How many people have SP?

It is hard to estimate exactly how many people have SP, because those who pick their skin rarely talk openly about it. Recent studies indicate that 2 percent of all dermatology patients and 4 percent of college students pick their skin to the point of experiencing tissue damage or scarring and significant distress or impairment in functioning. What this means is that a lot of people engage in this behavior! What used to be thought of as a pretty unusual or rare disorder is now turning out to be pretty commonplace.

What causes SP?

It is still unclear exactly what causes people to pick their skin or bite their nails, lips or cheeks. There is some evidence to support a genetic or biological link to the behavior. Skin picking or chewing is seen in the animal kingdom (e.g. dogs) and can cause significant tissue damage. Further, some women report that their picking increases or decreases with their monthly cycle supporting the notion that there may be some chemical or hormonal basis to the behavior.

Some people report picking/biting in an attempt to regulate their arousal levels (e.g. when they are bored or overly excited), while others describe picking/biting as a way of making bad feelings such as anxiety or sadness go away. Others describe picking solely as the result of itching. Further, many people with SP describe picking as a result of a tactile trigger, feeling a bump or irregularity in their skin or a dry piece of skin on the lip makes them want to remove it and, thus, make the area smooth again. Finally, many with SP report picking for the sheer pleasure of unclogging a pore or removing a substance from their skin. For these folks it is more the substance that is removed from the skin that is the focus of attention, rather than a sensation, emotion or neurological state. In any case, the result of picking seems to be some level of gratification or pleasure, albeit short lived, that drives the behavior.

Myths and misunderstandings

• SP is not OCD. Many people mistake skin picking for Obsessive Compulsive Disorder (OCD) because of the repetitive nature of the behavior. Actually, the treatment for OCD is quite different from that of SP, both from a therapy and a medication perspective.
• Skin picking is not the result of past trauma or abuse. There is NO evidence to support that SP is a result of trauma, abuse, molestation, or a bad childhood. That said, some people with SP do have a history of trauma. However, there is no evidence that the trauma was the cause of the SP because many people who have a history of trauma do not pick their skin and many who meet criteria for SP do not have a history of trauma.
• SP does not predict future problems such as self-mutilation, suicide, eating disorders, or depression.
• SP is not a form of self-mutilation. Skin picking is better understood as a self-soothing behavior, one that makes a person feel better in some way.
• SP is not the result of some underlying, unresolved issue such as low self-esteem or self-hatred. Skin picking is better understood as a behavior, much like nail biting, that occurs in a variety of situation and in response to various triggers.

Why do people pick their skin?

Through research and clinical experience, scientists are beginning to understand why people pick, scratch, bite, and tear at their skin and nails. Although the behaviors may look the same across people, each person is unique and, therefore requires individualized treatment.

What we know about SP is that it occurs when certain triggers are present. Triggers can either be internal (inside of a person like a sensation, thought, or emotion) or external (outside of a person like a place, activity, or thing). One person may have multiple triggers or combinations of triggers.

Charles Mansueto and his colleagues at the Behavior Therapy Center of Greater Washington have organized what researchers know about SP and call it the Comprehensive Behavioral Model (ComB). This model organizes skin picking behaviors into five areas or modalities: Sensory, Cognitive, Affective, Motor, Place. In addition, there is evidence that points to a genetic component to skin picking (it runs in families). In other words, people with SP have likely inherited a gene that is responsible for the behavior, e.g., you are not responsible for the fact that you have SP. However, people who suffer with skin picking behaviors ARE responsible for altering their behaviors to cause their picking behaviors to improve.

Sensory: Skin picking can involve one or more of the five senses.

• Touch: Stroking of the skin or nails in search of a bump, irregularity, rough spot, or jagged edge. Touch can be experienced on the skin or on the fingers.
• Sight: Visual scanning (with or without the use of mirrors) is oftentimes a trigger for picking.
• Smell: Smelling of the skin or substance removed from the body is not uncommon.
• Taste: Eating of the skin, scab, or substance removed from the body is not uncommon.
• Hearing: Less common is the hearing sense. Sometimes people will associate a noise with their picking behavior.
• Cognitive: People who pick their skin often report thoughts that occur when picking is present. Thoughts can be about picking, e.g., “If I pick this it will get better.” Or can be about life, e.g., worry, fears, problems.
• Affective: Many people report picking in response to feelings such as anxiety, tension, fear, anger, or boredom or to increase positive feelings such as gratification or relaxation.
• Motor: There are a variety of motor behaviors that come before or after picking, e.g., stroking the skin, looking into the mirror, or pulling the hair around a blemish. Sometimes these behaviors are so automatic that they occur outside of a person’s awareness. As a result, picking can also occur outside of a person’s awareness. StopPicking.com is designed to help people to increase their awareness about SP and to identify effective strategies to use on these trigger situations.
• Place: Where are you and what are you doing when you tend to pick? Most people have situations/activities that they associate with picking, i.e., looking in the mirror, lying in bed watching TV, driving, etc.

How do we treat SP?

The primary treatment approach for skin picking is a form of cognitive-behavioral therapy called Comprehensive Behavioral Model (ComB) developed by Dr. Charles Mansueto at the Behavior Therapy Center of Greater Washington. This comprehensive approach takes into account the internal (feelings thoughts and sensations) as well as the external (places, activities and things) that correspond with skin picking behavior. Once these factors are understood, alternate coping strategies are taught. ComB treatment involves helping a person become aware of skin picking behaviors and the triggers for it, as well as learning alternative ways to cope with urges.

