Annette Pasternak, Ph.D.: Skin Picking and Therapy

Professional Q&A with Dr. Annette Pasternak

Annette Pasternak, Ph.D.: Skin Picking and Therapy


Annette-PasternakAnnette Pasternak, Ph.D. is a certified holistic Health Coach, Brain Gym® Instructor/Consultant and yoga teacher based in Los Angeles. 

She has been an educator for more than a decade, first teaching biochemistry and chemistry in college and high school, and now Brain Gym to teachers, physical, occupational and educational therapists and other adults (  She also teaches yoga at the Sivananda Yoga Vedanta Center in Los Angeles. 

Annette suffered from chronic skin picking for more than two decades, before gradually learning to stop. 

While attending the Health Coach training program at the Institute for Integrative Nutrition in 2011-2012, Annette developed a specialized program to help others stop or greatly reduce their body-focused repetitive behaviors (BFRBs) and become calmer, happier, healthier, more confident individuals in the process. 

Annette now sees clients all over the world via Skype or phone.  For more information on coaching programs, a newsletter and blog with self-help tips, or to contact Annette, visit her website at


What is skin picking?  Is it different than dermatillomania?

People are generally talking about the same thing, using different terms, although some degree of skin picking is normal behavior.

Most everyone will pop an odd pimple, pick off some loose dry skin, or peel or nibble off a hangnail.  But when we are talking about habitual problematic skin picking (often called chronic skin picking or compulsive skin picking [CSP]), dermatillomania seems to be the most common name for it, though it is not the name the American Psychiatric Association (APA) has chosen to call it in the upcoming DSM-5 manual (the first edition that skin picking is listed as a diagnosable disorder).

It will be called excoriation (skin-picking) disorder, which is, in my opinion, a better name in that the “mania” in dermatillomania implies “crazy”.


Are there demographics that are more prone to suffering from skin picking than others?

Women are much more prone, on the order of ten times more likely, to suffer from skin picking.  Other than that, I don’t believe any information is known about demographics.


Are there many therapists who treat this disorder specifically?  Do you anticipate an increase in that number due to the inclusion in the DSM5?

The Trichotillomania Learning Center (TLC) website (, has a list of providers but the need for more still exists. In many locations there are simply no qualified therapists.

I have clients who start in my coaching program after I have suggested they check the TLC list (because they would like insurance coverage), and they found nobody (or nobody they clicked with) in their geographic area.


Are some treatments more effective than others in general?  For example is cognitive behavioral therapy (CBT) any more or less useful than dialectical behavioral therapy (DBT) or Emotional Freedom Technique (EFT)?

There is no way to compare objectively right now because CBT is the only one of those therapies for which there have been scientific studies published for skin picking.

CBT has been shown to be effective (it hasn’t been shown to “cure” people of these behaviors, but to reduce them, at least for a time).  From what I know about DBT, it includes training in mindfulness and acceptance/toleration of uncomfortable thoughts, emotions and sensations.  Those are key skills that I work with my clients to develop.  Anecdotally then, I can say DBT is useful and I believe it would be objectively found so if studies were done.  I also do some EFT with my clients and can also say that I have no question that it is helpful, but again there is no scientific proof.  Skin picking is such a challenge to treat that I believe it is most effective to use all the techniques that seem to work.

It is important to note that while there is no scientific support for these techniques and others, it is probably because they have not been looked at, not because they don’t work.  How can you see what you don’t look at?

As a former scientist and present holistic health coach, I can tell you that this subject makes me crazy.  Research is driven by the preferred methods of the medical and psychological establishments.  That is why drugs are the go-to treatment for diseases and disorders, both physical and mental, but in my experience and that of many, many others, appropriate food and lifestyle changes have a far greater healing effect than pharmaceuticals, and without side effects.

At this time diet and lifestyle factors are still considered “alternative” and therefore are not as often looked at scientifically, especially for lower profile disorders like skin picking, so there is no way for us to compare the effectiveness of these treatments in an objective, scientific way.


Does this behavior happen more frequently on its own or does it present in conjunction with other behaviors or addictions?

It happens at times on its own, but frequently with other behaviors, addictions and psychiatric conditions, including substance abuse, eating disorders, anxiety, depression and bipolar disorders, body dysmorphic disorder (BDD) and obsessive-compulsive disorder (OCD).


In general, is there a part of the body that skin picking is most often found?

The face is most common.


Do you find that someone in therapy for skin picking will sublimate their behavior with something that is equally destructive?

It is possible this would happen, depending on the type of therapy.  My clients learn to shed habitual negative cycles of thought and emotion.  They become happier, more energetic and calmer.  When you are able to naturally access a happy peaceful state, the need for addictive behaviors is gone.

Here’s an example:  I invite clients to set any number of goals at the beginning of our program in addition to the main one; to stop or greatly reduce their skin picking.

One of my clients had four goals, the last of which was to cut down on her clothes shopping, which she felt was problematic too, although not to the degree of the picking.  During her six months program, we never again talked about that issue.  But at our last session, in revisiting her goals I asked about it, and she reported that her shopping had gone way down too.  It naturally fell away.

But if the treatment aims to stop the picking without any real healing, then I would expect either failure or sublimation into another undesirable behavior.


How important is it that the person managing this behavior know that they are not alone?  Does this knowledge have any effect on quality of life?

I believe it is important.  If you don’t know there are others, you think there is really something deeply wrong with you, and you feel completely alone and ashamed.  The internet is a real blessing for people with these behaviors – you can look up “skin picking” and see plenty of evidence that you are far, far from alone.


What else would you like to share?  Please feel free to add more – your work is very meaningful and I’d appreciate anything you have to say. 

It’s not exactly about my work but more important, and more universal:  I know everyone may not be ready to commit to a meditation habit, but just ten minutes daily has been shown scientifically to provide wide-ranging physical and mental health benefits.

Calming your body and mind creates a state that, with practice, carries over into the rest of your day, and that state is incompatible with addictive behaviors.

Meditation profoundly improves your life, no matter what your challenges are.  And once it becomes a habit, it takes no energy at all.

Thank you for the opportunity to contribute to the BingeBehavior conversation.  I have enjoyed sharing my knowledge and experience on the topic of chronic skin picking.


If you would like to reach Annette Pasternak, Ph.D.:

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