Treating Skin Picking with Acceptance-Enhanced Behavior Therapy

Treating Skin Picking with Acceptance-Enhanced Behavior Therapy

Excoriation or skin picking has often been in the shadow of its nearest relative, trichotillomania or repetitive hair pulling. One good thing to come out of the DSM-5 was that it finally made skin picking disorder an official diagnosis—excoriation. Prior to the DSM-5, there was no official diagnosis for this condition. I suspect the lack of official diagnosis slowed research into skin picking disorder. As a consequence, there are few published treatment studies for excoriation.

A recent study looked at the use of an acceptance-based protocol that was originally created for trichotillomania. The protocol is Woods & Twohig’s Trichotillomania: An ACT-enhanced Behavior Therapy Approach therapist guide, part of the respected Treatments That Work series of treatment manuals published by Oxford Press. The protocol combines Habit Reversal Training (HRT) with Acceptance and Commitment Therapy (ACT). From the study description, the protocol remains largely the same as the published trichotillomania version, except that information about hair pulling is swapped out for skin picking.

The study

Four people with excoriation completed courses of AEBT. Three of the four completed treatment in 10-sessions—the standard protocol length—whereas the 4th completed 25 sessions of treatment. All four responded to treatment, although the individual who completed 25 sessions (“Rose”) struggled with periodic lapses (sudden increases in picking) during treatment. Of note: one of the primary treatment responders (“Amy”) completed all but the initial session through web-based video-conferencing. Treatment appeared to successfully address both skin picking as well as co-occurring problems including anxiety, depression, and life stress.

Because this is a small, uncontrolled study, results should be interpreted cautiously. However, it provides some additional evidence that the AEBT protocol is as effective for skin picking as it is for hair pulling. One prior multiple baseline study of AEBT included 2 participants with skin picking and also found reductions in pulling.

For therapists interested in treatment excoriation and trichotillomania, the AEBT protocol is a commercially available and flexible treatment manual with very good research support for hair pulling and some very promising evidence for its use in treating excoriation. Additionally, this study provides some evidence that treatment produces changes in conditions that are co-morbid with picking such as anxiety and mood problems. I draw from the treatment manual in my own practice and have found the handouts and treatment framework particularly helpful.

If you’re interested in reading the full study, you can download a pre-publication copy here.

UPCOMING TRAINING EVENTS

November 8 and 9, 2019, 8:30 am – 4:30 pm · Portland, OR · Details

This two-day workshop provides a thorough overview of the theory, principles, and techniques of Acceptance and Commitment Therapy. It is intended for those who are relatively new to ACT and for those who have done some reading on their own about ACT but who may not have had the opportunity to participate in more experiential learning, practice case conceptualization, and receive feedback while practicing using the ACT model. Read more

April 17 and 18, 2020, 9:15 am – 5:00 pm · Portland, OR · Details

Do you ever “get stuck” as a therapist? Do some of your clients press your “hot buttons”? Do you ever find yourself struggling and thinking about “what do I do next” or feeling anxious, scared or stressed in therapy? In this workshop we will work on clarifying your therapist values and defining what is “difficult” about “difficult” clients. Through discussions, demonstrations and roleplays we will then work on these difficult clients and look at the processes from a compassionate ACT perspective. Read more