Abstract
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.
Similar content being viewed by others
References
Alexander, J. R., Houghton, D. C., Bauer, C. C., Lench, H. C., & Woods, D. W. (2018). Emotion regulation deficits in persons with body-focused repetitive behavior disorders. Journal of Affective Disorders, 227, 463–470. https://doi.org/10.1016/j.jad.2017.11.035.
Basch, E. (2017). Patient-reported outcomes - harnessing patients’ voices to improve clinical care. The New England Journal of Medicine, 376(2), 105–108. https://doi.org/10.1056/NEJMp1611252.
Capriotti, M. R., Ely, L. J., Snorrason, I., & Woods, D. W. (2015). Acceptance-Enhanced behavior therapy for excoriation (skin-picking) disorder in adults: A clinical case series. Cognitive and Behavioral Practice, 22(2), 230–239. https://doi.org/10.1016/j.cbpra.2014.01.008.
Clark, S. L., & Muthén, B. (2009). Relating Latent Class Analysis Results to Variables Not Included in the Analysis. Avaliable online at: http://www.statmodel.com/download/relatinglca.pdf.
Curtiss, J. E., Levine, D. S., Ander, I., & Baker, A. W. (2021). Cognitive-behavioral treatments for anxiety and stress-related disorders. Focus (American Psychiatric Publishing), 19(2), 184–189. https://doi.org/10.1176/appi.focus.20200045.
Feczko, E., & Fair, D. A. (2020). Methods and challenges for assessing heterogeneity. Biological Psychiatry, 88(1), 9–17. https://doi.org/10.1016/j.biopsych.2020.02.015.
Flessner, C. A., & Woods, D. W. (2006). Phenomenological characteristics, social problems, and the economic impact associated with chronic skin picking. Behavior Modification, 30(6), 944–963. https://doi.org/10.1177/0145445506294083.
Flessner, C. A., Busch, A. M., Heideman, P. W., & Woods, D. W. (2008). Acceptance-Enhanced behavior therapy (AEBT) for trichotillomania and chronic skin picking: Exploring the effects of component sequencing. Behavior Modification, 32(5), 579–594. https://doi.org/10.1177/0145445507313800.
Grant, J. E., & Chamberlain, S. R. (2022). Skin picking disorder: Does a person’s sex matter? Annals of Clinical Psychiatry, 34(1), 15–20. https://doi.org/10.12788/acp.0049.
Grant, J. E., Stein, D. J., Woods, D. W., & Keuthen, N. J. (2012). Trichotillomania, skin picking, and other body-focused repetitive behaviors. American Psychiatric Pub.
Grant, J. E., Peris, T. S., Ricketts, E. J., Lochner, C., Stein, D. J., Stochl, J., Chamberlain, S. R., Scharf, J. M., Dougherty, D. D., Woods, D. W., Piacentini, J., & Keuthen, N. J. (2021). Identifying subtypes of trichotillomania (hair pulling disorder) and excoriation (skin picking) disorder using mixture modeling in a multicenter sample. Journal of Psychiatric Research, 137, 603–612. https://doi.org/10.1016/j.jpsychires.2020.11.001.
Hallion, L. S., Tung, E. S., & Keuthen, N. J. (2017). Phenomenology of Excoriation (Skin Picking) Disorder. In The Wiley Handbook of Obsessive Compulsive Disorders (eds J.S. Abramowitz, D. McKay and E.A. Storch). https://doi.org/10.1002/9781118890233.ch45.
Hicks, M. M., Mouton-Odum, S., Patyk, K. C., Zamora, R. J., & De Nadai, A. S. (2023). Latent class analysis of emotions experienced during compulsive hair-pulling episodes. Journal of Behavior Therapy and Experimental Psychiatry, 81, 101882. https://doi.org/10.1016/j.jbtep.2023.101882.
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.
Kass, R. E., & Raftery, A. E. (1995). Bayes factors. Journal of the American Statistical Association, 90(430), 773–795. https://doi.org/10.1080/01621459.1995.10476572.
Keuthen, N. J., O’Sullivan, R. L., Ricciardi, J. N., Shera, D., Savage, C. R., Borgmann, A. S., Jenike, M. A., & Baer, L. (1995). The Massachusetts General Hospital (MGH) Hairpulling Scale: 1. Development and factor analyses. Psychotherapy and Psychosomatics, 64(3–4), 141–145. https://doi.org/10.1159/000289003.
Keuthen, N. J., Wilhelm, S., Deckersbach, T., Engelhard, I. M., Forker, A. E., Baer, L., & Jenike, M. A. (2001). The skin picking scale: Scale construction and psychometric analyses. Journal of Psychosomatic Research, 50(6), 337–341. https://doi.org/10.1016/s0022-3999(01)00215-x.
