When treating skin picking, also known as excoriation or dermatillomania, it’s important to recognize that it can be both a behavioral problem and an emotional problem, and both need to be treated. In my experience it works best to use a combination of cognitive behavioral therapy, habit reversal training, mindfulness, and psychodynamic therapy. We want to address both the act of skin picking and the deeper emotional issues that can provoke it.
For example, on one level I might advise you to cover your mirrors if looking in the mirror triggered the urge to pick your skin. You might wear a bandana to bed if bedtime is a vulnerable time for you to pick your scalp. It’s common for people to pick more when they’re alone, so I might suggest creating a weekly social schedule to assure you are more often engaged with others. Social support can make a significant impact.
But there’s often more to the story. One of the most important questions is, when did you start picking? Clients often tell me that they started picking at a particularly stressful time. Maybe it was when they started school, or perhaps there was stress in the family, like parental fighting. Maybe a parent told them they were physically unattractive and they internalized this incorrect belief about themselves.
One of the reasons skin picking can be difficult to treat is that the motivations behind the behavior are wide-ranging. Some people have a compulsion to make their skin feel smooth. A client might say, “I feel scabs on my skin and need to remove them.” Removing them of course brings temporary relief, but eventually new scabs form, which need to be removed too, and the cycle continues. Others need to get rid of any visible skin irregularities. If they see a pimple, scab, blemish, or bump, they feel compelled to pick. Another group see imperfect skin as a sign of personal tarnishing. They feel that if their skin does not look perfect, something must be wrong with them in a deeper way. Others pick when they are over-stimulated or under-stimulated. When they are over-stimulated and feel stressed and anxious, picking is an effective way to help regulate their emotions. Others commonly pick when they feel under-stimulated or bored, sitting in front of a TV, in a car, at work, or in class. Some consciously pick to pass the time, while others pick unconsciously, in a trance-like state, and are unaware of their actions. Many people develop the behavior early in life and begin to become dependent on it as a way to tame anxiety.
There is also a biological component. Some people are biologically more predisposed to pick than others, just as some people are more genetically predisposed to certain medical conditions.
Understanding of the underlying meaning of your skin condition can help. Two things that look the same on the outside can be different on the inside. Our skin can be a reflection of our feelings. Skin conditions usually worsen during stressful times. However, many people don’t know where their stress is coming from or how it impacts them. If your mother is both your supporter and critic, it can be awfully hard to distinguish between what’s positive and what’s negative in the message.
Relaxation techniques can be very useful for managing picking. Another effective strategy is emotionally distancing yourself from your symptoms. Emotional discomfort is subjective, not objective. When you shine a flashlight in a dark room, you can focus on one object or another. That object will occupy more of your thoughts and feelings. Teaching someone how to view their symptoms from a different perspective can make a big change.
Sometimes visualization techniques can help manage picking. By imagining ourselves in a healing environment, we can use our healing thoughts to influence our symptoms. In some cases, it’s helpful to think about what life would be like if you could let go of picking. One particularly useful question is whether your damaged skin protects you in some way. For instance, if you have anxiety about socializing with others, picking your face or arms can be an excuse to avoid social interactions. After all, you couldn’t possibly go out if you’ve been picking your face and your skin is red.
Skin picking is often used for pain control. It can be a coping mechanism to relieve emotional discomfort, physical discomfort, or a blend of the two. Although there is seldom a magic bullet, the key is to figure out what the motivation behind the behavior is and find practical tools to change it.
Finally, receiving emotional support can make a difference. Whether it’s from a therapist or from a group who have experienced similar symptoms, human connection can be a very powerful tool.
Matt Traube, MFT
Child and Adult Psychotherapy
Phone: (805) 324-4684 and (781) 223-8629