For most of us, the skin is simply a boundary – a barrier between us and the world. But for those who live with body-focused repetitive behaviours (BFRBs) such as skin-picking, hair-pulling, or nail-biting, the skin can become the very site of emotional struggle.
BFRBs are a group of conditions characterised by repetitive and hard-to-control picking, pulling, biting, or otherwise manipulating the body resulting in damage to the tissue. BFRBs are often misunderstood as a ‘bad habit’, despite being recognised as part of the spectrum of obsessive–compulsive and related disorders (American Psychiatric Association, 2013). BFRBs affect an estimated 2-5% of people (Snorrason et al., 2012) and are associated with shame, emotional dysregulation, and considerable functional impairment. Yet we still know relatively little about the mechanisms that keep these behaviours going or how they relate to the way individuals experience their bodies.
Interoception – our ability to sense internal bodily signals such as heartbeat, tension or discomfort – has recently gained attention as a potential factor in conditions involving emotion-regulation difficulties (Khalsa et al., 2018). This includes emerging work on affective (C-tactile) touch, which plays a role in calming and social-emotional processing (McGlone et al., 2014). In skin-picking disorder (SPD), individuals often report urges, discomfort or “not-just-right” sensations preceding picking episodes, and relief or grounding afterwards (Snorrason et al., 2010). These observations have prompted researchers to explore whether interoception, including affective touch, may play a role in the onset, maintenance or regulation of BFRBs.
In this blog, we summarise and critically evaluate a recent systematic review by Kłosowska et al. (2025), which synthesises the small but growing evidence base on interoception in SPD. We also reflect on what these findings might mean for practice and for people living with BFRBs.
What is the role of bodily sensations and affective touch in relation to skin-picking disorder? This systematic review synthesises the evidence in relation to how we interpret internal bodily signals.
Methods
Five databases were searched using terms relating to skin-picking disorder (SPD) and interoception to identify quantitative studies exploring how people with SPD sense and interpret bodily signals. Articles were included if they were peer-reviewed, published in English, included a validated measure of at least one aspect of interoception (a modality or a dimension), and included a validated measure or DSM-5/ICD-11 diagnosis of SPD. Grey literature was excluded, as well as studies that explored skin-picking in the context of a different condition. Backward and forward citation chasing was also used to ensure that relevant studies were not missed.
Identified articles were double screened by two researchers, before relevant data was extracted. To account for the heterogeneity of study designs and measures, the team assessed methodological quality using the Mixed Methods Appraisal Tool criteria.
Results
Nine articles based on eight different samples were included in this systematic review, with data from a total of 1,338 participants. The majority of participants were female, with mean ages ranging from 23.87 to 34.32 years. Most studies compared individuals with skin-picking disorder (SPD) or SPD symptoms to healthy controls. Five studies were quasi-experimental, one was a randomised controlled trial, one used an intensive longitudinal design, and one was cross-sectional.
Several different interoceptive modalities were explored in relation to SPD, including:
- Visceral signals: One study found that in comparison to healthy controls, individuals with SPD symptoms showed significantly lower cardiac interoceptive accuracy after controlling for potential confounders. They also found that higher interoceptive accuracy in the SPD group was associated with a lower likelihood of skin-picking during the next measurement period (OR = 0.10, 95% CI [0.02 to 0.44], p = .002).
- Affective touch: Out of four articles based on three studies, one found a positive moderate correlation between skin-picking urges during affective (C-tactile) touch and SPD symptom severity, and two found that individuals with SPD rated touch (C-tactile and non-C-tactile) as significantly less pleasant and more arousing , with a higher urge to skin-pick in response to touch. An experimental study also found that the severity of SPD symptoms decreased from baseline to post-training after receiving either Soft Touch Training or Progressive Muscle Relaxation.
- Pain: Three studies explored altered pain processing in individuals with SPD. Two studies found no significant differences in pain tolerance between individuals with SPD and healthy controls and between individuals with SPD, trichotillomania, or healthy controls. A final study found that individuals with moderate or high SPD symptoms reported significantly less positive affect and greater arousal from electrocutaneous pulses in comparison to healthy controls, but there were still no significant differences in pain scores.
- Itch: One study found that individuals with SPD reported a significantly higher urge to itch in response to itch-related and picking-related stimuli in comparison to healthy controls, as well as a higher urge to pick in response to itch-related stimuli.
