Understanding Skin Picking and Inclusion in the DSM5

Professional Q&A with Dr. Annette Pasternak

Understanding Skin Picking and Inclusion in the DSM5


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 (www.wemovetolearn.com).  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 www.bfrbcoaching.com.


How did you get involved in this field?

Well, I struggled with compulsive skin picking myself, for more than twenty years, since I was a teenager.  It got bad in college, and increasingly worse throughout my twenties and most of my thirties.

After college I went to graduate school for a Ph.D. in chemistry, followed by postdoctoral research and a faculty position in biochemistry.  All those years I was overworking, stressed, unconfident and very hard on myself.  Then after all that training and finally becoming a professor, after a couple of years I just knew I didn’t want to do it anymore, so I quit and stumbled around, thinking I could be a writer but then having too much anxiety to really do it.

I had a total identity crisis too – who was I if not a scientist? – and my picking continued to get worse.  I went to massage therapy school but injured my forearms soon afterwards because the muscles were so tight from picking.  Then I returned to teaching chemistry in community college, high school, and tutoring.

One summer vacation I picked up The Complete Idiot’s Guide to Breaking Bad Habits, and for the first time in more than two decades I was able to significantly reduce my picking.  This was despite the fact that, during my twenties and thirties, I had tried psychotherapy three times, hypnosis three times, and Zoloft once.

With the stress of going back to school I relapsed. It’s important to know that, although my picking began to decrease again when I started doing Sivananda-style yoga and meditation, and Brain Gym® (both of which I now teach), I didn’t really know if it was possible to completely stop. I wasn’t certain until about a year and a half later, when I attended a therapy group for skin picking and hair pulling at the OCD Center of LA.  There, I learned key techniques that were essential and yet simple and after I left the group, I continued to improve on my own.

By this time I knew that I really wanted to help people with their lives, not their chemistry, and I toyed with the idea of being a life coach but decided I was more interested in health coaching.  During my health coach training, the teachers encouraged us to consider who we would enjoy working with and what we uniquely had to offer, perhaps based on our own health challenges.

I realized I was ideally suited to working with others who have body-focused repetitive behaviors (BFRB’s) like skin picking, and that this was work I would enjoy.


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”.


What are the signs that the behavior is a problem rather than an activity such as fidgeting or something that can be treated by a dermatologist?

The signs are obvious to the person who has the problem.

They are doing damage to their skin, they try not to do the behavior, but keep doing it anyway.  They spend considerable amounts of time doing it.  Their self-esteem suffers from the inability to control it, the feeling that they should be able to control it, and from their appearance that has been marred by the behavior.  Sometimes they restrict their activities when they don’t want people to see their skin, and as a result, miss social activities and even, in some cases, work.


Does climate have any effect?

Again, that has not been investigated.  However, with vitamin D (the “sunshine vitamin”) increasingly found to help prevent maladies including conditions such as anxiety and depression which may contribute to skin picking, I would not be surprised at all if skin picking was more of a problem in climates that receive less sun and therefore less vitamin D.


This seems to be a more recently acknowledged disorder.  For example, the APA has included skin picking, or excoriation as it will be known, in their Diagnostic and Statistical Manual (DSM5) which comes out in May.  What does that mean to the treatment field?

I believe it means that psychiatrists and psychologists will be able to diagnose skin picking as the primary disorder, whereas in the past they might have had to call it something else in order to bill a medical insurance company.

It raises the profile and “legitimizes” the disorder, which I expect will also help researchers obtain more grant funding to study it.


Does diet, alcohol or drug use contribute to this behavior?

Yes.  It has a large contribution.  In coaching, I support clients to make changes in their diet to stabilize them and reduce their physical need to do the behavior.

For some, simply adding breakfast where there was none, or a substantial lunch of real food instead of processed carbohydrate snacks, markedly decreases their picking.  Eliminating or greatly reducing sugar also works to a surprising and dramatic degree.  It is also common for clients to have food allergies or intolerances of which they are entirely unaware, but that are affecting them negatively, picking and otherwise, so I help them discover whether they suffer from any of these.

For some people, alcohol also contributes to picking, as do some drugs, both legal and illegal, mainly stimulants.  Certain medications for ADD have caused people to start picking, or caused it to worsen if they already pick.  Anything that stresses a person’s system, whether physical or mental/emotional, is likely to make the picking worse.  Proper food, sleep, exercise, wakeful relaxation and breathing, and a supportive environment and relationships can all help the person reduce their picking as they are employing CBT techniques.

Although my answer to this question is a big “yes”, the effects of diet on skin picking have not been investigated scientifically.

Interestingly, there is “almost” scientific support for sugar causing skin picking-type behaviors in mice.  Researchers fed mice a tryptophan solution sweetened with sugar that raised the mice’ serotonin levels.  This was in a strain of mice that are both low in serotonin and predisposed to picking behaviors.  The researchers expected that raising the mouse serotonin levels would decrease their picking, but instead it increased.  I’m sure the increase was due to the sugar, but the researchers did not do the proper control experiment – giving the mice sugar without the tryptophan – which would tell us for sure.  That’s why I say there is “almost” scientific evidence for sugar increasing picking.


If a person engages in skin picking regularly do they do it all over or is there a place that is specific to that person?

This is very individual.  Some people only do it in one place, whether it is their fingers, their legs, or their face.  Others start in one part of the body and over the years keep expanding the territory.


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

The face is most common.


Are there complications related to skin picking that make it a dangerous behavior?

Yes.  There is a huge risk of infection.

I have clients who have been hospitalized due to severe skin infections for which they needed intravenous antibiotics.  Infections are increasingly dangerous, potentially fatal, because of the rise of multi-drug resistant bacteria.


Do you come across people who don’t understand the seriousness of this behavior?  And if so, how do you educate them?  For instance, the person who doesn’t see a need for people to seek out professional help, but rather assume it to be a habit that can be quit with “enough willpower”.

I actually have not come across this directly.  I suspect that if people I speak to think it isn’t serious, they keep it to themselves!

I do know that, in ignorance, people do assume it can be quit through willpower.  I’ve had clients who tell me that is, in essence, what their dermatologists have told them.  “Just stop,” they say.  I can understand the doctors’ frustration, because they have no idea how to get their patients to stop, but it’s not at all helpful to the one who is doing the skin picking, because they do try to stop.  A lot.  They simply don’t know how to stop.


Do you see a role that “community” can play in a persons’ recovery?

Absolutely.  The shame of knowing that you do this thing, and possibly of thinking you’re the only one in the world who does, is tremendously stressful and upsetting.

Not to mention that loved ones may not understand, are often frustrated (and sometimes are essentially “picking on you” about it).

To be able to talk to others that do understand is huge.  My clients appreciate that I have been through this too so it gives them a comfort and trust right from the beginning.  They know I get it.

Even when you begin to learn what you have to do to stop picking, it is tremendously challenging, and you need someone for support, motivation, and cheerleading, so a community can be helpful.  However, I don’t think it is enough.  A group without any expert input can be a case of the “blind leading the blind”.


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.com 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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