Journal of Obsessive-Compulsive and Related Disorders 1 (2012) 41–47

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Journal of Obsessive-Compulsive and Related Disorders

journal homepage: www.elsevier.com/locate/jocrd

Do it yourself! Evaluation of self-help habit reversal training versus

decoupling in pathological skin picking: A pilot study
Steffen Moritz a,n,1, Susanne Fricke a,1, András Treszl b, Charlotte E. Wittekind a
a
University Medical Center in Hamburg-Eppendorf, Department of Psychiatry and Psychotherapy, Martinistr. 52, D-20246 Hamburg, Germany
b
University Medical Center in Hamburg-Eppendorf, Department of Medical Biometry and Epidemiology, Martinistr. 52, D-20246 Hamburg, Germany

a r t i c l e i n f o abstract

Article history: Pathological skin picking (PSP) is a rather frequent but yet underrecognized impulse control disorder at
Received 18 August 2011 the crossroads of dermatology, psychology, and psychiatry. The present pilot study assessed the
Received in revised form feasibility and efficacy of self-help interventions in the disorder. Habit reversal training (HRT), the
28 October 2011
current treatment-of-choice intervention, was tested against a newly developed technique entitled
Accepted 8 November 2011
decoupling (DC). Both techniques were conveyed by bibliotherapy. A total of 70 subjects with PSP were
Available online 15 November 2011
recruited via self-help forums and were randomly allocated either to HRT or DC. Manuals were sent via
Keywords: email attachment. Four weeks after the dispatch of the manual, each participant was recontacted and
Skin picking underwent the same questionnaires as before, which included the Modified Skin Picking Scale (M-SPS).
Impulse control
Pre-post comparisons indicated a strong symptom decline under HRT but not DC. Every second patient
Habit reversal training
reported a symptom decline due to HRT relative to every third patient in the DC condition (50% versus
Cognition
Decoupling 33%). The study affirms the efficacy of self-help HRT but discourages the usage of DC in PSP. Possible
Behavior therapy reasons why DC has exerted positive effects in prior trials on trichotillomania and pathological nail-
biting but not PSP are put forward.
& 2011 Elsevier Ltd. All rights reserved.

1. Introduction prevalence rates are therefore lacking, the available literature

Pathological skin picking (PSP) is a body-focused behavior
characterized by the repetitive scratching and picking of the skin.
PSP is sometimes also described as stereotypic movement disorder
(Stein et al., 2007). Whereas the majority of patients pick their
skin with their fingernails and fingers, some patients (52%) also
employ instruments such as pins or tweezers (Arnold et al., 1998;
Tucker, Woods, Flessner, Franklin, & Franklin, 2010; Wilhelm et al.,
1999). Skin picking may involve all body parts. Notwithstanding
that the phenomenology was first described more than 130 years
ago (see Fruensgaard, Hjortshøj, & Nielsen, 1978) and carries many
(virtually) synonymous terms (e.g., Acne Excoriée, neurotic excoria-
tion, psychogenic excoriation, dermatotillomania, body focused
repetitive behavior), as of yet it is both underrecognized and under-
diagnosed by many clinicians (Neziroglu, Rabinowitz, Breytman, &
Jacofsky, 2008). Many patients regard PSP as a bad habit and are
neither aware that it is considered a disorder nor that treatment is
available (Neziroglu et al., 2008).
Diagnostic screening instruments usually do not assess PSP
and most clinicians accordingly fail to ask about it. While solid
n
Corresponding author. Tel.: þ49 40 7410 56565; fax: þ 49 40 7410 57566.
E-mail address: moritz@uke.de (S. Moritz).
1
The first two authors split authorship.
suggests that PSP is not a rare disorder supporting current efforts
to add and explicitly name PSP in the DSM-V. In a community
sample (Hayes, Storch, & Berlanga, 2009), 62.7% of the partici-
pants endorsed some form of skin picking and 5.4% had clinical
levels of skin picking. In a study conducted by Bohne, Wilhelm,
Keuthen, Baer, and Jenike (2002), more than 90% of students
reported occasional skin picking. Based on a telephone survey on
2513 adult Americans, 16.6% (n ¼416) disclosed having suffered
from marked skin injuries due to skin picking (Keuthen, Koran,
Aboujaoude, Large, & Serpe, 2010). This proportion dropped to
1.4% (n¼34) when additional criteria had to be met such as
significant psychosocial impairments.
The clinical underrecognition of PSP is concerning in view of
its occasional severe somatic consequences. PSP can result in
various somatic complications including infections, tissue
damage, bleeding, injuries, and bruises (Neziroglu et al., 2008).
PSP may even culminate in life-threatening incidences. O’Sullivan,
Phillips, Keuthen, and Wilhelm (1999) reported a case where a
patient with PSP secondary to body dysmorphic disorder nearly
lacerated her carotid artery as a result of using tweezers in an
attempt to remove a perceived defect from her skin. Moreover, a
considerable subgroup of patients suffers from suicidal ideation
due to skin picking (Arnold et al., 1998).
Like other impulse control disorders, pathological picking is
usually preceded by negative emotions such as anxiety, tension,

