Not all skin picking is the same.

Everybody picks their skin sometimes, right?  If you tell your friends or family that you pick your skin, many of them might say “Oh, I do that, too”.  So, how do you know if your skin picking is severe enough to warrant a diagnosis of Dermatillomania, also known as Compulsive Skin Picking or Chronic Skin Picking (CSP)?

There are a variety of ways in which assessment of skin picking occurs. Self-assessment might occur by the person doing the skin picking when an individual realizes that he or she is causing scabs, scars, and/or infections. A person with Dermatillomania may also be aware that he or she is avoiding social situations, including work, school, and/or social functions such as weddings and parties.  After all, those who have picked to the point of bleeding and scabbing may be too embarrassed to be seen by others who might judge them or ask questions about their skin.

An assessment of Dermatillomania might also come from a dermatologist, aesthetician or family member who sees the physical and emotional consequences of the person’s skin picking. This person may recommend that the skin picker seek professional assistance for the picking.

Generally, most people do pick their skin, pimples, nails, or cuticles at some point. So, what makes the difference between someone who has CSP and someone who does not?

I heard a great classification of skin picking in a workshop by Dr. Charles Mansueto at the Trichotillomania Learning Center’s (TLC) 2006 Conference. I was inspired to create my own version of his classification system. I use it with all of my skin picking clients, and I call it the ABC’s of Skin Picking.

An “A” is something that almost “anyone” would pick. This could be a piece of dry skin hanging off your arm, a pus-filled whitehead on your chin that pops at your mere touch, or a scab that’s barely hanging on which you easily detach.

A “B” is a “bump”, pimple, scab, etc. that only a skin picker would pick. This is something that would either become an “A” over time or go away on its own if left alone. But, a skin picker will frequently start picking at it and make it significantly worse. It may then bleed, ooze, scab, and possibly become infected.  This in turn will cause two additional problems – it will cause the picker significant distress, and it will give him or her something new to pick at later. In my experience, I have found that clients with CSP classify at least 50% of their picking as “B’s”.

“C” stands for “Create”, meaning the individual with CSP is not picking at anything objectively “real”, but in the process of picking at her skin, he or she “creates” something such as a blemish, scratch or scab.  A “C” is something that only someone with Dermatillomania would pick. There is often nothing apparent on the skin, but the picker starts picking or scratching, and in the process creates a wound.

Treatment for Dermatillomania / CSP

The recommended treatment for CSP is with a trained psychotherapist who specializes in treating this misunderstood and often misdiagnosed condition.  Effective treatment focuses on Cognitive-Behavioral Therapy (CBT), with an emphasis on Habit-Reversal Training (HRT) and Mindfulness Based CBT.

In Cognitive Behavioral Therapy for Dermatillomania, the first behavioral goal is to stop picking any “C’s” – in other words, to stop creating new skin problems where none previously existed. Usually, a skin picker can learn to do this relatively easily by becoming more aware of their picking patterns.  Building awareness is generally done by keeping a skin picking log, and with the assistance of a habit-blocker such as wearing gloves.

Gloves provide a barrier to unconscious picking, and help in two ways.  First, the skin picker cannot easily pick at existing scabs, blemishes, etc.  Second, the gloves prevent identification of new places to pick that would otherwise be felt by random, unconscious, mindless “investigation” (touching) of the skin. If you are a skin picker, the previous sentence may resonate with you, and you may say, “I do that!” That would make sense as the two main triggers for skin pickers are touching and looking at their skin.

Removing the opportunity to touch your skin by wearing gloves is a good first start to becoming more aware of your unconscious “scanning”, and reducing the impulse to pick. After you get used to using a “habit blocker” like gloves, the focus of treatment turns to reducing your picking of “B’s.” What are the two most important factors to address in successfully reducing picking of “B’s”? You can read about that in Part 2 of The ABC’s of Skin Picking, coming soon.

•Karen Pickett, MFT is a psychotherapist at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions, including Dermatillomania.  Karen can be contacted at karen@ocdla.com.

Jon Hershfield, MA, of the OCD Center of Los Angeles discusses Cognitive Behavioral Therapy (CBT) for the treatment of Trichotillomania (compulsive hair pulling) and Dermatillomania (compulsive skin picking, or CSP).

My wife and I recently became vegetarians.  Well, she started using the word “vegetarian” to describe already never eating meat.  For me it required more of a lifestyle change.  I grew up on a small beef cattle farm, so I was used to the idea that you could grow meat the same way you grow vegetables.  Throughout my life it always felt as if meat was how one defined the difference between a “snack” and a “meal”.  So as part health experiment and part social consciousness attempt, I have given up meat for the time being.

