Do you struggle with ADHD Skin picking or biting like me? Do you, too, sport embarrassing raw or bloody spots somewhere on your skin because you can’t seem to stop doing it? If so, you aren’t alone.
ADHD overlaps with a lot of things: anxiety, depression, OCD, Autism… But maybe the strangest of all is the link between ADHD, skin picking, and auto-cannibalism AKA skin biting. (Let’s be honest, auto-cannibalism is a lot more fun to say, in a twisted kind of way.)
We’re notorious for this combination, struggling with it at a much higher rate than the general population for reasons we’ll get into throughout this article. The overlap and connections between these three issues are surprisingly strong. While researchers have some theories as to why, research is still too limited to answer definitively why ADHD, skin picking, and biting correlate. Today we’ll explore what we know so far. Buckle up, any article with ‘cannibalism’ in it is sure to be a wild ride.
BFRBs: the Alphabet Soup of Skin Picking & Biting
Frequent skin picking and auto-cannibalism fall into a category known as Body Focused Repetitive Behaviors. BFRBs are any repetitive and chronic behavior you inflict upon your body. Everyone picks at a bump every once in a while, but when it becomes compulsive, excessive, and chronic, it’s a BFRB.
Beyond skin picking and biting, BFRBs can also include nail biting, knuckle cracking, lip/cheek chewing, hair pulling, excessive nose picking, thumb sucking, hair pulling, and other similar repetitive, body based behaviors. While they definitely cause harm, it’s important to know that self harm is not the motivation behind the behavior. But we’ll talk more about that later in the article.
Skin picking and biting are among the most common BFRBs in ADHD. Among the general population, researchers aren’t actually positive how prevalent body focused repetitive behaviors are. Conservative studies show something like 3%, but others show upwards of 15%. In ADHD though? It’s thought to be much higher. Possibly up to 38%.
When a body focused repetitive behavior is severe enough to cause damage, especially of a lasting variety, it’s often referred to as a Body Focused Repetitive Disorder (BFRD). In the DSM 5, the only specifically diagnosable BFRD’s are Skin Picking, known as Excoriation, and Hair Pulling, AKA Trichotillomania. They are listed under the OCD umbrella, but they aren’t OCD.
ADHD, Skin Picking, and…Wolf Biting?
I’m not sure why each behavior needs 50 thousand different names, but someone decided they did and now there are several relevant labels to be aware of. At least some of them are interesting. The symptoms, however, suck no matter what you call them.
Skin Picking
Skin picking is also known and Dermatillomania, and in more extreme (read diagnosable) forms, Excoriation. Those are the most commonly used terms. But, less commonly, it’s also called Pathological Skin Picking, Neurotic Excoriation, and Psychogenic Excoriation. All those names reminds me of those parents we all know who gift 6 different names to their newborn because they love them all and can’t decide between them.
Skin picking can come in different forms, such as picking, squeezing, rubbing, scratching, or digging at your own skin. That can include things like:
- Scratching off scabs until they scar
- Excessive pimple popping
- Ripping off hangnails
- Tearing your cuticles
- Picking at uneven, rough, dead, or dry skin
That’s just a sample, but the possibilities are endless. Most people pick at their face, but the scalp, neck, fingers, hands, arms, legs, feet, and toes are also frequent targets. Remember, in these cases, we aren’t talking about occasionally popping a pimple or scratching at a scab. These are repetitive and chronic behaviors.
Skin picking can happen in both automatic and focused ways. Automatic picking happens on autopilot, like when you’re watching television and suddenly realize your face is bleeding. You weren’t paying attention to what you were doing, it just happened.
Focused picking is the opposite. It’s the more obsessive version; there’s a strong urge to pick at some perceived imperfection or sensation on the skin and you do it almost compulsively. You can’t seem to help yourself.
Skin Biting
Skin biting gets all the interesting names, starting with the one previously mentioned: auto-cannibalism. I have a morbid enjoyment of the term, but it’s a bit of a misnomer. Skin biters don’t necessarily eat their skin, they instead use their teeth of forcibly remove parts of it.
In addition to auto-cannibalism, skin biting is also called wolf-biting which might be just as fantastical a name. It was used after people observed a similar tendency for skin biting in trapped wolves.
