Skin: It’s a waterproof, insulating barrier that protects us from harmful chemicals, extreme temperatures, and ultraviolet radiation from the sun. We’re quite literally covered in the stuff, meaning that our “cutaneous membrane” has the distinction of being the largest organ in the human body.
As it is, we lose around 1.5 lbs of dead skin cells each year, and it’s pretty common for us to play an active role in at least some of this process, perhaps persistently scratching a particular spot due to stress. At this level, skin-picking is an entirely normal grooming behavior. Excoriation disorder, on the other hand, is a repetitive behavior that involves the urge to pick at one’s skin, and can have significant physical and emotional consequences that impact people’s lives and well-being.
This article explores the connection between compulsive skin picking, ADHD, and anxiety. We’ll also touch upon the fact that, while skin picking can be associated with these conditions, when it interferes in your day-to-day life, it may also be a body-focused repetitive behavior, or BFRB. We’ll round things out by offering some info about effective ways to stop excoriation disorder, whatever its underlying cause may be.
Understanding skin picking
As we’ve already mentioned, skin picking is a repetitive behavior characterized by the irresistible urge to pick at one’s skin.
“With skin-picking, there’s a set of physical impacts,” says April Kilduff, MA, LCPC, LMHC, and Clinical Trainer at NOCD. “In some cases, people will actually pick through the skin, creating an open wound, and later, scars. This damage isn’t just unsightly; it can also lead to infection. But there’s also a set of emotional impacts. People’s inability to resist the urge to pick at their skin can result in poor self-esteem and leave them thinking things like, ‘Why can’t I just stop picking? What’s wrong with me?’ If the picking is in a place that isn’t covered by clothing, some people are likely to either spend a lot of time and effort covering them up with makeup. Others may just start limiting how much they interact with other people because of their appearance and the shame or embarrassment they feel about it. These physical and emotional impacts are felt regardless of the skin picking’s underlying cause.”
Let’s look at some of those causes, starting with the condition that around one in 12 Americans will experience during their lifetimes: attention deficit hyperactivity disorder, or ADHD.
Skin-picking as a symptom of ADHD
ADHD is a neurodevelopmental disorder characterized by inattention, hyperactivity, and impulsivity. The underlying impulsivity and hyperactivity associated with ADHD can contribute to skin-picking behaviors. Indeed, research has shown that skin-picking commonly appears in people with the disorder.
People with ADHD may struggle to resist the urge to pick at their skin, especially when feeling restless or overwhelmed. Skin picking may serve as a self-soothing or self-regulating mechanism for people with ADHD, temporarily relieving their core symptoms.
“Sometimes people with ADHD engage in skin picking because they are hyperstimulated from a sensory perspective and want to self-soothe and come down from that experience,” explains Kilduff. “Others, however, may pick at their skin because they are understimulated, and use it to get the stimulation they feel they need.”
It’s important to note that not all people with ADHD will engage in skin picking, but the correlation between the two suggests a potential link. Successful treatment of this underlying cause is likely to reduce the frequency of skin picking in people with ADHD.
The first-line treatment for ADHD usually involves a combination of behavioral interventions and medication management. Behavioral interventions aim to help improve organization, time management, and impulse control.
Medication management can be an important part of treatment, too. Stimulant medications such as methylphenidate and amphetamines are commonly prescribed to reduce hyperactivity, impulsivity, and inattention. Non-stimulant medications like atomoxetine and guanfacine may be used if stimulants are not well-tolerated, or other conditions are present.
Treatment choice depends on factors like the severity of symptoms, age, personal preferences, and any other conditions that may be present. It’s important to work closely with healthcare professionals like psychiatrists or pediatricians who can provide thorough evaluations and create personalized treatment plans.
Skin picking as a symptom of anxiety
Skin picking can also be linked to anxiety disorders characterized by excessive worry, fear, and intrusive thoughts. Anxiety can drive compulsive behaviors like skin picking to alleviate the distress caused by anxious thoughts or feelings.
