Is Skin Picking a Form of Self-Harm?

Question: “Is skin-picking a form of self-harm”?

Thanks for your question E! This question highlights an overlap that often exists between different psychological issues. We often imagine clinical disorders as neatly-packaged and compartmentalized issues that we can clearly and easily organize, but you seem to be noticing that it may be more complex than this. Let’s explore the topic, starting with how skin-picking and self-harm are understood by clinicians.

“Skin Picking Disorder”

Skin picking is referred to by several names in the medical community, such as Excoriation Disorder or Dermatillomania. It is classified as a disorder when an individual rubs, scratches, picks at or digs into their skin in an attempt to improve perceived imperfections. The result is often tissue damage, discoloration or scarring.

Some of the symptoms listed in the Diagnostic and Statistical Manual – 5 (DSM-5) that can help identify an Excoriation Disorder include:

• Recurrent skin picking that results in skin lesions
• Repeated attempts to stop the behaviour
• 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

Like with all psychological disorders, it is important to explore the unique personal experience of the individual who it is affecting. Often times one set of behaviours could be caused by a handful of different disorders, so we want to make sure the behaviour isn’t better explained by something else. Skin picking, for example, can also occur for people who are dealing with a dermatological or autoimmune disorder, body dysmorphia, OCD, withdrawal from drugs such as opiates, a developmental disorder (such as something along the autism spectrum) or psychosis (reference #1)

“Self-Harm”

Self-harm (sometimes also called self-injury) is generally understood as the act of intentionally damaging a part of my body but not in an attempt to commit suicide. A common example of self-harm is cutting oneself with a sharp object, but people may also burn, scratch or hit themselves when engaging in self-injury. (reference #2) Some of the key symptoms listed in the DSM-5, where it calls these behaviours “Non-Suicidal Self Injury”, include:

• The person engaging in self-harm does so intentionally, not by accident
• Usually, negative feelings are being experienced just before the act of self-harm
• Self-injury provides relief from negative emotion, creates a positive feeling or is a way to deal with a personal issue
• The person often thinks about self-injury even when they aren’t engaged in the behaviour

Just like with skin-picking, it’s important to remember self-harm activities can take place in the context of other problems like a psychotic episode, delirium, substance intoxication or substance withdrawal. (reference #3)

Differences Between Skin-Picking and Self-Injury

If we look at how these two psychological concerns are described, we can see a couple of differences.

Skin-picking is focused on “fixing” perceived physical defects, while self-harm is focused on dealing with unbearable thoughts, feelings or sometimes as a form of self-punishment.

In skin-picking, injury to the body is usually an unintended side-effect of trying to make it look different, but with self-harm injury to the body is actually the intended action with the goal of changing the way that person feels. So while repetitive skin-picking may cause harm to your skin, if we do not have the primary intent of injuring ourselves as a form of punishment or relief from uncomfortable feelings or sensations, it would not technically be classified as self-harm or self-injury. However…

Similarities between Skin-Picking and Self-Injury

… if we take a step back and look at the goals behind both skin-picking and self-injury, we can also see some similarities.

First, while skin-picking may not be characterized as “self-harm”, it can lead to physical ailment or injury. So while the intent may not be to harm, injure or punish ourselves, we can still end up damaging our bodies.

Second, in both cases of picking at our skin or injuring our body, the behaviours appear to be methods that we are using to try to deal with some form of mental or emotional discomfort.

If you think about it, what is the worst part about seeing some defect or flaw in ourselves? Is my ability to function in the world somehow impaired the shape of my nose or my height or not being muscular enough? (just a few examples from my own relationship with my body) No, most often the problem with our flaws is how they make us feel. Sad, worthless, unlovable, these are just a few of the uncomfortable feelings that can show up when we identify one of our flaws.

Sometimes these feelings can grow from being painful to becoming unbearable, and it’s hard to go through life in that much distress. So we cope, we find ways to deal with the problem as best as we can. Hopefully, we have people around us, especially adults growing up, who can teach us how to deal with uncomfortable feelings in a way that is supportive and compassionate and helps us grow. A lot of us didn’t get that, unfortunately. Whether it was a parent’s abuse, neglect, or a great parent simply lacking resources in this one area, sometimes we have to figure it out ourselves in order to make it through.

So we pick our skin or injure ourselves or find some way to cope with the pain. And when we find something that works, it becomes a resource, so we keep using it. Many psychological “disorders”, funny enough, can be traced back to methods we developed to cope with life, which have now become problems in and of themselves. Solutions gone astray.

So while there are differences between them, both skin-picking and self-injury can be seen as ways that we are attempting to cope with a problem.

This highlights a key principle we should always remember when dealing with mental health: all human behaviour is purposeful and goal-oriented. Even our behaviours that we perceive as problems most likely started as attempts to deal with something we found distressing or uncomfortable. This is critical when it comes to changing these behaviours to something that is more helpful for us.

So what can we do about it?

When we are attempting to change our behaviours, it is very important for us to start from a position of being understanding and compassionate towards ourselves and the behaviours we don’t like, that we aren’t happy with or that aren’t helpful for us.

Why is that? Well, as we found earlier, most of these behaviours are attempts to solve problems, usually a problem that is making us distressed or uncomfortable.

