The Case For An Integrated Approach to Treatment

Skin picking, clinically known as Excoriation Disorder, is characterized by compulsive picking of the skin leading to tissue damage, significant emotional distress, and impaired interpersonal functioning. Other mental health disorders including anxiety and depression often co-occur with skin picking. In fact, about 53% of people with a body focused repetitive behavior (BFRB) like skin picking also have depression and about 63% have co-occurring anxiety. 

While skin picking is considered a chronic disorder, there are treatment approaches that have proven to be helpful. Of the behavioral therapies, Habit Reversal Training (HRT) has perhaps been studied the most extensively and there is ample support in the literature and anecdotally for its effectiveness in treating BFRBs. 

HRT works on the principle of competing responses. In its simplest terms, competing responses means that a person can’t do two opposing things at the same time. HRT consists of a set of key treatment components, each focused on one aspect of the behavior, with the goal of facilitating behavior change. In this case of a BFRB, the goal is a reduction or cessation of the injurious behavior.

While HRT has shown efficacy in the short-term, it isn’t without limitations. It has strong awareness, behavior blocking, and reinforcement components. However, HRT does not address the emotional and cognitive difficulties that usually occur with BFRBs. Achieving long-term improvement has been more problematic and relapse is not uncommon. As a result, researchers looked to other therapeutic modalities that may bridge the gap between the cognitive and behavioral aspects of skin picking. 

Cognitive behavioral therapy (CBT) is an evidence-based approach to therapy developed by Dr. Aaron Beck. CBT is based on the idea that our thoughts, feelings, and behavior are connected. By changing the way we think and act, we can change how we feel. CBT has long been established as the preferred approach for treating depression, anxiety and other mental health issues.

A Powerful Combination

Studies have shown that combining CBT and HRT seems to support significant reduction in symptoms of both skin picking and dysfunctional cognition and improved psychosocial functioning. Self-help CBT and HRT interventions, requiring fewer resources, have been shown to be effective for BFRBs including skin picking and comorbid depression. 

One of the things we know about BFRBs like skin picking is that the disorder is highly heterogenous. People experience the disorder differently and bring unique personal aspects to the treatment process. One team of researchers wondered whether those similar results with CBT and HRT could be found in a clinical setting using a formulated approach based on the patient’s needs, preferences, and experiences. 

The Case for A Formulated Approach

The case study reports on the use of a formulated approach to using HRT and CBT to treat both skin picking and comorbid anxiety and low mood. By taking the patient’s unique needs into account, they were able to personalize a treatment approach that held meaning and relevance. Aspects of the formulation included critical incidents (actions that break the rules or challenge core beliefs), relevant early childhood experiences, core beliefs and values, and assumptions/rules for living. 

A critical component for this patient was practicing self-compassion and drawing on her religious beliefs. She identified self-criticism as an obstacle for practicing competing responses. Guided by the formulation, aspects of compassion therapy were integrated into her plan as well as ways to draw on her faith. The patient reported improvement in symptoms of her skin picking as well as her anxiety and mood. 

This study further supports the need for sound clinical assessment and the consideration of individual experiences, preferences, and needs in treatment decisions. While much more research is needed, findings like these add to the understanding of the role that a formulated approach can play in treatment outcomes. 

References

1. Grant, J. E., & Chamberlain, S. R. (2020). Prevalence of skin picking (excoriation) disorder. Journal of psychiatric research, 130, 57–60. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7115927/

2. Jones, G., Keuthen, N., & Greenberg, E. (2018). Assessment and treatment of trichotillomania (hair pulling disorder) and excoriation (skin picking) disorder. Clinics in Dermatology, 36(6), 728-736. 

https://doi.org/10.1016/j.clindermatol.2018.08.008 

3. Wiese, A. D., Omar, Y., Swann, A. C., Goodman, W. K., & Storch, E. A. (2023). Habit reversal training for excoriation disorder: Differential outcomes of Telehealth versus in-person treatments. Psychiatry Research Case Reports, 2(1), 100099. https://doi.org/10.1016/j.psycr.2022.100099

4. Asplund, M., Lenhard, F., Andersson, E., & Ivanov, V. (2022). Internet-delivered acceptance-based behavior therapy for trichotillomania and skin-picking disorder in a psychiatric setting: A feasibility trial. Internet Interventions, 30. Retrieved from https://www.sciencedirect.com/science/article/pii/S221478292200080X?via%3Dihub

5. Batchelor, R., Penn, C., & Anderson, C. (2024). Cognitive behavioural therapy including habit reversal training for treating dermatillomania in the context of anxiety and low mood. The Cognitive Behaviour Therapist, 17. https://doi.org/10.1017/s1754470x24000163