Skin Picking and Scratching

By Ted Grossbart, Ph.D.

By Ted Grossbart, Ph.D., Boston, MA

Most of us pull off the odd bit of skin or squeeze 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.

Skin Picking on the Rise

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 else is going on. For others, as the stress ratchets up, so does their picking. For yet another group, what starts as a well-intentioned attempt to smooth out or improve an area of skin may quickly turn destructive when it’s combined with a relentless perfectionism.

An Overwhelming Sense of Guilt and Shame

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. It can seriously erode relationships, work, and leisure and 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 scarring, recurrent skin infections, 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, but then as the blood flowed, this would change into revulsion and self-reproach.

The Emotional Link

Intriguingly, a high percentage of pickers I’ve worked with were picked on by others when they were growing up. They may have been scapegoated at school or the victim of critical, perfectionist 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, saying, "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 effectively. The very specific prescriptive style worked 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.

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