Of course, it has more ‘official’ names, too. Dermatophagia is most commonly used; ‘Derma’ is Greek for ‘skin’ and ‘phagia’ meaning ‘to eat’. Auto-cannibalism makes additional sense in light of that, right? Less commonly, it’s also called Dermatodaxia.
While skin biting is not explicitly stated in the DSM criteria for Excoriation, it is often lumped within that umbrella if the symptoms are chronic and severe enough. Which also means ‘Dermatillomania’ is yet another possible name for this ferocious behavior. (Ferocious feels like a positive reframe that I think I’ll keep).
Skin biting can happen anywhere you have skin but fingers and lips are most common. I personally struggle with this one and my fingers nearly always have raw sores or scabs around the nail beds. Like with skin picking, this can happen in both automatic and focused ways. For me, it’s definitely, 100% both.
The ADHD Overlap
Despite the need for far more research into ADHD, skin picking, and skin biting and the links between them, what information we do have points to a strong correlation. For instance, research indicates that a quarter of people with Excoriation also have ADHD. Nearly 30% of all people with Trichotillomania have ADHD. While this article isn’t about trichotillomania (clinically diagnosable hair pulling), the BFRB nature of the struggle still makes it a relevant statistic.
Beyond the more extreme forms, we don’t have enough research to say with certainty how much more common the sub-clinical versions of these challenges is within ADHD, but it is thought to be just as significant. Some theories for this overlap link similar natures of the two conditions together. Others are more ADHD specific. We’ll delve into both sides.
ADHD & Skin Picking: Common Psychological Underpinnings
While Excoriation and other BFRBs are typically associated on the anxiety end of the psych spectrum and ADHD on the developmental end, one theory as to why they co-occur so frequently is this idea of common underpinnings. It also helps that over 50% of adult ADHDers meet the criteria for an additional anxiety disorder, meaning the two are already more likely to find each other.
So what are these common overlaps in their nature? We’ll start with the neurotransmitters.
Related: Do I Have ADHD or Anxiety? Here’s How to Tell
ADHD, Skin Picking, and the Role of Dopamine
Both ADHD and Skin picking (all BFRBs, really) have ties to neurological and genetic conditions as their main cause. If you’ve been around the block with ADHD, you may already know it’s connection to Dopamine, the ‘wellness’ neurotransmitter. Chiefly, that we lack an adequate supply. That directly relates to our core ADHD symptoms as Dopamine is responsible for our ability to feel well, find motivation, cultivate a productive amount of mental alertness we can use to push ourselves to do things, get organized, and stop procrastinating. It’s responsible for the sense of reward that comes with a job well done, how well our memory works, our ability to regulate emotion or attention, etc…
Dopamine helps us regulate our impulsivity and compulsivity, too. Having a less than adequate supply of this neurotransmitter is a big cause of why people with ADHD struggle with the particular executive functioning challenges we have.
Like with ADHD, Skin picking and other BFRBs are also believed to revolve around a Dopamine deficiency. In this case, that deficiency leads to the compulsive nature of BRBFs. Impulsivity and compulsivity aren’t all that different; while compulsions aren’t a typical feature of ADHD, our struggles with regulation and impulsivity create a similar effect. Both conditions include challenges with mindlessly engaging in behaviors (those autopilot responses, like picking at your skin without realizing) and hyper-fixating on certain behaviors or effects (like obsessing over a raised cuticle and tearing it off regardless of the damage you’re inflicting).
ADHD, Skin Picking and the Role of Serotonin
In the ADHD realm, we don’t talk enough about Serotonin, so some may not realize this neurotransmitter is also involved in our struggles. Serotonin plays a huge role in mood and emotion regulation. In both ADHD and skin picking / BRBFs in general, the genes that regulate our serotonin aren’t doing their job as effectively as we need them to.
Challenges with emotion regulation are a well-researched and proven reality for people with ADHD. The same part of the brain that regulates attention, regulates emotion as well, which is why we struggle with it. That dysregulated struggle is also why we are so much more likely to develop additional anxiety disorders, like Excoriation.
Skin picking and other BFRBs are often coping mechanisms people use in an attempt soothe dysregulated anxiety. That creates the focused, compulsive urge to pick at your skin that feels almost impossible to ignore. Once we successfully scratch off our scab or bite off the hangnail, we feel relief and pleasure, until the urge begins anew.
