Cognitive Restructuring For Dermatillomania

Dermatillomania is a clinical condition where the patient gets regular uncontrollable urges to pick his or her skin. The picking can sometimes be so severe that it causes injury and scarring and can even sometimes lead to infection. People with compulsive skin picking disorder are unable to control the compulsion to pick his or her skin. The parts of the body that are mostly affected are the lips and the face. However, the other parts of the body are often affected too, such as arms and legs, cuticles, scalp and even the gums. Picking is often followed by a sense of relief, but this often follows shortly after with feelings of shame and embarrassment. 

What is Cognitive Restructuring and Can it Help?

It is widely agreed that Cognitive Behavioural Therapy (CBT) is the most effective form of intervention for body-focussed repetitive behaviors (BFRBs) such as dermatillomania (now known as excoriation disorder).Cognitive Behavioral Therapy focuses on making the patient aware of what they are doing and why they are doing it, as well as providing effective means to find positive alternatives to the harmful actions. Cognitive restructuring is a major component of CBT. 

CBT is based on the principle that destructive habits are a response to faulty patterns of thoughts that lead to overwhelming negative emotions.  So, the therapy helps to gradually correct the faulty thinking patterns of the patients. Cognitive restructuring for dermatillomania is divided into four steps:

Step 1: Identify the event or situation that triggered picking

Your therapist may require you to keep a picking log and thought record. Each time you pick you will the environment you were in, and what thoughts or feelings you experienced just prior to, during and after picking.

Step 2: Becoming Aware of our Automatic Thoughts

You and your therapist might spend some time discussing your picking record to identify patterns of thinking and internal self-talk.

Step 3: Identifying Faulty Thinking

Next you will identify faulty patterns of automatic thoughts and identify how your thoughts impacts on your emotions and behaviors. You will examine your thoughts to see if they are unrealistic or inaccurate, rather than just accepting them as being fact.

Step 4: Challenging Faulty Thoughts and Replacing it with Realistic Alternatives

The third step is a gradual rational disputation of these automatic thoughts. You will start by first writing down the thought and evidence that objectively supports it. Next, identify and write down evidence that contradicts the automatic thought. By this stage, you've looked at both sides of the situation. You should now have the information you need to take a fair, balanced view of what happened.

What are Automatic Thoughts?

Our thoughts are constantly helping us to interpret the world around us, describing what is happening, and trying to make sense of it by helping us interpret events, sights, sounds, smells, feelings. Without even realising it, we are interpreting and giving our own meanings to everything happening around us. We might decide that something is pleasant or nasty, good or bad, dangerous or safe. Because of our previous experiences, our upbringing, our culture, religious beliefs and family values, we may well make very different interpretations and evaluations of situations than someone else. These interpretations and meanings we give events and situations, result in physical and emotional feelings.

There are different types of automatic thoughts:

1. Mind Reading:  You assume that you know what people think without having sufficient evidence of their thoughts.  He thinks Im a loser.
2. Fortune telling:  You predict the future negatively:  Things will get worse, or there is a danger ahead.  Ill fail that exam, or I wont get the job.
3. Catastrophising:  You believe that what has happened or will happen, will be so awful and unbearable that you wont be able to stand it.  It would be terrible if I failed.
4. Labelling:  You assign global negative traits to yourself and others.  Im undesirable, or Hes a rotten person.
5. Discounting positives: You claim that the positive things you or others do are trivial.  Thats what wives are supposed to do so it doesnt count when shes nice to me, or Those successes were easy, so they dont matter.
6. Negative filtering:  You focus almost exclusively on the negatives and seldom notice the positives.  Look at all of the people who dont like me.
7. Over generalizing: You perceive a global pattern of negatives on the basis of a single incident.  This generally happens to me.  I seem to fail at a lot of things.
8. Dichotomous thinking: You view events or people in all-or-nothing terms.  I get rejected by everyone, or It was a complete waste of time.
9. Shoulds: You interpret events in terms of how things should be, rather than simply focusing on what is.  I should do well.  If I dont then Im a failure.
10. Personalising:  You attribute a disproportionate amount of the blame to yourself for negative events, and you fail to see that certain events are also caused by others.  The marriage ended because I failed.
11. Blaming:  You focus on the other person as the source of your negative feelings, and you refuse to take responsibility for changing yourself.  Shes to blame for the way I feel now, or My parents caused all my problems.
12. Unfair comparisons:  You interpret events in terms of standards that are unrealistic for example, you focus primarily on others who do better than you and find yourself inferior in the comparison.  Shes more successful than I am, or Others did better than I did on the test.
13. Regret orientation: You focus on the idea that you could have done better in the past, rather on what you can do better now.  I could have had a better job if I had tried, or I shouldnt have said that.
14. What if:  You keep asking a series of questions about what if something happens, and you fail to be satisfied with any of the answers.  Yeah, but what if I get anxious? or What if I cant catch my breath?
15. Emotional reasoning: You let your feelings guide your interpretation of reality. I feel depressed; therefore, my marriage is not working out.
16. Inability to disconfirm:  You reject any evidence or arguments that might contradict your negative thoughts.  For example, when you have the thought Im unlovable, you reject as irrelevant any evidence that people like you. Consequently, your thought cannot be refuted.  Thats not the real issue.  There are deeper problems.  There are other factors.
17. Judgement focus:  You view yourself, others, and events in terms of evaluations as good-bad or superior-inferior, rather than simply describing, accepting, or understanding.  You are continually measuring yourself and others according to arbitrary standards, and finding that you and others fall short.  You are focused on the judgments of others as well as your own judgments of yourself.  I didnt perform well in college, or If I take up tennis, I wont do well, or Look how successful she is.  Im not successful.

Cognitive Restructuring is not an effective treatment for dermatillomania on its own, but rather an important component of a holisitic cognitive behavioral approach as it is a good starting point to understand the underlying influences on your picking behaviors.

External Sources:

Treatment Plans and Interventions for Depression and Anxiety Disorders by Robert L. Leahy and Stephen J. Holland.  Copyright 2000 by Robert L. Leahy and Stephen J. Holland.