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Acceptance-Enhanced Behavior Therapy for Excoriation (Skin-Picking) Disorder in Adults: A Clinical Case Series
Abstract
Excoriation disorder (ExD) involves habitual skin picking that causes significant tissue damage and psychosocial impairment. ExD is largely understudied, and efficacious treatments have yet to be established. Preliminary evidence suggests that habit reversal is a promising intervention for ExD and that acceptance and commitment therapy (ACT) techniques may further enhance the efficacy of habit reversal. This report details treatment of ExD in four adults using a combination of habit reversal and ACT, termed acceptance-enhanced behavior therapy (AEBT). Three of four patients experienced a clear decrease in ExD symptoms from pretreatment to posttreatment. Clinical considerations and directions for future research are discussed.
... Trichotillomania and skin picking are body-focused repetitive behaviors (BFRBs) that are chronically undertreated disorders despite the severity of their impact on the individual (Capriotti et al., 2015;Walther et al, 2010). Trichotillomania is characterized by repetitive hair pulling that leads to notable hair loss and negatively impacts various domains of functioning (American Psychiatric Association [APA], 2013). ...
... Given the impact of trichotillomania and skin picking, there has been an increase in intervention research in this area over the last two decades. Most of this work has been on trichotillomania (e.g., Keuthen et al., 2012;Lee, Homan, et al., 2018a, b;Twohig et al., 2021), but numerous studies have also been conducted for skin picking (e.g., Capriotti et al., 2015). These interventions include acceptanceenhanced behavior therapy (AEBT; Capriotti et al., 2015;Twohig et al., 2021), habit reversal training (HRT; Lochner et al., 2017;Teng et al., 2016), and dialectical behavior therapy (DBT; Keuthen et al., 2012). ...
... Most of this work has been on trichotillomania (e.g., Keuthen et al., 2012;Lee, Homan, et al., 2018a, b;Twohig et al., 2021), but numerous studies have also been conducted for skin picking (e.g., Capriotti et al., 2015). These interventions include acceptanceenhanced behavior therapy (AEBT; Capriotti et al., 2015;Twohig et al., 2021), habit reversal training (HRT; Lochner et al., 2017;Teng et al., 2016), and dialectical behavior therapy (DBT; Keuthen et al., 2012). Additionally, intervention research has included pharmacotherapies, but these have often demonstrated conflicting results and have yielded less robust outcomes than psychotherapies (Jones et al., 2018). ...
Background
In 2006, Marcks and colleagues assessed healthcare providers’ knowledge of trichotillomania and its treatment and found a general lack of knowledge of trichotillomania and limited experience in providing treatment. Due to growth in knowledge of and treatments for trichotillomania, we aimed to replicate Marcks and colleagues’ study and extend it to include skin picking.
Methods
In this study, all licensed mental health providers (e.g., social workers, psychologists; N = 329) in Utah were contacted via email to complete an online survey assessing knowledge and treatment of trichotillomania and skin picking.
Results
Approximately half of participants had never treated a client for trichotillomania or skin picking. Participants had largely outdated or inaccurate knowledge of diagnostic criteria for trichotillomania and skin picking, and inaccurately identified evidence-based treatments (e.g., 30% noted psychoanalysis and 25% noted hypnosis as effective Participants reported feeling that their training had not prepared them to treat either disorder and expressed interest in additional education.
Conclusions
Provider knowledge of trichotillomania and skin picking remains limited, and a need for enhanced education and training on these disorders exists. Providers indicated interest in training opportunities (e.g., workshops on diagnosis and evidence-based treatments). Implications of these findings and future directions are discussed.
... Individuals who skin pick often display elevated stress responses to normal stimuli (Lang et al., 2010), and skin picking appears to temporarily sooth such stress. Additionally, obsessive thoughts about skin imperfections and anxiety over not picking can be temporarily relieved by completing the behaviors (Capriotti, Ely, Snorrason, & Woods, 2015). As such, there is a behavioral component-in addition to the genetic and biological components of the disorder-that must be considered when understanding the etiology, assessment, diagnosis and treatment of excoriation disorder. ...
... Nonsuicidal self-injury is typically motivated by negative thoughts or feelings about the self in relation to others, and bodily harm provides a feeling of relief or euphoria (APA, 2013;Shapiro, 2008). Conversely, excoriation disorder is an obsessive-compulsive and related disorder and is more ritualistic; unwanted thoughts and feelings are directly related to bumps or certain types of scabs on the body, and clients have a routine related to removal (e.g., examining, picking) and disposal (e.g., playing with or eating) of such bumps or scabs (APA, 2013;Capriotti et al., 2015;Walther et al., 2009). ...
... Unfortunately, many providers fail to use evidencebased treatment approaches in their work with this population (Tucker et al., 2011). A relatively small number of randomized controlled treatment studies have been conducted on this population; however, the most evidence-based approaches include cognitive behavioral therapy, habit reversal training and pharmacotherapy (Capriotti et al., 2015;Kress & Paylo, 2015). ...
... However, previous literature has not yet considered the treatment of dermatillomania systemically, warranting further research. Furthermore, alternative interventions, including acceptance and commitment therapy (ACT) and acceptance-enhanced behaviour therapy (AEBT), which combines acceptance commitment therapy and HRT, have also shown promise (Asplund et al., 2021;Capriotti et al., 2015;Flessner et al., 2008;Twohig et al., 2006). Thus, future research could include moderation analyses to identify if patient subgroups (e.g. ...
Dermatillomania is characterised by repetitive skin picking, resulting in tissue damage and significant distress and/or functional impairment. Cognitive behavioural therapy (CBT) is the recommended psychological intervention for dermatillomania in clinical guidelines, with the evidence base also supporting habit reversal training (HRT) as part of CBT. However, research evaluating CBT and HRT for dermatillomania remains scarce. This case study describes a young woman with dermatillomania, in the context of co-morbid anxiety and low mood, treated with 20 sessions of CBT including HRT in a community setting. Guided by her formulation, additional techniques such as those fostering self-compassion were also integrated, and sociocultural factors were adapted for. Improvements were reported in client-centred goals and outcomes of global psychological distress, functioning, anxiety and symptoms and psychosocial impacts of skin picking. The intervention was well received by the client. Limitations as well as clinical practice implications and research recommendations for dermatillomania are discussed.
Key learning aims
• (1) To understand using CBT, including HRT, to treat a case of dermatillomania in the context of anxiety and depression.
• (2) To use a formulation-driven approach to guide the intervention.
• (3) To consider adapting interventions for sociocultural factors.
... Research into the impact of skin picking is almost exclusively quantitative, which limits our knowledge of patients' experiences considerably as it cannot represent the nuances of individual voices, emotions, and perspectives (Anderson & Clarke, 2019). Few qualitative studies have investigated treatment interventions (e.g., Capriotti et al., 2015) or clinical characteristics of skin picking (e.g., Odlaug & Grant, 2008). Some single-case studies have focused on the patient's emotional experience (Martinson et al., 2011). ...
Skin picking disorder (SPD) is a body-focused repetitive behavior recently added to the DSM-V. It mainly affects women, with a prevalence ranging from 1.5 to 5.4%. Picking causes skin lesions that can lead to serious infections and permanent skin problems, usually on the face, scalp, arms, and legs. The behavior impairs quality of life and is associated with psychological distress and difficulties in managing emotions. The disorder causes social embarrassment, leading to avoidance and social withdrawal. As the literature on the perspectives of people with SPD is limited, our research aimed to analyze the meanings they attribute to the behavior and its consequences. A second aim was to explore how interacting with an online community can affect the management of the condition. Using a qualitative descriptive approach, we interviewed twenty-one Italian women (aged 18–50) who self-identified as having SPD and were recruited through an online forum dedicated to the disorder. Three themes framed our analysis: “A stick in the wheel of everyday life,” “Other people’s eyes make you realize what you are doing is wrong,” and “The struggling search for control.” These themes highlight the impact of SPD on different areas of life, the difficulties in accessing competent healthcare providers, the stigma experienced by participants, and the usefulness of the online group on an informative, emotional, and social level. A better understanding of these patients’ perspectives can be useful for those providing professional care and those planning services for them in a Health Co-Inquiry approach that values patients’ activation.