Related: ADHD and Emotions: The Hidden Links You Need to Know NOW
ADHD, Skin Picking, and Sensory Processing Issues
Both ADHD and skin picking often involve differences in sensory processing. The repetitive aspect of skin picking and other BRFBs provides sensory input to the brain that is typically experienced as soothing and pleasurable. That helps calm anxiety, restlessness, and regulate attention. Sensory processing differences may contribute to a heightened awareness of skin imperfections or sensations that increase the urge to pick, bite, or otherwise resolve the issue.
ADHD Skin picking: the Specific Ways ADHD Leads to BFRBs
Beyond the commonalities between them, there are also inherent ways that ADHD specifically encourages (and exacerbates) these repetitive behaviors like skin picking and biting.
Stimming
Stimming is when a person repeatedly engages in the same behaviors or sounds. That might look like playing the same song 50 times in a row, repeating words in your head because you like how they sound, fidgeting with things, bouncing your leg, or, more relevant to this article, picking or biting at your skin.
ADHDers use stimming as a way to better regulate ourselves. It is thought to help us increase focus, attention, and mood, while decreasing stress, boredom, anxiety, and sensory overload. Especially for women with ADHD, skin picking is a very common way that sometimes stim.
Executive Functioning Challenges
The executive function challenges inherent to ADHD may contribute to our development of body focused repetitive behaviors and definitely exacerbates them. Impulse control, attention regulation, and mood regulation are all executive functions that people with ADHD tend to struggle with. Low impulse control coupled with an anxious mood or boredom and poor attention naturally lead us to engage in automatic repetitive behaviors without realizing it. Low impulse control coupled with sensory challenges and a hyper-focused state, often lead to focused or compulsive repetitive behaviors that are very hard to ignore.
When I’m in a distracted place, I can tear the skin around my fingers to shreds without realizing it. When I’m in an obsessive place, I swear I can feel a difference in sensation of the skin I want to ‘fix’, which is usually around my fingernail. That sensation will drive me to insanity if I can’t bite at the offending area. While sensory processing isn’t necessarily an executive function, the inability to regulate our thoughts around sensations to the point of hyper-fixating on that, certainly involves executive function.
In those moments of sensation hyper-focus, it’s hard to think about anything else but the way that finger feels. I’ve tried wearing gloves and other ways to hide the skin from view but the sensation continues to harass me. The only way I have successfully been able to move past that feeling without destroying my skin is to apply compression in a way that disrupts the sensations. A tight Band-Aid, preferably.
I said it before, I’ll say it again. This hyper-focused place we can get into around skin picking, biting, etc… looks almost identical to the compulsivity inherent to BFRBs.
Sensory Seeking and Cognitive Fatigue
While skin picking is often associated with the need to self sooth during times of anxiety, stress, overwhelm, or overstimulation, for people with ADHD, it can also be the opposite. I’ve often said that ADHD is like living on the edge of a tightrope between being overstimulated and being under-stimulated, overwhelmed or so far beyond bored we want to cry. That under-stimulated, existentially bored place often includes cognitive fatigue that complicates the the whole experience. It leaves us feeling unfocused, hazy, and exhausted.
Skin picking and biting are ways that ADHDers seek sensory input to relieve the discomfort of stimulation deprivation. It helps us feel more alert, distracts from the mental fatigue, and stimulates our tired, bored, overloaded brain.
Related: ADHD and Overwhelmed: How to Stop it In it’s Tracks
Treating ADHD & Skin Picking
Depending on the specific ways your ADHD Skin picking or other BFRB overlap, getting treated for ADHD may also improve your repetitive behavior. ADHD meds help us regulate everything better, which means less of a need to pick or bite at our skin. That’s not always the case, however. If you’ve developed a full blown, primary Excoriation disorder, for instance, your ADHD meds might help but they’re unlikely to stop the behavior. Here are the treatments most recommended for treating skin picking and other body focused repetitive behaviors.
Recommended Therapies
Several therapy models are helpful in treating body focused repetitive behaviors. Namely:
- Cognitive Behavioral Therapy: a type of therapy that relies on changing dysfunctional underlying beliefs as a way to effect positive changes in behavior.
- Habit Reversal Training: a type of behavioral therapy that helps elimminate unwanted behaviors by replacing them with other actions.
- Comprehensive Behavioral Treatment: an evidence based treatment for BFRBs that uses self monitoring and practical strategies to interrupt unwanted behaviors and replace them with healthier alternatives.