One further study investigated interoceptive sensibility, which is an individual’s perceived sensitivity to bodily sensation. They found that participants with SPD had lower emotional awareness scores in comparison to healthy controls, and that higher body listening scores were associated with reduced perceived control over skin-picking episodes in the next measurement period. This was the only included study that explored an interoceptive dimension rather than a modality.
Across nine studies, there appears to be an emerging pattern between disturbances in interoception (the interpretation of internal bodily signals) and skin-picking behaviours in individuals with Skin Picking Disorder.
Conclusions
Based on the findings from this systematic review, Kłosowska and colleagues conclude that there is preliminary evidence to indicate a relationship between skin-picking and disrupted interoception, highlighting a potential mechanism that could contribute to or help maintain SPD. However, with only nine articles identified, nothing is conclusive and much more research is required. As the authors state:
Firm clinical recommendations cannot yet be made […] advancing research on interoceptive processes in skin-picking disorder (SPD) could facilitate the development of novel interventions, addressing the current scarcity of available treatments.
While the findings of this systematic review highlight an interesting area future intervention, much further research on interoception in Skin Picking Disorder is required before this can be explored.
Strengths and limitations
There are several strengths to this systematic review, including the fact that it is the first systematic synthesis of interoception in skin-picking disorder (SPD), mapping out a highly under-explored area and offering a clear overview of what is currently known. This endeavour is helpful for clinicians and researchers in understanding what the current evidence-base is, and what gaps in knowledge remain. A rigorous methodology was also used, with the protocol pre-registered and the review reported according to PRISMA guidelines, which aids methodological transparency and the reliability of the data. The authors used a well-known, broad definition of interoception that captured multiple dimensions, which increases the likelihood that all relevant studies were identified and included. Finally, most studies were rated as having a relatively low risk of bias, increasing the reliability of the findings; however, there were queries in relation to selection, reporting, and omitted-variable bias.
However, there are limitations to the review itself and the included studies. First, the evidence base is extremely small, including nine articles conducted by four different research groups. Not only does this mean that there are limits to the statistical power of these findings and generalisability, but there is also the potential for investigator bias, which the authors acknowledge; however, this is often unavoidable in such an under-researched area. Furthermore, it is difficult to directly compare the different studies as there was a lot of methodological heterogeneity, which is why a meta-analysis was not conducted. This reduces the reliability of the conclusions drawn, hence why the authors are so tentative. Finally, the exclusion of grey literature could mean that relevant research was not included, such as studies that are currently under peer-review and have not yet been published. In a few years’ time, it could be interesting to undertake an updated systematic review to see how much the evidence base has expanded.
As the very first systematic review investigating interoception in relation to Skin Picking Disorder, this paper helpfully maps the current evidence base for researchers and clinicians. However, with small sample sizes and high heterogeneity, findings are still preliminary.
Implications for practice
Given the early stages of this evidence, any clinical implications from this systematic review should be drawn cautiously. However, there are some interesting areas for future consideration, including:
- Exploring bodily cues as part of assessment: For some individuals with skin-picking disorder (SPD), bodily sensations may precede skin-picking episodes. Clinicians might gently explore these sensations as part of a broader formulation, without assuming they operate in the same way for everyone.
- Supporting emotion regulation and body awareness: Given wider support for the theory that skin-picking is associated with emotional regulation (Khalsa et al., 2018) and the finding from one study in this review that individuals with SPD demonstrate lower emotional awareness, clinicians could consider interventions that strengthen emotion regulation or safe, compassionate body awareness. However, studies have yet to test interoception-focused interventions for SPD directly, meaning such approaches should be considered exploratory rather than evidence-based.
- Affective touch as a potential future area of interest: Preliminary findings on affective touch raise interesting questions about sensory comfort and dysregulation in SPD. While these results are too limited to inform clinical interventions, they highlight the potential importance of sensory factors in understanding how individuals soothe or regulate internal states.
- Trauma- and neurodiversity-informed practice: Some people with SPD may have heightened sensitivity to sensory cues or discomfort with interpersonal touch. Where relevant, clinicians may consider a trauma- and neurodiversity-informed approach, beginning with client-led exploration of sensations and ensuring any strategies involving touch prioritise consent, comfort and emotional safety.
