Article: My Secret Life as a Skin Picker

One of the problems I specialize in working with is repetitive skin picking (also known as excoriation or dermatillomania). People struggling with this problem experience intense urges to pick at blemishes or perceived imperfections in their skin. They may spend a few minutes to several hours (e.g., 8 hours or more) picking at many places on their body. The result is usually scabs, bleeding, and scarring—and everyone I’ve worked with experiences intense shame, guilt, and embarrassment immediately after they stop actively picking.

 

Many struggle to hide their picking for years without realizing that there’s a name for their condition—that other people struggle with similar problems. Even fewer are aware there is treatment. Unfortunately, few therapists are trained in what are called body focused repetitive behaviors such as skin picking.

 

I recently came across a first person account by a woman who struggles with skin picking called “My Secret Life as a Skin-Picker” that I think captures the experiences of many of the people with whom I’ve worked. She captures the urges to pick, the methods used, and the myriad ways people try to cover up the damage afterward. The author notes how she experiences urges to pick even as she types her essay:

 

As I write, as I pause to think about what’s next, my fingers unwittingly scan my face for rough edges of skin, for scabs, for sores, for the tiniest prick of coarse hair on my chin—an excuse to flee to the mirror. Search and destroy. I need to type with both hands, be satisfied with the click-clack of the keys, hypnotize myself with words, with this attempt to understand why I am the way I am.


I encourage readers to check out the full essay in The Establishment. I think it articulates the struggles of people who pick their skin extremely well.

Huffington Post Article on Hair Pulling and Skin Picking

One of my specialties is working with people who struggle with repetitive hair pulling (called trichotillomania) and/or skin picking (called dermatillomania or excoriation). Individuals with these conditions often do damage to their appearance.

In the case of hair pulling, some people pull enough to create thinning in their hair and sometimes bald patches. They may be noticeably missing eye lashes or eye brows. People with excoriation may create noticeable marks, scabs, or scarring from frequent picking. Everyone I’ve worked with has experienced some degree of embarrassment or shame about their appearance. Many are able to hide the damage through cosmetic means so that most people are unaware or do not notice, but others cannot.

One of the saddest experiences I’ve observed is that many people struggle with these problems for years without realizing they: 1. Have a recognized problem, 2. That they are not alone, that others struggle with similar problems, and 3. That there are proven treatment options. Even many trained therapists are not familiar with what are collectively known as body-focused repetitive behaviors, let alone how to effectively treat these problems.

Because these are not well-known phenomena, I was particularly excited to see an excellent article in the Huffington Post about skin picking and hair pulling disorders. As the article notes:

There are very few resources for people who suffer from body-focused repetitive behaviors (although the Trichtillomania Learning Center is one good one), and no psychotropic medications that have been deemed effective treatments thus far. According to Science of Us, the results of trials of the most thoroughly tested medication, Prozac, were inconclusive. And for such a common disorder, practitioners specializing in behavioral therapy for hair-pulling, and especially for skin-picking, are few and far between. 

I will second the article’s recommendation of the Trichotillomania Learning Center as a great resource about hair pulling and skin picking.

The Huffington Post is not always a great resource for mental health information, in my experience, as it sometimes gives spotlights to fringe ideas, pseudoscience, and opinions or anecdotes that don’t necessarily reflect the research literature. However, I was pleasantly surprised by this article and think it is spot on.

This article on hair pulling and skin picking provides a concise and accurate overview of these problems, and I’m glad to see them getting more mainstream press. You can read it here.

Hair Pulling (AKA Trichotillomania) and Skin Picking Problems – Greater Research Support for Behavior Therapy over Medication

Trichotillomania (or trich for short) is a condition in which people repeatedly pull out their body hair, often leading to bald patches and thinning. The scalp is a common site—as are eyebrows and eyelashes—but some may pick at hair anywhere on the body. A related condition is repetitive skin picking. This condition did not have an official diagnostic name until 2013, when the most recent edition of the DSM psychiatric guide decided on the name excoriation. People with an excoriation disorder pick or scratch at their skin—often at perceived imperfections or blemishes—to the degree that they may cause marks, bleeding, and scarring.

Both are broadly categorized as body-focused repetitive behaviors, and these have recently been more broadly categorized and obsessive-compulsive and related disorders. People with these problems often experience a great deal of shame and embarrassment about their difficulties and have an extremely tough time stopping.

Unfortunately, both conditions are understudied and not well-known. Many people struggle with them without realizing there is even a name for their condition.

