“I mostly pick my face,” Daniela W., who has skin-picking disorder, tells SELF. “But also my scalp, my back, and my chest. For me, the scarring is the most distressing part. They’re not deep scars, but I have a lot of them.” Daniela, 28, is one of an estimated 2 to 5 percent of people with the condition, also known as excoriation disorder or dermatillomania. Despite how many people have it, skin-picking disorder is often misunderstood—sometimes even by therapists. “It’s rare that I find someone who has actually heard of it, even professionals,” Daniela says.
Some people tend to dismiss skin-picking disorder as just another bad habit. After all, who hasn’t popped a zit or incessantly yanked at a cuticle? But compulsive skin-picking is a recognized mental health disorder, with potentially life-changing results like painful wounds and serious infections. People can’t “just stop” and instead need specialized treatment to manage their symptoms.
And in a cruel twist, the coronavirus pandemic has the potential to drastically exacerbate compulsive skin picking, just as it can with so many other mental health conditions. Keep reading to learn what excoriation disorder really is and is not, why the pandemic can make life with this condition harder than usual, and what you can do to cope if you deal with it.
Skin-picking disorder is a body-focused repetitive behavior, or BFRB.
BFRB is an umbrella term for different kinds of compulsive self-grooming. According to the TLC Foundation for BFRBs, this can include a host of behaviors like biting, pulling, picking, and scraping any part of your body. Other BFRBs include trichotillomania (hairpulling), cheek-biting, and onychophagia (nail-biting).
BFRBs are classified as “obsessive-compulsive and related disorders” in the Diagnostic and Statistical Manual of Mental Disorders (the official guide for diagnosing mental health conditions in the United States). That doesn’t mean BFRBs are the same as OCD, though. “With OCD, if you don’t do the compulsion, it causes tremendous anxiety,” Laura Santner, L.C.S.W., a clinical social worker and therapist specializing in BFRBs who has trained with the TLC Foundation, tells SELF. “A BFRB is very uncomfortable, but it’s not a feeling that something bad is going to happen if you don’t engage in the behavior,” says Santner, who has trichotillomania herself.
Of course, it’s completely possible to pick at your skin without having a BFRB. So when does this behavior cross the line into a disorder?
“It’s very common to pick at pimples, blisters, and scabs,” says Santner. “What makes it a disorder is if it interferes with your daily life and causes significant distress, like not wanting to go to work because you’re embarrassed or it hurts.” According to the TLC Foundation, other diagnostic criteria for skin-picking disorder include repeated attempts to stop picking, picking intensely enough that it causes damage to the skin, and the symptoms not having another cause, like substance use or a different mental health disorder.
Experts aren’t sure why some people develop dermatillomania and others don’t, though there does seem to be a genetic component, Santner says. And while not everyone picks for the same reasons, common triggers include difficult or distressing emotions, your skin feeling or looking a certain way that compels you to pick, and thinking your skin will feel or look a certain way if you pick at it, according to the TLC Foundation. Depending on what triggers you, you might be intensely focused on the act (like picking while staring at your skin in a magnifying mirror), or skin picking can be completely subconscious. “It’s something that we’re often not aware of until we’ve already done it,” Daniela says. “Sometimes you’re doing it while doing something else, like reading, or you’re just in a trance-like state. It’s very frustrating.”
By its very nature, skin-picking disorder causes an emotional roller coaster. For Serena P.*, 32, the urge to pick can stem from noticing a perceived fault in her skin. “It’s absolutely sheer panic,” Serena, who spent years co-organizing a BFRB support group, tells SELF. “Like, ‘There’s a problem, and I need to deal with it immediately!’ The pain that you feel when you’re doing it is almost pleasurable. It’s a massive sense of relief because you’ve dealt with the problem. The bigger issue is the self-hatred, guilt, and shame that follow when you know how your skin looks or there’s blood underneath your nails.”
Treating the disorder means, at a baseline, becoming more aware of where, when, and why you pick. A specific form of cognitive behavioral therapy called habit reversal training (HRT) is a mainstay of treatment. To build upon this understanding of your triggers, in HRT you create “competing responses” to do instead of picking, and more specifically, competing responses that make picking impossible (like balling your hands up into fists), the TLC Foundation explains. There’s also a type of treatment known as the comprehensive behavioral (ComB) model, where people use the term SCAMP (Sensory, Cognitive, Affective, Motor, Place) to understand what makes them pick and find strategies to stop—like using a fidget toy or journaling for anxiety. Mental health medications like selective serotonin reuptake inhibitors (SSRIs) can help reduce symptoms in some people, but results are mixed. Experts aren’t yet sure enough of the neurological mechanisms involved with BFRBs to know the best medication to treat them overall.
The coronavirus pandemic presents new challenges for people with skin-picking disorder.