... This class may be particularly amenable to acceptance-enhanced behavior therapy (AEBT), which is designed to address emotion dysregulation deficits that are not traditionally addressed by HRT (Franklin et al., 2023). AEBT has shown promise in a number of studies with CSP (Capriotti et al., 2015;Flessner et al., 2008)C and recently was supported in a randomized controlled for trichotillomania, which shares phenomenology with CSP (Woods et al., 2022). In contrast, Class 5 showed very broad dysregulation; it too may be amenable to AEBT, or it may ...
Background
While behavioral treatment for compulsive skin picking (CSP) is frequently effective, treatment response is often incomplete. This may be due in part to heterogeneity in symptom presentations, where certain patient subgroups may not have symptoms that conform to models of CSP that are used to design interventions. To investigate the problem, we used data-driven approaches to parse apart heterogeneity and identify specific subgroups of individuals who experience CSP. These subgroups were defined based on emotions experienced before and after picking episodes.
Methods
We applied latent class analysis to a large sample of participants who enrolled in an online treatment program for CSP (N = 1,636). During treatment, participants recorded their emotions before and after picking episodes, as well as a number of cognitive, behavioral, clinical, and situational variables associated with picking episodes.
Results
We identified five subgroups of individuals based on their emotional response patterns. Several subgroups followed traditional conceptualizations of CSP, including patterns that were consistent with CSP as a reinforcing emotion regulation strategy. An additional unexpected subgroup showed very strong emotional activation before and after picking episodes, where individuals may have experienced strong emotions before picking episodes that were not modified by picking behavior.
Conclusions
Using advanced data collection and analytic procedures, we identified emotional response patterns associated with specific subgroups of individuals who experience CSP. This information can be used to improve future intervention design and personalize treatment to specific presentations of CSP.
... Patients' initial intentions are not selfharm but instead a quest for improving appearance. 14 , [16][17][18] ...
Dermatologists are often the first to treat the medical consequences of body-focused repetitive behaviors (BFRBs) such as hair pulling, skin picking, and others. BFRBs are still under-recognized, and effectiveness of treatments is known only in limited circles. Patients exhibit varied presentations of BFRBs and repeatedly engage in these despite the physical and functional impairments. Dermatologists are uniquely placed to guide patients lacking knowledge about BFRBs and experiencing stigma, shame, and isolation. We provide an overview of the current understanding of the nature and management of BFRBs. Clinical suggestions for diagnosing and educating patients about their BFRBs and resources for patients to seek support are shared. Most importantly, with patients' readiness for change, dermatologists can guide patients towards specific resources for self-monitoring their ABC (Antecedents, Behaviors, Consequences) cycles of BFRBs and recommend specialized treatment options.
... 9,10 ED is also different from non-suicidal self-harm due to the focus on the removal (inspection/picking) and disposal (playing with/eating) of the skin lesion or scab. 11 The action may be an automated habit occurring with little awareness, or it may be done compulsively in order to relieve mounting anxiety. 3,9 Typically, intrusive thoughts or urges result in the act of skin picking and the picking temporarily relieves the mental discomfort. ...
Skin‐centered body dysmorphic disorder (BDD) and excoriation disorder (ED) are categorized under Obsessive Compulsive and Related Disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5) and are characterized by excessive or inappropriate skin picking. Patients with skin‐centered BDD and ED often first present to dermatology. These conditions are important to recognize and appropriately diagnose, as perpetuation of the disorder is inevitable without appropriate psychiatric treatment. These conditions are associated with increased morbidity and BDD is associated with increased suicide risk. This review aims to present a combined dermatologic and psychiatric approach to diagnosing, differentiating, and managing skin‐centered BDD and ED. Patient presentation, DSM‐5 criteria, and management approaches are reviewed.
This article is protected by copyright. All rights reserved.
... However, research on interventions for skin picking disorder has been very scarce until now. A limited number of studies have investigated pharmacological and behavioral interventions [12], including habit reversal training [13,14], acceptance and commitment therapy [15], cognitive-behavior therapy (CBT) [16,17], and combined approaches (eg, acceptance-enhanced CBT) [18,19]. Noteworthy, most of these previous studies showed severe methodological shortcomings (eg, small sample sizes, lack of control conditions), and most were conducted before the official DSM-5 criteria for skin picking disorder became available. ...
Background:
In spite of the psychosocial burden and medical risks associated with skin picking disorder, the health care system does not provide sufficient treatment for affected individuals to date. Therefore, an internet-based self-help program for skin picking was developed to offer easily accessible support for this population.
Objective:
This pilot study evaluated the internet-based self-help program SaveMySkin. The 12-week program is based on cognitive-behavioral therapy and contains comprehensive information and exercises, a daily supportive monitoring system, and dermatological and psychological counseling via internet chat. Primary objectives were the investigation of attitudes and expectations toward the program, intervention effects on skin picking severity, user satisfaction, adherence, and willingness to participate. Secondary outcomes included the feasibility of study procedures, adequacy of assessment instruments, effects on skin picking-related impairment, dimensions of skin picking, and general psychological impairment.
Methods:
A two-arm randomized controlled trial was conducted in a sample of 133 participants (female: 124/133, 93.2%; mean age 26.67 [SD 6.42]) recruited via the internet. Inclusion required a minimum age of 17 years and at least mild skin picking severity. Participants were randomly allocated to the intervention (64/133, 48.1%) or waitlist control group (69/133, 51.9%). All assessments were conducted online and based on self-report.
Results:
The willingness to participate was very high in the study, so the initially planned sample size of 100 was exceeded after only 18 days. Participant expectations indicate that they believed the program to be beneficial for them (131/133, 98.5%) and provide a feeling of support (119/133, 89.5%). Reasons for study participation were insufficient outpatient health care (83/133, 62.4%) and flexibility regarding time (106/133, 79.7%) and location (109/133, 82.0%). The post-assessment was completed by 65.4% (87/133) of the sample. The majority of the intervention group who completed the entire post-assessment were satisfied with SaveMySkin (28/38, 74%) and agreed that the program is an appropriate support service (35/38, 92%). On average, participants viewed 29.31 (SD 42.02) pages in the program, and 47% (30/64) of the intervention group used the monitoring at least once a week. In comparison with the control group, the intervention group displayed substantial improvements in the skin picking severity total score (Cohen d=0.67) and especially on the subscale Symptom Severity (Cohen d=0.79). No effects on secondary outcomes were found.
Conclusions:
This study confirms the need for easily accessible interventions for skin picking disorder and the high interest in internet-based self-help within the target population. It provides important insights into the attitudes toward online support and actual user experiences. Participant feedback will be used to further enhance the intervention. Our results point to the preliminary efficacy of SaveMySkin and may lay the foundation for future research into the efficacy and cost-effectiveness of the program in a multicenter clinical trial.
Trial registration:
German Clinical Trial Register DRKS00015236; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00015236.
International registered report identifier (irrid):
RR2-10.1016/j.conctc.2018.100315.
... However, research on interventions for skin picking disorder has been very scarce until now. A limited number of studies have investigated pharmacological and behavioral interventions [12], including habit reversal training [13,14], acceptance and commitment therapy [15], cognitive-behavior therapy (CBT) [16,17], and combined approaches (eg, acceptance-enhanced CBT) [18,19]. Noteworthy, most of these previous studies showed severe methodological shortcomings (eg, small sample sizes, lack of control conditions), and most were conducted before the official DSM-5 criteria for skin picking disorder became available. ...
