Excoriation vs. Self-Harm

Skin-picking and nonsuicidal self-injury do overlap in some ways, but because of the causes and consequences of the actions, the behaviors are quite different.

Mental health conditions significantly affect a person’s thoughts, but they regularly influence a person’s behaviors as well. Some people may even cause physical harm to their body due to high stress or a mental health disorder.

Excoriation and self-harm are two ways people injure their bodies. Although these behaviors appear to be similar, they are quite different. For a parent, a concerned loved one or the person engaging in these behaviors, separating excoriation from self-injury is essential.

Excoriation Symptoms and Causes

According to the American Psychiatric Association (APA) in its text the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), excoriation, also known as skin-picking disorder, is a body-focused repetitive behavior. Excoriation disorder symptoms have three distinguishing characteristics:

• The person repetitively picks their skin resulting in sores or wounds
• The person makes frequent attempts to stop their picking behaviors
• The skin-picking creates significant levels of stress or problems with relationships, work or other facets of life

The person may pick anywhere on their body, but the face, arms and hands are the most common spots. People may only pick with their hands or use tools like tweezers and pins to complete the task.

People with excoriation disorder commit a lot of attention to the picking and disposal of their skin. Often, there are elaborate rituals surrounding the process, which can take long periods of time.

The causes of excoriation depend on each person and their situation. In some cases, an intense feeling of tension caused by stressors triggers the urge to pick, while other people pick without realizing they are doing so.

Most people who pick their skin do so in private and have some level of shame around the behavior.

Self-Injury Symptoms and Causes

Whether it’s called self-injury, self-harm or nonsuicidal self-injury, the act of intentionally harming the body is a problematic and potentially dangerous behavior. Nonsuicidal self-injury is not currently a mental health disorder, but it is a condition the APA continues to investigate.

Self-harm is marked by self-inflicting damage to the body that produces bleeding, bruising or pain by:

• Cutting
• Burning
• Stabbing
• Hitting
• Rubbing

Self-harm is not a suicide attempt or a suicidal gesture. It is a negative coping skill aimed at:

• Relieving stress from an unwanted feeling or thought
• Resolving a conflict with a loved one
• Creating an improved mood or thinking pattern

Self-injury symptoms and signs include:

• Poor relationships, unwanted feelings or unwanted thoughts
• Frequent thoughts about self-harm
• Preoccupation with self-injury before the act that is difficult to control

In a person who self-injures, triggers like intense emotions or numbness are too uncomfortable, so self-harm becomes the solution to the problem. It may seem like the causes of self-harm produce the behavior, but it is a lack of coping skills in the individual that sets the action in motion.

Why Skin Picking Disorder Is Not Self-Harm

So, is skin-picking a form of self-harm? No. The DSM-5 specifically states that excoriation disorder should not be diagnosed if the behaviors are better explained by self-injury.

One of the main differences between excoriation vs. self-harm is repetition. Someone with excoriation could absentmindedly pick their skin hundreds or thousands of times per day. Self-harm occurs much less often, and there is always a conscious awareness of the action.

The level of pain is another contrasting point separating skin-picking disorder from self-harm. In self-injury, the behavior is performed to create a feeling of pain, but in excoriation, pain is not a motivating factor.

Treatment Differences

Determining the proper diagnosis of excoriation vs. self-injury is crucial to receiving the best treatment options. Since the conditions have unique contributors and outcomes, the same treatments delivered in the same way may not be effective.

For excoriation disorder treatment, a therapeutic style like habit reversal training (HRT) could be ideal. HRT helps those affected:

• Increase awareness of skin picking behaviors
• Develop a competing routine that will replace picking
• Celebrate periods without picking

Other treatment styles like cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) may also help with excoriation treatment.

Self-harm treatment follows a different path since self-injury is often a symptom of a larger problem like depression, anxiety or borderline personality disorder. Because of this, self-injury treatment tends to focus on the underlying problem contributing to self-harm.

Unlike excoriation treatment, medications may be an important aspect of self-harm treatment to target the source of the symptoms. Therapy for self-injury can also be used to:

• Identify and manage triggers
• Learn new coping skills
• Develop methods to manage uncomfortable emotions
• Boost self-esteem
• Strengthen social skills and communication style

Possible therapy options include CBT and dialectical behavioral therapy (DBT). Self-harm treatment is often undergone on an outpatient basis. Inpatient treatment for self-harm is only needed in situations where the harming behaviors are leading to severe mental or physical health concerns.

Determining excoriation vs. self-harm is complex, so if you have questions about symptoms linked to either condition, call The Recovery Village. The Recovery Village is a treatment provider specializing in helping people with substance use disorders and co-occurring disorders. Our treatment team can help begin your path to recovery.

If you or a loved one are suffering from excoriation, skin-picking, or other nonsuicidal self-injury disorders, the Nobu app might be able to help. It is free and for anyone that is looking to reduce anxiety, work through depression, build self-esteem, get aftercare following treatment, attend teletherapy sessions and so much more. Download the Nobu app today!

Editor – Megan Hull

Megan Hull is a content specialist who edits, writes and ideates content to help people find recovery. Read more

Medically Reviewed By – Eric Patterson, LPC

Eric Patterson is a licensed professional counselor in the Pittsburgh area who is dedicated to helping children, adults, and families meet their treatment goals. Read more