If you have skin-picking disorder and are having a harder time than usual during the pandemic, you’re not alone. There are so many reasons why this pandemic is making life with compulsive skin-picking harder. They basically all come down to the fact that many of us are dealing with unprecedented amounts of anxiety and a massive change in routine, which can lay the groundwork for an uptick in symptoms.
For instance, you’ve probably heard time and time again that we should all be doing our very best to not touch our faces with unwashed hands (and to break the face-touching habit overall just to be on the safe side). This is to reduce the chances of accidentally introducing the coronavirus into our systems via our fingers. (While this isn’t thought to be the main way the virus spreads, it’s still possible.) But for someone like Daniela, that’s nearly impossible. “In terms of face touching, it can definitely cause anxiety,” she says. “I’ve wondered, am I more susceptible to getting the virus because I have open wounds on my face and I touch them quite regularly?”
A drastically different routine can also give rise to more picking. “In the first week of the lockdown I was quite motivated to do all the recommended things, like exercise,” Daniela says. “Now that motivation has gone down. I’m taking fewer breaks and work is really stressful, so that causes me to pick more. I think it calms me down.”
Then there’s the sudden popularity of video calls, which can be so helpful for staying socially connected but can also be incredibly anxiety inducing if you pick at your skin. “The increase in video chats can be difficult,“ Serena says. “I did have a few really bad skin days where I didn’t want people to see me. The problem with skin picking is that you can see the repercussions for weeks and sometimes months. So one bad day can be a massive knockdown.” While phone calls and other ways of communicating are of course still an option, having to explain why you want to opt out of a video call when they’re suddenly so popular can lead to more anxiety and self-isolation.
That brings us to the seclusion of sheltering in place, which can logistically create the ideal environment for an increase in skin-picking symptoms. Daniela has switched from days spent in a busy office to working at home. “BFRBs are really private behaviors that a lot of people don’t do in public,” she explains. “I would be really unlikely to pick at my skin in front of my colleagues, but now that I’m at home, there’s a lot less social control.” Daniela is generally still managing her condition much better than she has in the past, she explains. “[But] when I have fewer other people around, it’s like my body knows that it has that freedom to pick again,” she says.
Daniela is also spending more time around mirrors now that she’s home so much, which she says is another big picking trigger for her. “Yesterday, I saw the mirror, and there was part of me that needed to release anxiety. I’m not really present when I do it, I just zone out, then afterward I’m like, ‘Oh, my God, what have I done?’”
The result is a perfect storm of triggers and potentially feeling cut off from support networks. “People have to really be accepting that the urges are going to increase,” Santner tells SELF. “You’re going to have slipups. Do the best you can to have a lot of self-compassion.”
Here’s what people with skin-picking disorder can do to live as well as possible right now.
Despite the challenges, there are still plenty of practical steps to manage skin-picking during the pandemic. “If you’re stuck at home, cover mirrors,” Santner says. “If you use tools [to pick], put them in the freezer. You don’t have to throw them away, but you want to make things more difficult for yourself. You can create barriers depending on where your hot spot is: long sleeves, tights, hats, that kind of thing.” She also suggests tips like wearing gloves so it’s harder to pick, along with making a daily plan so you can try to anticipate when you’ll feel most compelled to pick and prepare possible solutions with that in mind.
While it can feel difficult, keeping a routine is another way you can try to reduce stress and related skin picking. “I’m trying to exercise, eat healthfully, and sleep enough,” says Serena. “Those are the three main components that helped me to look after myself [in the past] and reduce my skin picking.” She adds that it’s important to be kind to yourself when things don’t go exactly as planned. “I’m trying to learn to be self-compassionate and not beat myself up. If you have a day where you just want to watch Netflix, that’s fine.”
It’s also a good idea to stay connected with other people. If video meetings are too stressful, that’s valid. This could actually be a great opportunity to share about your skin picking with really trusted people, like close friends. They’re probably also struggling with their mental health in some way right now even if it looks different for them. Talking about your skin picking with them might make them more likely to go for non-video alternatives to catch up, and it can also be a real relief for you. “For many years, I didn’t feel able to talk to anyone about it and now I do a lot more,” Daniela says. “My friends, family, and partner know, and that has been really helpful.” If you’re not ready to do that, that’s cool too. Texts and phone calls can work just as well, and you can blame it on feeling really Zoomed out. And if you think it might be helpful to talk specifically with people who know what you’re dealing with, here’s a list of online BFRB support groups if you’re not in one already, along with a directory of therapists who specialize in BFRBs.
Ultimately, living well with skin-picking disorder during the COVID-19 pandemic will be different for everyone. It’s not about being perfect or feeling ashamed for struggling during a hugely stressful global crisis. “I think it’s a misconception that recovery means you don’t do it anymore,” Santner says. “Recovering and living well [happen] when you feel good about yourself. It’s when you feel like you have control instead of the behavior having control over you. That doesn’t mean being pick-free, necessarily. It means that if you have a slipup, you’re able to keep going and get back on track.”
*Name has been changed.
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