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.

Evaluating Self Help: The Mindfulness & Acceptance Workbook for Anxiety

There’s no shortage of self-help books on the market. There is, however, a paucity of research on whether those self-help books are actually helpful to the people who use them. In an ideal world, every self-help book would be submitted to scientific scrutiny to determine if people actually benefit from using them. Unfortunately, this happens only rarely.

Even a self-help book that is based on well-researched cognitive behavioral principles and written by leaders in the field is not guaranteed to be effective.  For example, one recent study found that college students with greater rumination exhibited more depressive symptoms after using Greenberger & Padesky’s Mind over Mood, a well-respected cognitive behavioral self-help book for depression. These findings suggest that evidence-based psychotherapy interventions don’t always translate into effective self-guided techniques that people can use on their own, and in some instances can actually be harmful.

The Mindfulness & Acceptance Workbook for Anxiety

Over 5 years ago, I wrote a few blogs posts about Forsyth & Eifert’s The Mindfulness & Acceptance Workbook for Anxiety in 2 prior blogs for which I used to contribute. The first, on my blog Scientific Mindfulness, reported on pre-publication research I heard about at a conference. (Unfortunately, it appears the other post has been taken down.) The first author of the workbook, SUNY-Albany professor John Forsyth, PhD, conducted 2 studies on his ACT-based self-help book. He gave copies of the book to people for free, and had them complete online self-report measures at various intervals.

Dr. Forsyth recently posted a summary of this research on his personal blog in anticipation of the upcoming 2nd edition of The Mindfulness & Acceptance Workbook for Anxiety that will be released April 1, 2016. One paragraph in his blog post caught my attention:

Reductions in anxiety and fear did not happen by going after anxiety and fear directly. It was just the opposite. By first focusing on the skills needed to live a more valued life, readers then experienced a decline in their anxiety, fears, and depression, and ultimate improvements in their lives. This is an important message––one that supports the approach we offer in this workbook.

The workbook emphasizes ACT skills to help people engage in meaningful living, and it appears that those skills—rather than interventions aimed at alleviating anxiety and worry—appear the most effective.  Said another way, the findings suggest that people using the workbook improved more from doing things that were important to them than from any particular technique. This is quite profound, if you think about it, and very different from how many people approach anxiety. Attempting to directly suppress or control anxiety-related thoughts and feelings can often backfire.

Because it’s one of the rare self-help books that has been researched specifically as a self-help book, I find myself recommending The Mindfulness & Acceptance Workbook for Anxiety more than any other self-help books, and I was excited to hear there’s an updated edition coming out. I encourage readers to check it out.

Anxiety Treatment at Portland Psychotherapy

Fear of Fear Itself: Why Panic Isn’t Dangerous

Everyone has experienced intense fear at some point. Our hearts start racing when we realize we forgot to pick up the kids at school, our hands tremble and sweat as we struggle to unlock the door as a dark stranger looms in the shadows, or we feel dizzy and nauseous as we get up to present that speech we haven’t really prepared for. Whether a threat is great or small, the people and things we care about might get hurt if we don’t respond quickly.

We evolved the sympathetic nervous system to prepare us for threat

The physiological response we feel during intense fear and panic is a result of the body’s sympathetic nervous system. The sympathetic nervous system evolved to help us prepare to respond to dangerous situations.  Activation of the sympathetic nervous system leads to the kinds of biological changes we experience in fear and panic, including changes in heart rate, blood vessel dilation, breathing, digestion, and perspiration. These changes make us ready to face challenges to our safety through fighting (i.e., overpowering the threat), fleeing (i.e., getting away from the threat), and freezing (i.e., holding your breath and hiding by being still – think about the T-Rex in the movie Jurassic Park). Intense fear (i.e., panic) can be a real life saver, so be glad it’s there for you!

Panic involves an unnecessary but harmless misfiring of the sympathetic nervous system

The biological readiness we call panic mostly evolved to help us deal with immediate threats in the external environment (e.g., being chased by an actual lion), but in humans the same system can also get activated just by vividly imagining threats (e.g., anticipating having a heart attack or going crazy). It’s kind of like going to a scary movie – you can easily forget you’re actually in a nice safe theater and become so engrossed in the movie that you end up being afraid. When we get so caught up in our heads, it can start to feel (i.e., in our body) very much like we are in danger, when in fact we are safe. Even if there are “real dangers” in the distant future, such as dying of old age, actively anticipating them without a sense of perspective can make our bodies respond as if there were imminent danger right here and right now. This is where worry and anxiety come from – imagined threats. Nonhuman animals don’t worry and get anxious about things that aren’t actually happing right here and now – but people do. This ability to imagine future possibilitiess, plan for them, and feel emotions about them is an important part of what makes us human, but it also has this dark side.

