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Comprehensive Psychiatry 71 (2016) 77 – 85
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Skin picking in a non-clinical sample of young Polish adults.

Prevalence and characteristics
Katarzyna Prochwicz a,⁎, Alina Kałużna-Wielobób b , Joanna Kłosowska b
a
Institute of Psychology, Jagiellonian University, Krakow, Poland
b
Department of Psychology, Pedagogical University, Krakow, Poland

Abstract

Introduction: The aim of the study was to examine the prevalence and characteristics of skin picking behaviors in a sample of young Polish adults.
Methods: Five hundred and thirty-four participants completed measurements of skin picking frequency and severity. They also
retrospectively rated the intensity of affective states experienced before, during and after skin picking episodes.
Results: In total, 46.07% of the participants endorsed some forms of skin picking, and the prevalence of skin picking disorder (SPD) in the
study sample amounted to 7.67%. The characteristics of skin picking episodes in young Polish adults were similar to those reported in
previous studies conducted on different cultures. The results also showed that for the majority of individuals with skin picking, the intensity
of particular emotions (i.e. fear, anxiety, guilt, shame, self-aversion, boredom, and sadness) decreased significantly in the period from before
to after picking.
Conclusion: Larger community studies are needed to assess the SPD prevalence in Polish general population.
© 2016 Elsevier Inc. All rights reserved.

1. Introduction other important areas of functioning caused by picking. Skin

Picking, digging, and squeezing one's skin are common
human behaviors that in most cases do not reach the level of
pathology. However, some individuals pick their skin so
frequently, intensely, or repetitively that it leads to visible
tissue damage, significant distress, and impaired daily
functioning. Skin picking is considered to be a psychological
disorder in such cases [e.g. 1,2,3].
Skin picking behaviors have been described in the
medical literature since the 19th century [4]; however, skin
picking disorder (SPD) was only recently included in the
fifth edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5) as a distinct psychiatric condition
[5]. According to the DSM-5, the diagnostic criteria of SPD
are recurrent skin picking resulting in skin lesions, repeated
attempts to decrease or stop skin picking, and clinically
significant distress or impairment in social, occupational, or
⁎ Corresponding author at: Institute of Psychology, Jagiellonian Univer-
sity, ul. Ingardena 6, 30-060 Kraków, Poland.
E-mail address: katarzyna.prochwicz@uj.edu.pl (K. Prochwicz).
picking that meets the DSM-5 criteria of SPD cannot be
attributable to the psychological effects of substance abuse or
other medical conditions and cannot be better explained by
the symptoms of another mental disorder [5].
Numerous studies have demonstrated that skin picking
behaviors are quite common in the general population and
occur along a continuum from mild to severe forms. Hayes et
al. [2] examined a community sample of 354 adults in the
United States (US) and found that 62.7% of the participants
reported some form of skin picking; severe skin picking with
associated distress or functional impairments was reported
by 5.4% of the sample. Another large community study by
Keuthen et al. [6] found that the prevalence rate of severe
skin picking was 1.4% among 2513 US adults who were
studied in a telephone survey [6]. Very recently, Leibovici
et al. [7] reported that 5.4% of the Israeli adult population
meets the current diagnostic criteria of SPD.
Previous studies also revealed a relatively high preva-
lence of skin picking among young adults. The prevalence
rate of any form of skin picking behavior was 78.1% in a
sample of university students in a US study [8], and slightly
higher prevalence rates (87.8%) were found in Turkish [1]

http://dx.doi.org/10.1016/j.comppsych.2016.08.013
0010-440X/© 2016 Elsevier Inc. All rights reserved.
78 K. Prochwicz et al. / Comprehensive Psychiatry 71 (2016) 77–85
and in German (91.7%) student populations [9]. Recurrent
skin picking causing distress or significant functional
impairment was reported by 3.8% to 4.2% of students in
the US [8,10]; a similar prevalence rate (4.6%) was found
among students in Germany [9], whereas a Turkey study
reported the occurrence of severe skin picking among 2.04%
of a university sample [1]. More recently, Leibovici et al. [7]
found that 3.03% of Israel university students fulfilled the
diagnostic criteria of SPD, whereas Siddiqui et al. [11]
reported the prevalence rate of SPD in a sample of Pakistan
students as high as 9%. Several studies indicate that there is a
predominance of women among individuals who report
severe skin picking [e.g. 3,12–14]; however, studies on
non-clinical samples have not confirmed that women pick
their skin more frequently than men do [1,9].
Community studies clearly indicate that pathological skin
picking is a universal behavior that occurs in various
countries with similar prevalence. However, detailed anal-
ysis of the data obtained in different surveys indicates that
some characteristics of picking episodes, the factors
triggering picking, and the inclination to seek treatment
may vary across age cohorts and cultures [1,9,11,15–18].
Unfortunately, apart from a few studies [1,7,9,11,16,15],
most of the data about skin picking were gathered from
American adults, and there is a lack of data from other
countries, including European countries. To date, no studies
have examined the prevalence of skin picking behaviors in a
Polish population. Hence, the aim of our study was to fill this
gap by investigating skin picking frequency in a non-clinical
sample of Polish young adults. Since, in Poland, SPD is not
commonly recognized as a psychological disorder, and other
disorders affecting dermatological conditions such as
trichotillomania have already been found to be recognized
and treated inadequately by dermatologists [19], we
expect that Polish young adults with skin picking may differ
from those from other countries in terms of their awareness
of the psychological nature of that behavior, as well as in
terms of the inclination to seek psychological help due to
skin picking.
