One of the most common questions I get asked is what do I do during or after an exposure?
Number One, it’s so scary to do an exposure, and number two, there’s so many things that people have brought up as things to do, even me, this being Your Anxiety Toolkit. Maybe you get overwhelmed with the opportunity and options for tools that it gets too complicated. So, I want to make this super easy for you, and I want to go through step by step, like what you’re supposed to do during or after an exposure.
Studies have shown that those with obsessive-compulsive disorder (OCD) struggle with increased rates of insomnia compared to those without OCD.
We all have sleepless nights from time to time.
The stressors of daily life can have our minds racing and us tossing and turning through the early hours of the morning. This is very common.
However, for those with OCD, obsessive thoughts can keep them stuck in a miserable cycle of not being able to switch off their minds. Trapped in a restless cycle of racing thoughts and sleepless nights, insomnia adds a new layer of difficulty when managing OCD.
Obsessive-compulsive disorder (OCD) and attention deficit hyperactivity disorder (ADHD) are two common psychiatric disorders.
A person with little knowledge of these disorders could confuse the symptoms associated with attention and concentration, believing one disorder to be the other.
Unlike OCD which is classed as an anxiety disorder, skin-picking disorder (excoriation or dermatillomania) is known as a body-focused repetitive behavior.
Skin-picking disorder may also be known as a body-focused repetitive behavior. It may also be called an impulse control disorder due to an excessive and ongoing urge to perform the skin-picking act. And in other occasions may be named an ‘obsessive-compulsive spectrum disorder’ due to the features that overlap with OCD.
While skin-picking disorder and OCD are two separate conditions, people with skin-picking disorder are more likely to have OCD or OC spectrum disorders such as hair pulling, BDD, and tic disorders.
This is because of the urge to engage in those repetitive ritualistic behaviors that offer relief either from intrusive and unwanted thoughts, or negative feelings or emotions.
Let’s get into the differences between these two disorders…
OCD is a mental illness characterized by obsessive and unwanted thoughts or urges followed by repetitive physical or mental compulsions done to reduce the resulting anxiety.
It’s important to differentiate between everyday, low-frequency anxiety that many people will experience and disordered anxiety, brought on by these intrusive thoughts.
An intrusive thought may look something like this:
When these thoughts arise, someone with OCD feels compelled to solve for the uncertainty and anxiety that arises. This is why OCD is sometimes known as the ‘doubting disorder’.
OCD is egodystonic in nature which means the obsessions experienced by the sufferer goes against their values.
Unsurprisingly, when a disturbing thought arises, the uncertainty surrounding it can feel unbearable.
The OCD sufferer may find themselves ruminating on what this thought must mean about them and try to ‘figure it out’.
Why did I have this thought?
What does it mean about me?
What might happen if I don’t do something about it?
In an attempt to alleviate the uncertainty and anxiety brought about by this unwanted thought, the sufferer performs compulsions that offer short-term relief.
For example, someone with postpartum OCD may fear that their newborn child will stop breathing in their sleep. The compulsion might be to check on their baby at regular intervals which in turn disrupts their own sleep and has a greater knock-on effect to their mental and physical health.
Another example may be someone with contamination OCD. They may fear intrusive thoughts such as, “What if I catch a disease?” or “What if I get sick and die?”.
The compulsion in this example might be to excessively wash their hands and wipe down objects before touching them.
The disordered anxiety suffered by those with OCD can consume all aspects of their life.
Social gatherings may be avoided, relationships become strained, and work or school can become difficult to focus on. OCD can be very scary, especially if obsessions are violent in nature, but it is treatable and manageable with the right help.
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Skin picking disorder or excoriation is characterized by the habitual picking of skin, commonly around your nails, pimples, or blemishes.
People with dermatillomania may also create open sores by compulsively touching or picking at the skin, even if there is nothing there to pick at.
We’re all guilty of occasionally picking at our skin, but it becomes a disordered condition when it is near-constant and causes bleeding, open sores, or scars.
Although, to the untrained eye, skin picking may not seem overly distressing or a source for concern, those with excoriation disorder often find themselves trapped in a difficult cycle to break.
People may pick at their skin for a variety of reasons including boredom, anxiety, increased stress, or to cope with negative emotions.
While skin picking offers an initial burst of relief, it often follows with intense feelings of guilt or shame. Someone with excoriation disorder could spend hours each day picking their skin, thinking about picking their skin or trying to resist the urge to pick their skin.
It could be very easy for an observer to label this as an insignificant ‘bad habit’ but for the sufferer, skin picking can lead to greater implications that impact their quality of life.