BACKGROUND
In spite of the psychosocial burden and medical risks associated with skin picking disorder, healthcare does not provide sufficient treatment for affected individuals to date. Therefore, an Internet-based self-help program for skin picking was developed to offer easily accessible support for this population.
OBJECTIVE
The present pilot study evaluated the Internet-based self-help program ‘SaveMySkin’. The 12-week program is based on cognitive-behavioral therapy, and contains comprehensive information and exercising materials, a daily supportive monitoring system, and dermatological and psychological counseling via Internet-chat. Primary objectives were the investigation of attitudes and expectations towards the program, intervention effects on skin picking severity, user satisfaction, adherence, and the willingness to participate. Secondary outcomes included the feasibility of study procedures, the adequacy of assessment instruments, and effects on skin picking related impairment, dimensions of skin picking, and general psychological impairment.
METHODS
A 2-arm randomized controlled trial was conducted in a sample of N=133 participants (93.2% female, N=124; mean age: M=26.19; SD=6.52), who were recruited via Internet. Inclusion required a minimum age of 17 years, and at least mild skin picking severity. Participants were randomly allocated to the intervention (N=64) or waitlist control group (N=69). All assessments were conducted online and based on self-report.
RESULTS
The willingness to participate was very high in the present study, so that the initially planned sample size of N=100 was exceeded after only 18 days. Participants’ expectations indicate that they believed the program to be beneficial for them (98.5%, N=131), and provide a feeling of support (89.5%, N=119). Reasons for study participation were insufficient outpatient healthcare (62%, N=83), and flexibility regarding time (79.7%; N = 106), and location (82.0 %; N = 109). The post assessment was completed by 65.4% (N=87) of the sample. The majority of participants were satisfied with SaveMySkin (73%, N=28), and agreed that the program is an appropriate support service (92%, N=35). On average, participants viewed 29.31 (SD=42.02) pages in the program, and 47% of the intervention group (N=30) used the monitoring at least once a week. In comparison to the control group, the intervention group displayed substantial improvements of the skin picking severity total score (Cohen’s d=0.67), and especially on the subscale symptom severity (Cohen’s d=0.79). No effects on secondary outcomes were found.
CONCLUSIONS
The present study confirms the need for easily accessible interventions for skin picking disorder and the high interest in Internet-based self-help within the target population. It provides important insights into both, the attitudes towards online support and the actual user experiences. Participant feedback will be used to further enhance the intervention. Furthermore, the results point to the preliminary efficacy of the SaveMySkin and may thus lay the foundation for future research into the efficacy and cost-effectiveness of the program in a multi-center clinical trial.
CLINICALTRIAL
German Register for Clinical Trials (DRKS; DRKS00015236)
... However, research on interventions for skin picking disorder has been very scarce until now. A limited number of studies have investigated pharmacological and behavioral interventions [12], including habit reversal training [13,14], acceptance and commitment therapy [15], cognitive-behavior therapy (CBT) [16,17], and combined approaches (eg, acceptance-enhanced CBT) [18,19]. Noteworthy, most of these previous studies showed severe methodological shortcomings (eg, small sample sizes, lack of control conditions), and most were conducted before the official DSM-5 criteria for skin picking disorder became available. ...
... 20 Studies also mention acceptance and commitment therapy (ACT), which involves procedures for strengthening values and life goals, preparation to accept and deal with internal adverse feelings, and management of rigidity of thought associated with the excoriation behavior, as well as acceptance-enhanced behavior therapy, which consists of a union between ACT and a traditional behavioral approach called habit reversal treatment. 21 Habit reversal treatment is the most studied treatment for ED; it covers several strategies that target the immediate and lasting reduction of the undesirable habit by raising the individual's awareness of the moment when the excoriation behavior is most likely to happen, through the identification of triggers and the acquisition of new and competing behaviors (such as fist clenching), as well as aid from close contacts, who may help point out when a excoriation moment has started. 22 Although ED is being increasingly researched, there are yet few studies of ED that were controlled clinical trials and featured significant samples, which makes it difficult to reach any conclusions, both regarding pharmacologic treatment as well as psychotherapy. ...
Background:
Excoriation disorder (ED) is characterized by recurring excoriation of the skin resulting in tissue damage, usually associated with emotional deregulation. Psychotherapy is a valuable treatment; however, no studies emphasize the patients' interactional aspect, nor the potential benefit of group treatment.
Methods:
We recruited a convenience sample of 38 individuals with ED according to DSM-5 criteria, in which 19 individuals proceeded to treatment, 10 with psychodrama group therapy (PGT), and 9 with support group therapy (SGT) in an open pilot study.
Results:
The entire sample presented improvement of skin excoriation on both self-report and clinician rating and improvement of social adjustment; however, there was no difference between groups (ie, time × group interaction). Also, there was no relevant change for anxiety, depression, or emotional regulation throughout treatment. Emotional deregulation was associated with excoriation severity as well as depression, anxiety, and social maladjustment, both at the beginning and end of treatment.
Conclusions:
Although both groups showed improvement of skin picking, the results contradict our primary hypothesis that PGT would have a superior efficacy to SGT for patients with ED. The findings encourage future studies of group interventions for ED in larger samples with a focus on emotional regulation enhancement.
... Such research has used HRT in various modified forms. For example, Acceptance Enhanced Behavior Therapy (AEBT), in which Acceptance and Commitment Therapy (ACT) is combined with HRT, was used with some success in a case series of patients with Excoriation Disorder (Capriotti et al., 2015). ...
Background: Habit Reversal Therapy (HRT) has long been used in the treatment of Tourette Syndrome and Tic Disorders. It has more recently been used to treat Trichotillomania and skin picking behaviors, both considered as Obsessive Compulsive Related Disorders (OCRD).
Objectives: This literature review sought to establish and quality assess the existing randomized controlled trial evidence supporting the use of HRT in the DSM-5 family of OCRDs.
Search Methods: EMBASE, PsycINFO, PubMed, and Cochrane databases were searched for key terms relating to each OCRD (as classified in the DSM-5), and HRT.
Selection Criteria: Titles and abstracts were screened, and any literature matching pre-specified criteria were then selected to be reviewed further. Of these, 8 Randomized Controlled Trials (RCT) relating to Trichotillomania, and 2 RCTs relating to Excoriation Disorder, were extracted and reviewed against the 2010 Consolidating Standards of Reporting Trials (CONSORT) statement.
Results: The review identified 10 RCTs of HRT, but these were limited to patients with a primary diagnosis of Trichotillomania or “excoriation behavior,” only. There were some reports of the use of HRT in Tourette Syndrome or Tic Disorder with secondary OCD, but the OCD symptoms were not reliably reported on.
Conclusion: There is a gap in the current literature regarding the use of HRT in the DSM-5 OCRDs. In those RCTs that have been reported, the quality of study methodology was questionable as evaluated by CONSORT criteria. The implications of these findings are discussed, and suggestions are made for future research.
... Finally, a recent case-series study saw marked decreases in picking behavior and related psychosocial impairment in three of four individuals with skin picking using a similar ACT-enhanced behavior therapy protocol (Capriotti, Ely, Snorrason, & Woods, 2015). In summary, the support for ACT-enhanced behavior therapy is strong. ...
... Die folgenden verhaltenstherapeutischen Behandlungsbausteine basieren auf unseren eigenen Behandlungserfahrungen, einer Literaturrecherche zu Fallstudien [24] sowie der Sichtung von Behandlungsmanualen [25,26] und Selbsthilfebüchern [24 -28]. ...
Dermatillomania (pathologic skin picking; skin picking disorder) is defined by picking one’s skin (pulling, plucking, scratching) and feeling incapable of stopping. The behavior is experienced as gratifying, but also leads to distress and others find it difficult to comprehend the underlying motivations. This article aims to improve the clinicians’ ability to reliably diagnose the disorder, to gain a better understanding of it and to guide clinicians towards an effective treatment.