“Anxiety disorders often involve a heightened sensitivity to stress and a constant state of apprehension,” says Kilduff. “Skin picking may serve as a coping mechanism, providing people with temporary control over their anxious thoughts. It becomes a way to release tension and divert attention away from overwhelming emotions.”
The first-line treatment for anxiety disorders typically involves a combination of psychotherapy and medication. Cognitive-behavioral therapy (CBT) is a common form of therapy that helps people identify and change negative thought patterns and behaviors associated with some forms of anxiety. Habit Reversal Therapy (HRT) is also a useful form of treatment for, helping people to change their behaviors associated with skin picking.
Identifying skin picking as a BFRB
While skin picking can be associated with ADHD and anxiety, it is important to recognize that it can also be a distinct condition known as a body-focused repetitive behavior (BFRB). BFRBs are a group of behaviors characterized by repetitive actions—often self-grooming ones—that cause significant distress and impairment in daily functioning. These behaviors, including skin picking, hair-pulling, and nail-biting, share common features but have distinct characteristics.
When skin picking is classified as a BFRB, it is considered a primary condition rather than a symptom of ADHD or anxiety. BFRBs are often chronic and recurrent, requiring specific treatment approaches tailored to address the underlying mechanisms of these behaviors.
“BFRBs are typically characterized by a sense of tension called the premonitory urge before engaging in the behavior, followed by a feeling of relief or satisfaction afterward,” Kilduff explains. “People may experience difficulty resisting the urge to engage in the behavior, even when they are aware of the negative consequences it may have on their physical appearance or emotional well-being.”
Skin picking as a BFRB is not solely driven by impulsive tendencies or anxiety, but is a distinct behavioral pattern. It is important to differentiate BFRBs from symptoms of ADHD or anxiety to ensure accurate diagnosis and appropriate treatment.
Can Habit Reversal Training Help People Whose Skin Picking Is Related to Anxiety or ADHD?
“Habit reversal training, or HRT, is a therapeutic approach that can be effective in managing skin-picking behaviors, regardless of whether they are related to anxiety, ADHD, or standalone BFRBs,” says Kilduff.
HRT focuses on increasing self-awareness and developing alternative responses to replace the urge to pick. It involves several key principles, including awareness training, where people learn to identify triggers and patterns associated with skin picking. By recognizing the situations, emotions, or thoughts that precede skin-picking episodes, people can then develop strategies to interrupt the behavior.
This sets the stage for competing response training, another important aspect of HRT. It involves identifying and practicing alternative actions or behaviors incompatible with skin picking. These alternative responses can substitute for the urge to pick, helping people redirect their focus and manage their impulses effectively. Kilduff says that clenching hands together is a good competing response in this instance, as it makes picking at the skin impossible.
Social support plays a vital role in HRT as well. Connecting with therapists, support groups, or loved ones who understand and empathize with the challenges of skin picking can provide encouragement and reinforcement. This support network can help people stay motivated, provide a safe space for sharing experiences, and offer guidance during recovery.
HRT has shown promising results in reducing skin-picking behaviors and promoting positive habit change. Research studies have demonstrated its effectiveness in reducing the frequency and intensity of skin-picking episodes, improving overall quality of life, and reducing associated distress and impairment.
BFRBs and NOCD
The close relationship between OCD and BRFBs, such as excoriation disorder, led NOCD to train our licensed therapists in HRT, bringing accessible, effective care to people struggling with these commonly misunderstood conditions. And incidentally, it’s not uncommon for BFRBs and OCD to co-occur.
Like the gold standard treatment for OCD—exposure and prevention response therapy (ERP)—HRT can be delivered remotely, and a marked improvement is typically seen in weeks.
If you or someone you know is struggling with excoriation disorder—or any other BFRB—you can schedule a free call today with the NOCD Care Team to learn more about how a licensed therapist can help.
