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    Treatment for Dermatillomania - Compulsive Skin Picking (CSP)

    Treatment for Dermatillomania / Compulsive Skin Picking (CSP)
    by Karen Pickett, MFT, OCD Center of Los Angeles
    Tuesday, April 10th, 2012

    In my previous article on Dermatillomania (also known as Compulsive Skin Picking, or CSP), I wrote about a classification system for skin picking. Let’s review “The ABC’s of Skin Picking”:

    An “A” is something that almost anyone would pick. This could be a piece of dry skin hanging off your arm, a pus-filled whitehead on your chin that pops at your mere touch, or a scab that’s barely hanging on which you can easily detach.

    A “B” is a “bump”, pimple, scab, etc. that only a skin picker would pick, frequently causing it to bleed, ooze, scab, and possibly become infected. This in turn will cause two additional problems – it will cause the picker significant distress, and it will give him or her something new to pick at later. In my experience, clients with Compulsive Skin Picking classify at least 50% of their picking as “B’s”.

    “C” stands for “Create”, meaning the individual with CSP is not picking at anything objectively “real”, but in the process of picking at her skin, she “creates” something such as a blemish, scratch or scab. A “C” is something that only someone with Dermatillomania would pick. There is often nothing apparent on the skin, but the picker starts picking or scratching, and in the process creates a wound.

    Treatment for Dermatillomania / CSP
    Unfortunately, there are very few psychotherapists who understand Compulsive Skin Picking, and even fewer who know how to treat it appropriately. The sad truth is that most therapists have never even heard the term “Dermatillomania”, and their initial response to an individual presenting with the symptoms of this condition is either to suggest SSRI anti-depressants, or to simply say “stop doing that”. Of course, if it were that simple, nobody would suffer with with this often misdiagnosed condition.

    As with most Obsessive Compulsive Spectrum Disorders, the most effective treatment for Dermatillomania is Cognitive Behavioral Therapy (CBT). When treating Dermatillomania with CBT, the two most useful techniques are Habit-Reversal Training (HRT) and Mindfulness Based CBT. Increasing awareness of one’s picking patterns is central to the process of Habit Reversal Training, and is generally done by keeping skin picking logs. These logs help the individual to identify picking patterns that they previously may not have realized or understood. For many with Dermatillomania, Habit Reversal Training may also be made easier if they use “habit-blockers” such as gloves, which help to provide a barrier to unconscious picking.

    Mindfulness Based CBT for Compulsive Skin Picking
    The central thesis of Mindfulness Based CBT is that much of our emotional distress is a function of over-reacting to unpleasant, unwanted feeling states that are a normal part of the human experience. The goal of Mindfulness Based CBT is to learn to accept and tolerate these normal feeling states, despite the fact that they are unpleasant.

    The first of two important factors to address in reducing the picking of “B’s” is to gradually learn to tolerate the urge to pick. If a “B” is left alone, it will either go away or become an “A,” sometimes overnight. So, start small and build on your successes. When you see or feel a “B,” acknowledge it and tell yourself you will wait at least 24 hours to look at it or touch it again. In 24 hours, if the bump or blemish is still there, you can then decide whether to pick it or not.

    What? I’m giving you permission to pick? Yes, if you have waited at least 24 hours. By waiting, you teach yourself that you are able to resist the urge to pick immediately – that you can wait it out and see what happens. The more you practice doing this, the better you will become over time at resisting the urge to pick. Remember, picking is a choice – you don’t have to pick something just because you see it or touch it, or just because you have an urge to do so. This is what you teach yourself by mindfully acknowledging and accepting the urge to pick without automatically giving into that urge.

    As you build up your tolerance for delaying the urge to pick, you will find that you can add on to your 24-hour wait time. Next, you might go for 36 hours, then 48, and so on. Over time, this practice will ensure that you are only picking “A’s,” the kinds of things almost anyone would pick.

    For most individuals with Dermatillomania, skin picking is a self-soothing technique that helps them to better modulate their feelings. The second factor to work with in reducing the urges to pick (and you can do this concurrently with having a “wait time” to pick) is to identify the feelings you have been “getting out” through skin picking. What is the metaphor for your skin picking? What are you trying to get out? Are you sad, bored, angry, lonely, or anxious? Do you constantly “pick on yourself” internally with a critical inner voice telling you all the ways that you aren’t perfect?

    I’ve found that a very effective way to express these feelings is to write them out. You can journal and say anything you want. You can shred what you’ve written afterwards to protect your privacy and confidentiality. Once you get the feelings you’ve been suppressing out in this healthy way, you are likely to experience diminished urges to “get things out” by picking your skin. In other words, by allowing yourself to experience, acknowledge, and tolerate your uncomfortable feelings, you are less likely to need skin picking as a self-soothing technique.

    When you teach yourself these two new techniques, the likelihood of getting to a place where you are relatively pick-free is significantly improved. Remember, turn off the perfectionist voice that tells you that you “must” change overnight. Success is a series of steps in the right direction, and building the practices of tolerating the urge and expressing your feelings in a constructive way can lead to success with conquering Dermatillomania.

    See part one in our series of articles on Dermatillomania / Compulsive Skin Picking (CSP) at The ABC’s of Dermatillomania / Compulsive Skin Picking | OCD Center of Los Angeles.

    Karen Pickett, MFT is a psychotherapist at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions, including Dermatillomania.

  2. #2
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    Re: Treatment for Dermatillomania - Compulsive Skin Picking (CSP)

    Is this seen as self harm or just obsessive compulsive behavior
    It is the stress itself that causes sores to develop from inside not caused by the person anxiety builds up and sores develop that is called something else i believe neurodermatitis i think
    Anxiety depression pain inside i believe they are the cause not the person so i think dealing with the core issue will take away all the sores I hope that makes sense

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    Re: Treatment for Dermatillomania - Compulsive Skin Picking (CSP)

    In most cases, it is not self-injury, nor is it necessarily OCD, but it is a compulsive behavior, i.e., a behavior the individual has difficulty inhibiting.

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    Re: Treatment for Dermatillomania - Compulsive Skin Picking (CSP)

    Well written article. Presently CSP would be diagnosed as Impulse Control Disorder, NOS (312.30). In the new DSM, it will be considered an OC Spectrum Dx.

    CBT IS the tx therapists would use. However, a study published three years ago showed that 56% of people who took N-acetylcystene (NAC), an amino acid, reported dramatic improvements. I've seen people take 25% of the dose studied (2400 mg) and report greatly decreased urges. Last weekend at Trichotillomania Conference in Chicago, some are speculating, based on several functional MRI studies, that CSP and Trich may be due to abnormalities in the brain's processing of glutamate, which is why NAC is so often helpful.

    For more info on NAC, Body Focused Repetetive Behaviors (BFRBs), trained providers, a free info pack, and more, go to trich.org. These are increasingly treatable conditions.
    Mike Miller, PhD
    http://drmikemiller.com

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