Understanding OCD And Dermatillomania (Skin-Picking Disorder)

Dermatillomania, sometimes called excoriation disorder or skin-picking disorder, is a mental health condition characterized by repetitive, compulsive picking or scratching of the skin. It’s considered a body-focused repetitive behavior (BFRB) in which repetitive self-grooming actions like picking, pulling, or biting parts of the body lead to physical damage. Another BFRB is trichotillomania (repetitive hair-pulling disorder). BFRBs, including dermatillomania, fall under the umbrella of obsessive-compulsive and related disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). 

Not everyone who compulsively picks their skin has OCD, and not everyone with OCD has compulsive skin-picking behaviors. This article explores the relationship between OCD and dermatillomania, their potential underlying causes, and the impact these disorders can have on well-being. It also offers suggestions for dermatillomania and OCD coping and treatment options. 

Living with OCD or dermatillomania?

Online therapy can offer support and guidance

Obsessive-compulsive disorder (OCD): A brief overview

OCD is a condition characterized by persistent, intrusive, unwanted thoughts or urges (obsessions), often followed by repetitive behaviors or mental actions (compulsions). Obsessions can be related to various themes, such as contamination, aggression, safety, order, or morality. Compulsions are typically performed in response to obsessions to alleviate anxiety. For example, a person with obsessive thoughts about germ contamination might engage in excessive handwashing or housecleaning rituals. Someone with obsessive thoughts about their house burning down might check that the stove and oven are off multiple times a day—even if they haven’t been used.

Comparing OCD and dermatillomania (skin-picking disorder)

Dermatillomania is a disorder related to obsessive-compulsive disorder (OCD) in which individuals repeatedly pick at their skin, often causing damage and discomfort. Both OCD and dermatillomania usually involve repetitive behaviors. However, dermatillomania typically focuses on skin-related urges and behaviors, while OCD encompasses a broader range of obsessions and compulsions. 

Key similarities between obsessive-compulsive disorder and dermatillomania

Both OCD and dermatillomania involve repetitive behaviors that individuals experience a compulsion to perform despite negative consequences. Both conditions can also include behaviors that provide a sense of temporary relief from anxiety or distress. OCD and dermatillomania can both be effectively treated with targeted forms of cognitive behavioral therapy (CBT) and, in some cases, prescription medication, such as selective serotonin reuptake inhibitors (SSRIs). 

Key differences between OCD and skin-picking disorder

In skin picking, the primary motivation is often to reduce tension or alleviate anxiety, while in OCD, compulsions are usually performed to prevent perceived harm or alleviate anxiety related explicitly to obsessions. Skin picking is often performed in response to stress, anxiety, boredom, or thoughts about skin imperfections, while OCD compulsions are often performed in response to intrusive thoughts or obsessions. 

Additionally, while both conditions may benefit from similar treatment methods (like cognitive behavioral therapy), habit reversal training can be particularly helpful for skin picking. Habit reversal training normally focuses on changing the specific skin-picking behavior. 

Diagnostic criteria for dermatillomania 

The DSM-5 provides specific criteria for diagnosing dermatillomania (referred to as excoriation disorder), including recurrent skin picking resulting in skin lesions, repeated attempts to stop the behavior without success, and significant distress or impairment in social, occupational, or other important areas of functioning. Further, the skin picking cannot be attributed to the physiological effects of a substance or another medical condition, and it cannot be better explained as a symptom of another mental disorder.

Similar disorders

In addition to OCD, dermatillomania often overlaps with other disorder classifications. For example, along with many other BFRBs, dermatillomania is sometimes labeled as an impulse control disorder. These disorders are generally characterized by the inability to resist urges or impulses to perform actions that are potentially harmful to oneself or others. In some cases, skin-picking behaviors result from concerns over appearance. These behaviors can be associated with body dysmorphic disorder (BDD).

Possible roots of OCD and dermatillomania

Though research is ongoing, most scientists believe OCD and dermatillomania are caused by a combination of biological, psychological, and environmental factors. Biological factors might include genetic predisposition or differences in brain structure and function. Trouble regulating challenging emotions can exacerbate or cause symptoms in both conditions. Skin picking can also serve as a maladaptive coping mechanism to relieve negative emotions or distress. For some individuals with dermatillomania, the behavior might be driven by a compulsion to remove perceived skin imperfections.

Environmental factors, like stressful life events, trauma, neglect, or abuse, may contribute to the development of both conditions. Some scientific theories suggest that individuals might learn OCD behaviors as coping techniques, especially if they observed similar anxieties and compulsive behaviors in their early caregivers. Pre-existing skin conditions like acne or eczema can trigger skin-picking behavior in susceptible individuals. 

