Skin & Psych: Using Habit Loop Science to Interrupt the Itch-Scratch Cycle

Judson Brewer, MD, PhD, a psychiatrist and neuroscientist at Brown University's Mindfulness Center, joined the Skin & Psych podcast to discuss how principles of habit formation and mindfulness may apply to itch-scratch cycles in dermatologic conditions. Brewer, who serves as director of research and innovation at the center, outlined a framework clinicians can use to help patients recognize habitual responses to stress, anxiety, and itch.

Trigger, Behavior, and Result in Habit Formation

Brewer explained that habits form around 3 key elements: a trigger, a behavior, and a result. In anxiety, for example, feelings of anxiety can trigger worrying, which may provide a temporary sense of control and reinforce the behavior even though worrying does not resolve the underlying problem.

“So any habit is formed with three key elements: a trigger, a behavior, and a result,” said Brewer.

Patricia Delgado, NP, host of the Skin & Psych podcast, presented the example of a performer experiencing stress before a major event. That anxiety could potentially exacerbate eczema, leading to itching along the neck or flexural areas and subsequent scratching. Brewer mapped the habit loop onto the example, identifying stress as the trigger and scratching, along with worrying about the flare, as behaviors that can feed the cycle.

He noted that helping patients recognize that they are caught in such a cycle is an important first step. Mapping the process can transform an experience that feels unpredictable into one patients can begin to understand.

Using Curiosity to Interrupt the Cycle

Rather than instructing patients simply to suppress an urge, Brewer described bringing nonjudgmental awareness to the behavior and asking a counterintuitive question: What am I getting from this?

For worrying, patients may recognize that the behavior does not resolve their anxiety and may actually worsen it. Brewer suggested applying the same process to scratching by encouraging patients to examine what the behavior is actually providing.

“It’s not about judging ourselves and telling ourselves that we shouldn’t worry or we shouldn’t scratch,” said Brewer.

It’s not about judging ourselves and telling ourselves that we shouldn’t worry or we shouldn’t scratch, — Judson Brewer, MD., PhD,

According to Brewer, recognizing that a habitual behavior is less rewarding or helpful than the brain expected creates what is known as a negative prediction error. That mismatch can help patients become less drawn to the behavior rather than relying solely on willpower to resist it.

In a clinical study involving patients with generalized anxiety disorder, Brewer said his team observed a 67% reduction in clinically validated anxiety measures compared with a 14% reduction among patients receiving standard clinical care. He explained that the intervention targeted the habit mechanism by helping patients examine what they were actually getting from worrying.

Brewer emphasized that curiosity can also help patients experience an urge without immediately responding to it. Over time, patients can begin to recognize that urges arise and subside without necessarily requiring an action to make them disappear.

Body Scans and Self-Compassion Build Awareness

Brewer also discussed how clinicians can help patients recognize urges earlier, before they reach peak intensity. He recommended practices such as a body scan, performed before sleep or upon waking, to help patients become more familiar with physical sensations rather than distancing themselves from uncomfortable bodily experiences.

Alongside curiosity, Brewer emphasized kindness and self-compassion. Patients experiencing a flare may respond with frustration or rejection toward their bodies, he explained, whereas self-compassion practices can help them approach those experiences differently.

“I would say two main categories: curiosity and kindness, and they go really well together,” said Brewer.

For patients who struggle to extend compassion toward themselves, Brewer said he sometimes begins by asking them to recall a small act of kindness they received from another person and notice how that experience felt. From there, patients can consider experiences of showing kindness to others before eventually directing that same attitude inward.

Brewer described the process as a virtuous cycle in which practicing kindness toward oneself can, in turn, support greater kindness toward others.

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