Few things inspire fear in students as reliably as exams. Unless you are one of the happy few who a) have a photographic memory or b) enjoy the thrill of it all (I’m told these people exist), assessments are inherently stressful, and none more so than final university examinations. In my friendship group alone, during Finals, one person developed insomnia, another stopped stomaching solid food, and someone else convinced themselves they’d failed everything. We all had our idiosyncratic ways of coping, ranging from exemplary (exercising often) to mildly concerning (daily ‘crying breaks’). Other strategies were shared, such as trying to get enough sleep. Still others were less visible – and possibly less intentional.
One day, during peak exam season, I walked into the library and was struck by the number of people biting their nails or picking at their skin. I had recently learnt of body-focused repetitive behaviours (BFRBs), a catch-all term for such behaviours which, when they cause damage and impairment or distress despite efforts to stop, warrant a clinical diagnosis (American Psychiatric Association, 2013). One example is skin picking (excoriation) disorder (SPD), which occurs in approximately 3.5% of the general public (Farhat et al., 2023). Despite its widespread nature, little is understood about what causes or maintains SPD (e.g. this blog discusses interoception as a potentially relevant factor). However, in line with my observations in the library, one influential theory views BFRBs including skin-picking as a means to manage emotion (Roberts et al., 2013). Accordingly, a recent systematic review by Barber and Fitzgerald (2025) has explored the relationship between emotion regulation and SPD in more detail.
Body-focused repetitive behaviours, including hair-pulling, skin-picking and nail-biting, have been linked to emotion dysregulation and may be a way for people to manage their feelings.
Methods
The authors searched three databases for published English-language studies that explored whether:
- emotion regulation differed in adult SPD patients compared to healthy controls,
- emotion regulation difficulties predicted SPD severity, or
- the effect of emotion regulation on focused (intentional) compared to automatic (unconscious) picking (Walther et al., 2009).
Participants were adults across the range of SPD severity (i.e., nonclinical, subclinical and clinical levels); phenomena related to emotion regulation (e.g., distress tolerance, experiential avoidance and alexithymia) were also included. The review did not include any grey literature or non-English-language papers; the researchers also did not consult experts in the field, but they did search reference lists for additional relevant studies.
The authors used the JBI Critical Appraisal Checklist (Munn et al., 2023; Porritt et al., 2014) to critically appraise the quality of included studies, which were all reported as high quality.
Results
Nineteen papers were included in the systematic review, with sample sizes ranging from 18-285 participants. Of these, nine studies showed that SPD patients (and BFRB samples in general) had higher levels of emotion dysregulation compared to healthy controls. People with skin picking also:
- Had more trouble understanding (i.e., identifying and describing) their emotions and were less tolerant of psychological distress
- Were less likely to distance themselves from suffering than controls, implying that they may become trapped by difficult emotions that they experience as more intolerable than the general population
- (In one study) exhibited more experiential avoidance (an inclination to avoid emotion-provoking experiences) than those without.
Overall, these studies imply that people with problematic skin-picking may struggle to understand, tolerate and manage their feelings, which could contribute to SPD.
If people with SPD struggle to regulate their emotions, strong feelings could affect their behaviour differently to controls. Accordingly, three studies found that SPD patients struggle to control impulses, pursue goals and cope adaptively when experiencing difficult emotions. In terms of specific strategies, those with skin-picking may be particularly impaired at cognitive reappraisal (thinking differently about the emotional situation) rather than expressive suppression (hiding their feelings), but this finding does not always replicate. There is also some controversy about whether individuals with skin-picking have less emotional awareness, clarity and acceptance than controls, with different studies providing evidence for and against this possibility. Overall, although emotion regulation does seem reliably impaired in SPD, it hence remains uncertain how exactly this deficit manifests in terms of thoughts and actions.
Somewhat surprisingly, although those with and without SPD have different emotion regulation profiles, emotion dysregulation does not reliably correlate with skin-picking or BFRB severity. Studies supporting such a correlation are contradicted by others failing to do so; adding to this confusion, experiential avoidance appears to predict SPD symptoms whilst distress tolerance does not. Furthermore, in terms of specific strategies, skin-picking severity seems completely unrelated to expressive suppression and at best weakly related to cognitive reappraisal. Although emotion regulation may not predict skin-picking in general, five studies revealed that emotion regulation and related constructs consistently predicted focused picking; associations with automatic skin picking were weak or nonsignificant, and associations with emotion regulation strategies were inconclusive. Hence, emotion regulation problems (but not necessarily reappraisal or suppression) may be particularly related to a certain type of skin-picking rather than SPD in general.