Dual diagnosis: Why co-occurrence matters

Though not everyone with dermatillomania symptoms also has OCD, many do. Early recognition and accurate diagnosis tend to be key to positive treatment outcomes. If an individual suspects their dermatillomania symptoms are OCD-related, finding the link can provide a more complete picture of the individual’s challenges and help develop a tailored treatment plan. Habit reversal training (HRT) is the primary treatment for dermatillomania, while exposure and response prevention (ERP) is more often used for OCD. If both conditions are present, a therapist may recommend a combination of HRT and ERP.

The toll of dermatillomania on mental health

Guilt, shame, and self-esteem 

People with dermatillomania may feel ashamed of their visible skin damage and the compulsion to pick, possibly leading to guilt and embarrassment. The visible effects of skin picking can negatively impact a person's self-esteem and body image. When unaddressed, these emotions can cause or contribute to mood-related disorders. For example, research suggests that over half of individuals with skin-picking disorder also have depression.

Social withdrawal and stigma

Individuals with dermatillomania might withdraw from social situations due to embarrassment about their skin's appearance or the need to conceal their picking behavior. Skin picking may also consume significant time and energy, potentially interfering with work, school, and personal relationships. Misconceptions and lack of understanding surrounding these disorders can lead to stigma, compounding isolation and creating barriers for individuals to seek help or reveal their symptoms. 

CBT, habit reversal, and other treatment approaches

Treatment strategies for dermatillomania typically involve a combination of therapy, medication, and self-help strategies, depending on the individual's unique situation. For example, if the individual experiences comorbid depression or anxiety disorders, a therapist may focus on addressing them with antidepressants as well as therapeutic techniques. Additionally, the type of picking an individual does may influence treatment direction. 

• Automatic picking: This type of picking typically happens without directed attention. An individual might “scan” for places on the skin to find blemishes or other things that may be tempting to pick at without consciously realizing it.
• Focused picking: This kind of picking typically happens intentionally, with the individual focusing on a specific area. Focused picking tends to be more prolonged and causes more severe skin damage. 

Habit reversal training (HRT)

Habit reversal therapy is the most common method used to treat dermatillomania. It’s a type of cognitive behavioral therapy (CBT) with components targeted to address skin picking awareness, competing response, relaxation, and generalization training. 

Awareness training generally teaches individuals to become more aware of their skin picking and identify triggers. Competing response training can help them develop alternative behaviors to replace skin picking, such as using fidget toys, clenching fists, knitting, or sitting on one’s hands. Competing response training typically includes contingency management and reinforcing the alternative behavior. Relaxation training, including techniques like deep breathing and progressive muscle relaxation, is often used to manage stress and anxiety, which can sometimes lead to unwanted habits. Generalization training may ensure that the newly learned competing response can be used effectively in a variety of situations and environments. 

Self-care for healing

Practicing the skills you learn in therapy between sessions can be key to progress. Your therapist may ask you to keep a journal to track when, where, and why you're most likely to pick. Your therapist may also work with you to develop in-the-moment coping skills, such as deep breathing or grounding exercises, to manage stress and deter picking behaviors when they arise. Using an object like a fidget toy or stress ball can curb picking, as can wearing gloves, bandages, or finger puppets to physically restrict access to your skin.

You might manage stress at home by creating a soothing atmosphere with scented candles, soft lighting, and calming music. It may also help to participate in hobbies like knitting or beading that require using your hands as you relax. Spend time doing things that nurture and bring you joy, like enjoying nature or doing activities with friends and loved ones. 

Social support often plays a foundational role in healing. Some find it helpful to attend a support group for people with dermatillomania, where they can share their experiences and coping strategies. Sharing stories with other people in similar situations can mitigate guilt and shame, as well as boost self-esteem. 

The role of self-compassion in healing

Self-love and acceptance may play critical roles in healing from dermatillomania. Stay mindful of your thoughts to identify and eliminate negative self-talk and overcome self-criticism. This can increase emotional regulation and promote a more positive and adaptive approach to the condition. Instead of engaging in self-punishment for picking, focus on self-compassion and offer yourself the same empathy you might for a friend in the same situation. This sense of acceptance and understanding can lead to greater motivation for change and improved overall well-being. 

Living with OCD or dermatillomania?

Online therapy can offer support and guidance

Online therapy for OCD and skin-picking disorder

Virtual therapy can be a beneficial option for individuals with OCD and excoriation disorder. Individuals experiencing intense symptoms may feel uncomfortable speaking to a therapist in a traditional face-to-face environment, or they may not have geographical access to licensed therapists. 

Online therapy platforms like BetterHelp offer individuals access to a vast pool of licensed mental health professionals experienced in treating OCD with dermatillomania symptoms. You can attend sessions from the comfort of home on a schedule that fits your needs, often for less than traditional therapy without insurance. 

Online therapy is effective for many people, including those with certain BFRBs like hair pulling and skin picking. For example, scientists from Sweden's Center for Psychiatry Research followed patients' progress in an internet-delivered behavioral therapy (I-BT) model designed to treat skin picking and hair pulling. At the conclusion of treatment, the researchers found significant decreases in these behaviors.