Our study also investigated the basic characteristics of
skin picking episodes, the effect of skin picking on daily
functioning, and the study participants' inclination to seek
treatment for skin picking. Moreover, we gathered detailed
information about the emotions that are experienced before,
during, and after picking episodes. Our analysis also
examined gender differences in skin picking characteristics.
Given a lack of knowledge on the prevalence in the Polish
sample, our study was exploratory with no specific
hypothesis stated.
2. Methods
2.1. Participants
A total sample of 534 participants took part in the study
voluntarily after providing informed consent. The study was
approved by the local ethics committee. All the respondents
were high school students and university students from various
faculties of the Pedagogical University and the University of
Technology in Krakow, Poland. Of the 534 participants, 356
(66.67%) were women, and 178 (33.33%) were men.
The age of the participants ranged from 16 to 46 years
(mean = 21.33, SD = 3.39). The mean age of the female
participants was 21.28, SD = 3.43 and ranged from 16 to
46 years; the mean age of the male participants was 21.58,
SD = 3.30 and ranged from 16 to 37 years. The male and
female participants did not differ significantly in age
(t (522) = −0.94, p b 0.35, d = 0.08).
The instruments were administered to university students
in groups of 10–60 students during regular classes under the
supervision of a researcher. A scripted introduction describ-
ing the purpose of the study, participants' rights, and
instruction on completing the questionnaires were read out to
the students in each class. Participants were also told that
participation is voluntary and all of their answers would be
confidential. No financial remuneration or course credit was
offered as an incentive to participate.
2.2. Measures
2.2.1. Skin picking checklist
All participants completed a list of items that gathered
detailed information about skin picking behaviors. The list
was composed of questions divided into five parts: (1)
questions concerning the diagnostic criteria of skin picking
disorder (SPD); (2) questions concerning skin picking
characteristics (i.e. skin picking frequency, time spent
picking, body sites that are picked, methods of picking,
and picking triggers); (3) questions concerning the onset of
skin picking (i.e. the age of onset and the circumstances that
accompanied the first picking episodes); (4) questions
concerning the effect of skin picking on family and social
functioning (i.e. the occurrence of skin picking among
family members, the attitude of family members toward the
participant's skin picking, the effect of skin picking on close
relationships, the avoidance of social activity due to skin
picking, and work or school days missed due to picking); and
(5) questions concerning treatment-seeking practices: i.e. the
diagnosis (if any), the type of treatment received for picking,
perceived effectiveness of treatment, the types of profes-
sionals sought for help, and the inclination to seek treatment
in the future. For most of the items, participants were asked
to choose one or more of the listed response options, and
they also could add their own comments; for a few items,
they wrote answers in their own words. Questions concern-
ing DSM-5 criteria were answered using the dichotomous
yes/no scale.
Participants were given a list of emotions and asked to
indicate (yes or no) whether they experienced each emotion
before, during, and after a skin picking episode. They were
also asked when they noticed negative changes in their
appearance that were the consequences of picking.
 K. Prochwicz et al. / Comprehensive Psychiatry 71 (2016) 77–85
2.2.2. Skin Picking Scale (SPS)
The SPS [20] is a self-report scale that assesses the overall
severity of skin picking. The SPS measures six aspects of
picking behaviors during the preceding week: the urge to
pick, picking urge intensity, time spent picking, functioning
impairment caused by picking, distress, and avoidance
caused by picking. Each aspect is rated on a 5-point scale
from 0 (none) to 4 (extreme), resulting in a total score
ranging from 0 to 24 points. The Polish version of the SPS
used in this study was translated into Polish by the authors
using backward translation method. The Cronbach's alpha in
the current study was 0.89.
2.2.3. Skin Picking Impact Scale (SPIS)
The SPIS [21] is a 10-item self-report questionnaire that
assesses the psychological consequences of skin picking.
Participants rate each item on a scale with anchors of 0
(none) and 5 (severe). The SPIS yields total scores rating
from 0 to 50. The Cronbach's alpha of the Polish version of
the SPIS for the study was 0.95. The SPIS was translated into
Polish using backward translation method.
2.2.4. Statistical analysis
The statistical analyses were conducted using the SPSS
version 20. Descriptive statistical methods (mean, SD,
frequency) were used to assess skin picking frequency and
other skin picking characteristics. Student's t-test and the
chi-square test were used to compare gender differences in
skin picking phenomenology. The Cochran Q test and the
McNemar test were used to compare the number of subjects
reporting different emotions before, during, and after skin
picking. A significance level of p b 0.05 (two-tailed) was
used in all the analyses. The number of cases included in the
individual analyses varied as a result of missing data.