Skin-picking patients seem to have trouble understanding, tolerating and regulating emotions, and may struggle to think differently about emotion-provoking events.
Conclusions
Overall, the systematic review supports the role of emotion dysregulation and related factors (e.g., distress tolerance, alexithymia, experiential avoidance) in problematic skin-picking, implying that emotion regulation may play a role in the onset or maintenance of SPD.
These findings align with the emotion regulation model of BFRBs, which views skin-picking as a way for individuals to manage intense emotional states (Roberts et al., 2013).
However, some key questions remain unanswered, including why emotion regulation does not reliably predict SPD severity, how specific emotion regulation strategies relate to skin-picking and whether there is truly a distinction between focused and automatic picking.
Although people with and without skin-picking differ in terms of emotion regulation, the severity of emotion dysregulation is not associated with the severity of skin-picking.
Strengths and limitations
A strength of the systematic review included its comprehensive search strategy spanning three academic databases in addition to citation searching based on the reference lists of available papers. However, the search was restricted to published studies in peer-reviewed journals and may therefore have missed relevant papers. As journals are less likely to publish nonsignificant findings, the review risks overestimating the association between emotion regulation and SPD. As many effects were already quite small, the conclusions made must hence remain tentative.
Future work should mitigate the danger of publication bias by expanding the search to include grey literature. It would also be helpful to consult with experts who may be aware of additional unpublished or currently ongoing work. Including non-English language studies would further improve the comprehensiveness of the review, as we risk missing key studies otherwise.
The authors did, however, use a standardised checklist to evaluate the methodological rigour of included papers and transparently reported the outcomes of this assessment. As all were of sufficiently high quality, we can be confident in their findings. To further improve transparency and openness, the researchers could have provided key statistics and precision estimates for all studies, which would help the reader come to their own independent and fully informed conclusions about the strength of the relationships observed.
The informativeness of any review is largely limited by that of the studies included. Here, most studies were cross-sectional (conducted at one time point), so it is unclear whether emotion regulation predicts skin picking over time or vice versa. Future work should answer this query by following up participants longitudinally. It would also be useful to investigate whether the findings generalise to young people, who were excluded from the current review. Indeed, the sampling strategy of the review may not have been ideal: in addition to skin-picking samples, the authors included patients with BFRBs more broadly. Although we have reasons to believe different BFRBs are not dissimilar (Moritz et al., 2023), it would have been helpful to explore whether emotion regulation patterns differ between these groups.
Although there appears to be a relationship between emotion dysregulation and skin-picking, it is unclear which comes first and whether there is a causal association between the two.
Implications for practice
Although more research is needed to confirm the current findings, the review has important clinical implications. Firstly, if emotion dysregulation contributes to SPD, a promising treatment avenue may involve teaching clients to better manage their emotions. As highlighted by the authors, dialectical behaviour therapy (DBT) and acceptance and commitment therapy (ACT) explicitly target emotional processing and may therefore help to alleviate skin-picking (see this blog for a review of emerging therapies including DBT and ACT). DBT and ACT are currently under-researched in SPD so, before incorporating them into clinical practice, we first need to test whether they effectively reduce symptoms and how they compare to therapies without emotional elements.
Moreover, as people with and without skin-picking reliably differ in terms of emotion regulation, the authors highlighted how emotion processing deficits could help identify people vulnerable to developing SPD. Longitudinal research must confirm whether this is indeed possible; if so, we could provide at-risk individuals with targeted support to prevent problematic skin-picking. Moreover, if improving emotional processing reduces this risk, the findings would support the case for teaching emotion regulation in schools (Hoffmann et al., 2020). Although the evidence base is arguably too preliminary to inform policy at present, the findings hint at potential future interventions which could help reduce the suffering caused by SPD.