- Acceptance and Commitment Therapy: a type of mindfulness based behavioral therapy that emphasizes acceptance of negative thoughts, feelings, symptoms, or circumstances. It encourages increased commitment to healthy, constructive activities that uphold your values or goals.
Recommended Medications
There currently aren’t any medications that are specifically cleared to treat body focused repetitive behaviors. Currently, medications are used ‘off-label’ for treating them. So far therapy has been more effective, but some people require medical intervention before therapeutic work can get very far. In those cases, these medications are the most commonly used:
- Anafranil
- SSRIs such as Zoloft, Lexapro, or Prozac
- Other antidepressant medications including certain Tricyclic Antidepressants and SNRIs
- Naltrexone
- Neuroleptics like Zyprexa and Abilify
- Lithium
- N-acetyl cysteine (NAC)
Self Care Treatments
There are also some strategies you can use on your own to address skin picking, biting, and other BFRBs. They primarily revolve around 1. increasing awareness 2. Identifying and tracking triggers and contributing factors 3. Create need specific strategies to experiment with
Increasing Awareness
The successful treatment of anything begins with increasing your awareness of it. In this case, that’s gathering insight into your most common triggers for skin picking, the function it serves for you, factors that increase your need to engage or complicate your ability to shift away from the behavior, ect…
Of course, paying attention to oneself when you have ADHD can be…difficult. To say the least. Often, our awareness comes in retrospect, when our zoned out brain finally clues into the current moment. When you finally catch yourself picking at your skin, take note of how you’re feeling, what’s happening in your environment, and what it feels like you are getting out of the behavior.
If you are aware of the behavior, struggling in a hyper-fixated, obsessive urge to pick or bite, pay attention to what is drawing you. Is it the need to feel a specific sensation? The need to get rid of one? Is your mind latched on to how it feels, or is your body a life wire needing something to calm it down? Does it feel like you might cry if you stop?
Identifying and Tracking
As you start paying attention to what drives your behavior, write down your observations. I cannot stress that enough. You will forget if you don’t. That’s just ADHD for you. Don’t fall for the ADHD lie ‘it’s fine, I’ll remember.’ You won’t. Your brain is lying to you. Do what I do and create yourself a google doc (or a specific file on your phone, whatever works) where you can put all your observations.
Pay attention to patterns and themes. Does boredom show up a lot in your notes? Does it get worse when you’re sitting still? What activities, environments, or moods are least likely to trigger your skin picking? These kinds of patterns will tell you so much and help you figure out strategies that are more likely to help.
In noticing and tracking my own specific experiences with biting at my fingernails, beds, and cuticles I’ve been able to find a few strategies that do help. (FYI: They haven’t fixed it, I’m still working on that but they’ve helped). By focused observation, I’ve discovered that my biggest triggers are boredom, cognitive fatigue, high stress, and sensory issues.
Create Needs Specific Strategies
Through experimentation with this information, I’ve learned that when biting my skin is related to boredom or fatigue it really helps to have chewing gum, hard candy or something else I can mindlessly fidget with. I’m most likely to engage in bored/tired based skin biting while sitting still: watching tv, listening to a long speech, or sometimes while focusing.
Skin biting related to high stress typically needs a more physical way to let out extra energy and more self soothing coping strategies to help me avoid biting. If I’m stressed and sitting still, I’m almost guaranteed to destroy my fingers unless I have something very soothing and distracting. Coloring has helped a bit. So has journaling and getting exercise.
When it comes to the sensory issues factor, wrapping the offending area in a Band-Aid is the only thing I have found to quell the obsessive urge to bite at my skin. I wrap a fabric Band-Aid around the tip of the finger I’m hyper-fixated on, tight enough that even pressure of it disrupts the sensations I feel lingering on my skin.
Your own experiences may lead to different triggers, factors, and therefore which strategies you will find most effective. Take some time to work on really paying attention to why you pick your skin, what’s happening when you do it, and what it does for you. Then, experiment with different strategies from there.
That’s a Wrap
That’s the connection to ADHD, skin picking and biting, as promised. If you’re tearing at your skin while reading this article, don’t forget to take a minute and pay attention to what you’re feeling and what it’s doing for you. It’s complicated battle and one I haven’t completely won yet, but with the information and strategies listed above, I’m making progress toward stopping and you can too.
In your own struggle with ADHD and skin picking, what have you found that has helped? Drop a comment below; you never know who it might help.