3. Results
3.1. Skin picking severity
Of the 534 participants, 246 (46.07%) reported that they
picked their skin at least occasionally during the week before
the study. Among those who confirmed skin picking, 166
(67.48%) were women and 80 (32.52%) were men; the
women did not report picking significantly more frequently
than men (χ 2(1) = 0.03, p b 0.87, Φ = 0.01). Of those who
reported skin picking, 195 (36.52% of the total sample;
79.26% of skin pickers) admitted that they picked their skin
to an extent that it caused visible skin lesions, 133 (24.85%
of the total sample; 54.73% of skin pickers) reported that
they attempted to decrease or stop picking, 29 (5.43% of the
total sample; 11.78% of the skin pickers) confirmed that they
felt significant distress caused by skin picking, and 31
(5.80% of the total sample, 12.60% of the skin pickers)
reported functional impairment due to picking. Women did
not report having skin lesions more often than men did
(χ 2(1) = 0.49, p b 0.48, Φ = 0.05); women also did not differ
from men in attempts to decrease or stop picking (χ 2(1) = 3.64,
79
p b 0.06, Φ = 0.12), distress (χ (1) = 0.74, p b 0.39, Φ =
2
0.05), or functional impairment (χ 2(1) = 0.38, p b 0.54, Φ =
0.04). Of the 42 participants (7.87% of the total sample; 17.07%
of skin pickers) who reported distress or functional impairment
due to skin picking, 1 suffered from a dermatological illness that
caused picking; therefore, 41 of the participants (7.67% of the
total sample; 16.66% of skin pickers) met the current SPD
diagnostic criteria. Among those, 29 (70.73%) were women and
12 (29.26%) were men. Participants with SPD did not differ
from the study sample in terms of age (t(527) = 0.51, p b 0.6,
d = 0.10) or gender (χ 2(1) = 0.26, p b 0.60, Φ = 0.10).
3.2. Skin picking phenomenology
Most of the participants who picked their skin reported
that they spent less than a few minutes a day engaging in
picking behaviors. One half of skin pickers said they picked
less than once a day, one third reported having 1 to 8 picking
episodes per day, and 13 admitted that they picked ‘all the
time’. Forty persons reported that they picked ‘periodically’,
with periods of less frequent and more frequent picking;
thus, they could not estimate the average number of picking
episodes per day (see Table 1 for detailed information).
The most frequently picked body areas were the face,
cuticles around fingers, and the scalp and hands, but numerous
other sites were also picked; women did not pick their faces
more frequently than men did (χ 2(1) = 3.67, p b 0.06, Φ =
0.12). Among the 246 respondents who picked, 188 (76.42%)
admitted that they picked more than one body area.
The most frequently reported cutaneous manifestations
that triggered picking were acne, small scratches, and
pimples. Women reported picking pimples more frequently
than men did (χ 2(1) = 4.58, p b 0.05, Φ = 0.14). The most
common circumstances that triggered current skin picking
episodes were daydreaming, a desire to correct imperfections
in physical appearance, solving problems, and reducing
tension. Nearly all participants who picked their skin (N =
243; 98.78%) reported picking in many different situations
(see Table 2 for detailed information).
Nearly one fourth of the responders with skin picking
reported that they felt as if they had always picked their skin;
thus, they were not able to indicate the particular
circumstances or the age of onset of their picking behaviors.
However, some of them could identify the conditions
associated with the onset of skin picking. The most common
stressors that triggered the first picking episode were the
appearance of acne (more frequently reported by women
(χ 2(1) = 9.52, p b 0.01, Φ = 0.20)) and stressful exams
(see Table 2). In our study, 108 (43.90%) of the participants
who picked their skin reported that they started to pick before
the age of 18; among them, 87 (35.36%) reported that the
onset of skin picking was before the age of 15 years. We did
not observe gender differences in the number of participants
who started to pick before the age of 18 (χ 2(1) = 1.89,
p b 0.17, Φ = 0.09) or before the age of 15 (χ 2(1) = 0.58,
p b 0.45, Φ = 0.05) (see Table 2).
80 K. Prochwicz et al. / Comprehensive Psychiatry 71 (2016) 77–85

Table 1 Table 1 (continued)

Skin picking characteristics. N % of all % of participants
N % of all % of participants participants with skin picking
participants with skin picking Skin picking among family members
Frequency of picking Siblings 54 10.11 21.95
b Once a month 28 5.24 11.38 Parents 31 5.81 12.6
A few times a month 33 6.18 13.41 Aunt 2 0.37 0.81
A few times a week 62 11.61 25.20 Grandmother 2 0.37 0.81
Once a day 35 6.55 14.22 Cousin 1 0.18 0.40
2–5 times a day 35 6.55 14.22 Other 14 2.62 5.69
5–8 times a day 8 1.50 3.25
N8 times a day 7 1.31 2.84
All the time 13 2.43 5.28
Periodically 40 7.50 16.26
Estimated duration of episode 3.3. Affective states associated with skin picking
b A couple of minutes 172 32.20 69.91
A couple of minutes 29 5.43 11.78 Table 3 shows participants' emotional states before,
Half an hour 14 2.62 5.69 during, and after a typical picking episode and compares the
1h 9 1.69 3.65 emotions experienced by men and women at each stage of a
2h 2 0.37 0.81 picking episode. Women more frequently reported feeling
3h 3 0.56 1.21
sadness just before the act of picking (χ 2 (1) = 3.80,
3–5 h 2 0.37 0.81
5–8 h 4 0.75 1.62 p b 0.05, Φ = 0.12), as well as guilt (χ 2 (1) = 7.22,
N8 h 4 0.75 1.62 p b 0.01, Φ = 0.17) and self-aversion (χ 2 (1) = 6.11,
Picking sites p b 0.01, Φ = 0.16). In addition, women experienced fear
Face 165 30.90 67.07 (χ 2(1) = 6.12, p b 0.01, Φ = 0.16), guilt (χ 2(1) = 6.42,
Fingers 149 27.98 60.56
p b 0,01, Φ = 0.16), shame (χ 2(1) = 5.24, p b 0.05, Φ =
Scalp 111 20.79 45.12
Hands 72 13.48 29.26 0.15), sadness ( χ 2 (1) = 6.20, p b 0.01, Φ = 0.16),
Shoulders 65 12.17 26.42
Back 62 11.61 25.20
Arms 56 10.49 22.76 Table 2
Neck 51 9.55 20.73 Triggers of skin picking.
