‘Why couldn’t I stop picking my skin?’

When I started picking my skin as a teenager, mainly on my face and upper body, it didn't affect me much at first. Many of my peers had acne and imperfect skin seemed relatively common. However, already then, I felt less attractive, with likely impact on confidence and self-esteem.

By my mid-twenties, I noticed my peers' skin had cleared up, while mine remained marked with scars and blemishes. I felt different, defective, and ashamed. I masked through make-up and clothing, avoided social situations, and questioned: 'Why can't I stop? Why do I keep creating blood stains, wounds, infections, and scars? Why do I keep having to hide and feel horrible? Will this ever end?'. 

Picking felt good in the moment and often happened unconsciously; before I even realised it, the damage was already done.  I didn't know that I wasn't the only person who was doing this 'strange' thing, and that what I was doing to myself had a name.

That name is Body-focused Repetitive Behaviours (BFRBs), encompassing a range of psychosomatic conditions on the obsessive-compulsive and related disorders spectrum (APA, 2013). These include repetitive behaviours resulting in damage to the body's tissue like hair pulling (trichotillomania), skin picking (dermatillomania), and nail biting (onychophagia). Prevalence estimates vary between 2.5%-24% (Grant & Chamberlain, 2020; Moritz et al. 2024), making BFRBs a significant public health issue.

Despite their prevalence and impact, BFRBs are widely misunderstood, often dismissed as cosmetic issues or benign nervous habits. This stigma contributes to low help-seeking, even though these behaviours have profound psychological, social, and physical consequences (Flessner & Woods, 2006; Galliant et al., 2019; Odlaug & Grant, 2012). Alarmingly, many healthcare professionals remain unaware of these conditions, leaving those who suffer feeling hopeless and isolated. 

During my undergraduate degree, my skin picking became particularly severe due to elevated stress and challenging personal circumstances, intensifying and spreading to different parts of my body. I became even more self-conscious, especially about my face, now full of permanent craters that make-up could not fully cover anymore. I found myself withdrawing and passing on opportunities, thinking I won't be taken seriously because of my skin. I contemplated whether Psychology is the right profession for me, given my own mental health struggles, carried on my face for everyone to see. 

Feeling like a slave to my compulsion and desperate for answers, I started studying BFRBs and looking for help. 

Rock bottom: Searching for answers in Psychology

While psychotherapy, particularly CBT-based approaches such as ACT and DBT, combined with Habit Reversal Training, can be effective for BFRBs, high relapse rates remain a major concern (Wilhelm et al., 2011). These are often attributed to difficulties in managing emotional triggers and maintaining behaviour changes (Müller et al., 2014). Additionally, frequently present comorbid conditions, such as anxiety or depression, can negatively impact treatment outcomes, suggesting the need for more specialised, tailored interventions (McGuire & Ginsburg, 2020).

Over years, I have tried a multitude of practical approaches that would limit the opportunity to pick or change the experience of it to discourage it, such as creams, gloves, plasters, fake nails, sensory aids, dimmed lights – with minimal and short-lived results. When I reached out for professional help, I was refused a referral to Dermatology due to my skin issues being 'not severe enough' and seen as self-inflicted. Instead, I was prescribed SSRIs, which only made my picking worse and came with side effects like jaw clenching, teeth grinding, brain fog, and poor sleep. 

I completed counselling, which gave me space to talk about my issues, but it did not change them or move me towards it. I then pursued CBT with a Clinical Psychologist after a hard-fought referral from my GP. While I gained more knowledge and awareness, my symptoms did not improve. In fact, I felt more guilty – I now understood my condition, so why couldn't I still stop?

The turning point: Finding community

Everything changed when I joined a support group in Edinburgh run by Dr Bridget Bradley (University of St Andrews), co-founder of BFRB UK and Ireland, the UK's first dedicated charity working to increase awareness and grow community support. For the first time, I spoke with others who understood my experiences. 

The ability to relate and the sense of community were incredibly healing. Alongside shared humanity and mutual support, I learned that self-acceptance and compassion were more effective than guilt and shame. As my skin picking was normalised, I made my peace with it and eventually my picking gradually lessened to much more manageable levels. In turn, I embarked on turning pain into something empowering and of benefit to others. My personal struggle became a driving force for research and advocacy.

Since then, I have conducted and published two studies on skin picking and presented at multiple mental health conferences. However, my efforts to bring awareness to BFRBs have been met with mixed reactions, highlighting stigma in academia and healthcare. Many professionals dismissed my work. In conference presentations, I often encountered confusion, disinterest, and even disgust, with some attendees reacting with words like 'cringy' or 'eek'. Even some senior leaders seemed to view BFRBs as obscure and unworthy of academic focus. This mirrored the stigma people with BFRBs experience in their daily lives, leaving me feeling alienated in my advocacy. Despite the high prevalence of BFRBs, they remain stigmatised, understudied and under-discussed. The lack of recognition within clinical and academic circles creates barriers to effective treatment and widespread education.