The evidence also opens up exciting avenues for future work. Alongside the need for longitudinal studies, it would be interesting to explore whether incorporating emotion regulation skills in therapy for patients with SPD improves outcomes over and above existing treatments. As clients seem particularly impaired at cognitive reappraisal (rather than expressive suppression), future work should first confirm this finding and then compare the effect of targeting different emotion regulation strategies on skin-picking symptoms. Moreover, recent research has questioned the distinction between focused and automatic BFRBs, highlighting that they may not comprise truly distinct subtypes (Grant & Chamberlain, 2021). The field thus first needs to clarify whether it is meaningful to delineate between focused and automatic skin-picking and, if so, establish more conclusively whether emotion dysregulation is particularly central to one of these subtypes.
So, were my fellow students really picking their skin in an attempt to alleviate exam anxiety? Or was I just sensitised to BFRBs, recently having learnt about these behaviours? The former certainly makes for a better story. Unfortunately, though, even if individuals with skin-picking struggle to regulate their emotions, this does not necessarily mean skin-picking helps them to do so. It could even be making things worse. All I can do is wait for more research and hope to be forgiven for spinning this neat and tidy (albeit slightly misleading) anecdote in the interim.
If emotion dysregulation is a factor maintaining skin-picking, building emotion regulation skills in therapy may help to reduce symptoms and alleviate suffering.
Statement of interests
Daisy Cutting has no conflicts of interest to disclose with respect to the content of this blog post.
Edited by
Dr Nina Higson-Sweeney.
Links
Primary paper
Kathryn E. Barber, & Jacklynn M. Fitzgerald. (2025). Emotion regulation deficits in skin picking (excoriation) disorder: A systematic review. Journal of Affective Disorders, 388, 119500. https://doi.org/10.1016/j.jad.2025.119500
Other references
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: DSM-V. American Psychiatric Association.
Farhat, L. C., Reid, M., Bloch, M. H., & Olfson, E. (2023). Prevalence and gender distribution of excoriation (skin-picking) disorder: A systematic review and meta-analysis. Journal of Psychiatric Research, 161, 412–418. https://doi.org/10.1016/j.jpsychires.2023.03.034
Grant, J. E., & Chamberlain, S. R. (2021). Automatic and focused hair pulling in trichotillomania: Valid and useful subtypes? Psychiatry Research, 306, 114269. https://doi.org/10.1016/j.psychres.2021.114269
Hoffmann, J. D., Brackett, M. A., Bailey, C. S., & Willner, C. J. (2020). Teaching emotion regulation in schools: Translating research into practice with the RULER approach to social and emotional learning. Emotion, 20(1), 105–109. https://doi.org/10.1037/emo0000649
Isibor, M., & Higson-Sweeney, N. (2025). Inside the urge: Interoception, affective touch, and the emerging science of skin-picking disorder. The Mental Elf.
Munn, Z., Stone, J.C., Aromataris, E., Klugar, M., Sears, K., Leonardi-Bee, J., Barker, T.H. (2023). Assessing the risk of bias of quantitative analytical studies: Introducing the vision for critical appraisal within JBI systematic reviews. JBI Evidence Synthesis, 21(3), 467–471. https://doi.org/10.11124/jbies-22-00224.
Moritz, S., Penney, D., Mißmann, F., Snorrason, I., & Schmotz, S. (2023). Same but different? Phenomenological differences among various types of body-focused repetitive behaviors. Annals of Clinical Psychiatry, 35(4), 252–259. https://doi.org/10.12788/acp.0123
Porritt, K., Gomersall, J., Lockwood, C., 2014. JBI’S systematic reviews: Study selection and critical appraisal. American Journal of Nursing, 114(6), 47–52. https://doi.org/10.1097/01
Roberts, S., O’Connor, K., & Bélanger, C. (2013). Emotion regulation and other psychological models for body-focused repetitive behaviors. Clinical Psychology Review, 33(6), 745–762. https://doi.org/10.1016/j.cpr.2013.05.004n
Sampson, C. (2018). Is third-wave CBT good value?. The Mental Elf.
Walther, M. R., Flessner, C. A., Conelea, C. A., & Woods, D. W. (2009). The Milwaukee Inventory for the Dimensions of Adult Skin Picking (MIDAS): Initial development and psychometric properties. Journal of Behavior Therapy and Experimental Psychiatry, 40(1), 127–135. https://doi.org/10.1016/j.jbtep.2008.07.002