In 2009, a study was released using N-Acetyl Cysteine (NAC) with a group of hair pullers, also considered to be a body focused repetitive behavior. NAC is an amino acid that serves as a precursor to the synthesis of glutathione, a detoxifying agent in the body. Previous studies using NAC have shown decreases in pleasure-seeking behavior in laboratory rats. Dr. Grant hypothesized that NAC may be helpful in the reduction of hair pulling and skin picking for this very reason. This study demonstrated a significant reduction in hair pulling for 56 percent of the subjects taking NAC. To read more about the use of NAC for trich see trich.org/research/current.html for more information. Talk to your doctor about using NAC in conjunction with behavior therapy or StopPicking.com.

Because many people respond to the cognitive-behavioral approach, we have adapted this model to be used by individuals in the privacy of their home, through a confidential web-based application. StopPicking.com is designed to take you step by step through the process of learning about your individual thoughts, feelings, and behaviors, identifying your high risk situations, and teaching coping strategies that are right for you. StopPicking.com is not therapy, but an interactive self-help tool based upon behavioral and learning theories, which will guide you through analyzing and managing your problem.

A dermatologist’s perspective

Many, if not most, skin diseases have an emotional or psychological component on some level. Sometimes stress makes the skin disease worse, sometimes the disease itself causes stress, and sometimes the psychological component actually can cause the skin disease. SP can fall into any of these categories.

In dermatological terms, SP can be classified into one of several diagnoses. Most people using this program will fall into the diagnosis of neurotic excoriations and excoriated acne. Several other diagnoses will be mentioned for completeness.

Neurotic excoriations refers to the uncontrollable urge to pick and dig at the skin. This urge may be unconscious or may be deliberate in the belief that it corrects some minor abnormality or surface irregularity of the skin. The picking creates more pronounced abnormalities so that a vicious cycle is started. It involves picking, digging or scraping at the skin persistently often until what is described as a “thread” can be pulled from the skin. Many old scars, which can be disfiguring, are visible near areas of active picking. These pickers usually are middle-aged adults and may be depressed, anxious or obsessive-compulsive. Women are more likely to be affected than men.

Excoriated acne occurs usually in girls or young women with very mild acne or even no acne at all. Often a magnifying mirror is used to search for minor acne lesions. These minute lesions are compulsively picked leaving excoriations and scars. This primarily occurs on the face but can be on the chest or back as well.

Prurigo nodularis consists of multiple intensely itchy nodules mostly on the legs and arms. The itching is so severe that lesions are scratched to the point of causing pea-sized crusted and firm warty nodules with brown pigmentation. Prurigo nodularis can occasionally be associated with internal diseases such as HIV infection or liver disease. Like these other skin diseases it can be exacerbated by psychological stress, but unlike the others it is not caused by stress. It occurs mainly in adults with men and women being affected equally. It can be a chronic disease lasting for years.

Factitious dermatitis refers to self-inflicted skin lesions made consciously to simulate a naturally occurring skin disease. The lesions are made with the fingernails or by some other mechanical means or by the application or injection of chemical irritants or caustics. The lesions have a geometric, bizarre appearance which does not suggest natural causes, although extensive searches are often done looking for an organic cause. These patients have an underlying psychopathology or are true malingerers.

Delusions of parasitosis involves a single fixed delusion of infestation of the skin with parasites. These patients are so convinced of their infestation that others believe them as well. They often bring pieces of skin debris and lint to their doctor’s appointments in a tissue or jar insisting that the parasite is contained in their specimen. The skin exam may be normal or may reveal minor excoriations.

StopPicking.com is intended for those people who suffer from neurotic excoriation and acne excoriation. Treatment of prurigo nodularis, factitious dermatitis and delusions of parasitosis is beyond the scope of this program and a medical doctor should be consulted if you believe you have any of these other disorders.

Readiness for change

The advantages of using StopPicking.com on an ongoing basis are obvious: to reduce or stop skin picking and allow healing to begin, to decrease avoidance of activities because of scarring or skin damage, to improve self-esteem and confidence, to learn more about SP, and to feel in control of your behavior.

However, working this program is a daily commitment that will involve some time and energy each day. In order to gain control of your picking, scratching or biting, you will need to pay attention to your behavior, your thoughts, your feelings, and a number of other things each day. Even if you are not able to log-on every day, you will need to “catch up” the next time you log-on for the day(s) missed. Although this is a commitment of time and energy, it will be worth it if you can change your behavior.

Sometimes people realize that they are not willing to put forth the effort required to gain control of their picking. Oftentimes this is because they were not “ready” to make the changes in the first place. Readiness is a very important part of behavioral change. For example, many people want to start an exercise program and plan to do so and may even take some steps to begin a program (like join a health club). After a few weeks, however, they forget about the new program and fall back into old habits. The same is true with SP. Many people want to stop and may even make some efforts to make changes, but these efforts peter out after a short time and they “give up” or simply “forget” about their goals.

One goal of this section is to let people know that readiness for change is a very important ingredient in the recipe for success. If by reading this section you decide that you are not ready, that is okay! Lots of people want to stop picking, but are simply not there yet. Another goal of this section is to help people get to the point of readiness. We are hoping to help people who are almost ready to get to the point of action. Ways to get to the point of action are:

1. Begin to imagine yourself as someone who does not pick their skin, imagine your skin beginning to heal and your scars fading over time. Really fantasize about how this would be for you and really see yourself in a different way.
2. Tell someone that doesn’t know about your behavior that you pick. Because SP is a behavior surrounded with shame, people hide their symptoms from most people in their lives. Telling others that you pick your skin can start to break down the shame and foster self-acceptance. Joining a group of people who also pick or attending a TLC retreat or convention can catapult you into action and self-acceptance.
3. Start to educate others about SP. Once you have told some people about your behavior you can begin to educate others about what it is and how common a behavior it is (i.e., 4 percent of college students do it). You will likely be surprised at how others will not only support you, but may even tell you how they know people who do the same thing!