A new hope: Oxford BFRB Conference

Recently, BFRB awareness received a vital boost when Professor Clare MacKay (University of Oxford), who has lived experience of trichotillomania, turned her research interest toward BFRBs. Together with BFRB UK and Ireland, she co-hosted the first Oxford BFRB Conference (13-14 September 2024). 

This event marked a pivotal moment for the BFRB community in the UK and beyond. The conference brought together researchers, clinicians, and individuals with lived experience, providing a multidisciplinary perspective – spanning neuroscience, psychology, and social anthropology. This created a forum for both academic research and personal stories, fostering a deeper understanding of the complexities of these surprisingly common, yet paradoxically little-known and secretive (Isibor & Sagan, 2023) disorders. 

However, what truly set this event apart was its emphasis on lived experience and the power of community. In the face of the prevailing medical model dominance, this holistic approach is what is often missing. The scientific talks were followed by a 'lived experience scientist' panel, which as a dual-identity mental health service-user/service-provider I had a joy to be a part of, while the second day of the event was dedicated entirely to community activities. Individuals with BFRBs shared their personal stories, offering insights that are often overlooked in traditional clinical or academic settings. 

The narratives conveyed varied personal experiences with BFRBs, reflecting their heterogeneity, with prominent shared themes of shame, stigma, lack of support, and poor awareness. I finally felt genuinely listened to when speaking about BFRBs at such forum. Unlike previous conferences, where I encountered dismissiveness, here I found engagement – people understood or cared and wanted to understand. This has reignited my sparkle for BFRB advocacy that got somewhat dimmed by all the challenges around it, reminding me that our work is valid, important and needed. 

Looking ahead: A future without stigma?

The Oxford BFRB Conference made history and was a breath of fresh air, but there is still much work to be done. We need more research, more awareness, and more acceptance. BFRBs deserve scientific and public interest. We must challenge stigmatising attitudes, both in society and in academic and clinical spaces. Increasing awareness is a critical future direction. As many people with BFRBs do not seek treatment due to stigma or lack of knowledge, public education campaigns and the development of accessible evidence-based resources are essential to increase help-seeking and improve outcomes.

I hope that my article can become the next salient advancement and help BFRBs gain greater recognition, encourage interest, and send a message of hope to those who need to hear it. More awareness means better lives for those affected, their loved ones, and society as a whole. We all have a role to play in elevating mental health stigma. But if we are to truly break it, we need to identify and address all its elements. BFRBs constitute an important, overlooked piece of this puzzle. 

Marta Isibor (BSc Hons, MRes) is Clinical Psychologist Assistant Practitioner in Substance Misuse Psychology at NHS Lothian and Visiting Lecturer at Queen Margaret University. Using her research and lived experience of skin picking disorder, she advocates for greater awareness and understanding of body-focused repetitive behaviours (BFRBs), aiming to support affected individuals and advance knowledge in this area.

[email protected]

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Flessner, C. A., & Woods, D. W. (2006). Phenomenological characteristics, social problems, and the economic impact associated with chronic skin picking. Behavior Modification, 30(6), 944 – 963. Doi: 10.1177/0145445506294083

Gallinat, C., Moessner, M., Haenssle, H. A., Winkler, J. K., Backenstrass, M., & Bauer, S. (2019). Help-seeking attitudes and experiences in individuals affected by skin picking. Journal of Obsessive-Compulsive and Related Disorders, 23. https://doi.org/10.1016/j.jocrd.2019.100483

Grant, J. E., & Chamberlain, S. R. (2020). Prevalence of skin picking (excoriation) disorder. Journal of Psychiatric Research, 130, 57-60. https://doi.org/10.1016/j.jpsychires.2020.06.033

Isibor, M. & Sagan, O. (2023). "You get good at becoming secretive, at hiding it." Shame              and loneliness: the mental health impacts of skin picking disorder". Mental Health and Social Inclusion, 28(5), 869-878. https://doi.org/10.1108/MHSI-10-2023-0110

McGuire, J. F., & Ginsburg, G. S. (2020). Challenges in treating body-focused repetitive behaviors: The role of comorbid conditions. Journal of Anxiety Disorders, 74, 102268. 

Moritz, S., Scheunemann, J., Jelinek, L. Penney, D., Schmotz, S., Hoyer, L., Grudzien, D., & Aleksandrowicz, A. (2024). Prevalence of body-focused repetitive behaviors in a diverse population sample – rates across age, gender, race and education. Psychological Medicine, 54(8), 1552-1558. Doi:10.1017/S0033291723003392

Müller, A., Herpertz, S. C., & Böhnke, J. R. (2014). Cognitive-behavioral therapy for body-focused repetitive behaviors: A systematic review and meta-analysis. Journal of Clinical Psychology, 70(7), 688-701.

Odlaug, B. L., & Grant, J. E. (2012). Pathological skin picking. In J. E. Grant, D. J. Stein, D. W., Woods, & N. J. Keuthen (Eds.), Trichotillomania, skin picking, and other body-focused repetitive behaviours (pp.21-42). American Psychiatric Publishing.

Wilhelm, S., Keuthen, N. J., & Tolin, D. F. (2011). Cognitive-behavioral therapy for trichotillomania: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 79(4), 510-515