Keuthen, N. J., Koran, L. M., Aboujaoude, E., Large, M. D., & Serpe, R. T. (2010a). The prevalence of pathologic skin picking in US adults. Comprehensive Psychiatry, 51(2), 183–186. https://doi.org/10.1016/j.comppsych.2009.04.003.
Keuthen, N. J., Rothbaum, B. O., Welch, S. S., Taylor, C., Falkenstein, M., Heekin, M., & Jenike, M. A. (2010b). Pilot trial of dialectical behavior therapy-enhanced habit reversal for trichotillomania. Depression and Anxiety, 27(10), 953–959. https://doi.org/10.1002/da.20732.
Keuthen, N. J., Rothbaum, B. O., Fama, J., Altenburger, E., Falkenstein, M. J., Sprich, S. E., & Welch, S. S. (2012). DBT-enhanced cognitive-behavioral treatment for trichotillomania: A randomized controlled trial. Journal of Behavioral Addictions, 1(3), 106–114. https://doi.org/10.1556/jba.1.2012.003.
Kwon, C., Sutaria, N., Khanna, R., Almazan, E., Williams, K., Kim, N., Elmariah, S., & Kwatra, S. G. (2020). Epidemiology and comorbidities of excoriation disorder: A retrospective case-control study. Journal of Clinical Medicine, 9(9), 2703. https://doi.org/10.3390/jcm9092703.
Lee, M. T., Mpavaenda, D. N., & Fineberg, N. A. (2019). Habit reversal therapy in obsessive compulsive related disorders: A systematic review of the evidence and CONSORT evaluation of randomized controlled trials. Frontiers in Behavioral Neuroscience, 13, 79. https://doi.org/10.3389/fnbeh.2019.00079.
Leppink, E. W., Redden, S. A., & Grant, J. E. (2016). Impulsivity in body-focused repetitive behavior disorders: Disparate clinical associations between three distinct measures. International Journal of Psychiatry in Clinical Practice, 20(1), 24–31. https://doi.org/10.3109/13651501.2015.1102947.
Lin, A., Farhat, L. C., Flores, J. M., Levine, J. L. S., Fernandez, T. V., Bloch, M. H., & Olfson, E. (2023). Characteristics of trichotillomania and excoriation disorder across the lifespan. Psychiatry Research, 322, 115120. https://doi.org/10.1016/j.psychres.2023.115120.
Mansueto, C. S. (2013). Trichotillomania (hair pulling disorder): Conceptualization and treatment. Independent Practitioner, 4(33), 120–127.
Moritz, S., Fricke, S., Treszl, A., & Wittekind, C. E. (2012). Do it yourself! Evaluation of self-help habit reversal training versus decoupling in pathological skin picking: A pilot study. Journal of Obsessive-Compulsive and Related Disorders, 1(1), 41–47. https://doi.org/10.1016/j.jocrd.2011.11.001.
Muthén, L., & Muthén, B. (2017). Mplus user’s guide (8th ed.). Los Angeles, CA: Muthén and Muthén.
Najera, D. B. (2022). Body-focused repetitive behaviors: Beyond bad habits. JAAPA: Official Journal of the American Academy of Physician Assistants, 35(2), 28–33. https://doi.org/10.1097/01.JAA.0000817812.38558.1a.
Neziroglu, F., Rabinowitz, D., Breytman, A., & Jacofsky, M. (2008). Skin picking phenomenology and severity comparison. Primary Care Companion to the Journal of Clinical Psychiatry, 10(4), 306–312. https://doi.org/10.4088/pcc.v10n0406.
Odlaug, B. L., Lust, K., Schreiber, L. R., Christenson, G., Derbyshire, K., & Grant, J. E. (2013). Skin picking disorder in university students: Health correlates and gender differences. General Hospital Psychiatry, 35(2), 168–173. https://doi.org/10.1016/j.genhosppsych.2012.08.006.
Oh, Y., Choi, J., Song, Y. M., Jhung, K., Lee, Y. R., Yoo, N. H., & Kim, Y. (2020). Defining subtypes in children with nail biting: A latent profile analysis of personality. Psychiatry Investigation, 17(6), 517–525. https://doi.org/10.30773/pi.2019.0015.
Pozza, A. (2023). Chapter 9 - Skin picking and hair pulling disorders in children and adolescents: The role of cognitive behavior therapy. In C. R. Martin, V. B. Patel, & V. R. Preedy (Eds.), Handbook of Lifespan Cognitive Behavioral Therapy (pp. 101–108). Academic Press. https://doi.org/10.1016/B978-0-323-85757-4.00033-X.
