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We’ve all popped a pimple or picked at a scab. It can be a satisfying feeling, as shown by the fact that YouTube channels are devoted to these topics with hundreds of thousands of followers. But what happens when picking at your skin becomes a compulsion — or even worse, a way to self-harm? Compulsive skin picking, or “excoriation disorder,” affects around three percent of the population at some point during their lives, and it goes far beyond just normal grooming habits. It’s related to obsessive-compulsive disorder, which means it can be difficult or impossible to stop on your own. Below, we cover what excoriation disorder is, how to know when skin picking is self-harm, the psychological factors that drive this behavior, and potential treatment options and coping strategies.
Understanding Excoriation (Skin Picking) Disorder
Excoriation disorder is listed in the DSM 5 in the Obsessive-Compulsive and Related Disorders category. The diagnostic criteria include repetitive and recurrent skin picking that results in lesions to the skin and repeated failed attempts to stop. To qualify as excoriation disorder, the behavior must also not have a better explanation, such as a medical condition or a side effect of substance use, as is commonly seen with drugs like meth or cocaine.
The majority of those diagnosed with excoriation disorder are women, and the symptoms commonly start around puberty. In many cases, those with excoriation disorder may not even realize that they are picking at their skin. They may be watching TV or sitting in a meeting and only realize that they are picking after the fact. However, there are some people who also present with focused picking, which means they consciously choose a spot and are aware of the behavior the entire time.
Symptoms of Excoriation Disorder
Skin picking can present in a variety of ways. Some people may only pick existing wounds, such as when picking off scabs or extracting blackheads. Others may pick at otherwise normal skin until a lesion appears. Excoriation disorder may also be present alongside trichotillomania, which is a hair pulling disorder in which the person compulsively pulls their hair out. Key physical symptoms of excoriation disorder include:
- A higher concentration of lesions on the person’s nondominant side. If they are left-handed, there will be more lesions on the right side of their body and vice versa.
- Lesions with irregular borders. Skin picking causes injuries to the skin that result in jagged borders, as opposed to the clean lines commonly seen with cuts or scratches.
- Raised nodules. If the person is picking repeatedly in the same area, it can get a raised appearance that resembles a bump on the skin. Scarring may be present.
- Multiple lesions in various states of healing. Those with excoriation disorder generally have multiple lesions that may range from fresh wounds to healed scars.
- Wearing long sleeves or pants even in warm weather. This can be an attempt to hide scars and lesions.
Someone with excoriation disorder will also have mental health symptoms, such as:
- Feeling an intense compulsion to pick at the skin
- Feeling anxiety if they are unable to engage in skin picking
- Repeated unsuccessful attempts to stop picking
- A feeling of losing time when picking
- Immediate feeling of relief when they engage in skin picking behaviors
- Feeling of regret or shame after the session is over
One of the main questions of the mental health field is when does normal behavior cross the line into disordered behavior? The answer is generally when the behavior starts to negatively impact the person’s quality of life and they want to stop but feel like it’s out of their control. This perspective can also be helpful in understanding when skin picking becomes excoriation disorder. Occasionally popping a pimple or scratching off a scab doesn’t mean that you have excoriation disorder. But if you are doing it repetitively every day or for extended sessions even when you don’t want to or aren’t actively aware of it, these could be signs that it’s time to seek help.
When Is Skin Picking Self-Harm?
The skin picking involved in excoriation disorder isn’t necessarily the same as the behaviors found in people who self-harm — but it is possible to escalate to that level. In many cases, skin picking is a compulsive behavior that the person may not even be aware of. Self-harm, on the other hand, involves intentionally harming yourself, usually as a way to deal with overwhelming negative emotions or stress. The main differences between self-harm and excoriation disorder include:
- How often the behavior happens. Someone with skin picking disorder generally picks at their skin every day, multiple times a day. Those who engage in self-harm generally do so less frequently.
- The level of injury. While skin picking can increase the risk of infection and cause scarring, the level of injury to the skin is relatively minor compared to self-harming behaviors like cutting or burning. It’s not uncommon for those who self-harm to require stitches or medical care for their injuries.
- The level of pain. One of the characteristics of self-harm is seeking pain. The person intentionally hurts themselves to cause a level of pain that acts as a release for the overwhelming emotions they’re experiencing. While skin picking can be painful, it’s a much lower level, and pain is not a motivating factor in the behavior itself.
If you are noticing an increase in the level of injury or pain with skin picking or you have started to engage in other behaviors, such as cutting or burning, it’s a sign that the disorder has progressed to self-harm, and it’s time to seek help.
Psychological Factors Behind the Behavior
While there isn’t one specific cause of excoriation disorder and researchers still aren’t sure what triggers someone to start, there are some common factors that may play a role in someone’s risk of developing skin picking disorder. This includes genetics and differences in the brain structure itself. But it’s also common for excoriation disorder to have a psychological component.
Those with skin picking disorder often use it as a coping mechanism during stressful situations or when they are experiencing anxiety or even dissociative feelings. The picking behavior gives the brain something to focus on, which can help calm the mind when you’re feeling anxious. Someone who grows up in a volatile household where there is a lot of fighting may start to use picking as a way to separate themselves from the situation and soothe their brain. If someone is experiencing dissociative feelings, the sensation of picking and even the resulting pain can make them feel more present and aware in their body.
It’s important to keep in mind that skin picking disorder also has a compulsive component. The brain gets a reward — that feeling of relief — when you engage in picking, which starts to set up a behavior pattern that can be difficult to stop on your own. Over time, the compulsion to pick can be the main factor that drives the behavior.
Treatment Options and Coping Strategies
Excoriation disorder can often be treated with psychotherapy tools, such as:
- Cognitive behavioral therapy. CBT focuses on recognizing the thought patterns that contribute to maladaptive behavior like skin picking and using healthier coping strategies to retrain your brain.
- Habit reversal therapy. Because many people who engage in skin picking do so without being fully aware of it, habit reversal therapy can be helpful in recognizing when you’re picking and identifying specific triggers. It also helps you replace picking with other healthier habits.
- Acceptance and commitment therapy. This type of therapy focuses on the negative feelings of shame and guilt that can accompany excoriation disorder. You learn how to recognize when you’re spiraling emotionally and to replace those feelings with self-compassion and mindfulness to help you stop the behavior.
Some practitioners may also combine therapy with medications, such as antidepressants or antianxiety medications, depending on the severity of the picking and any other mental health disorders that may be present.
Skin picking is incredibly common, and it’s not something you need to be embarrassed about. Talking to a qualified mental health provider can help you understand what’s behind this behavior and start making positive life changes that support your health and wellbeing.
