Could skin-picking be a sign of ADHD or anxiety?

Skin: It’s a waterproof, insulating barrier that protects us from all sorts of things, from harmful chemicals and extreme temperatures, to the ultraviolet radiation from the sun. You’re literally covered in the stuff, meaning that this “cutaneous membrane” has the distinction of being the largest organ in the human body. 

Another interesting fact: You lose around 1.5 pounds of dead skin cells each year, and it’s pretty common to play an active role in at least some of this process—perhaps by scratching a particular spot due to stress, or plucking off the occasional hangnail. At this level, skin-picking can be entirely normal. Excoriation disorder, on the other hand, is a repetitive behavior that involves the urge to pick at your skin, and can have significant physical and emotional consequences that impact your life and well-being.

This article explores the connection between compulsive skin picking, ADHD, and anxiety. We’ll also look at whether skin picking might interfere so much with your day-to-day life that it could be considered a body-focused repetitive behavior, or BFRB. And perhaps most importantly, we’ll offer some effective ways to free yourself from excoriation.  

Understanding skin picking

As we’ve mentioned, skin picking is a repetitive behavior characterized by the irresistible urge to pick at one’s skin. 

“With skin-picking, there’s a set of physical impacts. In some cases, you’ll actually pick through the skin, creating an open wound, and later, scars. This damage isn’t just unsightly; it can lead to infection. And there’s also a set of emotional impacts,” says April Kilduff, MA, LCPC, LMHC, and Clinical Trainer at NOCD. “If you’re unable to resist the urge to pick your skin, it can cause poor self-esteem and leave you thinking things like, ‘Why can’t I just stop picking? What’s wrong with me?’ If the picking is in a place that isn’t covered by clothing, you might either spend a lot of time and effort covering the sores up with makeup, or limit how much you interact with other people because of the shame or embarrassment you feel about your appearance.”

Let’s look at some of those causes, starting with a condition that around one in 12 Americans will experience during their lifetimes: attention deficit hyperactivity disorder, or ADHD.

Is skin-picking a symptom of ADHD?

ADHD is a neurodevelopmental disorder characterized by inattention, hyperactivity, and impulsivity. The underlying impulsivity and hyperactivity associated with ADHD can contribute to skin-picking behaviors. Indeed, research has shown that skin-picking commonly appears in people with the disorder. 

People with ADHD may struggle to resist the urge to pick at their skin, especially when feeling restless or overwhelmed. Skin picking may serve as a self-soothing or self-regulating mechanism for people with ADHD, temporarily relieving their core symptoms.

“Sometimes people with ADHD engage in skin picking because they are hyperstimulated from a sensory perspective and want to self-soothe and come down from that experience,” explains Kilduff. “Others, however, may pick at their skin because they are understimulated, and use it to get the stimulation they feel they need.”

It’s important to note that not all people with ADHD will engage in skin picking, but the correlation between the two suggests a potential link. Successful treatment of this underlying cause is likely to reduce the frequency of skin picking in people with ADHD. 

The first-line treatment for ADHD usually involves a combination of behavioral interventions to help improve organization, time management, and impulse control, as well as medication. Stimulants such as methylphenidate and amphetamines are commonly prescribed to reduce hyperactivity, impulsivity, and inattention. Non-stimulant drugs like atomoxetine and guanfacine may be prescribed if stimulants are not well-tolerated, or other conditions are present.

Treatment choice depends on factors including the severity of symptoms, age, personal preferences, and any other conditions that may be present. It’s important to work closely with healthcare professionals like psychiatrists or pediatricians who can provide thorough evaluations and create personalized treatment plans.

Skin picking and anxiety

Skin picking can also be linked to anxiety disorders characterized by excessive worry, fear, and intrusive thoughts. This anxiety can drive compulsive behaviors like skin picking that are done in an effort to alleviate the distress these feelings cause.

“Anxiety disorders often involve a heightened sensitivity to stress and a constant state of apprehension,” says Kilduff. “Skin picking may serve as a coping mechanism, providing people with temporary control over their anxious thoughts. It becomes a way to release tension and divert attention away from overwhelming emotions.” 

The go-to treatment for anxiety disorders typically involves a combination of psychotherapy and medication. Cognitive-behavioral therapy (CBT) is a common form of therapy that helps people identify and change negative thought patterns and behaviors associated with some forms of anxiety. Habit Reversal Training (HRT) is also a useful form of treatment for, helping people to change their behaviors associated with skin picking.

Skin picking as a BFRB 

While skin picking can be associated with ADHD and anxiety, it is important to recognize that it can also be a distinct condition known as body-focused repetitive behavior (BFRB). BFRBs are a group of behaviors characterized by repetitive actions—often self-grooming ones—that cause significant distress and impairment in daily functioning. These behaviors, including skin picking, hair-pulling, and nail-biting, share common features but have distinct characteristics.

When skin picking is classified as a BFRB, it is considered a primary condition rather than a symptom of ADHD or anxiety. BFRBs are often chronic and recurrent, requiring specific treatment approaches tailored to address the underlying roots of these behaviors.

“BFRBs are typically characterized by a sense of tension called the premonitory urge before engaging in the behavior, followed by a feeling of relief or satisfaction afterward,” Kilduff explains. “People may experience difficulty resisting the urge to engage in the behavior, even when they are aware of the negative consequences it may have on their physical appearance or emotional well-being.”

Can Habit Reversal Training Help People Whose Skin Picking Is Related to Anxiety or ADHD?

“Habit reversal training, or HRT, is a therapeutic approach that can be effective in managing skin-picking behaviors, regardless of whether they are related to anxiety, ADHD, or standalone BFRBs,” says Kilduff. 

HRT focuses on increasing self-awareness and developing alternative responses to replace the urge to pick—including awareness training, where you learn to identify triggers and patterns associated with skin picking. By recognizing the situations, emotions, or thoughts that precede skin-picking episodes, you can develop strategies to interrupt the behavior.

This sets the stage for another aspect of HRT, called competing response training. It involves identifying and practicing alternative actions or behaviors that can substitute for the urge to pick, helping you redirect your focus and manage your impulses effectively. For example, Kilduff says that clasping your hands together may be a good competing response in this instance, as it makes picking at the skin impossible. 

Social support plays a vital role in HRT as well. Connecting with therapists, support groups, or loved ones who understand and empathize with the challenges of skin picking can provide encouragement, help you stay motivated, provide a safe space for sharing experiences, and offer guidance during recovery.

HRT has shown promising results in reducing skin-picking behaviors and promoting positive habit change. Research studies have demonstrated its effectiveness in reducing the frequency and intensity of skin-picking episodes, improving overall quality of life, and reducing associated distress and impairment.

BFRBs and virtual treatment

The close relationship between OCD and BRFBs, such as excoriation disorder, led NOCD to train our licensed therapists in HRT, bringing accessible, effective care to people struggling with these commonly misunderstood conditions. And incidentally, it’s not uncommon for BFRBs and OCD to co-occur.

Like the gold-standard treatment for OCD—called exposure and prevention response therapy (ERP)—HRT can be delivered remotely, and a marked improvement is typically seen in weeks.

If you or someone you know is struggling with excoriation disorder—or any other BFRB—I strongly encourage you to learn more about NOCD’s evidence-based, accessible approach to treatment for BFRBs and the conditions that are closely related to them, such as anxiety disorders and OCD.