... Die folgenden verhaltenstherapeutischen Behandlungsbausteine basieren auf unseren eigenen Behandlungserfahrungen, einer Literaturrecherche zu Fallstudien [24] sowie der Sichtung von Behandlungsmanualen [25,26] und Selbsthilfebüchern [24 -28]. ...
Wenn Menschen ihre Haut durch Knibbeln (Quetschen, Drücken, Kratzen) verletzen und sie damit kaum aufhören können, spricht man von Dermatillomanie (pathologisches Hautzupfen/-quetschen; Skin-Picking-Störung). Diese Angewohnheit wird als befriedigend erlebt, führt zu Leid und ist für Außenstehende schwer nachvollziehbar. Dieser Artikel soll helfen, das Störungsbild zuverlässig zu erkennen, einfühlsam zu verstehen und effektiv zu behandeln.
... Case studies are few in number and often focussed on treatment interventions (e.g. Capriotti et al., 2015). Some have qualitatively illustrated picking by presenting details of cases, often considering the client's emotions as central to their experience. ...
This article examines the accounts of individuals who problematically pick their skin and explores their subjective experiences. In total, 100 problem disclosure statements were taken from posts made to a publicly accessible online skin picking support forum. These posts were systematically analysed using thematic analysis. Themes of disgust, shame and psychosocial avoidance dominated the analysis and appeared central to the experience of skin picking. Skin picking was shown to be a heterogeneous experience with a complex emotional profile. We argue that disgust, shame and related avoidance behaviour should be considered when conceptualising skin picking and considering treatment interventions.
... In the case of HRT, patients are taught to recognize behavioral triggers and enact appropriate competing responses and/or coping skills. More recently, at least among adults, acceptance-enhanced behavior therapy (AEBT; i.e., ACT + HRT) has demonstrated efficacy [36]. While ACT alone has been examined as a treatment for adults with OCD [37], we are unaware of any study to employ HRT for the amelioration of OCD-related symptoms. ...
Opinion statement
Obsessive-compulsive disorder (OCD) and body-focused repetitive behaviors (BFRBs) have demonstrated considerable presence and impact among clinical populations. As consistent with any treatment approach, necessary intervention among these disorders begins with a comprehensive evaluation of client’s symptoms, with particular attention placed on potential comorbidities. Common practice among clinicians identifies exposure and response prevention (ERP) as a first line treatment of OCD. However, among client’s demonstrating BFRBs, habit reversal therapy (HRT) or novel emotion-based treatments (e.g., acceptance-enhanced behavior therapy [AEBT], dialectical behavioral therapy [DBT]) are used. Such therapies have demonstrated significant efficacy among their respective disorders. Notably, depending upon disorder severity, medications may also be suggested. Given frequent comorbidity between OCD and BFRBs, it is recommended that clinicians adequately modify interventions when presented with clients demonstrating such comorbid behaviors, perhaps combining effective facets of multiple approaches (see discussion below). From a pharmacological perspective, burgeoning research identifies two potential interventions applicable to both OCD and BFRBs (e.g., silymarin and n-acetyl-cysteine); however, given the novelty of this research, we recommend caution with use of such therapies. While current studies suggest potential efficacy, further research examining such pharmacological interventions is necessary.
Background: People affected by skin picking disorder (SPD) feel a strong urge to manipulate their skin and feel incapable of stopping. First studies on cognitive-behavioral treatments found moderate to large effects on the reduction of symptomatology. We developed an easy to access cognitive-behavioral self-help program and tested its efficacy on SPD.
Method: The program includes modules on self-awareness, psychoeducation, strategies to control picking and relapse-prevention. In a multiple baseline-design 43 women diagnosed with SPD accessed the online program. Symptomatology was assessed via skin picking scales before, throughout, and after the completion of the intervention. We analyzed the data using a repeated measurement ANOVA and planned contrasts.
Results: We found significant large effects for skin picking symptom reduction throughout a 6-month follow-up (.325 ≤ ηp² ≤ .430) for completers (n = 25). In planned contrasts the significant reduction of symptoms (after baseline self-monitoring) to 6-month follow-up was large (.281 ≤ ηp² ≤ .375).
Conclusions: With the internet-based self-help program Knibbelstopp we implemented an efficacious self-help tool for SPD, which requires further investigation regarding generalizability of this effect. Our self-help program is accessible online and may help to improve the health care situation for German speaking individuals with SPD.
The Habit Reversal Training (HRT) is a behavioral procedure for treating the so-called nervous habits, such as nail biting, hair pulling and thumb sucking. In addition to being an established clinical procedure, HRT is also a strategy for behavioral change that can serve the entire community. For this reason, this review aims to explore the studies proposing the use of HRT for the reduction of hand-to-face habits in the context of COVID-19 pandemic. Touching one's nose, mouth and eyes, indeed, is one of the means of virus transmission that many awareness campaigns seek to highlight. After an overview of how HRT works and of the current epidemiological situation, studies supporting Habit Reversal Training for the reduction of risky hand-to-face habits are presented. The possible strategies are then exposed and critically discussed to identify their limitations and propose a new version according to the Relational Frame Theory.
Objectives
Problematic skin picking (SP) is a poorly understood experience characterised by a drive to pick the skin and related psychosocial impact. In the DSM‐5, problematic SP is classified as ‘excoriation (skin picking) disorder’. The aim of this article is to present a rare qualitative perspective on the lived experience of problematic SP, prioritising participants' voices and sense‐making.
Design
An in‐depth qualitative study of individuals who self‐identified as picking their skin problematically and experienced related distress.
Methods
Seventeen UK‐based participants were recruited online and interviewed about their SP. Participants were given choice of interview modality, including instant messenger platforms, telephone, email and Skype, to maximise comfort and improve the accessibility of the study. Transcripts were analysed using thematic analysis.
Results
Three themes offering novel insight into the phenomenology of participants' SP are highlighted and explored: (1) how cognitions and circumstances drove and permitted SP, (2) how participants ‘zoned out’ while SP and the escape or relief that this attentional experience offered and (3) participants' feelings of shame and distress in how they felt their SP may appear to others.
Conclusions
This study contributes in‐depth and novel ideas to the understanding of SP phenomenology and identifies how environmental factors, cognitions, contextual distress and shame may be considerations in therapeutic intervention. It presents the complexity of SP sense‐making and demonstrates the need for individual formulation.
This study piloted the use of ACT-informed exposure as an adjunct to habit reversal training (HRT) for excoriation disorder (ExD). Using a nonconcurrent multiple baseline single case design, four participants completed sessions of exposure and HRT. Repeated measures and self-report data were collected on skin picking and psychological flexibility. Two participants completed HRT followed by exposure, and two participants completed exposure followed by HRT. Results support the effectiveness of HRT in reducing picking. Results suggest exposure may have some impact in reducing picking, but effects were weaker compared to HRT. Contrary to predictions, repeated measures and self-report data did not indicate consistent improvement in psychological flexibility during exposure phases. As any reduction in picking may be clinically meaningful and all participants maintained gains at follow-up, there is some indication that exposure may be a second-line treatment worth further study. Limitations and future areas of research are discussed.
Excoriation is a disorder in which individuals repetitively scratch or pick their skin, resulting in visible tissue damage. The skin lesions that occur from excoriation can lead to physical disfigurement, functional impairment, and emotional distress. Although skin picking is a common behavior that can negatively impact various domains of a person's life, many clinicians are unaware that there are instances in which this condition can be classified a pathological disorder. This article focuses on the prevalence, course, etiology, assessment, diagnosis, and treatment of excoriation. A case scenario is included to demonstrate how a client may present in session, followed by suggested approach to treatment. Implications for clinicians are also discussed.
