The Role of Cognitive Behavioral Therapy in Excoriation Disorder Treatment


The purpose of this article is to provide readers with an in-depth understanding of how Cognitive Behavioral Therapy (CBT) serves as a cornerstone in the treatment of excoriation disorder, also known as skin-picking disorder.


CBT for People Who Broke Up

Excoriation disorder, or skin picking disorder, was originally diagnosed in 1875 and since that time has been categorized as a compulsive disorder with the compulsive need to:

  • Dig
  • Bite
  • Squeeze
  • Scrub
  • Pinch
  • Touch
  • Rub
  • Pick
  • Scratch 

Those who struggle with this diagnosis feel compelled to pick at their skin in any of these ways to such a degree that they cause lesions, and they understand that it’s self-destructive, but they can’t stop themselves from doing it anyway. 

This causes significant distress and interferes with occupational and social functions. There is a strong need for effective treatment approaches to address this condition. Excoriation disorder treatment is seeing positive results, with CBT as a promising therapeutic option.

Excoriation Disorder Treatments

The most common excoriation disorder treatments revolve around psychotherapy and cognitive behavioral therapy in particular.

Understanding Cognitive Behavioral Therapy (CBT)

With these treatments for excoriation disorder, cognitive behavioral therapy helps to modify the factors contributing to skin-picking behavior in order to achieve relatively long-lasting brain function changes so that individuals do not fall subject to repeated, harmful behaviors.

Cognitive behavioral therapy works best when individuals fully participate in their end of the treatment. Cognitive behavioral therapy goes through several stages of improvement alongside homework and journaling requirements. This helps people become more aware of their emotional regulation while also reversing some of their learned habits.

A therapist might be there to provide psychoeducation about the disorder for those who don’t necessarily understand it, but the efficacy of cognitive behavioral therapy comes from clients’ self-reflection and growth generated through homework and journaling. 

Techniques and Strategies Used in CBT for Excoriation Disorder

With this type of treatment for excoriation disorder, the most successful techniques are things that control stimuli, things that trigger the skin-picking behavior. With cognitive behavioral therapy, patients can learn how to avoid this behavior and replace it with positive alternatives.

For example:

  1. A psychiatrist might suggest that part of the treatment for excoriation disorder involves keeping both hands busy while watching television. In this case a client would do things like open and close their fists or use stress balls that they can squeeze so that their hands stay busy.
  2. A psychiatrist might suggest that part of the treatments for excoriation disorder extend to reading a book so that both hands are occupied holding the book at all times or, if holding a book with one hand, the other hand uses the same type of stress ball used when watching TV.
  3. Depending on the condition it might be suggested that all types of sharp or pointed objects be removed from the house.
Difference between CBT and Psychotherapy

Effectiveness of CBT in Treating Excoriation Disorder

So, how effective is CBT skin excavation disorder treatment?

Currently, it is the most commonly used treatment for excoriation disorder because it has the highest impact. 

It works by helping with habit reversal and emotional regulation. 

Habit Reversal

As mentioned, the habits that are utilized in cognitive behavioral therapy are designed to reverse negative compulsions. This involves three steps:

  1. Becoming aware of the skin picking and identifying skin-picking behaviors 
  2. Learning response training where you perform preventative behaviors before skin-picking
  3. Receiving social support from a close friend or family who acts as a cheerleader in support of positive behaviors
Step 1

The first step is becoming aware of the skin picking behaviors as well as how an individual feels both before and after performing the behavior. It’s not uncommon for people to perform skin picking without being aware that they are doing it.

A big part of achieving this step is making detailed notes about their behaviors on a regular basis, including the emotions or warning signs that signal an upcoming episode.

For example, some patients describe feelings of tension or tingling on their skin prior to an episode. A good psychiatrist will help individuals recognize two or three warning signs of an impending skin picking behavior. Doing so helps lead to the application of the second step.

Step 2

The second step is learning response training. Response training is a behavior that an individual learns to perform when they get those warning signs. The purpose of this is to prevent skin-picking behavior. Preventative behavior is something that, once the warning signs appear, should be completed for at least one minute.

This might be something as simple as crossing the arms or making fists and squeezing very hard rather than giving in to the compulsion.

It is important that the preventative measures adhere to the following:

  • They have to be things that prevent skin picking, like crossing arms or closing fists.
  • They have to be things that can’t be noticed by other people.
  • They have to be things that clients are willing and able to do.

During cognitive behavioral therapy sessions, individuals will have the opportunity to practice their response training.

Step 3

Finally, social support is a key element. Individuals should choose someone with whom they are close, like a partner or a friend, who will help them become more aware of their behaviors, pointing out when they are doing it without realizing it. Social support will also encourage individuals to use the response training as a preventative measure.

Emotional Regulation

Tangentially, emotional regulation is an important element of cognitive behavioral therapy for excoriation disorder treatment. Cognitive restructuring can help individuals control the way they respond to stress through things like muscle relaxation and recognize when negative emotions or irrational thoughts contribute to skin-picking behavior. With this recognition, individuals can learn to modify their irrational thoughts to more rational ones.

Integrating CBT into Comprehensive Treatment Plans

For some people, excoriation disorder treatment involves other behavioral therapies and/or medications like SSRIs or anti-anxiety medications. 

CBT can be easily integrated into a comprehensive treatment plan involving any of these other courses of action with approval from a doctor. 

Evaluating Progress and Adjusting Treatment Plans

At the start of skin exploration disorder treatment, especially incorporating cognitive behavioral therapy, a psychiatrist or physician will start by diagnosing the severity of the picking behavior. 

This starts with the client taking inventory by way of daily reflection and journaling as to their daily behavior, including:

  • Where they picked on their skin
  • What it occurred
  • What they were doing when it occurred
  • What they were thinking or feeling before and after
  • How picking changed their thoughts and emotions

Following this diagnosis, interventions are designed to reduce repetitive, compulsive behaviors by providing clients with positive reinforcement that encourages control over stimuli and prevents symptoms of excoriation disorder.

Throughout the course of treatment, a psychiatrist will review the efficacy of these measures and encourage individuals to complete several forms of homework in order to help with this. The homework and the session serve as an opportunity for continued evaluation of progress. If, for example, an intervention to control the stimuli, like reading a book, is not working, then a psychiatrist might adjust the treatment plan to add a different intervention technique, such as watching television.

Summing Up

Excoriation disorder treatment requires personalized approaches with CBT. There are several complementary therapeutic approaches, like muscle relaxation, stress management, and meditation, that can help. 

CBT holds great significance as a therapeutic intervention for excoriation disorder. If you are struggling with excoriation disorder, seek professional help and explore CBT as part of your treatment journey towards recovery.