What Is Picking Disorder? Causes, Symptoms, and Treatment

Picking disorder, known clinically as excoriation disorder or dermatillomania, is a mental health condition defined by the repetitive and compulsive picking of one’s skin to the point of causing tissue damage. This condition is classified as a body-focused repetitive behavior (BFRB), placing it in a category of disorders related to obsessive-compulsive disorder. The behavior is a complex disorder that can cause significant disruption in a person’s life.

Identifying Skin Picking Behaviors

The main feature of picking disorder is recurrent skin picking that results in lesions or sores. The behavior is not better explained by another medical condition, such as scabies, or a psychiatric condition like body dysmorphic disorder. Individuals make repeated, unsuccessful attempts to reduce or stop their picking, which causes them considerable distress.

The physical actions can include scratching, squeezing, rubbing, lancing, or biting the skin. People may use their fingernails or tools like tweezers and pins. While any part of the body can be a target, the most common areas are the face, arms, hands, and legs. The focus is often on minor skin irregularities such as pimples, scabs, or even healthy skin.

This behavior is often linked to emotional states. Many individuals experience a growing sense of tension or an urge before a picking episode. During the act, they may feel a sense of pleasure or relief, which is frequently followed by feelings of guilt and shame about the behavior and its visible consequences. The picking can be automatic, with the person unaware they are doing it, or it can be a focused activity they feel powerless to stop.

Exploring Potential Causes and Triggers

The development of picking disorder stems from a combination of biological, psychological, and environmental factors. A genetic predisposition may exist, meaning the disorder can run in families. Neurochemical factors, such as imbalances in brain chemicals like dopamine and serotonin that regulate mood and behavior, may also play a part.

Psychological states are strongly linked to the onset of picking episodes. Feelings of stress, anxiety, boredom, and sadness can all act as triggers. For some, skin picking serves as a coping mechanism to manage overwhelming emotions. Underlying psychological traits, such as perfectionism, may also contribute when an individual picks at their skin to remove perceived flaws.

Certain situations and environmental cues can precipitate picking behaviors. Being alone often provides an opportunity to pick without social scrutiny. The presence of mirrors can be a trigger, as they allow for close inspection of the skin. Sedentary activities that require less active use of the hands, such as watching television or reading, can also be associated with automatic picking.

Impact on Physical and Mental Well-being

The most direct consequence of chronic skin picking is physical damage. This can range from minor skin lesions to more severe outcomes like infections, permanent scarring, and tissue damage that may require medical intervention. In some cases, complications such as epidermal abscesses can arise, and severe instances have required procedures like skin grafting.

Beyond the physical effects, the disorder carries a substantial mental and emotional weight. Individuals often experience profound feelings of shame, guilt, and embarrassment related to the picking and the resulting appearance of their skin. This can lead to low self-esteem and a negative self-image, and may contribute to or worsen other mental health issues like anxiety and depressive disorders.

The social and functional impact can be extensive. Shame may cause individuals to avoid social situations, particularly those where their skin might be exposed, such as swimming. This avoidance can strain relationships and lead to social isolation. The time spent picking, which can amount to several hours a day for some, can interfere with responsibilities at work, school, and home.

Picking disorder frequently co-occurs with other mental health conditions. It is often seen alongside other BFRBs like trichotillomania (hair-pulling disorder). There is also a strong association with obsessive-compulsive disorder (OCD), body dysmorphic disorder (BDD), and various anxiety and depressive disorders, which can complicate treatment.

Approaches to Diagnosis and Treatment

A diagnosis of excoriation disorder is made by a mental health professional or medical doctor based on established criteria. The assessment evaluates the recurrent nature of the picking, the resulting skin damage, and the significant distress or impairment it causes. Seeking a professional evaluation is the first step toward getting appropriate help.

Therapy is a primary treatment, with several evidence-based approaches available. Habit Reversal Training (HRT) is a behavioral therapy that involves awareness training to recognize triggers and competing response training to substitute picking with a less harmful action. Other models include the Comprehensive Behavioral Model (ComB), Acceptance and Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT), and Cognitive Behavioral Therapy (CBT).

In some cases, medication may be prescribed to help manage symptoms. Medications like selective serotonin reuptake inhibitors (SSRIs) can address underlying anxiety or depressive symptoms that may trigger picking. The antioxidant N-acetylcysteine has also shown some promise in reducing the urge to pick. Medication is most often used in combination with therapy.

Alongside professional treatment, various self-help strategies can be beneficial. These include:

• Using stress management techniques, such as mindfulness and relaxation exercises, to reduce emotional triggers.
• Creating physical barriers by wearing gloves or applying bandages to targeted areas to make picking more difficult.
• Using fidget tools or sensory objects to provide an alternative way to keep hands occupied.
• Redirecting the urge to pick toward a non-harmful, competing activity.