Background: Trichotillomania and skin picking appear to be compulsory and chronic. The present study attempts to investigate the effectiveness of this type of treatment in improving the symptoms of adolescents. Methods: This study used single case design scheme of multi stepped on four patients (two patients for each disorder) with 10 sessions over the course of three month follow up. Data was gathering through Skin Picking, trichotillomania Scale, Milwaukee Inventory for Subtypes of Skin Picking and hair pulling. Results: The intervention had significant effects in the reduction of symptoms of focused and automatic skin picking and trichotillomania and follow-up over three month revealed that the treatment effects were maintained. Conclusion: The AEBT could be effective in treating patients with trichotillomania and skin picking, and follow-up over three month revealed that the treatment effects were maintained.
Wenn Sie dieses Kapitel gelesen und die Aufgaben bearbeitet haben, wissen Sie was Habit Reversal Training (HRT; Deutsch: Training zur Gewohnheitsumkehr) ist. Das Kapitel unterstützt Sie dabei, passende Übungen zur Gewohnheitsumkehr (Knibbel-Gegenbewegung) zu finden und diese gezielt anzuwenden.
In diesem und den folgenden drei Kapitel geht es um konkrete Strategien gegen das Knibbeln. Wenn Sie dieses Kapitel beendet haben, wissen Sie, wie Sie Ihre Auslöser für Knibbelepisoden eingrenzen, beseitigen und/oder vermeiden können. Mit den Übungen dieses Kapitels wenden Sie vermehrt Aktivitäten oder Dinge an, die Sie vor dem Bearbeiten Ihrer Haut schützen, und suchen gezielt Situationen auf, in denen Knibbeln unwahrscheinlich ist.
This chapter discusses habit disorders with a focus on nervous habits and discusses the research on behavioural treatment of nervous habits. Nervous habits are repetitive movements that involve objects or body parts and may include behaviours such as hair pulling, nail biting, thumb sucking, oral habits, skin picking, and scratching. Nervous habits become a problem when they occur excessively or cause distress or tissue damage. Nervous habits are maintained through positive reinforcement when they provide stimulation (e.g. oral or digital stimulation for thumb sucking) or negative reinforcement when they result in relief from tension or anxiety. Habit reversal, the most commonly used intervention for nervous habits consisting of multiple components with a focus on promoting awareness and the use of a competing response, has been shown to be effective when used alone or with additional behavioural interventions.
El trastorno de excoriación fue descrito por primera vez en 1875 por Erasmus Wilson. No obstante, luego de más de 140 años de su descubrimiento, el mismo todavía no ha sido completamente estudiado y comprendido. A lo largo de los años ha recibido una multiplicidad de nombres (excoriación neurótica, excoriación psicógena, rascado cutáneo patológico, rascado cutáneo compulsivo) y recién desde finales de 2012 ha sido incluido en guías diagnósticas. El trastorno de excoriación puede ser un trastorno desafiante para el terapeuta no experimentado. El tratamiento de primera línea para el trastorno de excoriación es la psicoterapia cognitivo conductual. Esto también se aplica para otras conductas repetitivas centradas en el cuerpo, como la tricotilomanía. En este artículo de revisión presentamos los principales elementos de este tipo de psicoterapia para el tratamiento de estos pacientes psicodermatológicos.
This chapter describes psychological interventions for excoriation (skin-picking) disorder (SPD) and focuses on clinical characteristics and assessment of SPD. Then, it discusses viable psychotherapy strategies for SPD. The chapter also examines treatment efficacy research and provides clinical recommendations. Skin picking often causes discomfort and inconveniences, such as bleeding, soreness, and temporary large excoriations. Skin picking secondary to body dysmorphic disorder (BDD) is perhaps the most common differential psychiatric diagnosis in SPD. Another differential diagnosis is nonsuicidal self-injury. The chapter also describes therapeutic strategies that are included in cognitive behavioral treatment (CBT) protocols. It focuses on CBT because it is the only therapeutic approach that has been tested with experimental examination. The current expert consensus is that habit reversal training (HRT) should be the first line of treatment for SPD. This recommendation is given because HRT has the most empirical support for SPD and related conditions.
Acceptance and commitment therapy (ACT) is a contextual and mindfulness-based psychotherapy that falls under the larger umbrella of cognitive behavioral therapy (CBT). The use of ACT alone for treating obsessive compulsive (OC)-spectrum disorders has been examined in two studies. The first employed ACT with five participants who met criteria for chronic skin-picking using a multiple-baseline across participants design. At posttreatment four of the five participants had reached near-zero levels of skin-picking; however, only one participant retained these levels at a 3-month follow-up. The second study used the same protocol, but examined ACT as a treatment for problematic internet pornography viewing. Habit reversal training is the most recommended treatment for several OC-spectrum behaviors. Some researchers have similarly noticed internal experiences as separate barriers to treatment success and have tested a dialectical behavior therapy enhanced version of HRT with success.
Background and Objectives: Trichotillomania disorder is a repetitive pulling of hair to the point of noticeable loss. TTM has been tied to a number of negative effects and avoidance of important activities. The purpose of this study was to investigate the effectiveness of combination of Acceptance and Commitment Therapy (ACT) with Habit Reversal Training (HRT) on reduction of trichotillomania symptoms.
Subjects and Methods: In this study single-case experiment with A-B design with follow up was used. Two patients were selected by purposeful sampling. In order to gather information and data, in addition to the diagnostic interview based on DSM-5, Milwaukee Inventory for subtypes of trichotillomania–Adult Version: MIST-A and The Massachusetts General Hospital (MGH) Hair-pulling Scale were used. Seven-session ACT plus HRT protocol was delivered for each participant individually. Data drawn in three phases of baseline, intervention and follow-up, for participants separately.
Result: Data were interpreted by visual analysis and result showed that the combination of ACT and HRT was effective in reducing TTM symptoms in both patients, and the treatment out come was maintained in follow-up phase.
Conclusion: The results showed a traditional behavioral approach (HRT) combined with an approach that addresses the cognitive and emotional components of the behaviour (ACT), significantly reduce TTM symptoms. Combined ACT with HRT is more treatment of TTM.
Keywords: Habit Reversal Training, Acceptance and Commitment Therapy, Trichotillomania.
Various studies suggest that selective serotonin reuptake inhibitors (SSRIs) may be useful in treating pathological skin picking (PSP). This study sought to assess effectiveness of citalopram in comparison with placebo in treating PSP. Forty five individuals with PSP were recruited in a four-week, randomized clinical trial of citalopram (20 mg/day) in comparison with placebo. Study measures assessing skin picking severity, mental health status, obsessive compulsive disorder and quality of life were given at baseline, weeks 2 and 4. PSP severity, general health status, obsession-compulsion severity and quality of life level were similar between two groups at baseline (P > 0.05). Treatment analyses revealed significant improvements in quality of life, general health status and obsession-compulsion severity in citalopram group compared to placebo group (P < 0.05). Mean PSP severity reduction in citalopram group was more than placebo group but this difference was not significant. Citalopram can improve general health status and quality of life in individuals with PSP but its effect on skin picking behavior doesn't differ significantly with placebo. Other trials with longer duration are needed to determine the exact efficacy of citalopram on PSP.
Despite the substantial distress and impairment often associated with skin picking, there currently is only limited research examining various phenomenological aspects of this behavior. The present research contributes to the existing literature by investigating phenomenological variables related to skin picking, such as family involvement, anxiety, depression, and the emotional consequences of skin picking. Moreover, on the basis of symptom severity level, differences were explored between individuals with skin picking who were from a psychiatric population.
Forty individuals with various clinician-ascertained DSM-IV diagnoses in addition to skin picking symptomatology participated in the present study, which was conducted from September 2002 through January 2003. Participants were administered a self-report questionnaire (which assessed demographic, symptom, and past diagnostic information) as well as the Beck Depression Inventory, the Beck Anxiety Inventory, and the Self-Injury Interview.
