Skin Picking and Addiction

By Shannon Kelley 05/15/11
Cutting gets most of the media ink these days, but an equally prevalent form of self-injury—skin picking—is increasingly afflicting many addicts. Shannon Kelley gets to the root of the problem.

When Annie, a 35-year-old recovering addict in Brockton, Mass., who has been sober six months, talks about picking her skin, she could just as easily be talking about using.

“When I pick, it’s the same feeling,” she explains—when she’s skin picking, her thought process reminds her of when she was using. “It’s like, ‘Okay, I’m only going to pick one or two cuts, but I won’t do them all.’ And then... It’s sick, but it makes me feel good, so I do it more. Then I get those feelings of, ‘Ohhh, what did I do? Why did I do this?’ I’m so angry at myself, so I say, fuck it, why not just pick at all of the scabs, because now I look horrible anyways, so what does it matter if I do the rest of them? I end up feeling guilty and ashamed and embarrassed and I have to cover it up so nobody knows.” She sighs. “It’s the same euphoria, the same feeling of trying to hide it, the same embarrassment. And shame and regret and guilt. All the same feelings.”

Annie’s not alone. In More, Now, Again, Elizabeth Wurtzel’s 2002 memoir of addiction, she writes not just of her drug addiction but of her compulsive hair tweezing that would result in bleeding legs. Lilly, a 30-something addict in New York, has managed to kick booze, cocaine, and cigarettes, but not picking the skin on her fingers -- from the cuticles down to the knuckles. Even when she’s not doing it, it preoccupies her thoughts, and once she starts, she admits, “it’s like a never-ending train.”

Though you’d never know it from how much the disorder has been covered in the media—it hasn’t—addicts picking at their skin (a condition known clinically as dermatillomania) or pulling out their hair (trichotillomania) isn’t all that unusual. Still, knowing what to call it is tricky. Skin picking and hair pulling are often labeled “body focused repetitive behaviors” (B.F.R.B.s), but also fall under the umbrella term for “non-suicidal self-injuries” (N.S.S.I.s), which includes more severe behaviors, such as cutting. Classification is up for debate, too; some believe B.F.R.B.s belong on the O.C.D. spectrum, although many disagree. Meanwhile, dermatillomania is currently listed as an “impulse control disorder.” And, while there are similarities, skin picking is not the same as cutting.

“In general, skin picking is a more compulsive behavior associated with anxiety disorders and it’s similar to O.C.D.,” says Dr. Joseph Shrand, Instructor of Psychiatry at Harvard Medical School and Medical Director of CASTLE and the Adult Inpatient Psychiatric Unit for High Point Treatment Centers in Plymouth, Mass. “Cutting is often associated with more complex character pathology such as borderline personality disorder, while skin picking is frequently associated with trauma.”

Dr. Simone Madan, a San Francisco-based psychologist who specializes in treating people dealing with B.F.R.B.s, offers a significant stat: 25% of those who suffer from a B.F.R.B., 25% are addicts. But numbers, too, are problematic. Because of the shame around such behaviors, it’s safe to assume that they’re extremely under-reported. That said, recent literature estimates that around four percent of the population has trichotillomania, while anywhere between two and 5.4 percent of the population is affected by pathological skin picking. Skin pickers and hair pullers are more likely to suffer from body dysmorphia, depression, anxiety, and other mood disorders.

This is no coincidence, says Shrand. He’s treated several patients who are dealing with both addiction and N.S.S.I.s and says that when there’s an underlying psychological issue—such as depression or anxiety—drinking, using and even skin picking become “ways to suppress these uncomfortable feelings and overcome them with feelings of pleasure.” The problem, he says, is that “at some point, it’s not pleasure anymore. It’s simply a way to not feel the other feelings.”

While the notion of picking at skin to feel pleasure might sound odd, Dr. Shrand explains, it makes sense thanks to a trick of evolution. “It was important to be able to suppress pain if you were being chewed on by a saber-toothed tiger, so you’d release an endorphin, suppress pain and run away fast.” Endorphins, he adds, are “our bodies’ morphine”: they sit in the same receptors as opioids do and deliver the same high. Any N.S.S.I. will offer a taste. Shrand points out that, although the causation is different, this is where skin picking and cutting are similar; both, he says, “appear to have the same end point of endorphin release and relief.” On the television show House, when Dr. House is attempting to kick Darvon, he cuts himself to get a fix. In A Million Little Pieces, James Frey writes of ripping off his toenails while in rehab to get some relief. Skin picking and hair pulling offer a little dose of the same medicine—a high or escape. Madan says her patients report feeling like they’re in a “trance-like state” while engaged in the behaviors.

This makes sense, according to Shrand. “You get this sense of relief and a high,” he says. “With picking, you don’t feel actual pain at the time. There’s this buildup of emotional pain, this anxiety, and the brain has learned, ‘Well, if I pick at myself, I will release an endorphin’—which is the brain basically going, ‘Ah, this is great, I feel so much better, I’m so relieved: thank you!’ And you really don’t feel the pain until maybe 20 or 30 minutes later.”

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