The treatment literature is relatively small compared to problems such as depression and anxiety. However, I recently came across a nice summary of treatment options for trichotillomania and skin picking, as well as other conditions more broadly called obsessive-compulsive and related disorders.

Cognitive Behavioral Therapy

For hair pulling, cognitive behavioral therapy has the greatest research support. An intervention called habit reversal training has been the most studied, either by itself or in combination with a more comprehensive cognitive behavioral treatment such as Acceptance and Commitment Therapy (called “act” for short).

With excoriation, there is evidence that treatments that work for hair pulling also work for skin picking. Unfortunately, the treatment evidence for excoriation is more limited. Although it was studied for decades before being given an official diagnosis in 2013, I suspect not having an official diagnosis slowed research interest. Hopefully, we will begin to see more research on skin picking.

Medication

Rigorous research on the use of medication is much less robust than the research on therapy. There’s some evidence that the antidepressant clomipramine may help reduce hair pulling, but controlled studies on the use of SSRI’s—the most common class of antidepressants—have not shown much effectiveness. Of the SSRI’s, fluoxetine has been the most studied, but it’s effectiveness with hair pulling has been very mixed.

There’s some research support for the use of antidepressants in reducing skin picking; however, there have been no large controlled trials.

My Impressions

The research matches my experience as a therapist. Many people I’ve treated for hair pulling or skin picking have tried medication first and have either not found it helpful at all or have been unclear about whether it was effective or not. If someone’s anxiety is contributing to pulling or picking behavior, medication may help reduce the tendency somewhat but is not likely to be a total cure.

I should also acknowledge that behavioral treatment for picking and pulling is hard work. It takes a lot of attention and effort to change these habits, and many people who do well with treatment continue to struggle with it to some degree. For these reasons, it is important to see a specialist in hair pulling and skin picking. Generic talk therapy is unlikely to be of much help.

Summary

In sum, some form of cognitive behavioral treatment—especially with habit reversal training—with an experienced specialist should be the first-line treatment for hair pulling and skin picking.

As I’ve written about before, the Trichotillomania Learning Center is a great grassroots resource for learning more about hair pulling and skin picking.

If you’d like to read the full article yourself, you can download it here.

Problems with Pulling Your Hair or Picking at Your Skin?—Try a Little TLC

Have you ever heard of trichotillomania or the wonderful organization called the Trichotillomania Learning Center (TLC)? See below to learn more.

What’s Trichotillomania?

Trichotillomania—or “trich” for short—is a problem that’s a little obscure even for professionals, but it impacts a lot of people. People with trich pull at their hair so often that it causes noticeable hair loss. The most common place is the scalp, but it can be a problem anywhere there’s hair, including the eyebrows and pubic region. Because others may notice the damage, people with trich are frequently embarrassed by their appearance. They may wear hats or wigs to hide the hair loss.

Although the word “trichotillomania” refers to hair pulling specifically—“trich” is Greek for “hair”—many experts see trich as a close cousin to skin picking. People with problematic skin picking develop marks and scabs on their faces and body. Like “trich,” people who struggle with skin picking may feel self-conscious in social situations. Unfortunately, there’s not a specific name or diagnosis for skin picking, so it fall under an umbrella category of “impulse control disorders.”

Additionally, it’s hard for other people to understand. People who pick and pull often want to stop but have great difficulty without help. Unfortunately, many professionals aren’t trained to evaluate, let alone effectively treat, these problems. Research shows that picking and pulling don’t tend to respond to basic talk therapy. Instead, addressing these problems requires a structured and multifaceted approach.

The Trichotillomania Learning Center (TLC)

TLC was started 1991 by Christina Pearson, a woman who herself struggled for years with hair pulling. Her grassroots effort to create a resource for other people who struggle with pulling and picking took off. It‘s now aided by a Scientific Advisory Board made up of the biggest names in this area of research. Their website is an incredible resource for laypeople and professionals alike.

Although TLC has grown since Ms. Pearson first created it more than 20 years ago, vestiges of its grassroots beginnings remain. I ordered some books from them recently and handwritten in green ink on corner of the packing slip was, “Thank you – Donna – TLC.”

If you struggle with picking or pulling or know someone who does, I urge you to visit the TLC website. It’s the go-to place for information on picking and pulling. I also think it makes for wonderful model of how to make resources available to professionals and non-professionals.

If you want specialized treatment for trich or skin pulling, that’s available too. Feel free to contact me (503-281-4852 x14)  and if I can’t provide treatment, I’d be happy to help connect you with resources.


Archives by Month