inspect or clean the skin excessively.
• In the second stage, you might pick the skin, squeeze it, gouge it, remove and examine it.
• The final stage usually involves getting rid of the skin and perhaps camouflaging it with cover-up sticks or using make-up.
Describe the sequence of what you do in as much as detail as possible.
What are the immediate consequences of your picking that provide a pay-off? For example, you might get a positive feeling of satisfaction from removing a scab; or it might be escape from bad feelings such as feeling lonely or bored or a physical sensation.
What are the unintended consequences of your picking? Examples might include the physical damage, such as ulcers or scarring, or a deep sense of shame or criticism from others.
Examples might include feeling ashamed (which could also act as a trigger for further picking) or because you become aware of the damage you are causing or you are feeling pain. Alternatively, you might finish because a relative interrupts or you have to leave for an appointment.
Having done your analysis, you will now be able to choose the most appropriate steps to take and when to use them. We’ll assume that you are ‘ready’ to change and you want to stop (or at least reduce how often you pick), rather than just wanting to stop feeling ashamed about your picking.
If you are not ready to change, then it won’t work and you may need to talk through some of the benefits and costs of picking with a therapist first.
You may also need to test out your motivation to pick. For example, if you believe ‘I must have smooth skin or I will be rejected’, you can test this belief by seeing whether others do indeed respond to you differently on a day when you feel worse about your skin. You may find that they don’t react to you any differently, or that you can cope with this belief differently.
The first step towards overcoming compulsive skin-picking is self-monitoring. The rationale for self-monitoring is that:
• You increase your awareness of your picking so you are better able to resist the urge.
• You can build on the analysis you have already done and identify different chains of events so it is possible to predict when and where future episodes of picking will occur. Being more aware of the chain of events allows you to anticipate high-risk situations, and therefore to resist the urge to pick.
• You can monitor whether what you do to help yourself works or not by a change in how often you pick.
Try to complete the self-monitoring form overleaf while you are picking or immediately after the picking so it will be as accurate as possible. Do this for at least one or two weeks and keep a record of the number of times you picked each day. When it is frequent you might find it easier to count how often you pick by using a tally counter, which you can order from a website.
You can train your mind to stop picking by using a method called habit reversal. First, you need to identify a ‘competing response’ that is incompatible with picking (for example, clenching your fist, squeezing a ball or sitting on your hand).
Whatever you choose:
• it should be incompatible with the habit
• it should be possible to maintain for a minute or more
• if you are with others you should be able to do it without behaving oddly
• it should not interfere with normal activities
• and lastly it should heighten your awareness that the picking is not occurring.
Practise the competing response at times of the day when you are not picking so that it becomes a habit. It should be held for at least a minute until an urge to pick has subsided. You should also practise the competing response in your imagination and several times a day when there is no urge to pick. In this way it will eventually become automatic and a part of your routine. It is often helpful to practise relaxing and breathing with your diaphragm when the picking urge occurs, before applying the competing response.
Now introduce the competing response as soon as you are aware of your urge to pick. If you start to pick, use the competing response to interrupt the picking or use it as soon as you have finished picking. If the urge persists, then the competing response should be repeated. When you get the urge, just notice the urge and any intrusive thoughts and feelings, without buying into them. Thank your mind for its contribution and quietly ignore it whilst you relax and use the competing response. When you successfully use the competing response instead of picking, give yourself a reward or treat. Make sure you give it to yourself immediately after successfully resisting an urge to pick.
Keep a record of your practice (see overleaf) and the number of times that you use the competing response on the habit reversal form below. Note whether you used the competing response before, during or after an episode of picking. You can also use the form to keep a record of the number of times you practised the competing response when there was no urge to pick.
You should have identified a typical chain of events in your analysis. Although the goal is to use the competing response before the chain begins, you may have to start by introducing the competing response near the end of the chain. With practice, you will be able to add the competing response earlier and earlier in the chain so that it eventually replaces the picking.
It is worth emphasizing that the success of the technique cannot at first be measured in terms of reducing how often you pick but whether you are using the competing response at all (even if you use it after you pick). This is important, as many people will otherwise give up too early.
There are various things you can do to help you relax in the high-risk situations that you identified in your monitoring chart. You could use meditation or exercise, take a warm bath, or use muscle relaxation or diaphragmatic breathing. Have an action plan ready with a list of the activities you can do when you get the urge – for example, do some exercise, make a phone call, bake a cake. Try to distract yourself when the urge occurs (e.g. have a bath or shower (possibly a cold shower); apply an ice pack, especially if you have an itching or burning sensation on your skin; or put on a facial mask).
Some people have found that it is easier to resist the urge to pick by wearing gloves; using artificial (acrylic) nails over their real nails; or cutting their fingernails short. These strategies may also enhance awareness training as they alter the sensations on the skin. Try posting ‘High risk area’ signs at the door of the bathroom and other areas associated with picking.
There are various strategies that can help block the habit by decreasing the opportunity to pick, for example agreeing not to touch your skin unless it is for an agreed activity; wearing bandages on the fingers used for picking; wearing white cotton dermatological gloves in bed or other high-risk areas; keeping your nails trimmed and smooth. Some people have enlarged a photo of the area of picking, taken at its worst, and kept it by the most common locations for picking.
Others have used a reminder of all the unintended consequences of picking, which you can easily read in locations where you are likely to pick.