It is not uncommon for those with excoriation disorder to avoid social events, isolate themselves from loved ones, have difficulty managing their condition at work, and fall into episodes of depression due to feeling ‘out of control’.
Are skin picking and OCD the same?
There are similarities between the symptoms of skin picking and OCD but they are not the same.
They are, however, both categorized as obsessive-compulsive and related disorders under the DSM-V (Diagnostic Statistical Manual) due to their overlapping features and the frequency with which they are simultaneously diagnosed within individuals.
It is the compulsive need to pick that lands this particular disorder in with other obsessive-compulsive and related disorders.
Medical reviewers have even found that those who suffer from skin-picking disorder are more likely to also have OCD compared to those without.
You can be a skin picker without OCD
For those with skin-picking disorder, the act of excessively picking skin is often done to alleviate the constant urge to pick or touch the skin.
Similar tools are used with sufferers of OCD in that compulsive and ritualistic behavior is used to diffuse the uncertainty and anxiety felt by obsessive thoughts.
However, a skin-picking disorder focuses purely on picking scabs, spots, and scars, and can occur without comorbid OCD. You can receive an excoriation diagnosis without also receiving an OCD diagnosis.
With OCD, there is a wider range of compulsive ritualistic behaviors as a result of intrusive and obsessive thoughts. For example, some compulsive rituals might include:
The urge to pick may be an obsessive-compulsive behavior but it is not, in isolation, a symptom of OCD.
When does skin picking become a problem?
Skin picking becomes a problem when it begins to affect your daily life.
If skin-picking behavior gets to the point that it is near-constant, affecting your ability to see friends or carry out your responsibilities at work and school, this may be the time to seek a medical assessment to see if you are dealing with excoriation disorder.
Someone with a skin-picking disorder can develop damage to areas of their body that are easily seen by those around them. Scars and skin damage to the face are incredibly common and can leave the sufferer feeling embarrassed and ashamed.
This is not a disorder to be taken lightly despite how minor it may appear to someone with little knowledge of the condition.
While people with dermatillomania may not want to stop picking their skin, they don’t like the consequences of doing so and they feel very controlled by these urges. They feel as though they have little control over this strong urge and they feel like they have to pick.
There’s a reason that disorders such as this are often accompanied by high levels of anxiety, stress, and depression. It’s because it can be psychologically and emotionally difficult to manage day-to-day life.
It’s important to know that skin picking can be treated and managed so if you suspect you might be struggling with this condition, seek appropriate support from a mental health professional.
Both OCD and excoriation disorder – together or separately – can be treated effectively.
The ABC’s of Skin Picking
OCDLA created a simple and clear classification of dermatillomania to help us understand when skin picking becomes a problem. Because let’s face it, we all pick! But when does it start to matter?
“A” is something almost anyone would pick.
Something that anyone would feel inclined to pick might be some dry skin hanging from your arm or elbow, a scab that’s mostly fallen off, or a full spot on your chin that’s ready to burst!
“B” is a bump, pimple, or scab.
This is something that only a skin picker would pick at. At this stage, there is very little there to actually pick unlike the things noted in the “A” category. But a skin picker may feel for little bumps or potential spots and begin to pick.
Everything in the “B” category has the potential to turn into something from the “A” category or would disappear if left alone. But a skin picker will pick at these things and make them worse which ultimately causes high levels of distress and skin damage.
Those with skin-picking disorder may contribute at least 50% of their skin-picking to this category.
“C” stands for create.
Only someone with dermatillomania will find themself in band C. In this category, the sufferer does not pick at anything real per se, they pick at seemingly healthy skin and therefore create something such as a cut or blemish that was not there before.
In this category, the picker does not pick at anything apparent on their skin. Instead, they create skin damage through the act of picking at healthy skin.
What are the causes of skin picking?
Photo Credit: Engen Akyurt
The exact causes of excoriation disorder, like causes of OCD, are unknown. But there are a few factors that can trigger people to pick at their skin.
Boredom
Stress
Anxiety
Feelings of guilt or shame
Acne or eczema (skin lesions)
There may be a spot or scab that is deemed unsightly that the person wants to remove
Research suggests that the disorder may be linked to genetics. A study from 2012 found that out of 60 people with excoriation disorder, 28.3% had close family members who shared the same disorder.
(OCD) and body dysmorphic disorder (BDD), two types of obsessive-compulsive and related disorders, are also more common in people with skin picking disorder than in those without the disorder.
Research figures highlight that 28% of those with BDD also have excoriation or skin-picking disorder.
