Obsessive compulsive disorder - OCD treatment and therapy from NOCD

Why do I pick at my scalp until it bleeds? Advice from a therapist

By Jessica Migala

Nov 28, 20239 min read minute read

Reviewed byApril Kilduff, MA, LCPC

People pick. There are those who pick their noses, mess with a scab on their arm or leg, or constantly go at their cuticles. Oh, and there’s that whole pimple-popping habit that’s tough enough for anyone to resist. (There’s an insanely popular YouTube Channel and tv show where you can watch this all happen if you need more proof.) It can feel satisfying to pick at yourself in these ways, and just because you pick on occasion does not mean you have a problem.

But, picking can tip over into skin picking disorder, and if you’re worried about how often you’re picking or the damage you’re causing—such as to your scalp or other areas of your body—this article can help provide some clarity around if there’s reason to worry, what you can do about it, and how to find effective treatment that keeps your hands off your head. Here’s what you need to know.

What is excoriation or skin picking disorder? 

If you’re picking at your scalp until it bleeds and forms scabs (which you then pick off, too), you may have skin picking disorder, also called excoriation. It helps to understand just how common skin picking is. It’s so common that excoriation disorder, “is accepted and validated by the medical community as a genuine and often highly harmful diagnosis,” says licensed clinical psychologist Nicholas Farrell, PhD, Regional Clinical Director at NOCD.

This mental health illness is considered a type of body-focused repetitive behavior (BFRB) that affects 1.4 to 5.4% of American adults, according to Mental Health America (MHA). It is distinct from obsessive-compulsive disorder (OCD), but does belong in the class of Obsessive-Compulsive and Related Disorders, according to the DSM-5

According to The TLC Foundation, an organization that supports people with BFRBs, other types of BFRBs include:

What are the symptoms?

The DSM-5 lists five criteria for excoriation, or skin picking disorder:

  • Recurrent skin picking resulting in skin lesions
  • Repeated attempts to decrease or stop skin picking
  • Skin picking causes distress or impairment
  • Skin picking is not done due to substance use or another medical condition
  • Not better explained by symptoms of another mental disorder that could cause skin picking, such as delusions, body dysmorphic disorder, or nonsuicidal self-injury

When it comes to distress or impairment, skin picking—and more specifically scalp picking—can cause serious problems. “With the extent of lesions that a person has, as well as a lack of allowance for letting those lesions heal and form scabs, their picking behavior can be responsible for causing serious skin infections,” Dr. Farrell says. “Some people with untreated and severe excoriation disorder have actually required hospitalization for significant skin infections,” he adds.

In addition, people with skin picking can cause tissue damage and scarring, as well as emotional distress, shame, blame, and low self-esteem, reports a 2021 study in Frontiers in Psychiatry. You might find that you avoid social situations because your scalp-picking behaviors are obvious or you’re worried that your habit will raise questions—perhaps you even try to leave class or work in order to find a private place to pick when the urge becomes too intense. Or it gets in the way of romantic relationships when your partner sees you pick and wants you to stop. All of these effects build up to a significant impact: people with skin picking disorder had a generally lower quality of life compared to those without it, per research in CNS Spectrums in 2018.

While it feels good in the moment, the long-term effects can be really detrimental. “So many people report a host of other problems associated with skin picking, such as diminished engagement in social activities, a loss of a sense of interpersonal connectedness, isolation, and guilt over not being able to will themselves out of the problem,” says Dr. Farrell. In addition, someone may engage in skin picking so often that it impairs their ability to focus and concentrate, and they can’t complete tasks they need to do, he explains.

Why am I picking at my scalp, anyway?

Though anyone can develop excoriation disorder, those who do are more likely to be female and have other mental health conditions, such as generalized anxiety disorder, depression, or panic disorder, according to a 2020 study in the Journal of Psychiatric Research. The International OCD Foundation suggests that there are both biological and environmental factors that promote the development of skin picking.

It’s also important to understand the role that picking your scalp serves for you, which is why people report that they don’t feel as if they can stop picking, despite negative physical consequences. 

“What we see often is that people—almost by accident—inadvertently learn that the skin picking behavior—whether picking the scalp, cuticles, or another body part—temporarily serves some sort of functional purpose,” Dr. Farrell says. “Picking might offer relief from some kind of unwanted state, such as tension or stress. Other people say that it fills a void in response to boredom or lack of sensory stimulation. In that case, picking is then providing some sense of gratification or stimulation,” he explains. 

What Type of Treatment works best for skin picking disorder?

