Dermatillomania: Addiction vs. Compulsion Explained

Despite common assumptions, repetitive skin picking is more than just a “bad habit”. It’s not an attention-seeking behavior. It’s not due to weakness or poor hygiene or a lack of concern for oneself. Dermatillomania or Excoriation Disorder, commonly known as skin picking disorder, is a body-focused repetitive behavior (BFRB) classified as an Obsessive-Compulsive Related Disorder (OCRD). It is characterized by repetitive skin picking that results in damage to the skin, significant emotional distress, and impaired interpersonal functioning. While it is not the same as obsessive compulsive disorder (OCD), it does share similarities with OCD. Skin picking is a complex disorder that remains the focus of much debate as to its origins and how best to treat it.

Historically, skin picking was not classified as a distinct disorder but rather as a symptom of OCD or an impulse control issue along with hair pulling and pathological gambling. Skin picking had no specific criteria. That changed in 2013 when skin picking was given the clinical designation of Excoriation Disorder and categorized as an OCRD.

Much of the research suggests that BFRBs are more closely related to OCD supporting the designation as an OCRD. They point to the compulsive nature of skin picking and its similarities to OCD. Skin picking is driven by sometimes irresistible urges to pick at one’s skin, often to the point of injury. The person is unable to simply stop, even when they desperately want to. People who pick their skin describe feeling compelled to pick, experiencing growing tension until they do. After a picking episode, many describe feeling a sense of relief.

Other evidence suggests that skin-picking characteristics are more closely aligned with behavioral addictions such as gambling:

• High rate of addiction associated with skin picking.
• Skin picking shares similar characteristics with addiction:
  • Continuing the behavior despite the harm it causes
  • The presence of urges
  • Elevated impulsivity
  • Similar responses to treatments including psychotherapy and medications such as naltrexone and topiramate

In fact, if you were to look at the diagnostic criteria for skin picking, OCD, and behavioral addictions like gambling, you would see considerable overlap in the criteria used to diagnose each disorder.

Addiction or compulsion – does it really matter? Delving deeper into the nuances of skin picking reveals a stark contrast between addiction and compulsions.

What Is a Compulsion?

A compulsion a type of behavior (e.g., hand washing, checking the door locks) or a mental act (e.g., counting, praying) engaged in to reduce anxiety or distress. Typically, the individual feels driven or compelled to perform the compulsion to reduce the distress associated with an obsession or to prevent a dreaded event or situation. It is a repetitive, hard-to-control, and unwanted behavior or urge that when acted upon relieves some kind of internal distress.

Compulsive behaviors are usually performed to:

• Avoid some obsessive fear from happening
• Reduce feelings of distress related to the obsessive thoughts
• Make things look or feel “just right” 

Compulsive skin picking often arises from a variety of triggers, including stress, anxiety, boredom, or even a subconscious response to perceived imperfections on the skin. Triggers can be mental (thoughts or feelings) or related to physical sensations (e.g., itching, tingling). Some people may experience both. They may experience an intense sense of tension or anxiety leading up to the picking episode, followed by a temporary sense of relief during the act itself. However, this relief is short-lived, as feelings of guilt, shame, and regret often follow once the damage is done.

People with skin picking tend to be very aware of their behavior and even have some insight into why they pick.

What Is an Addiction?

Addiction is generally defined as a compulsive, chronic, physiological or psychological need for a substance, behavior, or activity having harmful physical, psychological, or social effects and typically causing well-defined symptoms (such as anxiety, irritability, tremors, or nausea) upon withdrawal or abstinence.

At its core, addiction typically revolves around the pursuit of pleasure or relief, driven by the brain's reward system. The person experiences a sense of euphoria or temporary relief from stress or discomfort. Whether it's the rush of dopamine from drugs, the thrill of gambling, or the gratification of consuming certain foods, addictive behaviors are often rooted in the anticipation of pleasure.

