Excoriation (Skin-Picking) Disorder (SPD) is characterized by repetitive skin picking resulting in tissue damage. This study examined associations between the tendency to experience a sense of incompleteness (henceforth trait incompleteness) and pathological skin picking across two studies.
In study 1, undergraduate students (n = 481) completed self-report measures of skin picking severity, trait incompleteness, perfectionism, obsessive-compulsive symptoms, and negative affect (i.e., depression, anxiety). In study 2, undergraduate students with a diagnosis of SPD (n = 61) and a control group without SPD (n = 63) rated skin picking severity, trait incompleteness, obsessive-compulsive symptoms, and negative affect (i.e., depression, anxiety, and stress).
In study 1, linear regression showed that trait incompleteness significantly predicted skin picking severity, after controlling for other variables. In study 2, logistic regression showed trait incompleteness significantly predicted SPD diagnosis, after controlling for other variables. There was no significant correlation between incompleteness and symptom severity within the SPD group.
The results indicate a robust association between SPD and trait incompleteness. More research is needed to establish whether trait incompleteness may represent a vulnerability factor underlying SPD, or if skin picking leads to susceptibility to trait incompleteness.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Antony, M. M., Bieling, P. J., Cox, B. J., Enns, M. W., & Swinson, R. P. (1998). Psychometric properties of the 42-item and 21-item versions of the depression anxiety stress scales in clinical groups and a community sample. Psychological Assessment, 10, 176–181.
Belloch, A., Fornés, G., Carrasco, A., López-Solá, C., Alonso, P., & Menchón, J. M. (2016). Incompleteness and not just right experiences in the explanation of obsessive-compulsive disorder. Psychiatry Research, 236, 1–8.
Bjelland, I., Dahl, A. A., Haug, T. T., & Neckelmann, D. (2002). The validity of the hospital anxiety and depression scale: An updated literature review. Journal of Psychosomatic Research, 52, 69–77.
Bohne, A., Wilhelm, S., Keuthen, N. J., Baer, L., & Jenike, M. A. (2002). Skin picking in German students: Prevalence, phenomenology, and associated characteristics. Behavior Modification, 26, 320–339.
Bottesi, G., Cerea, S., Razzetti, E., Sica, C., Frost, R. O., & Ghisi, M. (2016). Investigation of the phenomenological and psychopathological features of trichotillomania in an Italian sample. Frontiers in Psychology, 7, 256.
Brown, T. A., Chorpita, B. F., & Barlow, D. H. (1998). Structural relationships among dimensions of the DSM-IV anxiety and mood disorders and dimensions of negative affect, positive affect, and autonomic arousal. Journal of Abnormal Psychology, 107, 179–192.
Coles, M. E., Frost, R. O., Heimberg, R. G., & Rhéaume, J. (2003). “Not just right experiences”: Perfectionism, obsessive-compulsive features and general psychopathology. Behaviour Research and Therapy, 41, 681–700.
Coles, M. E., Heimberg, R. G., Frost, R. O., & Steketee, G. (2005). Not just right experiences and obsessive-compulsive features: Experimental and self-monitoring perspectives. Behaviour Research and Therapy, 43, 153–167.
Dieringer, M., Beck, C., Verrel, J., Münchau, A., Zurowski, B., & Brandt, V. (2019). Quality and temporal properties of premonitory urges in patients with skin picking. Cortex, 121, 125–134.
Ecker, W., & Gönner, S. (2017). Current status of research concerning incompleteness in obsessive-compulsive disorder. Verhaltenstherapie, 27, 120–128.
Falkenstein, M. J. (2016). Clinical aspects of hair pulling, skin picking, and nail biting. Current Treatment Options in Psychiatry, 3, 375–384.
Foa, E. B., Huppert, J. D., Leiberg, S., Langner, R., Kichic, R., Hajcak, G., et al. (2002). Obsessive-compulsive inventory: Development of a short version. Psychological Assessment, 14, 485–496.
Franco, K., Díaz, F., Torres, P., Telléz, Y., & Hidalgo-Rasmussen, C. (2014). Internal consistency, test-retest reliability and construct validity of the frost multidimensional perfectionism scale. Revista Mexicana de Trastornos Alimentarios, 5, 91–97.
Frost, R. O., Marten, P., Lahart, C., & Rosenblate, R. (1990). The dimensions of perfectionism. Cognitive Therapy and Research, 14, 449–468.
Hayes, S. L., Storch, E. A., & Berlanga, L. (2009). Skin picking behaviors: An examination of the prevalence and severity in a community sample. Journal of Anxiety Disorders, 23, 314–319.
Herrmann, C. (1997). International experiences with the hospital anxiety and depression scale-a review of validation data and clinical results. Journal of Psychosomatic Research, 42, 17–41.
Integrated Postsecondary Education Data System 2020-21 Data Collection System. (2020). 12-month Enrollment 2020–21. Data report. Retrieved from https://www.wisconsin.edu/education-reports-statistics/download/ipeds(2)/12_month_enrollment/MIL_2020-21_12-month_Enrollment.pdf.
Keuthen, N. J., Koran, L. M., Aboujaoude, E., Large, M. D., & Serpe, R. T. (2010). The prevalence of pathologic skin picking in US adults. Comprehensive Psychiatry, 51, 183–186.
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, 337–341.
Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the beck depression and anxiety inventories. Behaviour Research and Therapy, 33, 335–343.