For me (Marta), as both a researcher and lived-experience advocate, the findings from this systematic review feel deeply validating. For years, attachment-based and emotion-regulation models of BFRBs have been overshadowed by behavioural and neurobiological explanations. Yet the emerging science of interoception and affective touch offers a language many of us recognise intuitively — safety, connection, and relief through the skin. Our earliest experiences of care are communicated through touch, and empirical work increasingly supports this link: insecure attachment predicts altered sensitivity to affective touch (Krahé et al., 2018) and higher BFRB severity (Isibor, 2025; Shen, 2024). Although preliminary, this suggests that touch and attachment form a shared sensory–emotional system that underpins how we regulate distress. Seeing interoception and affective-touch research highlight these same pathways, brings both scientific validation and personal recognition.
These findings also resonate with my clinical work and my role as a parent of neurodivergent children. I see daily how sensory experiences shape emotional regulation; sometimes soothing, sometimes overwhelming. For some people with SPD, bodily cues such as tension, irritation, or a “build-up” of discomfort precede picking; for others, touch itself can be dysregulating. Trauma histories, sensory sensitivities, and neurodiversity can all influence how the body is felt and how safety is signalled. This means that any future sensory-based approaches must remain client-led, gentle, optional, and grounded in consent.
Overall, these findings invite cautious optimism. The evidence is not yet strong enough to guide clinical practice, but it encourages curiosity about the body’s role in self-soothing. Beneath many repetitive behaviours may lie a body trying to regulate itself; and the skin, far from being the enemy, could be part of the solution.
While further research is needed before interventions targeting interoception can be considered for skin-picking, these findings provide food for thought regarding the role of emotional regulation and body awareness within practice.
Statement of interests
Marta has lived experience of Body-Focused Repetitive Behaviours and has co-authored research in this area. She is also involved in advocacy and psychoeducational work relating to BFRBs. No other conflicts of interest to declare.
Marta used AI assistance (OpenAI GPT-5) for structuring this blog. All writing and reflections are her own.
Edited by
Dr Nina Higson-Sweeney.
Links
Primary paper
Kłosowska, J., Żegleń, M., Badzińska, J., & Prochwicz, K. (2025). Interoception abnormalities and skin-picking disorder: Systematic review and narrative synthesis of preliminary evidence. Neuroscience & Biobehavioral Reviews, 106349. https://doi.org/10.1016/j.neubiorev.2025.106349
Other references
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Isibor, M. (2025). Emotion regulation as a mediator of the association between attachment security and skin-picking disorder symptom severity. Attachment: New Directions in Psychotherapy and Relational Psychoanalysis, 19(1), 54–69. https://doi.org/10.33212/att.v19n1.2025.54
Khalsa, S. S., Adolphs, R., Cameron, O. G., Davenport, P. W., Feinstein, J. S., Feusner, J. D., … Zucker, N. (2018). Interoception and mental health: A roadmap. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 3(6), 501–513. https://doi.org/10.1016/j.bpsc.2017.12.004
Krahé, C., von Mohr, M., Gentsch, A., Guy, L., Vari, C., Nolte, T., & Fotopoulou, A. (2018). Sensitivity to CT-optimal, affective touch depends on adult attachment style. Scientific Reports, 8(1), 14544. https://doi.org/10.1038/s41598-018-32865-6
McGlone, F., Wessberg, J., & Olausson, H. (2014). Discriminative and affective touch: Sensing and feeling. Neuron, 82(4), 737–755. https://doi.org/10.1016/j.neuron.2014.05.001
Shen, T. (2024). A correlation study of attachment and body-focused repetitive behaviour in non-treatment-seeking people. Lecture Notes in Education Psychology and Public Media, 47. https://doi.org/10.54254/2753-7048/47/20240894
Snorrason, I., Belleau, E. L., & Woods, D. W. (2012). How related are hair pulling disorder (trichotillomania) and skin picking disorder? A review of evidence for comorbidity, similarities and shared etiology. Clinical Psychology Review, 32(7), 618-629. https://doi.org/10.1016/j.cpr.2012.05.008
Snorrason, Í., Smári, J., & Olafsson, R. P. (2010). Emotion regulation in pathological skin picking: Findings from a non-treatment seeking sample. Journal of Behavior Therapy and Experimental Psychiatry, 41(3), 238-245. https://doi.org/10.1016/j.jbtep.2010.01.009
