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Compulsive Skin Picking (CSP)

Compulsive Skin Picking (CSP).

Compulsive Skin Picking (CSP), also known as Dermatillomania, is an impulse control disorder and form of self-injury, characterised by the repeated urge to pick at one's own skin, often to the extent that damage is caused and can be a compulsion of body dysmorphic disorder (BDD).

The disorder is characterised and defined by the habitual and excessive picking of skin lesions, or the excessive scratching, picking, gouging or squeezing of otherwise healthy skin, to the extent of causing bleeding, bruising, infection, and/or permanent disfigurement of the skin.  These behaviours are carried out solely to relieve the anxiety or urges being experienced by the sufferer.

Compulsive Skin Picking falls into the family of Obsessive-Compulsive Disorders and is linked quite closely with OCD, BDD and the hair pulling disorder, Trichotillomania. It is not uncommon for a person to suffer with a combination of these disorders. Research has shown that around a quarter of those diagnosed with OCD or BDD also have CSP.
Compulsive Skin Picking, which is a response to specific situations and events, can occur at any time during the day but is often more severe during the evening. The individual with CSP is frequently unaware of these triggers.

Usually, but not always, the face is the primary location for skin picking, although of course any part of the body can be the focus. People with CSP may pick at normal skin variations such as freckles, moles or acne, or at imagined skin defects that nobody else can observe. Individuals with CSP may use their fingernails, as well as their teeth, tweezers, pins or other instruments.

While this problem is the source of considerable anxiety and distress to those who pick, it is also distressing for family and friends when they see the results.
People with CSP often feel the need to try and hide or camouflage their blemishes with make-up or clothing. As with other disorders within the OCD spectrum, CSP can be a socially lonely disorder.  Social embarrassment can lead the sufferer to stay indoors and avoid friends. It can also cause problems at work: lateness, owing to time taken by picking and make-up routines, and absence, when the poor state of the skin makes the sufferer reluctant to be seen in public.

The characteristics of skin picking include:

  • Recurrent skin picking - face, lips, scalp, hands or arms.
  • Immediately before picking there is a high level of tension and an ‘itch’ or ‘urge’.

As with all disorders in the OCD spectrum, most people develop CSP in their teens or early 20's. It may start as a frequently carried out and unconscious habit which develops into uncontrollable picking.

What treatments are available? Initially, see your GP. Many are still less informed about CSP than they are OCD, but you should receive a referral to psychologist or psychiatrist.
Very often patients are referred, first of all, to a dermatologist, which may be appropriate if there is a skin disorder that needs treating, but ultimately you will also need to see a psychologist or psychiatrist for CBT.

A regular form of Cognitive Behavioural Therapy may be used, although nowadays Habit Reversal Training (HRT) is the preferred method of treatment for CSP.

Habit Reversal Training challenges CSP in two ways. Firstly, the individual learns how to become more consciously aware of situations and events that trigger skin-picking episodes. Secondly, the individual learns to utilise alternative behaviours in response to these situations and events.

Habit Reversal was developed in the 1970s by psychologists Nathan Azrin and Gregory Nunn for treating nervous habits which are done automatically, such as tics, stammering and skin-picking. Therapy should focus initially on developing Habit Awareness and patients may be asked to keep records of when, where and under what circumstances they normally pick.

Many people believe that if they stop one bad habit it will be replaced with another bad habit. However, one of the key ideas of habit reversal is to replace the harmful habit with another harmless habit that makes the bad habit impossible. This new behaviour is known as a competing response.

Tips for quitting

  • If you get the urge to pick, try doing something that ties up your hands for a period of time until the urge passes, or even put oven mitts on your hands until the urge decreases. Even if you hold the urge off for 15 minutes you can work with it, next time try holding it off for 20 minutes and so on.
  • Keep your skin as clean as possible. Use anti-bacterial soap or an oil-free cleanser. Try to see a dermatologist. The more clear your skin is, the less of an urge you’ll have to pick at it.
  • Cover your mirror with paper if your face is the usual area that your picking focuses on.
  • If you bite the inside of your cheeks try eating crunchy snacks when you feel the urge to bite.
  • Use long or false nails! The thick tips help reduce picking.
  • As with all disorders in the OCD spectrum, stay busy.  The busier you are the less time your mind has to play with the urges to pick.
  • When tempted to pick, care for your skin by applying a moisturising lotion instead.
  • Get rid of all implements such as tweezers and pins used for picking.
  • Try replacing some of the sensory aspects of skin-picking with a more desirable alternative. For example, keep an object by you that you can manipulate (squeeze or pull) such as a soft rubber ball or some Blu Tak.

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