Ears 47 8.80 19.10 Triggers N % of total % of participants
Chest 43 8.05 17.47 sample with skin picking
Toes 39 7.30 15.85
Feet 37 6.93 15.04 Cutaneous
Buttock 25 4.68 10.16 Acne 151 28.28 61.38
Stomach 24 4.49 9.75 Small scratches 126 23.60 51.21
Dry lips 6 1.12 2.43 Pimples 124 23.22 50.40
Legs 3 0.56 1.21 Mosquito bites 89 16.67 36.17
Pubic area 2 0.37 0.81 Healthy skin 69 12.92 28.04
Mark on the skin 1 0.18 0.40 Scars 67 12.55 27.23
Implement used Open sores 44 8.24 17.88
Fingernails 184 34.46 74.79 Other 25 4.68 10.16
Fingers 158 29.59 64.22 Triggers of current episodes
Tweezers 19 3.56 7.72 Daydreaming 243 45.51 98.78
Pins 13 2.43 5.28 Desire to correct appearance 242 45.32 98.37
Teeth 11 2.06 4.47 Solving problems 241 45.13 97.96
Razor blade 2 0.37 0.81 Tension 241 45.13 97.96
Scissors 2 0.37 0.81 Entertainment 239 44.76 97.15
Comb 1 0.18 0.40 Unpleasant physical sensations 238 44.57 96.74
Knife 1 0.18 0.40 Work 237 44.38 96.34
Needle 1 0.18 0.40 Looking in the mirror 174 32.51 70.73
Onset of skin picking Other 149 27.90 60.56
As long as he/she can remember 131 24.53 53.25 Triggers of first episode
Between 6 and10 years old 38 7.12 15.44 Acne 67 12.55 27.23
Between 10 and 15 years old 49 9.18 19.91 Stressful exams 50 9.36 20.32
Between 15 and 18 years old 21 3.93 8.53 Family conflicts 15 2.81 6.09
After 18 years old 11 2.06 4.47 School problems 15 2.81 6.09
Consequences of skin picking Somatic disease 6 1.12 2.43
Avoidance of social situations 15 2.81 6.09 Death of close person 6 1.12 2.43
Skipping school 9 1.69 3.65 Hospitalization 5 0.94 2.03
Problems with fulfilling duties 6 1.12 2.43 Desire to make good impression 3 0.56 1.21
Skipping work 5 0.94 2.03 Relocation 2 0.37 0.81
Problems with finding a job 4 0.75 1.62 Other 42 7.87 17.07
 K. Prochwicz et al. / Comprehensive Psychiatry 71 (2016) 77–85 81

Table 3
Emotions experienced by participants before, during, and after picking episodes.
Emotion Before During After Before/during Before/after During/after
N (% of total sample) Cochran's Q p η 2Q a Pairwaise comparisons (McNemar with
Bonferroni adjustment) – significance level b
Anger 154 (28.84) 121 (22.66) 112 (20.97) 28.64 b0.001 .03 b0.001 b0.001 .759
Happiness 77 (14.42) 67 (12.55) 69 (12.92) 1.81 0.404 .00 - - -
Fear 149 (27.90) 106 (19.85) 77 (14.42) 72.98 b0.001 .07 b0.001 b0.001 b.001
Anxiety 167 (31.27) 123 (23.03) 99 (18.54) 67.88 b0.001 .07 b0.001 b0.001 0.006
Guilt 136 (25.47) 114 (21.35) 108 (20.22) 14.36 0.001 .01 0.006 0.003 1.00
Pleasure 92 (17.23) 108 (20.22) 88 (16.48) 5.36 0.069 .01 - - -
Same 140 (26.22) 111 (20.79) 106 (19.85) 23.91 b0.001 .02 b0.001 b0.001 1.00
Calmness 92 (17.23) 107 (20.04) 105 (19.66) 4.47 0.107 .00 - - -
Self-aversion 114 (21.35) 98 (18.35) 90 (16.85) 9.26 0.010 .01 0.222 0.024 1.00
Arousal 70 (13.11) 64 (11.99) 56 (10.49) 3.60 0.165 .00 - -
Boredom 146 (27.34) 111 (20.79) 82 (15.36) 50 b0.001 .05 b0.001 b0.001 .003
Sadness 119 (22.28) 103 (19.29) 82 (15.36) 18.41 b0.001 .02 0.354 b0.001 .021
Disgust 92 (17.23) 89 (16.67) 81 (15.17) 1.41 0.494 .00 - - -
Tension 227 (42.51) 225 (42.13) 68 (12.73) 270.39 b0.001 .27 1.00 b0.001 b0.001
Satisfaction 83 (15.54) 93 (17.42) 99 (18.54) 3.61 0.164 .00 - - -
a
Maximum corrected measure of effect size for Cochran's Q test.
b
McNemar test was calculated only if Cochran's Q test was significant.