Neal, M., & Cavanna, A. E. (2013). “Not just right experiences” in patients with Tourette syndrome: Complex motor tics or compulsions? Psychiatry Research, 210, 559–563.
Neziroglu, F., Rabinowitz, D., Breytman, A., & Jacofsky, M. (2008). Skin picking phenomenology and severity comparison. Primary Care Companion, 10, 306–312.
Odlaug, B. L., Kim, S. W., & Grant, J. E. (2010). Quality of life and clinical severity in pathological skin picking and trichotillomania. Journal of Anxiety Disorders, 24, 823–829.
Ólafsson, R. P., Emmelkamp, P. M. G., Ólason, D. P., & Kristjánsson, A. (2020). Disgust and contamination concerns: The mediating role of harm avoidance and incompleteness. International Journal of Cognitive Therapy, 13, 251–270.
Parker, W. D., & Adkins, K. K. (1995). A psychometric examination of the multidimensional perfectionism scale. Journal of Psychopathology and Behavioral Assessment, 17, 323–334.
Phillips, K. A., Stein, D. J., Rauch, S. L., Hollander, E., Fallon, B. A., Barsky, A., et al. (2010). Should an obsessive-compulsive spectrum grouping of disorders be included in DSM-V? Depression and Anxiety, 27, 528–555.
Schmidt, J. P., & Stasik-O’Brien, S. M. (2017). Not just right experiences in obsessive-compulsive and related disorders. Psi Chi Journal of Psychology Research, 22, 193–205.
Sinclair, S. J., Siefert, C. J., Slavin-Mulford, J. M., Stein, M. B., Renna, M., & Blais, M. A. (2011). Psychometric evaluation and normative data for the Depression, Anxiety, and Stress Scales-21 (DASS-21) in a nonclinical sample of U.S. adults. Evaluation & the Health Professions, 35, 259–279.
Smári, J., Ólason, D. T., Eyþórsdóttir, Á., & Frölunde, M. B. (2007). Psychometric properties of the obsessive compulsive inventory-revised among Icelandic college students. Scandinavian Journal of Psychology, 48, 127–133.
Snorrason, I., Belleau, E. L., & Woods, D. W. (2012a). How related are hair pulling disorder (trichotillomania) and skin picking disorder? A review of evidence for comorbidity, similarities and shared etiology. Clinical Psychology Review, 32, 618–629.
Snorrason, I., Ólafsson, R. P., Flessner, C. A., Keuthen, N. J., Franklin, M. E., & Woods, D. W. (2012b). Skin picking scale-revised: Factor structure and psychometric properties. Journal of Obsessive-Compulsive and Related Disorders, 1, 133–137.
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, 238–245.
Snorrason, I., Smári, J., & Ólafsson, R. P. (2011). Motor inhibition, reflection impulsivity, and trait impulsivity in pathological skin picking. Behavior Therapy, 42, 521–532.
Summerfeldt, L. J. (2004). Understanding and treating incompleteness in obsessive-compulsive disorder. Journal of Clinical Psychology, 60, 1155–1168.
Summerfeldt, L. J., Kloosterman, P. H., Antony, M. M., & Swinson, R. P. (2014). Examining an obsessive-compulsive core dimensions model: Structural validity of harm avoidance and incompleteness. Journal of Obsessive-Compulsive and Related Disorders, 3, 83–94.
Summers, B. J., Matheny, N. L., & Cougle, J. R. (2017). ‘Not just right’ experiences and incompleteness in body dysmorphic disorder. Psychiatry Research, 247, 200–207.
Taylor, S., McKay, D., Crowe, K. B., Abramowitz, J. S., Conelea, C. A., Calamari, J. E., & Sica, C. (2014). The sense of incompleteness as a motivator of obsessive-compulsive symptoms: An empirical analysis of concepts and correlates. Behavior Therapy, 45, 254–262.
Tucker, B. T. P., 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, 88–95.
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, 127–135.
Wilhelm, S., Keuthen, N. J., Deckersbach, T., Engelhard, I. M., Forker, A. E., Bear, L., et al. (1999). Self-injurious skin picking: Clinical characteristics and comorbidity. Journal of Clinical Psychiatry, 60, 454–459.
Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67, 361–370.
Conflict of interest
Dr. Ricketts has received research support from the BFRB Precision Medicine Initiative granted by the TLC Foundation for Body-Focused Repetitive Behaviors, and National Institute of Mental Health (NIMH). Dr. Snorrason, Dr. Ólafsson, Ms. Sigurvinsdottir and Mr. Mathew declare that they have no conflict of interest. Dr. Woods has received royalties from Oxford University Press and Springer Press. Dr. Lee has received research support from the TLC Foundation for Body-Focused Repetitive Behaviors, and the Tourette Association of America.
Research Involving Human Participants
Study 1 approval was granted by the National Bioethics Committee of Iceland and study 2 approval by the University of Wisconsin-Milwaukee Institutional Review Board. These studies were performed in line with the principles of the Declaration of Helsinki.
Informed consent was obtained from all participants included in these studies.
No animal studies were carried out by the authors for this article.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Ricketts, E.J., Snorrason, Í., Mathew, A.S. et al. Heightened Sense of Incompleteness in Excoriation (Skin-Picking) Disorder. Cogn Ther Res (2021). https://doi.org/10.1007/s10608-020-10201-5
- Just right