Many people have probably squeezed a spot during their adolescence or picked at a scab. An inner voice may have forewarned, ‘do not pick at it, it is going to leave a scar’, but was ignored. Some individuals are born with blemish-free skin and struggle less with urges, while others are not so lucky. This all sounds natural and normal, but when it crosses over into picking, hour after hour without being able to stop, despite wanting to, a mental illness called excoriation—or skin picking—disorder (SPD) may be in motion. Sufferers report a loss of control and significant distress that, in turn, disrupts healthy functioning in other areas of their lives.
SPD is a chronic mental illness that is classified under obsessive–compulsive disorder and related disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association, 2013). Symptoms include recurrent skin picking, scratching, rubbing and digging or urges to do so that go on for extended periods of time (at least 1 hour), resulting in skin lesions and behaviour that interferes with functioning in other domains, such as school, work, social or merely personal grooming. Repeated attempts have been made to decrease or stop skin picking but are unsuccessful.
The most common area to pick at is the face. However, those with SPD are known to pick from multiple body sites, such as the arms, fingers or hands. While most individuals pick with their fingernails, many use tweezers, pins or other objects (American Psychiatric Association, 2013). Most of the time, this is done while alone or before immediate family members. Individuals may pick at healthy skin, minor skin irregularities, bumps on smooth skin surfaces, lesions (such as spots or calluses) or at scabs from previous picking (American Psychiatric Association, 2013). The triggers are visual or tactile. The anomalies do not have to be major; in many cases, they are usually invisible to the naked eye. If imperfections are visible in the mirror and noticeable enough to be commented on by others, the added stressor of worrying about what others think, potentially resulting in an avoidance of social situations, which can make matters worse. The development of social anxiety has also been found (Pozza et al, 2016). Lastly, touching the anomaly can also serve as a trigger and a sufferer can pick at their skin for extended periods of time while, for instance, lying in bed in the darkness.
Triggers and instant gratification
In many cases, the individual is driven to pick so as to seek a release of tension, either immediately before picking the skin or when attempting to resist the urge to pick. A release of tension, as well as gratification and pleasure can result when the skin or scab is picked (American Psychiatric Association, 2013). Skin picking lies on the end of impulsivity, of out-of-control, pleasure-seeking behaviour. The gratification can last from seconds to even minutes and to avoid confronting the remorse that results from creating skin damage, the skin picking continues. Arguably, picking can serve as an avoidance mechanism. The trouble lies when one cannot stop oneself, time is wasted, responsibilities are not tended to and a litter of scars result.
Various emotional states can trigger SPD, such as feelings of anxiety or boredom that are followed by remorse, regret and embarrassment over the loss of control and further damage to the skin. Additionally, some individuals report that they do it automatically, with minimal awareness of their behaviour. It is only when they notice bleeding that they realise they have been picking their skin (Pozza et al, 2016).
In recent years, SPD has been categorised under the family of body-focused repetitive behaviours (BFRBs) (Mevorach et al, 2019). However, there are some elements associated with mental and physical impairment belonging to the obsessive–compulsive spectrum (Mevorach et al, 2019). Although SPD was once considered rare, increasingly, it is found to be rather common, with a lifetime prevalence of 1.4% in adults and perhaps higher (Grant et al, 2012). Most sufferers are female, and the age of onset is usually during adolescence with the rise of puberty and acne (American Psychiatric Association, 2013).
SPD commonly co-occurs with obsessive–compulsive disorder and body dysmorphic disorder (Lochner et al, 2017). SPD and other BFRBs, such as nail-biting and trichotillomania (hair pulling disorder) frequently co-occur (Snorrason et al, 2012).
A chronic condition
SPD can wax and wane over years, but this condition is considered to be chronic (Grant et al, 2012). Medical complications of skin picking include tissue damage, scarring and infection and, in extreme cases, it can be life-threatening.
Time loss is a major consequence of skin picking that then interferes with the ability to move on throughout the day. Individuals with SPD report finding it difficult to concentrate on work/school and to manage responsibilities, often resulting in avoidance by taking days off (American Psychiatric Association, 2013). Subsequently, many report embarrassment, shame and a loss of control. Unsurprisingly, these individuals also avoid going out in public and being present in other social situations. Social anxiety, depression and anxiety are co-occurring disorders (Machado et al, 2018).
One telltale sign of SPD is the compulsion to camouflage. The time spent putting on make-up is unreasonably long and out of the ordinary. They can compulsively check their perceived blemishes against reflected surfaces, such as puddles, windows and mirrors. Reapplication of make-up is done unabashedly in public, without concern for social etiquette, and for long periods of time, sometimes spending from 1–8 hours a day applying make-up.
» Individuals are constantly fixing their skin through repetitive facials, procedures, usage of new products and laser surgeries, but the satisfaction from the dermatological intervention is short-lived (if there is any), as the underlying issue of the repetitive behaviour of skin picking is not being addressed «
For aesthetic practitioners
Sufferers are rarely found in psychiatric offices (Grant et al, 2012). Many people with SPD assume their behaviour is a bad habit and do not realise it is an identifiable illness (Snorrason et al, 2012). Less than a fifth of those with SPD seek treatment (Snorrason et al, 2012). Embarrassment and shame are also reported as barriers to getting help. Predominantly, patients are seen in dermatologist and cosmetologist offices to address blemishes and scarring. An inherent contradiction exists for these individuals as they want to get rid of these imperfections, but they are causing and/or worsening the situation. Individuals with SPD are constantly fixing their skin through repetitive facials, procedures, usage of new products and laser surgeries. However, the satisfaction from the dermatological intervention is short-lived (if there is any), as the underlying issue of the repetitive behaviour of skin picking is not being addressed. The individual will repeatedly pick at their skin again in an out-of-control fashion and will again find themselves at the dermatologist office in an effort to camouflage their disorder.
Screening
Screening for sufferers of SPD is important. By enforcing dermatological interventions without proper screening, those with SPD are caught in a vicious cycle. Such aesthetic procedures will only serve to reinforce the disorder and make the SPD worse. To screen for such individuals, the practitioner can ask the following questions:
Treatment
Empirically backed treatment modalities include cognitive behavioural therapy (CBT), habit reversal therapy (HRT), acceptance-enhanced behaviour therapy, exposure and response prevention (ERP) and medication (such as selective serotonin reuptake inhibitors or N-acetyl cysteine) (Lochner et al, 2017). CBT involves psychoeducation, cognitive restructuring and an emphasis on relapse prevention through an enhancement of self-efficacy. In HRT, the patient learns self-awareness through self-monitoring assignments. Gradually, they are exposed to the stimulus that triggers the urge to pick but are instructed to substitute skin picking with an incompatible action, such as fist clenching (Lochner et al, 2017). Lastly, in ERP, a stimulus is again employed, but the patient is instructed to tolerate the urge. In short increments, the exposure to the stimulus is again employed to provoke the urge and the patient must build a tolerance to the urge without skin picking.
Conclusion
SPD is found to be a chronic disorder associated with substantial comorbidity. It is a rather common disorder with an estimated 1.4% or higher afflicted with the illness in the general population. Fortunately, a number of treatment modalities, such as CBT, HRT and ERP, are effective in reducing skin picking behaviours.