self-aversion (χ 2(1) = 4,67, p b 0,01, Φ = 0.14), and dis-
gust (χ 2(1) = 5.04, p b 0.05, Φ = 0.14) more often than
men did during the act of skin picking. After a skin picking
episode, women more often reported feeling anger (χ 2(1) =
7.23, p b 0,01, Φ = .17), anxiety ( χ 2 (1) = 10.69,
p b 0.001, Φ = 0.21), guilt (χ 2(1) = 9.98, p b 0.01, Φ =
0.20), shame ( χ 2 (1) = 9.35, p b 0.01, Φ = 0.17),
self-aversion (χ 2(1) = 7.06, p b 0.01, Φ = 0.17), sadness
(χ 2(1) = 6.85, p b 0.01, Φ = 0.17), and disgust (χ 2(1) =
5.18, p b 0.05, Φ = 0.15).
The most frequently reported feelings that participants
experienced when they noticed negative changes in their
physical appearance were anger, shame, and guilt. Women
experienced disgust (χ 2(1) = 4.62, p b 0.05, Φ = 0.14),
guilt (χ 2 (1) = 8.63, p b 0.01, Φ = 0.19), self-aversion
(χ 2(1) = 5.38, p b 0.05, Φ = 0.15), and sadness (χ 2(1) =
9.68, p b 0.01, Φ = 0.20) more often than men did.
3.4. Psychological impact
The mean score of participants on the SPIS was 4.07, SD =
8.65 (ranging from 0 to 50), and the mean SPIS score was higher
for women (mean score 4.73, SD = 9.46) than it was for men
(mean score 2.82, SD = 6.61; t(454.109) = 2.67, p b 0.01,
d = 0.23). After excluding the non-pickers from the sample, the
mean score was 8.20 (SD = 10.69), which was still higher for
women (9.22, SD = 11.35) than for men (6.02, SD = 8.79;
t(236) = − 2.16, p b 0.03, d = 0.31). However, when the mean
score was calculated only for those who met the SPD diagnostic
criteria (16.26, SD = 13.16), the gender difference became
non-significant (the mean score for women was 16.96, SD =
14.45; the mean score for men was 10.5, SD = 9.21, t(39) =
1.42, p b 0.16, d = 0.53). We also did not find any gender
differences in regard to impairments in social or occupational
functioning, based on participants' responses to the checklist
(see Table 1).
Of the individuals who pick the skin, 90 (36.58%)
admitted that they have at least one relative who picks their
skin; these family members were predominantly siblings.
Women and men reported having relatives with skin picking
in equal proportions (χ 2(1) = 1.7, p b 0.18, Φ = 0.08).
Participants with and without skin picking family history did
not differ in terms of the skin picking severity measured by
SPS (t(229) = −1.21, p b 0.23, d = 0.16); however, those
who endorsed having relatives with skin picking reported
stronger negative impact of picking behaviors on daily
functioning, which was reflected by higher SPIS scores
(t(229) = −4.46, p b 0.001, d = 0.59).
Among all of those who pick their skin, 160 (65.04%)
confirmed that their relatives were aware of their picking;
however, most of their relatives (N = 90; 36.58%) did not
consider skin picking as an important problem.
Twenty-seven of those who picked their skin (10.97%)
confirmed that the family members tried to support their
effort to stop picking, 17 (6.91%) reported that their relatives
did not understand that they were not able to stop picking,
and 6 (2.43%) reported family conflicts caused by skin
picking. Among those who picked their skin, 34 (13.82%)
reported that family members said they look ugly because of
their skin picking.
3.5. Seeking treatment
When asked about their opinions and experiences related
to skin picking treatment, 240 of the participants (44.94% of
the total sample) reported that skin picking should be treated
by professionals, including 216 who picked their skin. Most
of the skin pickers indicated that skin picking should be
82 K. Prochwicz et al. / Comprehensive Psychiatry 71 (2016) 77–85

Table 4 reported that they believed that they could manage the
Professional help for skin picking a. problem themselves without any help. Of all 246 skin
Question N % of participants pickers, 24 (9.75%) reported that they had received a
with skin picking diagnosis due to their skin picking.
What type of professional should treat skin picking?