At first I felt like I was denying myself something purely enjoyable.  I’m used to it, I like it, so why don’t I just do it?  Saying, “I want to change” or “I’m not happy with the consequences” doesn’t seem to be much comfort.  However, nearly 4 months into this experiment, I now get what can only be described as a “resistor’s high” – an addictive satisfaction derived from choosing not to eat meat.

The other night I had dinner at someone’s house and literally had to stare down an absolutely gorgeous pork chop fresh off the grill.  It appeared to be taunting me as I ate the otherwise perfectly delicious pasta and veggie sides, but I made a conscious effort to reserve analyzing the situation until after dinner.  As it turns out, it felt great not to have eaten the pork chop because it felt great to have committed to a choice.  I even get a similar buzz from locating and ordering the vegetarian options on restaurant menus.  So what is this phenomenon?

When you do something for a long time without putting much thought into it, you begin to adopt it as part of your worldview.  I live in a world where meat is something to be eaten every day.  So not eating meat every day seems like a different world.  Similarly, people who grow up engaging in body-focused repetitive behaviors like Trichotillomania (compulsive hair pulling) and Dermatillomania (compulsive skin picking) often fail to identify these behaviors as problematic until the consequences are impossible to ignore.  They live in a world where hair gets pulled and skin gets picked.  If you pull and/or pick every day, and it feels good, how do you find the strength to stop only because you know you should?

Trichotillomania (TTM) and Compulsive Skin-Picking (CSP) function as both behavioral addictions and Obsessive-Compulsive Spectrum Disorders.  As an addiction, a behavior is repeated for a reward, but the reward becomes increasingly difficult to obtain and the behavior continues to be repeated to excess.  The good feeling that comes from picking one’s skin or pulling one’s hair is soon followed by a sense of shame and helplessness as the brain prepares itself to motivate for the next fix.

Viewed from the perspective of obsessive-compulsive spectrum disorders, both TTM and CSP sufferers have distorted thoughts about their ability to experience and  resist uncomfortable urges.  The desire to engage in the addictive behavior is made greater by the fear that feeling and resisting the urge will be overwhelming and unmanageable.  Perhaps as a more familiar analogy, a compulsive hand washer may intellectually understand when washing is unnecessary, but feels that the anxiety produced by not washing is too painful to be tolerated.

Treatment for TTM and CSP follows two parallel Cognitive Behavioral Therapy (CBT) protocols to address both the obsessional urge and the behavioral addiction:

• Habit Reversal Training (HRT) uses a straight-forward pragmatic approach of blocking the addictive behavior with non-destructive alternatives.  This could involve anything from making picking too difficult by wearing gloves, to covering mirrors to aid in resisting checking, to occupying the hands with a competing stimulus (such as a stress ball or piece of string).  HRT also involves strategies for helping the individual with TTM or CSP become more aware of the behavior when it might otherwise be performed absent-mindedly.

• Mindfulness-Based Cognitive Behavioral Therapy uses a combination of mindfulness, cognitive restructuring, and behavioral conditioning:

~ Mindfulness – learning to acknowledge that sensations, feelings, and thoughts about pulling and picking are inevitable, normal occurrences that do not intrinsically mean you have to pull or pick;

~ Cognitive Restructuring – identifying the thoughts, feelings, and sensations that precede the behavior and challenging the distorted thoughts that make the behavior more difficult to resist;

~ Behavioral Modification – while treatment for TTM and CSP typically does not involve exposure the way it does in the treatment of Obsessive Compulsive Disorder (OCD) and other OC spectrum disorders, it does involve practicing the ability to tolerate the anxiety that comes from experiencing and resisting an urge.

Finding your personal “resistor’s high” will likely mean employing all of the above techniques simultaneously.  To learn to love the feeling of not picking and pulling, you need to experience it for extended periods.  People tend not to enjoy training for marathons, but they do appear to enjoy completing them.  The early work toward overcoming TTM and CSP involves regular confrontation with discomfort, and faith that your resitor’s high will come in time.

By using HRT to interfere with your ability to pull or pick, mindfulness to accept your urges as they are, and cognitive restructuring to address your  distorted beliefs about your ability to resist those urges, you can then practice absorbing and digesting the urge.  Taking the urge in and letting it wash over you becomes increasingly rewarding when paired with resisting the urge over time.  In the end, the behavioral addiction can be replaced by fascination with one’s own ability to emerge victorious from inner struggles.

•Jon Hershfield, MA, is a psychotherapist at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions, including Trichotillomania and Compulsive Skin Picking.  He can be contacted jon@ocdla.com.