Try to disrupt the chain of events in your daily routines that lead to picking. This might mean altering the settings in which you pick to disrupt your opportunity to pick and reducing the time spent in high-risk areas. For example, you could:
• remove or temporarily cover mirrors (especially magnifying mirrors) or bright lights
• wear dark or tinted glasses when around mirrors
• remove any glasses or contact lenses before looking in a mirror
• give the equipment you use for picking to a significant other or throw it away
• switch grooming and applying make-up to times of the day when they are less risky
• stay out of certain high-risk area rooms or find an alternative
• tell a significant other(s) about your picking and allow them to point it out when you pick
• reduce time spent alone and use a different routine
• use plasters and petroleum jelly or antibiotic ointment on scabs and skin to aid healing
It may also be necessary to replace or increase stimulation in your fingers in high-risk situations. This can include activities such as knitting, crocheting, embroidery, sewing; playing a musical instrument (or taking lessons); stroking or massaging a pet; playing with Silly Putty or squeezy balls; popping the bubbles on bubble-wrap; playing with worry beads; playing a video game that requires the use of both hands on a controller; nibbling food (e.g. sunflower seeds); or taking a facial steam bath (to provide a feeling that impurities are being removed from your face).
You might be able to decrease the likelihood of picking by the use of a penalty. This should be used as a last resort but, if you do, use it immediately after picking. You could, for instance, donate a set amount of money each time you pick to your most hated organization. This is an under-researched strategy so we would be interested to hear of your outcome.
When you are ready, and have managed to stop picking for a few months, try re-exposing yourself to those situations that are associated with picking. You should begin with low-risk situations for short periods of time (e.g. up to 5 minutes). You can then gradually increase the time and location, eventually reaching high-risk situations. Continue to resist the urge to pick, and try to visualize your desired outcome instead of picking.
Sharon is 29 years old. She usually picks her skin in the bathroom mirror at night when her boyfriend is asleep and she has privacy, or when she has just come home and checks her skin when she feels feel dirty and tired. This is more likely to occur if she feels anxious, bored, brooding, hurt or frustrated. When she sees or a feels a spot or blemish, immediately she will squeeze it and it will lead her to check and squeeze the rest of her face. Sometimes she will feel a scab in the morning in bed and mindlessly pick it, even if it has not healed. Touching and looking at scabs often will lead her to pick it off before it is healed (which then leaves a scar and a further bout of squeezing and scabs). Physical sensations such as feeling greasy or throbbing will also make her more likely to pick. Her picking might also start while feeling her face for small imperfections which is done automatically with no intention of picking. The problem becomes more voluntary if she happens to find a blemish. She then becomes like a shark smelling blood, something else takes over and she feels she cannot stop.
She will not squeeze in front of others (apart from very superficial squeezing in front of a family member). The absence of tweezers will probably help for the rare occasions that she might use them. The absence of mirrors or hand compact and bright lighting helps her not to pick. If it is hot and humid and she feels sweaty, then she feels her skin gets spottier and so her urge to squeeze it increases. She then thinks her skin is greasy and pus is gathering under the skin and her skin is getting out of control. If she aimlessly puts her fingers over her skin, that encourages picking. If she has scars forming, then she tells herself that she will allow herself to just pick at one spot, as if to appease her craving. Unfortunately this always triggers further picking. Very occasionally if she has resisted the urge to pick then she thinks she can reward herself and release the tension and allow herself to squeeze. Initially it feels like a relief, but it is short lived as this prompts further picking and she then feels deflated and angry with herself.
When she does pick she just squeezes it with her fingernails. Usually she will squeeze it a bit more than necessary to ensure everything is out. If it is deep down, sometimes she will scratch off the first layer of skin with her nails and then squeeze it, so it has a way of being expelled rather than sinking deeper. If the pus will not come out, sometimes she makes it worse when she really scratches at her skin till it bleeds and she presses the flesh together to squeeze it in a very violent way. Sometimes she will use tweezers to pluck the flesh and hairs away. The amount of stuff becomes insignificant and laughable when she see how little it is, but she feels satisfied as it is no longer feels under her skin. If it has been an insignificant picking session that hasn’t caused much damage, she will usually just splash her face with cold water and cover up the spots with make-up and go to sleep (so that her boyfriend will not be able to see her spots in the darkness.) But if she has caused a lot of damage to her face, usually she will have to wash her face, and apply make-up for hours, in between holding a tissue or cloth to her wounds to soak up the fluid. She has to stop the fluid flowing so that she can apply the make-up powder in a way that it sticks.
The immediate pay off is a sense of satisfaction if she has squeezed a lot of pus out, especially if it is a ‘problem spot’ which means one she has been trying to expel the pus from for a while but been unable to. Very occasionally if the squeezing is straightforward and not messy, and hasn’t left any significant damage or red marks, she feel extremely proud of herself that she has managed to clean up her face without losing control and hurting herself.
However, the long-term consequence is shame and anger against herself. This just triggers her to pick more. Ultimately what usually stops her is when she is feeling out of control in her picking and there is nothing more to squeeze, making her face an absolute mess. In these cases it is not shame or realization of damage that stops her. It is simply impossible to squeeze anything else out.
Sharon found the functional analysis helpful in making sense of her compulsive skin-picking. The act of selfmonitoring started to make her more aware of her picking and times of vulnerability and how her picking became a self-perpetuating cycle. She found it particularly helpful to identify frequent chains of events that inevitably resulted in skin-picking. Having identified the chain of events, she found it important to talk to her boyfriend and get his support in encouraging her to go to bed earlier. She would also talk a friend on the telephone or have a cold shower in order to disrupt the chain of events when she came home and felt vulnerable. She found it helpful to have a Turkish bath at a gym so she felt that impurities were being removed. Of course it was not all plain sailing and there were frequent setbacks. However, she practised habit reversal as soon as she was aware that the chain had begun. At first she practised clenching her fist after she had picked and in situations which did not lead to picking. She then gradually managed to increase awareness of her actions and to implement habit reversal at an earlier stage, so that eventually she was able to use it before she picked. Her skin improved and she had help to reduce her self-consciousness learning not to engage with her intrusive thoughts and images.
