Compulsive Skin Picking in Anorexia Nervosa: A Qualitative Study of Emotional and Interoceptive Dysregulation

Background: Body-focused repetitive behaviors (BFRB), including compulsive skin picking, are observed in patients with anorexia nervosa (AN). However, their functional significance remains unclear. AN is characterized by chronic energy restriction and altered interoceptive processing, which may contribute to persistent internal tension beyond overt eating symptoms. This study aimed to explore the functional meaning of compulsive skin picking as a potential behavioral marker of emotional and interoceptive dysregulation relevant to clinical assessment and treatment planning. Methods: A qualitative descriptive study was conducted among 33 hospitalized patients with AN who reported recurrent skin picking leading to tissue damage. Patients were undergoing structured nutritional rehabilitation. Individual semi-structured interviews were performed. Results: Patients with AN described a consistent emotional and physiological sequence preceding skin picking: increased internal tension followed by short-term relief and subsequent self-directed negative emotions. Episodes occurred in contexts of emotional overload, understimulation, reduced emotional awareness, and, in some cases, hunger- or meal-related stress. Participants described the behavior as partly intentional, serving to reduce tension, but at times occurring almost automatically. It was closely connected with eating-related anxiety and dissatisfaction with the body. Conclusions: The findings indicate that compulsive skin picking in AN may reflect underlying emotional and interoceptive instability, instead of being an unrelated co-occurring symptom. In the broader context of chronic energy restriction, such behaviors may reflect attempts to modulate internally generated physiological arousal. Incorporating routine assessment of BFRB into clinical practice could improve the identification of ongoing emotional instability and support more coordinated multidisciplinary care. Future studies combining qualitative insights with physiological measures would help clarify the mechanisms underlying this association.