Two types of skin picking:
Automatic: This type of skin picking is more habitual and can be done without a person knowing they’re even doing it. Within this type of skin picking, the person may be seen running their fingers over their skin to check for any areas that feel different and could be a focus area for skin picking. This behavior is also known as ‘scanning’ and can be described as being in a trance-like state. In this trance-like state, they can lose track of time completely and fall into trance-like behaviors when they are picking.
Focused: This type of skin picking is more intentional, and an episode can last four extended periods of time, leading to greater skin damage.
There are several symptoms of skin-picking disorder:
Excessive and compulsive picking
Picking to the point of skin damage – being required
Digging into the skin using fingers, tweezers, knives, teeth, etc.
Common areas of focus such as the face where acne may be present are typical, and moles or freckles are targeted in an attempt to remove what is considered a blemish.
People with skin picking disorder will exhibit behaviors absent-mindedly, scanning for areas without much thought, but they can also have focused “sessions” where specific areas are targeted with picking lasting for hours at a time.
This is the more severe behavior trait and in some cases can result in surgery.
Diagnosis of skin-picking disorder
Source: Diana Polekhina
Diagnosing excoriation disorder requires a physical exam from a healthcare professional and some questions about any skin-picking behaviors to try and figure out if a skin-picking habit has crossed into a disorder.
Diagnosing this condition requires meeting all five of thefollowing criteria:
Recurrent skin picking that damages the skin.
Repeated attempts to stop or to do it less often.
Detrimental impact on various aspects of your life because of shame or embarrassment due to skin picking.
Skin-picking behavior occurs without the influence of any other medical condition such as scabies, eczema, acne, or drug use, whether recreational or prescription.
Picking isn’t the result of another mental health condition, such as body dysmorphic disorder, where you believe that you have a perceived physical defect that impacts your sense of self-worth and self-confidence so you pick at your skin to relieve those negative feelings.
Treatment for OCD
Source: Brooke Cagle
OCD is a long-term condition and the treatment for OCD will reflect this. The most effective treatments are psychotherapy and medication.
Psychotherapy
Cognitive behavioral therapy or CBT is used for many psychological problems, including OCD. Exposure and response prevention (ERP), is a type of CBT that involves gradual exposure to obsessions while resisting the urge to perform compulsive behaviors as a coping tool. The aim is to help teach your brain that you are capable of managing anxiety and uncertainty without the use of these coping mechanisms.
Medication
Antidepressants known as selective serotonin reuptake inhibitors (SSRIs) are designed to increase the levels of serotonin in the brain. These are often prescribed alongside psychotherapy.
Medication should only be taken if prescribed by a mental health professional. Please seek medical assistance and effective medication treatment that is tailored to you and your needs.
Treatment for excoriation disorder
Source: Andre Hunter
Medication isn’t used to treat excoriation disorder, treating skin-picking disorder follows two main kinds of psychotherapy…
As with OCD, CBT has been shown to be effective at treating excoriation disorder by helping to change how their relationship and response to stressful or overly emotional situations. More specifically, a technique called habit reversal training is used to help identify what causes these urges and develop alternative, less harmful behaviors.
Making changes to your surroundings and limiting the opportunity to act on urges to pick is also effective.
This is known as stimulus control and a therapist will work with you to make it harder to act on these urges. Wearing gloves or band-aids can help by reducing the opportunities to pick and other changes, such as removing mirrors or covering reflective surfaces, limits exposure to face acne or other blemishes that may usually trigger the urge to pick.
This is Your Anxiety Toolkit – Episode 318, and welcome 2023.
Welcome back, guys. Happy 2023. Happy New Year. I want you to imagine you and I are sitting down at a table and we both have the most wonderful, warm tea or coffee or water or whatever it is that you enjoy, and we are going to have a talk. You’re not getting a talking too, I’m not saying that. But I want you to imagine that I’m standing in front of you or sitting in front of you and we’ve got eyes locked, and I am dead serious in what I’m talking to you about because I believe it to be the most important thing you need for 2023. I really, really do.
So, let’s talk. Okay, you’ve got your tea. I’ve got my tea. Let’s do this. Okay.
Trichotillomania – also known as the ‘hair-pulling’ disorder – is categorized as the repetitive and uncontrollable urge to pull hair from your body. While some confuse it with OCD, it is in fact a separate condition.
While hair can be pulled from any part of your body with this condition the most common areas include the scalp, eyelashes, eyebrows, arms, pubic hair, and armpits.
Hair pulling is a real mental health condition and can lead to feelings of low self-esteem and a lack of self-confidence.
