Skin Picking Through the Lens of Lived Experiences: What Can We Learn?

Skin picking is not uncommon. Who hasn’t picked at a pimple or scab just a little too much? For most people, it’s a benign activity and quickly forgotten. For others, skin picking can become a repetitive behavior that causes emotional distress and injury to the skin. When that happens, the picking becomes problematic and may be a sign of skin picking disorder.

There’s a lot we know about skin picking disorder:

• Clinically referred to as Excoriation Disorder, skin picking is a body-focused repetitive behavior (BFRB) characterized by the repetitive picking of the skin causing injury to the skin.
• It is a disorder classified as an Obsessive Compulsive Related Disorder (OCRD) along with OCD, hair pulling (trichotillomania), hoarding, and body dysmorphic disorder.
• It can cause considerable distress and impact on a person’s interpersonal functioning.
• It tends to affect females more than males.
• Age of onset tends to be early adolescence.
• There is no “cure” or single treatment that works for everyone.
• There are sub-types of skin picking.
• It can be associated with high levels of distress, shame, and psychosocial avoidance.

What we also know about skin picking is that it is highly heterogenous. People experience skin picking in many different ways and with varying severity.

Empirical research can tell us a lot about the clinical presentation of skin picking and its possible origins and identify possible interventions, but it doesn’t tell the whole story. It doesn’t tell us much about the experience of living with skin picking. Just what is that experience like? Why do they pick?

It has been suggested that some of this lack of understand of the experience of skin picking comes from a lack of qualitative data and that the best way to learn about the experience of skin picking is from those who live with it. What can we learn from their experiences and about how best to help and support them? A recent study takes a look at skin picking through the lens of the lived experiences of people living with skin picking prioritizing participants' voices and sense-making.

Experiences and Themes Revealed

Through gathering responses about their experiences, the study sought to answer the question, “What is the lived experience of problematic skin picking?”

Using a semi-structured interview process, participants completed their interview using one of several options that included phone, email, messaging apps, or Skype. This approach was used to support comfort and to allow for participants to use their own language in describing their experiences.

Responses were analyzed along 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. Three themes emerged:

• Skin Texture Must Go - Thoughts and attention focused on the skin texture motivated picking.
• ‘Oh Well’ and ‘So What’: Resignation to Picking – Patterns of thinking contributed to feeling resigned to picking, that it was somehow inevitable, tolerable, or manageable. Interestingly, when picking was seen as less manageable, the behavior decreased.
• Picking Because I Can: Permissive Circumstances – 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 In to Zone Out - Participants described “zoning out” during picking episodes. This is in keeping with the automatic picking subtype and picking trances. 

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

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

This dimension focused on dealing with the perceptions of 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:

• Shame of Picking - Participants reported feeling self-conscious about their damaged skin which led to social avoidance and attempts to conceal their skin.  Some worried that others would think they were infectious or lacked self-control.
• I am Misunderstood – Feeling misunderstood led to frustration and a reluctance to seek help. They also reported relieved when they felt understood by others.

The authors shared several quotes from the participants. Their words describe skin picking in ways quantitative research cannot. Theirs is the voice of lived experience. 

What The Findings Mean for Treatment

The goal of the study was to gain a better understanding the experience of skin picking as described by those who live with the disorder and the thought processes that accompany the behavior.

This research highlights the need for contributions from both quantitative and qualitative research. Both bring valuable information that complement each other and play a key role in the development of effective and innovative treatments.

Attention to individual differences is pivotal in developing effective treatment plans that meet the individual’s needs. Treatment should be guided by their priorities, needs, strengths and goals. Individualized treatment puts the person in the best position to succeed.

Qualitative studies like this one offer hope for more effective, individually focused treatments for those living with skin picking and other BFRBs. Understanding their real, lived experiences serves as a poignant reminder that the experience is uniquely individual and that it touches lives in so many ways.

References

1. 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://journals.sagepub.com/doi/10.1177/1359105317700254

2. Anderson, S., Clarke, V., & Thomas, Z. (2022). The problem with picking: Permittance, escape and shame in problematic skin picking. Psychology and Psychotherapy: Theory, Research and Practice, 96(1), 83-100. https://bpspsychub.onlinelibrary.wiley.com/doi/10.1111/papt.12427