As much as you try to stop, it may be challenging to give up picking at your scalp. After all, it feels as if it’s serving a very specific purpose in your life, and you can’t just tell yourself to stop and think that’ll be the end of it. Very often, it may be such an ingrained habit you may not even realize that your fingers are floating up toward your head to pick at your scalp—until you start digging your nails in and scratching. At that point, it’s difficult to reverse course. 

Although skin picking disorder is an OCD-related disorder, treatments for BFRBs and OCD differ. With OCD, the gold standard treatment is Exposure and Response Prevention, or ERP. This is a type of therapy where you are purposefully exposed to a trigger for your obsessions (unwanted and distressing thoughts, images, or urges) but make a conscious decision to not engage in a compulsion (a behavior done to neutralize the discomfort). In this case, you’re confronting a fear and sitting with the anxiety until it subsides.

With BFRBs, including picking at your scalp until it bleeds, the best treatment is Habit Reversal Training, or HRT, says Dr. Farrell. HRT is a type of cognitive behavioral therapy. That said, OCD and BFRBs commonly occur together. If that’s the case for you, your clinician will talk to you about a combination treatment of both ERP and HRT. 

Though there are many layers to this treatment and it will be individualized for you and your unique needs and challenges, there are two foundational skills of HRT that you will develop in therapy, Dr. Farrell says. These two primary elements are:

  • Awareness training
  • Competing response training

So, how do they work? “Awareness training helps a member improve their identification and recognition of the warning signs of the most common antecedents for skin picking,” says Dr. Farrell. In other words, you will learn what triggers your skin picking. This requires self-monitoring and paying close attention to the thoughts or feelings that you notice immediately prior to the urge to pick your scalp—and continue to pick until there’s bleeding.

Regarding the second component, competing response, this involves helping a member in therapy to practice a behavior or response that competes with the behavior that you want to stop, which is scalp picking in this case. One example, says Dr. Farrell: “If you’re trying to prevent yourself from picking your scalp, you might fold your hands together in a clasp, which physically prevents you from picking at your scalp,” he explains. Of course, you could absolutely unclasp your hands and go ahead and pick. But developing a strategy like this allows you to pause and put space between the urge and the action, putting you in better control of your behavior. You only need to hold this for a minute or so before you can unclasp.

You will want to go ahead and pick your scalp, but you’re challenged to allow the urge to pass, and once it does, you won’t feel compelled to pick. “This is the learning we want to facilitate. People are so quick to respond to that urge to pick, there’s never an opportunity to learn that even though it’s bothersome, you can endure the situation without giving into that craving,” Dr. Farrell explains. Resisting the urge one time does not “cure” the condition—this is a mental health disorder, and there are no quick fixes. However, by practicing these strategies, overtime you will find that you crave scalp picking less and less. “The tolerance in one’s ability to accept and live with the urge grows and the intensity of that craving diminishes,” he says. 

And yes, if it sounds simple, that’s because it is—but that’s the power in this particular form of therapy. “HRT is pragmatic and straightforward and has decades worth of research supporting it,” Dr. Farrell adds. Research shows that HRT can be used for both skin picking disorder and trichotillomania, no matter how severe the symptoms are, suggests research in Clinics in Dermatology in 2018. 

One limitation of HRT, the authors say, is that HRT does not address the “underlying emotional triggers for BFRBs,” so it’s important to talk to your therapist about other strategies that may be needed in your treatment to get to the heart of the cause of skin picking for you. For example, if you also have generalized anxiety disorder, you should also seek treatment to help you manage anxiety, which could then help alleviate some skin picking, if that was one underlying reason that contributed to the picking. 

You might also talk to your clinician about what’s called stimulus control, which means removing items that promote skin picking, like tweezers, putting up barriers to picking (such as wearing a hat or applying acrylic nails where you can’t pick), or keeping hands busy with things like fidget tools, the aforementioned research explains. 

You can start your recovery journey today

The good news is that HRT can be effectively given both through in-person and telehealth visits, suggests 2023 research in Cognitive Therapy and Research. Certain factors may influence which format is best suited for an individual, so don’t hesitate to speak with a clinician who is specialized in BFRBs about the best treatment approach and modality for you. 

Here at NOCD, our therapists receive intensive, specialized training in treating BFRBs like excoriation disorder with HRT therapy, as well as common related conditions like OCD and anxiety disorders. If you think you may be struggling with picking your scalp and you’re interested in learning how you can recover, I recommend reading more about NOCD’s accessible approach to treating BFRBs.

We specialize in treating OCD

Reach out to us. We're here to help.