In panic, people misinterpret normal bodily signs of anxiety as threatening

People who have recurrent and repeated problems with attacks of panic (sometimes called panic disorder) experience their bodily sensations of anxiety and fear as if there were an imminent threat happening here and now. That is, their minds accidentally interpret fear itself as a being a threat. A classic example is when someone interprets an elevated heart rate as evidence of a heart attack, and then takes this interpretation too seriously. The vividly imagined threat of a heart attack activates the sympathetic nervous system, which then further elevates the heart rate, which then provides more “evidence” of a heart attack, and so forth until the person is totally convinced that he or she is going to die. Feedback loops like this can lead to a major meltdown. A “panic attack” is just that – a catastrophic interpretation of otherwise harmless bodily sensations, leading to more and more fear and panic. The problem lies with how the sensations of fear and panic are interpreted, not with the sensations themselves.

The solution to panic attacks

Stop running and instead, feel the fear. Get warm and cozy with it. After all, panic is your good buddy who is trying to keep you safe, not an enemy looking to harm you. A friendly relationship with panic can be very counterintuitive at first – after all, panic doesn’t feel safe. You may be tempted to try to get rid of it with medications (fighting), or to try to stay away from situations in which you might panic (fleeing), or maybe if you just hunker down and wait it out it won’t happen again (freezing). See the problem here? That is all more panic! You can’t fight fire with more fire, but the good news is you don’t need to in the first place. If instead you learn to “hang out” with panic, you can learn that it is in fact perfectly safe despite how it feels.

This can of course be a fairly difficult thing to learn; a “just do it” approach to accepting panic sensations is often not helpful. Fortunately, you can find guidance in learning how to be less reactive to your own thoughts and feelings – a mindfulness practice is a great way to help gain perspective, and there are good self-help books out there that can be helpful. Furthermore, there are evidence-based psychotherapies that have been proven to help people with panic disorder – give me a call if you’d like to schedule an initial consultation.

If there is a real threat out there in the world – attack it, run from it, or hide! But your own sympathetic nervous system is not your enemy. You are safe with yourself.

Anxiety Treatment at Portland Psychotherapy

The Difficulties of Accessing Effective Treatment: OCD as an Example

I resonated with a recent article in Psychology Today about the difficulties people have in finding therapists who offer effective treatment. The authors Dean McKay and Scott Lilienfeld—especially Dr. Lilienfeld—have been extremely active in promoting science-based psychotherapies.

As an example, they offer the experience of “Jerry” (a pseudonym). Jerry struggled with obsessive-compulsive disorder (OCD). Having educated himself on OCD, Jerry knew that exposure and response (or ritual) prevention (ERP, for short) was the most researched and effective treatment for OCD. ERP involve systematically helping people with OCD learn to confront obsessions while resisting the urge to engage in compulsions or rituals.

Despite living in a major city, it took Jerry 3 years to find a therapist who offered and was proficient in ERP for OCD. Jerry’s experiences are similar to those of a Yale graduate student with OCD.

Many clients I’ve seen have similarly struggled. Some were misdiagnosed by prior therapists and did not even realize they had OCD until they did their own research. Some therapists correctly identified them as having OCD but when it came to treatment, they “just talked.”

Most people with OCD with whom I’ve worked have seen at least 1 or 2 therapists who have not been particularly helpful. Hair pulling (trichotillomania) and skin picking (excoriation) are two other problems that people with whom I’ve worked have struggled to find effective treatment.

The article by Drs. McKay and Lilienfeld provides a sober reminder that there are a number of people who would benefit from effective treatments such as ERP but cannot find therapists who practice it or are aware enough of their competency to refer out to a specialist. Unlike Jerry, many people with problems such as OCD, trichotillomania, and excoriation don’t even realize there’s a name for their struggles, let alone effective treatment, and they may drift in and out of therapists’ offices being misdiagnosed and receiving substandard treatment.

Drs. McKay and Lilienfeld recommend that:

The adoption of the new clinical practice guidelines is probably our field’s best hope for placing long overdue pressure on therapists to incorporate scientifically based approaches into their clinical practices. Practice guidelines would also assist mental health consumers with the daunting task of selecting more effective treatments.   


Sadly, there are many licensed therapists who do not believe in science-based approaches. For people with mild to moderate depression/anxiety, generic talk therapy and nonscientific approaches can offer some relief. For people like Jerry with OCD, these unscientific approaches are unlikely to be of much help.

I’m inspired that psychologists such as Drs. McKay and Lilienfeld take time from their busy schedules as full-time professors and respected researchers to promote scientific approaches. You can read their blog post here. I encourage readers to carefully research the therapists you or your loved ones see, and not to stay in therapy with someone who doesn’t seem to be very helpful.

A Brief Video about OCD

I ran across this excellent 5 minute video on obsessive-compulsive disorder (OCD) by Helen Blair Simpson, MD, PhD through the Mental Health Channel. Dr. Simpson is a professor at Columbia University and director of the Anxiety Disorders Clinic. She is one of the leading experts on anxiety and OCD and related disorders.

In this brief video, Dr. Simpson walks through different types of OCD and describes the range of severity with which people may struggle. She provides specific examples of some of the people with whom she has worked. At the very end, Dr. Simpson gives provides a summation of our current understanding of OCD and the brain in plain language.

If you or someone you know struggle with OCD, I highly recommend you check it out. It’s very concise and yet covers a range of different OCD-related symptoms. You can watch the video here.