When we feel upset or emotionally distressed, there is actually a physiological response paired with this called “Fight-or-Flight” or more technically, hyperarousal.

We enter this state when we feel like we are under threat because something has triggered our nervous system’s threat detection sensors. Maybe it was something we saw, something someone said or an approaching difficult or scary experience. So when we get upset with or punish ourselves for our behaviours, usually only makes it worse because it perpetuates the feeling that we are under threat, only now we are threatening ourselves.

It doesn’t matter if we “cognitively” think we should do something different, the “emotional” and “physiological” parts of us are often the ones at work when we are in distress. I mean that literally, when we are in Fight-or-Flight, the brain stem and limbic system are the primary parts of our brain operating. The cerebral cortex, where most of our rational thinking takes place, actually becomes less active. Ever struggled to put a sentence together or think through a problem when you’re stressed out? Its because that part of your brain isn’t functioning like it usually would, it’s going dormant to allow more blood to flow to other parts of your body that could protect you from a threat. Usually, when we speak down to our body from our cognition while under stress the message doesn’t register, or its interpreted as yet another threat.

Self-compassion can help us relax and feel safe, which can alleviate the driving force behind the behaviours.

So whether we are dealing with skin-picking, self-harm, or some other behaviour we don’t want to engage in anymore, here are some basic approaches we can take:

1. Find things that help calm us.

Breathwork and grounding exercises are a great place to start with this since they operate on that lowest physiological level of distress. Sometimes we have objects, past experiences or people with us who can also help us feel safe and calm.

When you have some tools that you can use, start making each time the unwanted behaviour shows up as a signal that we are in some distress need to engage in some calming tools in that moment. This way it doesn’t become about stopping our unhelpful behaviour, but just transitioning to a more helpful behaviour. This way we stop dealing with the secondary problem (our coping behaviour) and more right to the primary issue (our level of distress).

2. When we notice the unwanted behaviour, step back and take a look at how you are speaking to yourself.

Often we will find we speak to ourselves pretty angrily about the behaviour you’re engaging in (such as “see? You did it again. Other people are going to notice, this is going to look so bad on you, why can’t you control yourself?” Things like that.)  When we talk to ourselves that way, even in our own minds, it can actually make our feeling of distress worse, which often leads us to try to cope. It brings us right back to engaging in the behaviour we are upset with, creating a pretty vicious cycle.

So instead, speak gently to yourself with compassion and express understanding that your behaviour is probably coming from a part of you that is trying to solve a problem but doesn’t have any better solution that the unhelpful coping behaviour, or that this was how you learned to deal with distress when you were growing up and didn’t have any other options available. This can help us look beyond the unhelpful coping behaviour to the distress that is driving it.

A good way to practice changing our self-talk is to think about how we would speak to a friend we deeply and genuinely loved if they were dealing with a similar problem. Would we berate and belittle them? Probably not. We would probably attempt to comfort them (which is a great way of lowering that level of distress that is driving our behaviour). So try talking to yourself like you were someone you genuinely loved and cared for.

3. Gently redirect yourself to the more helpful coping tool that you’ve found, rather than punishing yourself for the unwanted behaviour.

A negative reinforcement tool in the aftermath of these behaviours will probably only contribute to creating more distress, which means the unwanted behaviour that shows up to cope with distress will just reemerge. Using the same style of self-talk you discover when treating yourself like a friend you care about, remind yourself about the other tools you can use to alleviate your distress.

Offer these other tools to yourself like good options that you can choose to take rather than things you have to do. Again, a more relaxed approach is going to have the effect of lowering your physiological arousal, thus your distress, thus your need to engage in unhelpful coping behaviours.

There are also other ways you can approach behaviour change in a way that treat yourself kindly, I’ve found Atomic Habits by James Clear to be a very helpful resource both for clients and in my own life! (reference #4)

Closing Thoughts

Thanks for your question, E. Navigating the world of categorizing the problems we’re dealing with can be helpful to give us ground to stand on but also confusing since it isn’t as neat and tidy as clinical diagnoses would often lead us to believe. When we try to navigate these concerns, I always recommend working with a professional to have some support as you work through it. Psychology Today is a great resource to find a psychologist, counsellor or clinical social worker who can walk this road with you.

References:

1. The TLC Foundation for Body-Focused Repetitive Behaviours. n.d. What Is Excoriation (Skin Picking) Disorder?. [online] Available at: <https://www.bfrb.org/learn-about-bfrbs/skin-picking-disorder> [Accessed 2 September 2020].
2. Mayo Clinic. n.d. Self-Injury/Cutting – Symptoms And Causes. [online] Available at: <https://www.mayoclinic.org/diseases-conditions/self-injury/symptoms-causes/syc-20350950> [Accessed 2 September 2020].
3. Theravive.com. n.d. Nonsuicidal Self-Injury DSM-5 – Therapedia. [online] Available at: <https://www.theravive.com/therapedia/nonsuicidal-self–injury-dsm–5> [Accessed 2 September 2020].
4. Clear, J., 2018. Atomic Habits: An Easy & Proven Way To Build Good Habits And Break Bad Ones. New York, NY: Random House Business.

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