Pozza, A., Albert, U., & Dèttore, D. (2020). Early maladaptive schemas as common and specific predictors of skin picking subtypes. BMC Psychology, 8(1), 27. https://doi.org/10.1186/s40359-020-0392-y.
Prochwicz, K., Antosz-Rekucka, R., Kaluzna-Wielobob, A., Sznajder, D., & Klosowska, J. (2022). Negative affectivity moderates the relationship between attentional control and focused skin picking. International Journal of Environmental Research and Public Health, 19(11), 6636. https://doi.org/10.3390/ijerph19116636.
Ricketts, E. J., Snorrason, Í., Kircanski, K., Alexander, J. R., Thamrin, H., Flessner, C. A., Franklin, M. E., Piacentini, J., & Woods, D. W. (2018). A latent profile analysis of age of onset in pathological skin picking. Comprehensive Psychiatry, 87, 46–52. https://doi.org/10.1016/j.comppsych.2018.08.011.
Schienle, A., Zorjan, S., Übel, S., & Wabnegger, A. (2018). Prediction of automatic and focused skin picking based on trait disgust and emotion dysregulation. Journal of Obsessive-Compulsive and Related Disorders, 16, 1–5. https://doi.org/10.1016/j.jocrd.2017.10.006.
Snorrason, I., Smári, J., & Ólafsson, R. P. (2010). Emotion regulation in pathological skin picking: Findings from a non-treatment seeking sample. Journal of Behavior Therapy and Experimental Psychiatry, 41(3), 238–245. https://doi.org/10.1016/j.jbtep.2010.01.009.
Snorrason, I., Berlin, G. S., & Lee, H. J. (2015). Optimizing psychological interventions for trichotillomania (hair-pulling disorder): An update on current empirical status. Psychology Research and Behavior Management, 8, 105–113. https://doi.org/10.2147/PRBM.S53977.
Snorrason, I., Goetz, A. R., & Lee, H. J. (2017). Psychological treatment of Excoriation Disorder. The Wiley Handbook of Obsessive Compulsive Disorders, 2, 990–1008.
Teng, E. J., Woods, D. W., & Twohig, M. P. (2006). Habit reversal as a treatment for chronic skin picking: A pilot investigation. Behavior Modification, 30(4), 411–422. https://doi.org/10.1177/0145445504265707.
Tucker, B. T., Woods, D. W., Flessner, C. A., Franklin, S. A., & Franklin, M. E. (2011). The skin picking Impact Project: Phenomenology, interference, and treatment utilization of pathological skin picking in a population-based sample. Journal of Anxiety Disorders, 25(1), 88–95. https://doi.org/10.1016/j.janxdis.2010.08.007.
Walther, M. R., Flessner, C. A., Conelea, C. A., & Woods, D. W. (2009). The Milwaukee Inventory for the Dimensions of adult skin picking (MIDAS): Initial development and psychometric properties. Journal of Behavior Therapy and Experimental Psychiatry, 40(1), 127–135. https://doi.org/10.1016/j.jbtep.2008.07.002.
Weller, B. E., Bowen, N. K., & Faubert, S. J. (2020). Latent class analysis: A guide to best practice. Journal of Black Psychology, 46(4), 287–311. https://doi.org/10.1177/0095798420930932.
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.
Woods, D. W., Ely, L. J., Bauer, C. C., Twohig, M. P., Saunders, S. M., Compton, S. N., & Franklin, M. E. (2022). Acceptance-enhanced behavior therapy for trichotillomania in adults: A randomized clinical trial. Behaviour Research and Therapy, 158, 104187. https://doi.org/10.1016/j.brat.2022.104187.
Xavier, A. C. M., de Souza, C. M. B., Flores, L. H. F., Bermudez, M. B., Silva, R. M. F., de Oliveira, A. C., & Dreher, C. B. (2020). Skin picking treatment with the Rothbaum cognitive behavioral therapy protocol: A randomized clinical trial. Revista Brasileira de Psiquiatria, 42(5), 510–518. https://doi.org/10.1590/1516-4446-2019-0636.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Participant information was de-identified by the online treatment program that was the source of study data (StopPicking.com), and approval for research use of the data was granted by the Texas State University Institutional Review Board (IRB).
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic Supplementary Material
Below is the link to the electronic supplementary material.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
De Nadai, A. Defining Compulsive Skin Picking Subgroups Based on Emotional Response Patterns and Data-Driven Methodology. Cogn Ther Res 48, 137–146 (2024). https://doi.org/10.1007/s10608-023-10431-3
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10608-023-10431-3