Phenomenological data on various aspects of individuals with skin picking are presented. Individuals with mild skin picking and individuals with severe skin picking were compared and found to differ in the level of distress they experienced (t = -2.35, p = .05) and the amount of damage caused by their picking behavior (t = -3.06, p = .01).
Overall, skin picking represents a behavior with its own unique characteristics and accompanying levels of distress and impairment that warrants specific attention by clinicians.
In this study, habit reversal was evaluated as a treatment for skin picking in typically developing adult male siblings using a nonconcurrent multiple baseline across participants design. Results showed socially valid decreases in reported picking as a result of treatment.
The purpose of this study was to compare the effectiveness of habit reversal (HR) to a wait-list control as a treatment for chronic skin picking in adults. Twenty-five adults with a chronic skin-picking problem were randomly assigned to a wait-list control or HR group. At pretreatment, posttreatment, and a 3-month follow-up, self-reported skin picking was assessed, and photographs were taken of the damaged areas and later rated by independent observers. Treatment acceptability data were collected at posttreatment only. Results showed that HR produced a greater decrease in skin picking at posttreatment and follow-up when compared to the wait-list control group. Data from the independent raters confirmed these findings. HR was also viewed as an acceptable intervention by the participants.
In this study, the authors collected data on the demographic characteristics, phenomenology, and social and economic impact of skin picking. A total of 92 participants completed an anonymous, Internet-based survey through a link to the Trichotillomania Learning Center's home page. Results indicated that skin pickers experienced social, occupational, and academic impairment, a number of medical or mental health concerns, and financial burdens, which they attributed to skin picking. Results also revealed moderate, statistically significant relationships between skin picking severity and symptoms of depression, anxiety, and experiential avoidance. Subsequent mediational analyses demonstrated that the relationship between skin picking severity and symptoms of anxiety and depression was partially mediated by experiential avoidance. Implications, conclusions, and future areas of research are discussed.
This pilot study examined the utility of acceptance-enhanced behavior therapy (AEBT) for trichotillomania (TTM) and chronic skin picking (CSP) and the impact of altering treatment sequence on overall treatment efficacy. Participants referred to a TTM and CSP specialty clinic were assessed by an independent evaluator within separate, nonconcurrent, multiple-baseline designs across participants. The first group of three participants received habit-reversal training (HRT) followed by acceptance and commitment therapy (ACT), and the second group of two participants received ACT followed by HRT. Results indicated that AEBT greatly reduced pulling/picking for all five participants and that the order in which ACT and HRT were implemented made little or no difference in short-term treatment outcome. Conclusions, limitations, and future areas of research are discussed.
Trichotillomania (TTM) is a complex disorder involving pulling of hair that is difficult to treat as few effective therapeutic options exist. Behaviour therapy has the greatest empirical support, but the number of mental health providers familiar with TTM and its treatment is quite small. This online manual is a tool for therapists to become familiar with an effective treatment for TTM. The treatment approach described in this guide blends traditional behaviour with therapy elements of habit reversal training and stimulus control techniques with the more contemporary behavioural elements of Acceptance and Commitment Therapy (ACT). Therapists help clients to see urges for what they really are and to accept their pulling-related thoughts, feelings, and urges without fighting against them. Via a 10-week course, clients learn to be aware of their pulling and warning signals, use self-management strategies for stopping and preventing pulling, stop fighting against their pulling-related urges and thoughts, and work towards increasing their quality of life. Self-monitoring and homework assignments keep clients motivated and engaged throughout.
Now in softcover for the first time, the most comprehensive guide to behavioral treatment for these prevalent yet understudied disorders.
As upsetting as they are to clients, tics, trichotillomania, and oral-digital habits such as thumb-sucking and nail-biting tend to be resistant to traditional forms of therapy. The repetitiveness of their actions, however, makes these dissimilar disorders particularly receptive to behavioral treatment. Editors Woods and Miltenberger have assembled 22 therapist/researchers to create a state-of-the-art resource for clinicians challenged by clients with repetitive behavior disorders (RBDs). This book contains:
• Three complete treatment manuals explaining step-by-step therapy for tic disorders, trichotillomania, and oral-digital RBDs
• Clear rationales for why behavioral methods are so effective for these disorders
• Guidelines for direct and indirect assessment
• Interventions for related RBDs, including bruxism, rumination, pica, and stuttering
• A Separate chapter on treating RBDs in persons with developmental disorders
• Contact information for advocacy and educational groups
Recent studies have established the effectiveness of behavioral treatment for these disorders, and the re-issue of this book will continue to bring this important modality to the fore. While it is especially geared toward practitioners, the contributors have made Tic Disorders relevant to researchers and sufficiently accessible to be recommended to patients and their families as well.
Background: Repetitive skin picking, a self-injurious behavior that may cause severe tissue damage, has received scant empirical attention. The authors examined the demographics, phe-nomenology, and associated psychopathology in a series of 31 subjects with this problem. Method: Subjects were administered the Structured Clinical Interview for DSM-IV for Axis I and Axis II disorders. They also completed several mood questionnaires and a new self-report inventory designed to assess phenom-enology, triggers, cognitions, emotions, and consequences associated with skin picking. Results: The mean age at onset on self-injurious skin picking was 15 years, and the mean duration of illness was 21 years. All subjects picked at more than one body area, and the most frequent sites of skin picking were pimples and scabs (87%). The most common comorbid Axis I diagnoses were obsessive-compulsive disorder (OCD; 52%), alcohol abuse/dependence (39%), and body dysmorphic disorder (32%). Forty-eight percent (N = 15) of the subjects met criteria for at least one mood disorder, and 65% (N = 20) for at least one anxiety disorder. The most common Axis II disorders were obsessive-compulsive personality disorder (48%) and borderline personality disorder (26%). Conclusion: Self-injurious skin picking is a severe and chronic psychiatric and dermatologic problem associated with high rates of psychiatric comorbidity. It may be conceptualized as a variant of OCD or impulse-control disorder with self-injurious features and may, in some cases, represent an attempt to regulate intense emotions.
An ACT Approach Chapter 1. What is Acceptance and Commitment Therapy? Steven C. Hayes, Kirk D. Strosahl, Kara Bunting, Michael Twohig, and Kelly G. Wilson Chapter 2. An ACT Primer: Core Therapy Processes, Intervention Strategies, and Therapist Competencies. Kirk D. Strosahl, Steven C. Hayes, Kelly G. Wilson and Elizabeth V. Gifford Chapter 3. ACT Case Formulation. Steven C. Hayes, Kirk D. Strosahl, Jayson Luoma, Alethea A. Smith, and Kelly G. Wilson ACT with Behavior Problems Chapter 4. ACT with Affective Disorders. Robert D. Zettle Chapter 5. ACT with Anxiety Disorders. Susan M. Orsillo, Lizabeth Roemer, Jennifer Block-Lerner, Chad LeJeune, and James D. Herbert Chapter 6. ACT with Posttraumatic Stress Disorder. Alethea A. Smith and Victoria M. Follette Chapter 7. ACT for Substance Abuse and Dependence. Kelly G. Wilson and Michelle R. Byrd Chapter 8. ACT with the Seriously Mentally Ill. Patricia Bach Chapter 9. ACT with the Multi-Problem Patient. Kirk D. Strosahl ACT with Special Populations, Settings, and Methods Chapter 10. ACT with Children, Adolescents, and their Parents. Amy R. Murrell, Lisa W. Coyne, & Kelly G. Wilson Chapter 11. ACT for Stress. Frank Bond. Chapter 12. ACT in Medical Settings. Patricia Robinson, Jennifer Gregg, JoAnne Dahl, & Tobias Lundgren Chapter 13. ACT with Chronic Pain Patients. Patricia Robinson, Rikard K. Wicksell, Gunnar L. Olsson Chapter 14. ACT in Group Format. Robyn D. Walser and Jacqueline Pistorello
Psychogenic excoriation (also called neurotic excoriation, acne excoriée, pathological or compulsive skin picking, and dermatotillomania) is characterised by excessive scratching or picking of normal skin or skin with minor surface irregularities. It is estimated to occur in 2% of dermatology clinic patients and is associated with functional impairment, medical complications (e.g. infection) or substantial distress.