People with addictions tend to lack awareness that there is a problem or of the harm their behaviors or actions are inflicting on themselves or those around them. Insight usually only comes after extensive damage to both self and social circumstances, often as a result of input from others or from treatment experiences.

Addiction or Compulsion or Both?

When it comes to defining skin picking as a compulsion or an addiction, the picture is not clear and opinions vary even among people who live with skin picking.

On one hand, skin picking shares quite a few characteristics with addictions:

• engaging in something harmful despite being aware of its negativity
• feelings helpless to control the behavior
• the overwhelming urge to engage in the behavior
• pleasurable or relieved feelings that result from engaging in the behavior 
• feelings of intense pleasure followed by feelings of guilt, shame, and embarrassment following the act

On the other hand, skin picking is classified as an OCRD but obsessive thoughts that are the hallmark of OCD are generally absent with skin picking. The pleasure that comes with picking is not associated with OCD. However, research suggests that the intense pleasure that comes from picking may be due to the release of endorphins in response to stimulated pain receptors. The pleasure from non-chemical addictions is thought to be related to the release of brain chemicals such as adrenaline or dopamine when engaging in the behavior.

It has been suggested that rather than an either/or, skin picking and other BFRBs may actually represent a unique group of disorders that share some qualities of both OCD and behavioral addiction.

What This Means for Treatment

Just as they share some characteristics, skin picking, OCD and addictions also seem to share similar responses to certain treatment modalities. Although it is clearly not a “perfect fit”, when it comes to treatment, the most important consideration is the person’s experience.

Cognitive-behavioral therapy (CBT) is a cornerstone of treatment for BFRBs like skin picking as well as for behavioral addictions like gambling. Therapy can help you identify triggers, develop coping strategies, and challenge negative thought patterns that contribute to the problem. Additionally, habit reversal training (HRT) aims to replace skin picking with alternative coping strategies, fostering healthier ways of managing stress and anxiety. While there is no single medication used to treat skin picking, there is some evidence that medications used to treat addictions may hold promise for skin picking.

The variance that is commonly seen in mental health disorders speaks to the need to consider the person and how they experience their disorder. Individualized treatment means a tailored approach that can lead to better outcomes. While more research is needed to fully understand the dynamics, viewing skin picking through a broader lens rather than an either/or perspective may reveal new treatment options and pathways to recovery. Until then, working with your mental health provider can help you to find the treatment options that are right for you.

References

1. Stein, D. J., Kogan, C. S., Atmaca, M., Fineberg, N. A., Fontenelle, L. F., Grant, J. E., Matsunaga, H., Reddy, Y. C. J., Simpson, H. B., Thomsen, P. H., van den Heuvel, O. A., Veale, D., Woods, D. W., & Reed, G. M. (2016). The classification of Obsessive-Compulsive and Related Disorders in the ICD-11. Journal of affective disorders, 190, 663–674. https://pubmed.ncbi.nlm.nih.gov/26590514/

2. Anderson, S. (2021). The Problem with Picking: Permittance, Escape and Shame in Problematic Skin Picking (Doctoral dissertation, University of the West of England). (2021). Retrieved from https://uwe-repository.worktribe.com/preview/8675330/The%20Problem%20with%20Picking%20-%20Full%20thesis_%20with%20Appendix%206%20redacted.pdf

3. Odlaug, B. L., & Grant, J. E. (2010). Pathologic skin picking. The American journal of drug and alcohol abuse, 36(5), 296–303. https://www.tandfonline.com/doi/full/10.3109/00952991003747543

4. . APA Dictionary of Psychology. (n.d.). Compulsion. Retrieved from https://dictionary.apa.org/compulsion

5. APA Dictionary of Psychology. (n.d.). Obsession. Retrieved from https://dictionary.apa.org/obsession

6. Definition of addiction. (2023, September 27). Retrieved from https://www.merriam-webster.com/dictionary/addiction