– Scratching the surface: the secretive behaviour behind skin picking disorder

Stress management takes on different forms for different individuals: for some, hobbies like exercise, meditation, or journaling are common activities. But according to Calgary-based registered psychologist Dr. Corrick Woodfin, 5 to 7 per cent of the population deal with stress in a very different way: by picking their skin.

Dermatillomania, or skin picking disorder (SPD) was added to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in May 2013, and is classified as a body-focused repetitive behavior, or BFRB, in which those afflicted spend a significant portion of each day picking at their skin to the extent of causing damage. In many cases, the face is the focus of this behavior, but it may involve other parts of the body as well.

Dr. Woodfin is one of only three registered psychologists in Canada who openly treats SPD and other related BFRBs like trichotillomania, or hair-pulling disorder, and says that the underrepresentation of treatment modalities and the stigma associated with the disorder are what spurred his interest in learning how to affectively treat it.

“In a city the size of Calgary, we know that there are 20,000 to 30,000 people that experience SPD. That’s probably an underrepresentation, because people don’t tend to report it or seek treatment,” explains Woodfin, who says that 25 per cent of his current clientelle is made up of SPD sufferers.

Danielle Roberts, a Calgary-based freelance writer in her late twenties, has suffered from SPD for 11 years. Her disorder was first triggered at age 17, when someone pointed out a spot on her shoulder and suggested that she squeeze it. That came during a time of turmoil in her life, and for Roberts, the mental reward and stress relief associated with picking the spot were instant.

“The sensations before picking can range from extreme and intense anxiety to being completely unaware of what I’m doing,” she reveals.

“While I’m picking, I am extremely focused on the task at hand. I’m remarkably determined to ‘fix’ whatever imperfection I’ve focused on. It feels so relieving when I feel that I’ve ‘fixed’ something, but afterwards, I feel shameful, ugly, and frustrated.

“Logically, I know that I’m not fixing anything and actually making my skin worse, but the impulse and belief are not ones I’ve yet been able to get away from.”

Once thought to have been related to obsessive-compulsive disorder (OCD), Woodfin says that the origins of SPD are still being pinpointed.

“The understanding that we’ve got is that it’s far more complex than simply an impulse disorder – in terms of etiology, we know that it likely has a genetic component. With research and our understanding now, this is very much a disorder in its own right,” reasons Woodfin.

He says that where individuals with OCD hate the process of their impulsive behaviors, those with SPD find the behaviors to be pleasurable.

“Another idea is that it tends to run in people who have a propensity for addictions. If we think about the nature of the urges that people with this disorder have, you can argue that it has an addictive component, because the urges themselves are quite addictive in nature.”

Dr. Woodfin says that the challenging thing about treating SPD is that while the behavior is used as a method of stress management, it can also function as a stress activator.

“It’s a very effective behavior at managing all sorts of moods, and that in many ways is why it’s very challenging to treat, but that’s also why it tends to be something that goes throughout the life course of the individual.

“The impact of body-focused repetitive behaviors like skin picking on the activities of daily life is huge. It can be extremely debilitating for people. The troubling thing is, there is a genetic underpinning to this, and we can’t modify our genetic makeup.

“I don’t think this is something that people can recover from where it is eradicated.”

Dr. Woodfin uses various methodologies with his clients, not to “cure” them of the disorder, but to help them manage their behavior. While historically, habit reversal training (HRT) was used to treat BFRBs, cognitive behavioral therapy (CBT) is one of Woodfin’s main treatment orientations.

“It takes a great deal of effort from the individual to want to try and manage this, but if they’re willing then what we can work towards is effective management, so that the client is aware of their triggers, they’re aware of what maintains the problem, and they’re aware of how to target it,” he conveys.

Although she has seen a therapist and was taking medication for a short period of time, Roberts has now learned to effectively manage her disorder through the help of support groups and online resources. SPD is still so unknown that the therapists she saw were initially unaware of it and its causes.

“While none of my therapists knew of the condition, they were extremely diligent in trying to grasp it. It was frustrating though. When you go in for help – especially when you’re paying for it – you shouldn’t have to educate the person you’re paying to help you,” laments Roberts.

It was through online resources and forums that Roberts discovered the Canadian BFRB Support Network (CBSN), a recently developed federally registered non-profit organization based in Toronto. Soon afterward, she began writing for the network because she was inclined to raise awareness about SPD.

She has also attended CBSN’s monthly support groups, and says that meeting others with SPD “in the flesh” for the first time only three months ago has allowed her to realize how much in common she has with other SPD sufferers.

“To finally vocalize the frustrations with others who understood, to be able to joke about it and provide hope for others, it was exhilarating,” she recalls.

“For me, I go to the groups to support others, as I’ve got a reasonable grasp on my condition. I haven’t yet needed the boost from my peers, but it’s great to know that they are there for me.”

Dr. Woodfin recognizes that not all individuals with SPD or related BFRBs are interested in seeking help from a clinical psychologist, and suggests that methods similar to those that Roberts has employed are a great way to manage the disorder on a personal level.

“If people think that they’ve got a mental health disorder and that they’re crazy, it’s going to encourage the stigma that people aren’t seeking support. I would direct people to websites and support groups within Calgary, and to really arm themselves with information about what this is and what it isn’t,” suggests Woodfin.

“Part of getting rid of the stigma is recognition that there is information out there that is helpful and supportive, but the first thing is realizing that you’re not alone.”