What Works

[Dr Ted Grossbart Boston]

HOW TO STOP COMPULSIVE SKIN PICKING AND SCRATCHING

Everyone pulls off the odd bit of skin or squeezes a random pimple.  But for some people the squeezing, scratching, or picking becomes an absolutely monstrous compulsive behavior that threatens to take over their lives.  Concealing what they are doing and its impact, can trigger desperate attempts at camouflage and the avoidance of activities and relationships.   

As a practicing skin psychologist for 30 years, I have seen a huge recent increase in people coming in with skin picking and scratching problems.  Some have an underlying skin disease, but the behavior itself may be the whole story. Feeling great shame, people become isolated, rarely talking to friends and neighbors about their problem.  This makes it hard for them to connect with others for support. The Internet may become their key source of support and information.

Pickers and scratchers range from very emotionally troubled, to otherwise quite healthy and successful people. PICKING PROBLEMS THAT LOOK THE SAME FROM THE OUTSIDE CAN BE VERY DIFFERENT ON THE INSIDE. Treatment needs to be carefully individualized--simple formulas and stock programs are often not enough. The treatment approach MUST be matched to both what is fueling the picking and the individual’s personal psychology.

Many different paths can lead to a picking problem. Any area may be the target, some people use tweezers or nail files and produce deep permanent scars. Many people describe looking for self-soothing, and go into a trancelike daze when they pick.  Some people do most of their picking when they are bored, reading, or watching a movie,  and little is going on.  For others as the stress ratchets up, so does their picking. For yet another group, what starts as a well-intentionned attempt to smooth out or improve an area of skin may quickly turn destructive when it combines with a relentless perfectionism.

Deep guilt and shame can easily compound the problem.   Sarah G. told me,  "Over the years I have gradually shared all my secrets with my husband except one.  Ever since college I have been disappearing into the bathroom to tear at my skin.  I don't know if he suspects or not.  I feel like a freak,  I know I should tell him, but..." For her, ‘coming out’ was a critical step. Probably no treatment approach would have worked without it.

Not seeing their problem as a serious 'real' disorder, some deny themselves serious treatment.  Picking can become a major focus of life and can seriously erode relationships, work, and leisure and really make people feel crazy and out of control. People who are hard on their skin are typically also hard on themselves about it. Fiona O. put it sharply, "I'm doing it to myself, so I deserve what I get."

When Julia B. got out her magnifying mirror and bright light she knew trouble was coming.  Deep scaring, recurrent skin infections and and an overwhelming sense of shame were no match for her compulsion to keep digging deeply at the skin on her arms. At first picking would bring her a blissful, trancelike sense of peace, and then as the blood flowed this would change into revulsion and self-reproach.

Intriguingly,  a high percentage of pickers I’ve work with were picked on by others when they were growing up.  They may have been scapegoated at school or the the victim of critical, perfectionistic parents.  Being picked on then becomes a pattern that people loyally continue by internalizing the problem and picking on themselves.  

Emma L. described her erratic parents and chaotic childhood,  "Picking was the one stable thing I could depend on." As she was able to build a more solid identity and sense of herself in therapy, she was able to let go of the picking.

Natalie M.’s focus on her picking as part of a lifelong pattern of obsessions and compulsions let her use medication and behavior therapy very effectively. The very specific prescriptive style worked very well for her. In contrast Brent L. came to think of his picking as an “addiction without a substance” and adapted parts of the AA 12-step approach. He found he could stop picking if he was able to focus on, and sit with, the emotional pain that it was masking.

For others really pushing to get at the emotions that are lurking when picking starts is key.  Picking can be an angry act, as I suggested to Brad K., if he did to someone in the street what he did to himself, they would put him in jail.  Anne R. usually picked only in private, but when she got a cell phone call in a crowded car telling her that her boy friend was also dating someone else, the picking started and her blood started to flow. Her skin took the beating she wished she could have delivered to him.  People like Anne and Brad need help to feel their feelings in their hearts instead of in their skins.  


TREATMENT: WHAT WORKS

I have been most impressed with the effectiveness of three treatment tools:

1.) MEDICATION: Antidepressants (SSRI’s) and mood stabilizers have been very helpful for some of my patients, and a disappointment for others. If you want to go this route it is important to be persistent and expect to experiment with different drugs and dosages.

2.) PSYCHOTHERAPY: With literally hundreds of different approaches, it is hard to be an educated consumer. Look for good personal chemistry: someone you feel ‘gets’ you. Look for a depth of experience working with picking and scratching. Someone can be a great therapist for people with other problems, yet ignorant and ineffective in this area. Ideally a therapist should be competent to address behavior change, cognitive (thinking) issues, and also the emotional side of the problem. A therapist who is too strictly committed to one approach or technique may have major blind spots.

3.) HYPNOSIS and SELF-HYPNOSIS: These adjunctive techniques are best taught by a qualified psychotherapist. With an impressive record of success for habit control, these approaches are especially useful for people who go into a spacey trance state when they pick. You can learn to turn this “inadvertent negative hypnosis” into an effective treatment technique.




Ted A. Grossbart, Ph.D. is a licensed clinical psychologist in private practice in Boston. He is a Senior Associate and Clinical Supervisor for Beth Israel-Deaconess Hospital's Department of Psychiatry, and an Assistant Clinical Professor of Psychology at Harvard Medical School. He has been a pioneer in the use of relaxation, imaging, hypnosis, and psychotherapy for skin problems. His best known writing is his book SKIN DEEP: A Mind/Body Program for Healthy Skin, now in its second edition. The SKIN DEEP WEB SITE (http://grossbart.com) is a major resource on skin psychology and psychodermatology.

Note the book chapter “Breaking the Itch-Scratch Cycle” (http://www.grossbart.com/sd/Skin_Deep9.html).