Psychogenic excoriation is not yet recognised in the DSM. We propose preliminary operational criteria for its diagnosis that take into account the heterogeneity of behaviour associated with psychogenic excoriation and allow for subtyping along a compulsivity-impulsivity spectrum.
Psychiatric comorbidity in patients with psychogenic excoriation, particularly mood and anxiety disorders, is common. Patients with psychogenic excoriation frequently have comorbid disorders in the compulsivity-impulsivity spectrum, including obsessive-compulsive disorder, body dysmorphic disorder, substance use disorders, eating disorders, trichotillomania, kleptomania, compulsive buying, obsessive-compulsive personality disorder, and borderline personality disorder.
There are few studies of the pharmacological treatment of patients with psychogenic excoriation. Case studies, open trials and small double-blind studies have demonstrated the efficacy of selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors in psychogenic excoriation. Other pharmacological treatments that have been successful in case reports include doxepin, clomipramine, naltrexone, pimozide and olanzapine.
There are no controlled trials of behavioural or psychotherapeutic treatment for psychogenic excoriation. Treatments found to be effective in case reports include a behavioural technique called ‘habit reversal’ a multicomponent programme consisting of self-monitoring, recording of episodes of scratching, and procedures that produce alternative responses to scratching; and an ‘eclectic’ psychotherapy programme with insight-oriented and behavioural components.
Trichotillomania is a behavioral problem, and is often referred to as a habit disorder, but it is important to consider the cognitive and emotional components of the behavior. Current treatment recommendations include a traditional behavioral approach (Habit Reversal Training; HRT) combined with an approach that addresses the cognitive and emotional components of the behavior (Acceptance and Commitment Therapy [ACT] or Dialectical Behavior Therapy [DBT]). Current evidence indicates a combination of ACT and HRT is an effective treatment for trichotillomania. The goal of this article is to replicate the effectiveness of the ACT/HRT treatment package for trichotillomania and to provide practical clinical guidance on how to deliver the treatment. This guidance is presented in the context of an empirical study in which 5 participants demonstrating high levels of pulling at pretreatment were treated with 8 sessions of a combination of ACT and HRT. Treatment resulted in an 88.87% reduction in pulling across participants from pretreatment to posttreatment, and all 5 responded to the treatment. At 3-month follow-up, 2 participants maintained the treatment gains, 2 lost half of the treatment gains, and 1 was at pretreatment levels. A discussion of the results is presented along with implications for clinical practice and future directions for research.Highlights► Replication of the effectiveness of the ACT/HRT treatment for trichotillomania. ► Detailed guidance for clinicians on treatment delivery. ► 87% reduction in hair pulling with moderate maintenance at follow-up.
This book represents the most comprehensive collection of information available on the behavioral approach to the assessment
and treatment of tic disorders, trichotillomania, and other repetitive behavior disorders. As you read the book, you will
notice we addressed a variety of audiences including researchers, practicing clinicians, and persons or parents of persons
with the disorders. For example, the treatment manuals should be valuable as a guide for clinicians, but may also be of interest
to researchers engaged in treatment outcome studies or individuals with the disorders who may wish to become better-educated
consumers.
We realize that this book is only a start. New research is being conducted that will lead to better understanding of, and
more effective treatments for, these disorders. However, behavioral technology has something to offer now, and there is no
good reason to keep persons with these disorders waiting. Let’s begin.
Thirty-four college students suffering from pathological skin picking were randomly assigned to a four-session cognitive-behavioural treatment (n=17) or a waiting-list condition (n=17). Severity of skin picking, psycho-social impact of skin picking, strength of skin-picking-related dysfunctional cognitions, and severity of skin injury were measured at pre-, post-, and two-months follow-up assessment. Participants in the treatment condition showed a significantly larger reduction on all measured variables in comparison to the waiting-list condition. The obtained effect sizes for the outcome measures were large, ranging from .90 to 1.89. Treatment effects were maintained at follow-up. In conclusion, cognitive-behavioural therapy, even in brief form, constitutes an adequate treatment option for pathological skin-picking behaviour.
The current study examined the characteristics of pathological skin picking (PSP) in a population-based sample. Participants were recruited through several online resources for PSP and related conditions to complete a web-based survey assessing the functional and topographical phenomenology, physical and psychosocial impact, treatment utilization, and associated psychopathology of PSP. A total of 1663 participants consented, of whom 760 were over 18 and met study criteria for PSP. Results showed considerable heterogeneity in picking methods, body sites, and function (e.g., regulation of emotional, sensory, and cognitive states). Participants generally reported moderate psychosocial and physical impact from picking and tended to perceive available treatment as poor in quality. Severity of associated symptoms of psychopathology (depression, anxiety, and stress) was comparable to severity levels found in previous samples of persons with trichotillomania and obsessive-compulsive disorder. Severity of PSP was a statistically significant predictor of overall impairment after controlling for depression and anxiety symptoms. Results suggest that PSP is a significant public health concern in need of further rigorous investigation.
Despite increasing recognition of the potentially severe medical and psychosocial costs of pathologic skin picking (PSP), no large-sample, randomized investigation of its prevalence in a national population has been conducted.
Two thousand five hundred and thirteen US adults were interviewed during the spring and summer of 2004 in a random-sample, national household computer-assisted phone survey of PSP phenomenology and associated functional impairment. Respondents were classified for subsequent analysis according to proposed diagnostic criteria.
Of all respondents, 16.6% endorsed lifetime PSP with noticeable skin damage; 60.3% of these denied picking secondary to an inflammation or itch from a medical condition. One fifth to one quarter of those with lifetime PSP not related to a medical condition endorsed tension or nervousness before picking, tension or nervousness when attempting to resist picking, and pleasure or relief during or after picking. A total of 1.4% of our entire sample satisfied our criteria of picking with noticeable skin damage not attributable to another condition and with associated distress or psychosocial impairment. Pickers satisfying these latter criteria differed from other respondents in demographics (age, marital status) and both picking phenomenology and frequency.
This article describes the development and initial psychometric properties of the Milwaukee Inventory for the Dimensions of Adult Skin picking (MIDAS), a measure designed to assess "automatic" and "focused" skin picking. Data were collected from 92 participants who completed an anonymous internet-based survey. Results of an exploratory factor analysis revealed a two-factor solution. Factors 1 ("focused" picking scale) and 2 ("automatic" picking scale) each consisted of 6 items, and preliminary data demonstrated adequate internal consistency, good construct validity, and good discriminant validity. The MIDAS provides researchers with a reliable and valid assessment of "automatic" and "focused" skin picking.
Psychogenic excoriation, characterized by excessive scratching or picking of the skin, is not yet recognized as a symptom of a distinct DSM-IV disorder. The purpose of this study was to provide data regarding the demographics, phenomenology, course of illness, associated psychiatric comorbidity, and family history of subjects with psychogenic excoriation.
Thirty-four consecutive subjects were recruited from an outpatient dermatology practice and by advertisement. Subjects completed the Structured Clinical Interview for DSM-IV augmented with impulse control disorder modules, the Yale-Brown Obsessive Compulsive Scale, and a semistructured interview for family history, demographic data, and clinical features.
Most subjects were women who described a mean age at onset of 38 years and a chronic course. Subjects excoriated multiple sites, most frequently the face. The behavior caused substantial distress and dysfunction. All 34 subjects met criteria for at least 1 comorbid psychiatric disorder, with a mood disorder the most common. Family histories were notable for depressive disorders and psychoactive substance use disorders. Most subjects experienced both mounting tension before excoriation and relief after excoriation as in impulse control disorders. A minority of subjects excoriated skin as part of obsessive-compulsive disorder. Body dysmorphic disorder with preoccupation about the skin's appearance precipitated excoriation in about a third of subjects.