Psychiatrist/psychologist 109 44.31
Dermatologist 156 63.41
4. Discussion
Primary care physician 10 4.06
Beautician 26 10.57
Other 1 0.41 The results of our study demonstrated that skin picking is
What type of professional did you contact due to skin picking? a common behavior among young Polish adults. Nearly half
Psychiatrist/psychologist 3 0.12 of the participants (46%) reported some forms of skin
Dermatologist 14 5.69
picking, and 41 (7.67%) of them met the diagnostic criteria
Beautician 7 3.25
Other 1 0.40 for skin picking disorder (SPD) [5]. These results indicate
What was the diagnosis? that the prevalence rate of occasional, non-pathological
Facial acne 8 3.25 forms of picking was lower in our Polish sample than the
Anxiety disorder 1 0.40 prevalence rate found in other student and community
Allergy 1 0.40
samples (62.75–91.7%) [1,2,8,9]. However, the SPD rate
Obsessive-compulsive disorder 1 0.40
Stress disorder 1 0.40 was higher than that reported in previous studies (1.4–5.4%)
Trichotillomania 1 0.40 [1,2,7–10], with the exception of a 9% rate for a university
Do not remember 7 3.25 sample in Pakistan [11]. The particularly high prevalence
What type of treatment was chosen by specialist? rate of SPD in our study may be explained by previous
None 13 5.28
findings indicating that high rates of severe picking are often
Dermatological therapy 10 4.06
Pharmacotherapy 8 3.25 reported by young adults, which probably reflects some
Psychotherapy 3 0.12 developmental phenomenon, i.e. increased impassivity,
Other 6 2.43 brain maturation, increasing stress, or the appearance of
Efficiency of treatment in responders' opinion facial acne [3,10]. However, although our sample included
Very efficient 13 5.28
relatively young participants (i.e. 16 and 17 years old), we
Efficient 11 4.47
Not very efficient 10 4.06 found that the respondents with SPD did not differ in age
Not efficient 7 3.25 from respondents who reported milder forms of picking or
a
Data were reported only for responders who reported skin picking
denied picking their skin. Also, the mean age of our Polish
(N = 246). sample (21.33 years) was similar to the mean age in other
studies of university samples with lower rates of pathological
forms of picking [1,8–10]. Another possible explanation of
the relatively high rate of SPD among young Polish adults is
the self-report method used for gathering data. The lack of a
treated by a dermatologist, but other professionals were also medical examination could have led to an overestimation of
mentioned. Many participants chose more than one profes- pathological forms of picking in the study sample. This
sional (see Table 4). interpretation is also supported by the finding that only
Twenty-seven participants (10.97%; 21 women and 6 20.51% of the participants with SPD sought professional
men (χ 2(1) = 1.32, p b 0.25, Φ = 0.07) who picked their help and received a diagnosis; therefore, it is possible that
skin confirmed that they received treatment for skin picking, individuals who appeared to meet the SPD diagnostic criteria
but only 8 of these persons met the criteria for SPD; might have suffered from other dermatological or psychiatric
therefore, just 20.51% of severe skin pickers had received illnesses, which had not been diagnosed yet.
professional help (see Table 4 for detailed information). We did not observe gender differences in the prevalence
Only 4 people (0.74%) reported that it was difficult to of skin picking; women and men reported both mild forms of
receive treatment for picking. Of the participants who picked skin picking and SPD in equal proportions. We also did not
their skin, 30 (12.19%; 25 women and 5 men, 2.03%) find gender differences regarding attempts to decrease or
(χ 2(1) = 3.56, p b 0.06, Φ = 0.12) said that although they stop picking, distress, or impairment in social functioning
had not sought treatment yet, they did not exclude the caused by picking. These results are consistent with the
possibility of seeking professional help in the future. A total results from other studies of non-clinical samples [1,6,9];
of 168 (65.04%; 105 women, 59 men; χ 2 (1) = 1.47, however, they are inconsistent with studies reporting a
p b 0.22, Φ = 0.08) reported that they were not going to preponderance of women in clinical samples [3,12–14]. The
seek any treatment in the future, and 185 (75.20%; χ 2(1) = higher female to male ratio usually observed in studies of
0.001, p b 0.98, Φ = 0.001) claimed that they were not clinical groups is often attributed to the fact that male skin
seeking help because there was no need for it. Another 64 pickers are underrepresented in patient populations because
participants (26.01%; χ 2(1) = 0.01, p b 0.91, Φ = 0.01) they are less inclined to seek treatment for skin picking.
 K. Prochwicz et al. / Comprehensive Psychiatry 71 (2016) 77–85
Since SPD sufferers in our study were identified on the basis
of self-reports and were not recruited from patients who had
received an SPD diagnosis, we may not have observed a
difference in gender distribution between individuals with
and without SPD. Summing up, our findings seem to be
consistent with previous findings that SPD is equally
distributed among men and women in non-clinical samples.
Nearly 44% of the individuals in our Polish sample who
picked their skin reported that the onset of their skin picking was
before the age of 15 years. It is worth noting that apart from
them, the other 53.25% of participants with skin picking
admitted that they picked their skin ‘as far back as they
remember’, so it is likely that the onset of their skin picking was
also before the age of 15. This implies that 88.61% of individuals
in our sample who reported skin picking started to pick their skin
in the early years of life. These findings are consistent with the
results reported in previous studies that the onset of skin picking
in most individuals occurs before 15 years of age.
