Sensory Overresponsivity and Skin Picking: What’s the Connection?

Even if you’re not fully aware, you experience the world using all of your senses. Your brain receives information via your five senses – smell, sight, taste, touch, and sound – and processes that information in order to respond. It’s the foundation of everything you do and how you “read” the world. And it’s not just for those “fight or flight” moments – it’s something you do a million times a day, often without giving it a second thought. 

For example, having a piece of key lime pie is more than just taking a bite, although that first bite is pretty enticing. You see the piece of pie sitting on the plate. You can smell the tart/sweet aroma. You feel the sensation of the fork in your hand as you take that first bite and experience the flavors and texture your brain recognizes as key lime pie.  Who knew that pie was such a multisensory experience. And you probably don’t give it a second thought, but you know it feels good.

Sensory processing (also known as sensory integration) is the way the brain receives, interprets, and responds to this information. Our senses can affect our thoughts, feelings, and behaviors. But what does sensory processing have to do with a skin picking disorder? More than you might think.

Skin picking (clinically known as Excoriation Disorder) is a disorder characterized by repetitive picking of the skin that results in skin lesions and injury, emotional distress, and impaired functioning. It is classified, along with other body focused repetitive behaviors (BFRBs) like hair pulling, as an Obsessive Compulsive Related Disorder (OCRD). While not the same as OCD, skin picking and other BFRBs do share similar important qualities. Sensory phenomena are often seen with OCD as well as with skin picking and other disorders along the OCD spectrum including autism spectrum disorder (ASD) and Tourette’s. These sensory experiences are often described as the need to feel good or a need to alleviate tension. Problems arise when that need is difficult to satisfy. 

People with OCD often report difficulty with the feeling of incompleteness and an intolerance for not just right experiences (NJREs) or imperfection. This phenomenon is similar to what is seen in the focused subtype of skin picking suggesting that sensory reactivity and how sensory information is processed may also play a key role in skin picking and similar disorders. Research suggests that this connection between OCD-related disorders is important and may hold some clues to how they develop and present, but the connection isn’t clear. A new study suggests that one aspect of sensory processing, sensory overresponsivity, may be the key to understanding the connection between skin picking, OCD and other compulsive behaviors. 

Sensory Processing and Overresponsivity

The idea that skin picking and other BFRBs are related to sensory processing isn’t new. Research and anecdotal evidence have found that people often report that they find the experience of skin picking to be satisfying in some way. Some people report that they search for imperfections that feel a certain way or that picking certain ways (e.g., using tools) elicits a certain feeling. 

Problems of sensory processing can be viewed along three dimensions: 

• Problems with modulation (e.g., over responsivity, under responsivity, seeking or craving)
• Sensory-based motor disorder (e.g., dyspraxia – problems with coordination)
• Problems with sensory discrimination (recognizing the different qualities of input, e.g., do you have a dime or a quarter in your pocket)

Sensory overresponsivity (SOR) is an intense, prolonged, or exaggerated response to a non-painful sensory stimulus. It’s an avoidance response with the goal of alleviating the distress it creates. This heightened response can result in impairment in daily functioning. The study sought to explore how SOR is related to symptoms across the full obsessive compulsive spectrum (e.g., OCD, body dysmorphic disorder, hoarding, skin-picking, and hair-pulling symptoms) and how it might influence the heterogeneity of these symptoms.

Using a web-based survey method, they found that SOR is related to the major obsessive compulsive spectrum symptoms. There was no clear indication that SOR was more strongly associated with some symptoms than others. Some data suggested that SOR may be a predictor of later obsessive compulsive symptoms, but it was noted that more research is needed in this area.

Other key findings included:

• SOR can be adequately measured using a web-based version of the SOR Scales.
• Results consistent with other studies in which sensory experiences were associated with OCD, especially in relation to symmetry or “just right” and “ordering” symptoms.
• Unlike previous studies, SOR was not more strongly related to hair pulling or skin picking than other disorders. Rather, results suggest that SOR is a transdiagnostic factor linked to all symptoms across the obsessive compulsive spectrum. 
• Hearing was the SOR domain that showed the most difficulties, followed by touch, smell, sight, and taste. These findings are in keeping with previous research.

What Do These Findings Mean for Treatment?

Having an accurate way to assess SOR aids in the diagnostic process. An accurate diagnosis is the foundation of effective treatment. Given that this was a web-based study, it further advances the use of online therapeutic resources and potentially opens up care for those in geographically distant or underserved areas. 

Understanding how SOR affects the emergence and progression of symptoms may lead to more effective and individualized treatment approaches. It may even be possible that similar disorders may respond to similar treatments although much more research is needed in this area. 

One area that has received a lot of attention in the literature is that of the gut-brain axis. This connection is becoming the focus of research of late. The study authors suggest that future research into SOR might benefit from the exploration of the influence of SOR across the obsessive compulsive spectrum.   

Findings like these advance the understanding of skin picking and other obsessive compulsive related disorders. They offer insight and hope for the development of innovative and individualized treatment interventions for skin picking and related disorders.

Resources

1. Houghton, D. C., Alexander, J. R., Bauer, C. C., & Woods, D. W. (2018). Abnormal perceptual sensitivity in body-focused repetitive behaviors. Comprehensive Psychiatry, 82, 45-52. https://epublications.marquette.edu/cgi/viewcontent.cgi?article=1330&context=psych_fac

2. Allen, A., King, A., & Hollander, E. (2003). Obsessive-compulsive spectrum disorders. Dialogues in clinical neuroscience, 5(3), 259–271. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181632/

3. Moreno-Amador, B., Cervin, M., Martínez-González, A. E., & Piqueras, J. A. (2023). Sensory Overresponsivity and symptoms across the obsessive-compulsive spectrum: Web-based longitudinal observational study. Journal of Medical Internet Research, 25, e37847. https://www.jmir.org/2023/1/e37847/

4. Miller, L. J., Anzalone, M. E., Lane, S. J., Cermak, S. A., & Osten, E. T. (2007). Concept evolution in sensory integration: a proposed nosology for diagnosis. The American journal of occupational therapy: official publication of the American Occupational Therapy Association, 61(2), 135–140. https://pubmed.ncbi.nlm.nih.gov/17436834/