Psychogenic excoriation is chronic, involves multiple sites, and is associated with a high rate of psychiatric comorbidity. The behavior associated with the excoriation is heterogeneous and spans a compulsive-impulsive spectrum. Most subjects in this sample described features of an impulse control disorder.
Repetitive skin picking, a self-injurious behavior that may cause severe tissue damage, has received scant empirical attention. The authors examined the demographics, phenomenology, and associated psychopathology in a series of 31 subjects with this problem.
Subjects were administered the Structured Clinical Interview for DSM-IV for Axis I and Axis II disorders. They also completed several mood questionnaires and a new self-report inventory designed to assess phenomenology, triggers, cognitions, emotions, and consequences associated with skin picking.
The mean age at onset on self-injurious skin picking was 15 years, and the mean duration of illness was 21 years. All subjects picked at more than one body area, and the most frequent sites of skin picking were pimples and scabs (87%). The most common comorbid Axis I diagnoses were obsessive-compulsive disorder (OCD; 52%), alcohol abuse/dependence (39%), and body dysmorphic disorder (32%). Forty-eight percent (N = 15) of the subjects met criteria for at least one mood disorder, and 65% (N = 20) for at least one anxiety disorder. The most common Axis II disorders were obsessive-compulsive personality disorder (48%) and borderline personality disorder (26%).
Self-injurious skin picking is a severe and chronic psychiatric and dermatologic problem associated with high rates of psychiatric comorbidity. It may be conceptualized as a variant of OCD or impulse-control disorder with self-injurious features and may, in some cases, represent an attempt to regulate intense emotions.
Psychogenic excoriation (also called neurotic excoriation, acne excoriée, pathological or compulsive skin picking, and dermatotillomania) is characterised by excessive scratching or picking of normal skin or skin with minor surface irregularities. It is estimated to occur in 2% of dermatology clinic patients and is associated with functional impairment, medical complications (e.g. infection) or substantial distress. Psychogenic excoriation is not yet recognised in the DSM. We propose preliminary operational criteria for its diagnosis that take into account the heterogeneity of behaviour associated with psychogenic excoriation and allow for subtyping along a compulsivity-impulsivity spectrum. Psychiatric comorbidity in patients with psychogenic excoriation, particularly mood and anxiety disorders, is common. Patients with psychogenic excoriation frequently have comorbid disorders in the compulsivity-impulsivity spectrum, including obsessive-compulsive disorder, body dysmorphic disorder, substance use disorders, eating disorders, trichotillomania, kleptomania, compulsive buying, obsessive-compulsive personality disorder, and borderline personality disorder. There are few studies of the pharmacological treatment of patients with psychogenic excoriation. Case studies, open trials and small double-blind studies have demonstrated the efficacy of selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors in psychogenic excoriation. Other pharmacological treatments that have been successful in case reports include doxepin, clomipramine, naltrexone, pimozide and olanzapine. There are no controlled trials of behavioural or psychotherapeutic treatment for psychogenic excoriation. Treatments found to be effective in case reports include a behavioural technique called 'habit reversal'; a multicomponent programme consisting of self-monitoring, recording of episodes of scratching, and procedures that produce alternative responses to scratching; and an 'eclectic' psychotherapy programme with insight-oriented and behavioural components.
Various studies suggest that selective serotonin reuptake inhibitors (SSRIs) may be useful in treating pathologic skin-picking. The authors investigated the effectiveness of fluoxetine in treating this behavior. Fifteen subjects with clinically significant skin-picking were recruited by newspaper advertisement. They received 6 weeks of open-label treatment with fluoxetine. Responders were then randomized to 6 weeks of double-blind fluoxetine or placebo. Treatment effect was assessed with standardized rating scales. All 15 subjects completed open-label treatment, and 8 were responders. Of these eight, the four randomized to double-blind fluoxetine maintained clinically significant improvement. The four randomized to placebo returned to their baseline symptom level. Larger studies are needed to determine which individuals are likely to respond to fluoxetine and the relative effectiveness of fluoxetine, other SSRIs, and other forms of treatment.
Although trichotillomania and pathological skin-picking are both characterized by repetitive self-injurious stereotypic behaviors, the former is classified as an impulse control disorder, while the latter is not given a specific diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders (4th edition) [APA, 1994]. There are, however, few empirical data on phenomenological similarities and differences between these disorders. Patients with trichotillomania and pathological skin-picking were compared in terms of several demographic (age, gender), clinical (comorbid axis I and II disorders), and personality variables.
Trichotillomania and pathological skin-picking were very similar in demographics, psychiatric comorbidity, and personality dimensions. Dissociative symptoms may be more common in trichotillomania than in pathological skin-picking. These data support the concept of phenomenological overlap between trichotillomania and pathological skin-picking. Future work to assess the implications of overlap for clinical evaluation and intervention in the two conditions may be useful. Depression and Anxiety 15:83–86, 2002.
Self-injurious skin picking is characterized by repetitive, ritualistic, or impulsive skin picking that leads to tissue damage and causes significant distress or impairment in daily functioning. Little is known about effective behavioral or cognitive-behavioral treatments for self-injurious skin picking. As described by Azrin and colleagues, habit reversal is a promising behavioral treatment for modifying nervous habits or tics. To the authors' knowledge, only one case series currently exists in the literature that shows self-injurious skin picking, in the absence of an underlying dermatological condition or without psychiatric comorbidity, can be successfully treated with habit reversal. In the current article, the authors describe the implementation and outcome of cognitive-behavior therapy for three patients with severe self-injurious skin picking, two of which had psychiatric comorbidity.
This randomized trial compared a combined Acceptance and Commitment Therapy/Habit Reversal Training (ACT/HRT) to a waitlist control in the treatment of adults with trichotillomania (TTM). Twenty-five participants (12 treatment and 13 waitlist) completed the trial. Results demonstrated a significant reduction in hair pulling severity, impairment ratings, and hairs pulled, along with significant reductions in experiential avoidance and both anxiety and depressive symptoms in the ACT/HRT group compared to the waitlist control. Reductions generally were maintained at a 3-month follow-up. Decreases in experiential avoidance and greater treatment compliance were significantly correlated with reductions in TTM severity, implying that targeting experiential avoidance may be useful in the treatment of TTM. Other implications and suggestions for future research are noted.
This study sought to detail the phenomenology and medical consequences of pathologic skin picking (PSP).
Sixty subjects (11.7% males) with PSP (mean+/-S.D.=33.7+/-11.6 years) were assessed. Subjects seen in a pharmacological study as well as those from an ongoing outpatient longitudinal study comprised this sample. Subjects were assessed for current and lifetime psychiatric comorbidity (using the Structured Clinical Interview for DSM-IV Axis I Disorders), clinical severity (using the Clinical Global Impression - Severity scale) and psychosocial interference due to picking (using the Sheehan Disability Scale). Clinical characteristic data, including time spent picking per day, sites picked and medical complications directly resulting from skin picking behavior, as well as family history, were also obtained.
The mean age (+/-S.D.) of onset for PSP was 12.3+/-9.6 years. The face was the most common area picked. Subjects reported picking a mean of 107.6 min each day. Scarring, ulcerations and infections were common. Few had ever sought psychiatric treatment for their behavior. Current comorbid Axis I psychiatric conditions were found in 38.3% of the sample. Trichotillomania (36.7%), compulsive nail biting (26.7%), depressive disorder (16.7%) and obsessive-compulsive disorder (15%) were the most common current comorbid conditions.
PSP appears to be time consuming and frequently associated with medical complications. Research is needed to optimize patient care for individuals with this behavior.
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