Skin-Picking (Excoriation) and Nail Biting

Skin picking (also known as excoriation or dermotillomania) and nail-biting, are one of a group of body focussed repetitive self-grooming behaviours which result in damage to the body. Other similar body focussed repetitive behaviours (BFRB) include finger sucking, nail biting, lip or cheek biting and hair pulling. People who experience problematic skin picking repetitively touch, rub, scratch, pick at or dig into their skin resulting in sores or scabs developing that may eventually become infected or cause scarring.

BFRBs usually first present around 11-13 years of age, however certain types of BFRB may present in younger age groups (e.g., finger sucking). Some individuals first experience a feeling of tension, itchiness, pain or tingling, leading to a strong urge to engage in the behaviour. They then experience pleasure and relief from the sensation when engaging in the behaviour (this is called focussed behaviour). At other times individuals may engage in automatic BFRBs without awareness of what they are doing. This type of behaviour is more likely to occur during sedentary activities such as watching television. Individuals suffering from BFRBs may also search for perceived irregularities in their appearance which they attempt to fix by engaging in the behaviour.

 

Treatment for Skin-Picking

A comprehensive behavioural intervention has been shown to reduce the problem behaviour, improve ability to cope with unpleasant thoughts, feelings and sensations, and improve overall quality of life.

The main components of treatment for all of these conditions are:

Awareness Training: This involves teaching the individual to describe in detail their body focussed repetitive behaviour and become more aware of the urges and triggers associated with the behaviour. The individual then practices noticing the triggers, and real or simulated BFRBs.

Competing Response Training: The individual is helped to choose a behaviour that is physically incompatible with the skin picking or other behaviour. For example, if skin-picking occurs while reading, a competing response would be to always hold the book with both hands. In order to break the link between the urge and the actual behaviour the individual practices this behaviour when the urge or warning signals are noticed or when the individual notices they have started the behaviour.

Stimulus Control: Factors in the environment that trigger the repetitive behaviour are identified and a problem-solving approach is taken to identify strategies to manage or avoid these environmental factors. For example, if the behaviour occurs while looking in the mirror, mirrors may be removed or covered up for a period of time.

Managing Difficult Thoughts and Feelings: Individuals with BFRBs often experience a number of co-morbid conditions including anxiety, low self-esteem, shame, self-consciousness, social isolation/rejection and depression. Cognitive Behavioural Therapy (CBT) can be used to teach strategies to cope with and manage the symptoms of these co-occurring conditions and to manage unpleasant thoughts, feelings and urges that are likely to result in the repetitive behaviour. This is particularly important as internal states such as stress and anxiety are likely to influence the frequency and intensity of focussed BFRBs. Acceptance and Commitment Therapy (ACT) can also be used to assist the individual to identify their values and use these values as motivation to make space for and respond differently to unpleasant thoughts, feelings and sensations.

Improving Quality of Life: Many individuals have withdrawn from social relationships, vocational interests and other life activities as a result of their skin-picking or other repetitive behaviours and the feelings of shame associated with the behaviour. One goal of therapy is to assist with re-engaging in these activities and addressing difficult thoughts and feelings that may get in the way of this.

 

If you would like to find out more about our treatment for skin picking or other body-focused repetitive behaviours, or to book an appointment with one of our clinical psychologists who provides treatment for these conditions, please email or call the clinic on 0405 430 530.

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