Over 18% of participants in our study with skin picking
reported at least one picking episode per day. This shows that
the frequency of picking episodes in our Polish sample was
lower than the frequency reported in similar German (57.9%)
and Turkish (43.6%) university samples [1,9]. In terms of
time spent picking, our results seem to be similar to the
findings reported in previous studies. Most of the responders
with skin picking in our Polish sample (75.34%) reported
spending a few minutes or less per day picking their skin,
and 79.65% spent less than an hour per day engaging in
picking behaviors. Bohne et al. [9] found that 68.45% of
German students spent no more than 10 min per day
picking, whereas 86.5% spent less than 60 min. Keuthen et
al. [8] found that 80.8% of their non-clinical sample of
American students reported picking their skin less than
5 min each day, while 96.2% reported picking their skin no
longer than one hour a day. However, since other studies of
university samples used different time periods to assess the
duration of skin picking episodes, it is difficult to compare
the findings.
Similar to previous studies on clinical and non-clinical
samples [1,3,8,9,12–14,21], we found that the face was the
most common site to be picked. Since our sample was
composed of young adults, this finding could easily be
attributed to the appearance of facial acne during adoles-
cence [9]. Apart from the face, the cuticles around the fingers
were the most frequently mentioned site of skin picking in
our Polish sample, with the frequency ratio of 29.59%,
similar to that reported by American students (28.2%) [8].
Although the cuticles were the second most frequently
picked body area, the frequency of picking the cuticles was
lower than that reported in a German university sample
(52.6%) [9].
Most of the participants in our study picked with
fingernails or fingers, which were reported to be the most
commonly used instruments for picking the skin in previous
studies of clinical [3,12,21] and non-clinical groups [1,8,9].
Only 9.36% of the Polish sample reported using instruments
83
(e.g. tweezers, pins), which is lower than the percentage
reported in other university samples [1,8,9].
The most commonly reported cutaneous triggers of skin
picking in our Polish sample were similar to those identified
in other studies [1,3,8,9,18]. However, it should be noted that
12.92% of the Polish young adults in the study reported
picking at healthy skin, which is a higher rate than that
reported in samples of American students (7.7%) [8] and
Turkish university students (9.8%) [1]; however, it is lower
than the rate found in a German study (18.0%) [9].
Our results are consistent with previous studies, which
revealed that unpleasant tension precedes skin picking
episodes and decreases during the act of picking [22]. This
finding supports the hypothesis that tension reduction is a
common motivation underpinning picking behaviors. How-
ever, it is worth noting that participants in our study reported
a significant reduction in tension only after skin picking,
whereas the tension level during the act of picking was
reported to be as high as it was before a picking episode.
Participants reported changes in various emotional states
during the act of picking, apart from tension reduction. We
found a gradual decrease in fear, anxiety, shame,
self-aversion, boredom, and sadness during the picking
episodes. We also found an immediate decrease in anger and
guilt, which occurred at the beginning of a picking episode.
Participants in our sample also reported feelings of anger,
shame, guilt, anxiety, and self-aversion when they noticed
the negative changes in their physical appearance after
picking episodes; therefore, we can assume that picking may
produce an immediate decrease in unpleasant internal states
and a delayed increase in negative emotions and tension
when skin pickers become aware of the consequences of skin
picking.
The finding of decrease of negative emotions experienced
by participants during skin picking episodes is in line with
the results of previous studies showing that skin picking may
serve as a mechanism of coping with some negative
emotional states, such as fear or anxiety [23]. The
observation that skin picking may decrease the level of
guilt or shame seems to be inconsistent with some previous
observations indicating that these emotional states tend to
increase as a result of picking. However, since guilt and
shame are also related to unpleasant tension, it is likely that
participants' experience of decrease of shame and guilt
reflects their general experience of tension reduction rather
than the experience of decreasing particular emotional states,
including shame and guilt. This assumption is consistent
with the finding that the same group of participants
commonly reported the decrease of unspecified tension
during picking episodes. What is more, since our findings
were based only on self-reports provided retrospectively by
participants, it is likely that they may not adequately
recognize particular emotions experienced before, during,
and after skin picking and that the retrospective nature of the
study may influence the assessments of experienced
emotional states and, consequently, the results.
84 K. Prochwicz et al. / Comprehensive Psychiatry 71 (2016) 77–85
The gender comparisons clearly showed that women
experienced more negative emotions than men did, including
more feelings of disgust, guilt, sadness, and self-aversion
when they recognized the tissue lesions caused by picking.
This gender difference could be caused by the fact that social
expectations related to physical appearance are stronger in
women compared to men; therefore, women may experience
more negative feelings when they notice imperfections on
the surface of the skin, and they are more inclined to remove
these imperfections by picking. For the same reason, women
may experience more negative emotional states when they
notice the negative changes in their appearance caused by
picking. Other possible explanations are that women are
generally more aware of their emotional states, that they
express emotions more readily than men do [24], and that
they use a more diverse vocabulary to describe their
emotions [23–25]. Since our data are based only on
self-reports, we could not exclude the possibility that the
reported gender differences in emotions could be partially
affected by gender differences in the ability to report
emotional states. It is also interesting to note that we did
not find a significant increase in any positive emotional
states (i.e. pleasure, calmness, and satisfaction) as a result of
picking. This finding is inconsistent with the results of
previous studies indicating that pleasure seeking is a
common motivation for picking the skin [8,9,21].
