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.”

But then, what a hangover it is. Annie has been in and out of the hospital for infections including MERSA (a bacterial infection that’s highly resistant to some antibiotics), which required a two-day course of I.V. antibiotics. Showers can hurt. She only wears white pants to avoid getting dark lint into her wounds and causing more infections. “My skin, my body is scarred from head to toe,” she says. “I’ve destroyed every inch of my body.” The worst part, according to Annie, isn’t the pain or the scars but the isolation. “It’s a very lonely thing to deal with,” she admits. “It’s very shameful; you feel embarrassed and people judge you because you look different and they just don’t understand, because what grown woman mutilates her whole body?”

Lilly learned early on that picking her skin was something to keep under wraps. “When I was a freshman in high school, I remember this girl seeing my completely bloody and picked-at thumb and going, ‘Oh my God, what happened to your finger?’ She was horrified and it was the first time I realized other people could see it and that it was something I just had to keep private.” Now that she’s been sober for over half a decade, she confesses that her skin picking is “just as shameful, if not more, as my coke habit used to be.”

While she’s desperate to stop, Lilly says it’s not that simple. “With using, I went to rehab and it was a solution that worked,” she says. “With this, I went to a psychiatrist, a hypnotist, and a manicurist and nobody really had the answer. I went on a medication that was supposed to help and it didn’t. For years, I wore fake nails, thinking that would make my hands look nice and I’d leave the skin around them alone. I didn’t. Sometimes I go through periods where I do it a lot less and I always feel very proud of myself, but by and large I haven’t found a solution.”

Lilly’s not alone. “Unfortunately,” says Madan, “treatments are not advanced to the point that we can get rid of this problem completely. Still, if people are motivated, we have pretty good success at getting them to reduce the behavior and increase awareness.”

Shrand believes there is a place for medication. He’s found some success with Suboxone (frequently used to treat opioid addictions), and believes that if doctors are able to treat the psychiatric condition—such as depression or anxiety disorder—the patient won’t feel the need to self-soothe in this way. Doctors may prescribe the same medications that are used to treat O.C.D., including S.S.R.I.s—although Madan notes she hasn’t found tremendous success along that route. Both doctors agree that any treatment should include behavioral therapy focused on finding other anxiety-reducing techniques. And there are steps anyone can take, whether they’re in therapy or not – like keeping the hands busy. (Koosh balls are mentioned a lot.) Because these behaviors can become somewhat unconscious, another important step is cultivating awareness by paying attention to the triggers. Keeping a journal can help with that. And anxiety-reducing techniques like meditation and simple deep breathing can offer some relief.

But according to Shrand, the greatest hope for recovery may be the kind of communal support that 12-steppers experience. “If you feel ashamed, you will deprive yourself of some of the very treatment you need, which is human companionship and a sense of being valued by somebody else,” he says. “If we don’t get that, we become very anxious and the anxiety will continue to drive the self-mutilation—and then you can see the vicious cycle you get into.”

Fortunately, interest is growing and hopefully, in turn, the stigma will be lessened. Research is beginning to emerge, and there is a possibility that the American Psychiatric Association’s next manual, D.S.M.-V, might include non-suicidal self-injuries. 

While Annie says she and her doctors have tried everything short of “knocking me out,” she’s still struggling. She’s currently on Suboxone, and is hoping cognitive behavioral therapy will help her develop better coping skills. But, for her, it seems that Shrand’s emphasis on human connection could be the best treatment of all. “I feel blessed to talk to you, because it might help people like me,” she says. “I want to help others to know that they’re not alone.” 

Shannon Kelley is the author of the book Undecided and a columnist at the Santa Barbara Independent. Her work has appeared in Woman's Day, The Christian Science Monitor and Santa Barbara Magazine.

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