"As a doctor, I quickly recognised that the nascence and development of her work came from the centre of her being. Ironically, the glimpse into her interior is from her encapsulating exterior, her skin. Yet, as so often is the case in medicine, it is dermatological conditions that provide the clues to disorders of internal medicine. Liz’s journey of courage through recognising, accepting, understanding, revealing and healing holds a medical cogency for me. She draws on her greatest strengths in her whole person, that of extraordinary perceptiveness, sensitivity and integrity."
Dr Sarah Chin GP
Body-Focused Repetitive Behaviours such as Compulsive Skin Picking (CSP or Dermatillomania) and Hair-pulling (Trichotillomania) are seldom recognised and treatment is often very hard to access. They are much more common than initially thought and among the most poorly understood, misdiagnosed, and undertreated groups of disorders. BFRBs may affect as many as 1 out of 25 people.
Compulsive Skin Picking, also known as Dermatillomania or Excoriation, is a complex physical and mental disorder. Individuals who struggle with this disorder touch, rub, scratch, pick at, or dig into their skin in an attempt to improve perceived imperfections, often resulting in tissue damage, discoloration, or scarring. Skin picking disorder is one of a group of behaviors known as body-focused repetitive behaviors (BFRBs), self-grooming behaviors in which individuals pull, pick, scrape, or bite their own hair, skin, or nails, resulting in damage to the body.
Occasional picking at cuticles, acne, scabs, calluses or other skin irregularities is a very common human behavior; however, research indicates that 2% - 5% of the population picks their skin to the extent that it causes noticeable tissue damage and marked distress or impairment in daily functioning. 75% of people affected are female. The behavior typically begins in early adolescence, although skin picking disorder can begin at any age. Without treatment, skin picking disorder tends to be a chronic condition that may wax and wane over time.
Signs & Symptoms
Excoriation (skin picking) disorder is currently classified as an “obsessive-compulsive and related disorder” in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
The DSM-5 diagnostic criteria include:
Recurrent skin picking that results in skin lesions
Repeated attempts to stop the behavior
The symptoms cause clinically significant distress or impairment
The symptoms are not caused by a substance or medical, or dermatological condition
The symptoms are not better explained by another psychiatric disorder
Why do some people engage in body-focused repetitive behaviors while others do not?
Research indicates that some people may have an inherited predisposition to skin picking or hair pulling. Several studies have shown a higher number of BFRBs in immediate family members of persons with skin picking or hair pulling than would be expected in the general population. A recent study examined hair pulling in identical and fraternal twins and produced results consistent with a significant inherited component in TTM.
Even if a predisposition toward BFRBs is inherited, there are other factors involved as well, including temperament, environment, age of onset, and family stress factors. One interesting point is that other species engage in similar behaviors. Primates, such as the great apes or certain types of monkeys, will pull hair, overgroom and pick at nits and other insects on their own fur and the fur of others. Birds will pull out their feathers, mice will pull fur or “barber” themselves and their cage mates, dogs and cats may lick their skin or bite at an area, removing fur until there are bald spots. Researchers interested in animal models of BFRBs are trying to understand these behaviors in animals in order to shed some light on the complex neurobiology that underlies the human experience of BFRBs.
Given the possibility that BFRBs have genetic and neurobiological origins, the TLC Foundation launched the BFRB Precision Medicine (BPM) Initiative in 2014, bringing the cutting edge approach of precision medicine to the goal of finding new, more effective treatments for BFRBs. Precision medicine uses behavioral, genetic, and biological indicators to describe an individual pattern of disease in order to develop individualized treatments. It has revolutionized cancer treatment, and the TLC Foundation’s national team of scientists is bringing this same approach to BFRB research.
Skin picking was, for me, from a young age, a way to release tension in my body, to block out emotions and hit a 'zoned-out' sense of calm. It became a private vicious cycle that totally dominated my life behind closed doors. My body was littered with wounds and marks beneath my clothes. It also developed into something I did subconsciously so there were hours where I would be picking my skin. Some nights I would pick until the early hours of the morning, I would even pick in my sleep. Many times I would be poised at the bathroom mirror, a private space. No one knew about it. I masked and covered the illness from those closest to me, wearing clothes that concealed the parts of my body covered in scabs and scars, making excuses and even using make-up on my body to mask it.
I experienced intense anxiety, followed by guilt and shame about something I was doing that caused harm to my own body yet felt no control or ability to stop. I suffered in silence for a very long time. The illness was actually undiagnosed until my early 30s, by that point I’d been picking for the best part of 25 years, and it was only through internet searches that I realised it had a name. I had even hidden it from various Drs over the years. I got to a point where I didn’t want this illness controlling me anymore. There were perpetual cycles of shame, embarrassment and anxiety and I had no choice really to try and help myself because it was destroying me.
But the body has always been my fascination for me. I had studied dance and drama throughout my education and in my early 30s I signed up for a Masters in Dance, and it was then that I found I had to confront the illness head-on. Studying movement meant I could no longer avoid the picking. As part of the course, were encouraged to study our everyday movement patterns. For the first time I looked at how this illness dominated my physicality. Very slowly I began to document what the illness had done to my body. I began to recognise the illness was a unique dance, and that I could turn it into something else, something creative to move away from the harm it was doing to me. Though dance I was able to express things I didn’t have language for and channelled the specific movements of the illness across my body into something positive. I began making artwork through film and photography, using the skin as a soft canvas and terrain for imaginative transformation and healing. I explored the way my body moved; I used body-focused repetitive behaviour as an art practice and miraculously began to get better. I now create artworks with textural materials like latex, clay, acrylic paint to transform the skin. I have exhibited my artwork in therapeutic settings and galleries all over the world, including Japan, Los Angeles, Melbourne and London.
I aim to normalize Compulsive Skin Picking; I’m speaking about my experience in an attempt to destigmitise it and help others with this devastating condition who may feel they have nowhere to turn. Skin picking dominated my life but there are ways to recover. CBT and medication can be prescribed through your GP. I use my experience of CSP not only to inspire and contribute to my own artistic work and development, but allow me to normalise, manage and improve the condition. I developed an understanding of the body and use my artistic practice to keep well, and I now have some degree of control over my condition. The marks and scars will always be with me, but many are fading and I now see them as being an important part of the tapestry of my lived experience, as well as inspiration for my artwork.
Are you are suffering with similar symptoms?
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, you learn 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.
"Liz is an important cultural educator about the rising social issues of Compulsive Skin Picking through her art. She has incorporated her own personal history into her excellent award winning artwork. Her solo exhibition at Bethlem Gallery helped normalise and raise awareness for the condition, as well as providing an ongoing positive message of hope."
Simon Darnley, Interim Deputy Director
Psychological Medicine and Integrated Care CAG
"So honest and open! A real trailblazer! You are wonderful"
Jo Good, BBC Radio London
Tips for quitting
• If you get the urge to pick, try doing something that occupies your hands for a period of time until the urge passes, or even put gloves on your hands until the urge decreases. Even if you hold the urge off for a few minutes you can work with it, next time try holding it off for 10 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. Set a timer in the bedrrom or bathroom to stop 'zoning out' in a location you might pick.
• Use long or false nails! Some people say 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)
Charity supporting those who suffer from a skin condition.