Emotional Experiences and Skin Picking: Voices of Experience

Skin picking behavior is a common and usually, benign activity. After all, who hasn’t picked at a scab a little too long or scratched a little too long? For some, skin picking becomes a repetitive behavior that causes emotional distress and injury to the skin. This type of picking is known as excoriation or, more commonly, skin picking disorder.

Skin picking is a body-focused repetitive behavior (BFRB) where someone recurrently and compulsively picks at their skin to the point of injury. Research has identified certain characteristics and factors associated with skin picking but it remains not well-understood and is difficult to treat. The diagnostic criteria for skin picking disorder include, “the skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.” What that actually means is highly dependent upon the individual and how they experience their skin picking. It’s not a “one-size-fits-all”.

When someone engages in a behavior that is out of the ordinary or self-injurious, like skin picking, questions often turn to the “why”:

Why does someone pick?

What do they get out of it?

How does it feel?

These are all legitimate questions to ask, and researchers have speculated about these very issues and more. They’ve done studies and developed interventions. However, the answers to many of these kinds of questions remain elusive.

Research describes skin picking as a heterogenous obsessive-compulsive related disorder that is associated with high levels of distress, shame, and psychosocial avoidance. What it has struggled to describe is the emotional experience of skin picking. Defining the experience of shame or guilt or distress is hard to quantify. Just what is that experience like and how does it affect the individual?  Understanding these individual differences and experiences can be an important key to finding effective, nuanced treatments.

A recent study suggests that some of this lack of understanding comes from a lack of qualitative data. In other words, what’s lacking are the voices of those who pick their skin. How do they experience skin picking and what can we learn from them about how to help? This new study seeks to explore the lived experiences of those who live with skin picking disorder.

The Study

Using information from people with a skin picking disorder, the study sought to draw on their subjective experiences to answer the question, “What is the lived experience of problematic skin picking?”

Information was gathered using a semi-structured interview process with a choice of how participants completed their interviews. Choices included WhatsApp or Messenger, email, phone, or Skype. This approach was used to support each individual’s level of comfort and to allow participants to use their own language in describing their experiences.

Experiences Revealed

Data were analyzed along with the three over-arching themes and dimensions:

• The Voice that Permits Picking: Cognitions Drive Picking and Undermine Resistance (the drive to pick)
• Switching Everything Else Off (the experience of picking)
• I Worry About People Looking and Judging Me: Distress in how Picking is Seen (the consequences of picking)

The Voice that Permits Picking: Cognitions Drive Picking and Undermine Resistance

This dimension explored the drive to pick. Picking behaviors were driven by thoughts and circumstances that allowed picking, and that diminished the will to stop. These experiences fell within three themes:

• Skin Texture Must Go - Thoughts and attention focused on the skin motivated picking. Thoughts about skin texture seemed to be particularly prevalent.
• ‘Oh Well’ and ‘So What’: Resignation to Picking – Participants reported patterns of thinking that contributed to resignation to picking, that it was somehow inevitable, tolerable, or manageable. Interestingly, when picking was seen as less manageable, the behavior was reduced.
• Picking because I Can: Permissive Circumstances – Picking would happen whenever an opportunity is presented. The opportunity seemed to be a trigger to pick (e.g., free time or free hands)

Switching Everything Else Off

This dimension explored the experience of picking. Three main themes emerged:

• Zoning Into Zone Out - Participants described having the experience of “zoning out” during picking episodes. This is in keeping with the previous findings related to automatic picking style and picking trances. 

• It Comes with Negative Emotions - Picking was often associated with feelings of stress or distress. Participants reported that this zoned-out style of picking brought relief.
• Reducing Emotional and Mental Noise – Participants described the picking as mental and emotional relief, being a means for coping or relaxation. Several participants noted the difficulty in managing their stress.

 

I Worry About People Looking and Judging Me: Distress in how Picking is Seen

This dimension focused on how the person dealt with how their picking might be perceived by others. Hiding their picking and skin damage was a common action. Shame, embarrassment, and disgust seemed to be exacerbated by social interaction. Two dominant themes emerged:

• The shame of picking - Participants reported feeling self-conscious about their damaged skin which led to social avoidance and attempts to conceal their skin.  Underlying thoughts included worried that others may think they are infectious or lacked self-control.
• I am Misunderstood – Many felt misunderstood by others. This led to frustration and a reluctance to seek help. They also reported being relieved when they felt understood by others.

The study included a number of quotes from the participants that describe these dynamics and their experiences in their own words. They describe skin picking in ways quantitative research cannot. They represent the voice of experience.  

Implications for Treatment

The goal of the study was to gain a better understanding of:

• Individual experiences of picking
• the relationships between these experiences
• the processes by which people understand their picking problem

These findings don’t negate what quantitative research has found. On the contrary, this type of qualitative research allows skin picking to be viewed through the lens of experience and how individual patterns of thinking can shape the course of their picking disorder.

This research highlights the value and the need for the voices of experience to be heard. Understanding individual differences are pivotal in developing effective treatment plans that meet the individual’s needs. Treatment should be guided by their priorities, needs, strengths, and goals.

Research like this offers hope for more effective, individually focused treatments for those living with skin picking and other BFRBs.

 

References

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

2. Anderson, S., & Clarke, V. (2019). Disgust, shame and the psychosocial impact of skin picking: Evidence from an online support forum. Journal of Health Psychology, 24(13), 1773–1784. https://doi.org/10.1177/1359105317700254

3. Anderson, S. (2021). The problem with picking: Permittance, escape and shame in problematic skin picking [Doctoral dissertation]. https://uwe-repository.worktribe.com/output/7239383