Among the individuals in our study with non-clinical
forms of picking, the psychosocial impact of skin picking
measured by the SPIS was greater in women compared to
men. However, this gender difference disappeared in the
group of respondents who met the SPD diagnostic criteria.
Since women are culturally more inclined to pay attention to
their physical attractiveness, they could perceive the
consequences of mild skin picking on their physical
appearance as being more severe. Seeing that SPD caused
more visible skin lesions than milder forms of picking, all the
SPD sufferers, regardless of their gender, could have
perceived that picking had a severe effect on their quality
of life. The lack of gender differences in the group of
respondents with SPD is consistent with the fact that we
failed to find that women were more likely to avoid social
events or have problems at work or school as a result of skin
picking. It is also noteworthy that the mean score on the SPIS
for SPD sufferers in the Polish sample (16.26) was lower
than the mean score of 27.54 reported by Keuthen et al. [6]
and the mean score reported by Tucker et al. (29.39) [18].
Generally, the data from our Polish sample suggest that skin
picking mildly interferes with daily functioning, with the
effect being greater in the relationship domain.
Only 20.51% of the respondents in our study with skin
picking had sought professional help for picking, which is
lower than that found in some samples of severe skin pickers
[18]. This relatively low rate of participants who were
motivated to seek treatment may be due to the fact that most
of them did not perceive the consequences of skin picking as
being severe. The finding that skin picking only slightly
affected the social and occupational functioning of our
respondents also is consistent with the relatively high rate
(75.20%) of skin pickers who claimed that they were not
going to seek help in the future, since, in their view, there
was no need to do so. It is also interesting in terms of help
seeking to note that one fourth of skin pickers reported that
they were able to manage skin picking themselves. This
could reflect a cultural difference in the reluctance to seek
psychological help between SPD sufferers in our Polish
sample and SPD sufferers from other countries.
This study has several limitations that should be noted.
First, we only used self-administered assessment methods,
and the study sample was not medically examined to
determine whether or not participants suffered from
dermatological or psychiatric disorders; therefore, the
presence of other medical or psychiatric comorbidities may
have inflated the estimation of skin picking rates among
young Polish adults. Since in our study we did not directly
measure the presence of psychopathological symptoms other
than skin picking, we are not able to determine whether
participants reporting skin picking also reveal symptoms of
other psychiatric conditions, which may underlie their
picking. It is likely that among participants reporting
picking, the skin occurrence of body dysmorphic disorder
(BDD) may trigger efforts to improve the physical
appearance, and therefore may trigger skin picking episodes.
This assumption is consistent with the data showing that in
our study, the attempts to correct perceived skin imperfec-
tions were commonly reported to be skin picking trigger.
Since the preoccupation with ‘imagined’ defects in one's
appearance is a common symptom of BDD, the unrecog-
nized BDD comorbidity may also underlie picking among at
least some individuals taking part in our study. Future studies
should employ face-to-face diagnostic interviews and use a
more rigorously selected sample of individuals satisfying the
SPD diagnostic criteria. Second, our results are based only
on self-reports; therefore, the data may not reflect the actual
prevalence of skin picking and the characteristics of skin
pickers (e.g. the emotional states they experience during skin
picking episodes). Third, we gathered data only on the
picking behaviors and emotions of which the participants
were aware and which could be easily verbalized. Moreover,
all the participants rated their behaviors and emotions
retrospectively. Consequently, we recommend that further
research take into account physiological–emotional corre-
lates before, during, and after picking, or at least control for the
general level of emotional awareness and the ability to verbalize
emotional expression by participants. It should also be noted that
our study sample was composed only of young adults, most of
whom were university students; thus, the findings cannot be
generalized to the entire Polish adult population.
In spite of these limitations, our study indicates that skin
picking is a common behavior among young Polish adults
and that equal numbers of females and males engage in both
non-clinical and clinical forms of picking. Although the
characteristics of skin picking episodes are similar to those
 K. Prochwicz et al. / Comprehensive Psychiatry 71 (2016) 77–85
observed in research conducted in other countries, we also
found some differences that may reflect cultural differences.
The main differences detected in the study were the
relatively low ratio of non-clinical skin pickers among
Polish young adults along with the higher prevalence of SPD
and the lack or only little inclination to seek medical help due
to skin picking, accompanied with the widespread belief that
skin picking is a problem with which an individual should
cope alone. Our participants also differ from other
community samples [6,18] in terms of perceived impact of
skin picking on the daily functioning; generally, they
evaluated it as less severe emphasizing its role primarily in
the relationship domain. In terms of skin picking episode
characteristics, we found that the Polish sample differs from
similar student samples in the number of daily skin picking
episodes, which seems to be lower than in most similar
student samples [1,9]; Polish young adults also reported that
they pick with instruments less frequently than individuals
examined in other university countries [1,8,9]. Our results
also confirmed that skin picking behavior leads to a decrease
in some negative emotional states, which supports the
hypothesis that picking is performed to reduce emotional
discomfort.
Conflicts of interest
The authors declare that they have no conflicts of interest
concerning this article.
Role of funding source
None.
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