2211-3649/$ - see front matter & 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jocrd.2011.11.001
42 S. Moritz et al. / Journal of Obsessive-Compulsive and Related Disorders 1 (2012) 41–47
and boredom (e.g., Keuthen et al., 2010; Wilhelm et al., 1999).
During picking, many patients report a (mesmerized) trance-like
mental state, satisfaction, and relief (Arnold et al., 1998;
Snorrason, Smari, & Olafsson, 2010; Wilhelm et al., 1999). In
stark contrast, these short-term positive feelings later fade and
are overshadowed by shame, pain, and guilt (Snorrason et al.,
2010; Wilhelm et al., 1999). Further, a subgroup of patients adopt
skin picking as an emotion regulation strategy (Deckersbach,
Wilhelm, Keuthen, Baer, & Jenike, 2002; Wilhelm et al., 1999)
and the disorder has been associated with difficulties in emotion
regulation (Snorrason et al., 2010).
Apart from psychopharmacotherapy (mainly antidepressant
medication; see Arnold, Auchenbach, & McElroy, 2001), cognitive-
behavioral techniques, especially habit reversal training (HRT),
currently represent the treatment-of-choice. HRT (Azrin & Nunn,
1973) involves different behavioral techniques, whereby awareness
training and competing response training (CRT) are considered
its most essential elements (Woods & Miltenberger, 1995). CRT
teaches patients to substitute the misbehavior with a (freezing)
alternative behavior (e.g., clenching one’s fist for some time or
holding tight to a stone). The new behavior should be contingent
upon the occurrence of the target behavior (Miltenberger & Fuqua,
1985). Various (small) studies assert the efficacy of HRT in the
disorder. Twohig and Woods (2001) employed HRT in two adults
with chronic skin-picking problems. Decreases in self-reported skin
picking were confirmed by independent ratings. However, the
behavior was not eliminated and treatment gains were maintained
for only one participant after three months. In another trial
conducted by the same group (Teng, Woods, & Twohig, 2006), 25
subjects were allocated to either HRT or a wait-list control group.
Despite few treatment sessions HRT exerted large effects, which
were maintained at follow-up. In a small study on five patients,
acceptance-enhanced behavior therapy (AEBT) involving HRT
greatly reduced both picking and trichotillomania (TTM) in all
participants (Flessner, Busch, Heideman, & Woods, 2008). Other
successful case reports were published by Kent and Drummond
(1989) on a single patient who maintained treatment gains after
4 months and Deckersbach et al. (2002) on three patients.
Deckersbach et al. (2002, p. 374) speculate that HRT may be less
effective in patients who – reminiscent of borderline personality
disorder – engage in skin picking as a form of emotion regulation. In
contrast, those who pick habitually may experience greater ther-
apeutic benefit. Whereas HRT emerged as effective across all prior
studies, these investigations are limited by several factors, most
notably small sample sizes and uncontrolled designs. A recent
randomized controlled study on 34 college students with PSP
demonstrated that brief cognitive-behavioral therapy (non-HRT)
produced large effect sizes relative to a wait-list control, which
were maintained at follow-up (Schuck, Keijsers, & Rinck, 2011).
A variant of HRT entitled decoupling (DC) has been recently
developed by our group (Moritz & Rufer, 2010). Both HRT and DC
interfere at the motor level. The core difference concerns the
terminal movement. Whereas HRT teaches the subject to perform
Fig. 1. Competing response training (CRT) as a part of HRT. Options for competitive responses: clenching fists (A), sitting on hands (B) or folding hands (C).
an antagonistic behavior (e.g., clenching one’s fist) for some time
instead of the malbehavior, DC requests that the subject performs
a motor sequence that mimics the usual behavioral pattern (e.g.,
PSP) but alters its behavioral goal: the original movement is
deviated rather than frozen. Close to the former behavioral goal, a
new terminal movement with a different (benign) behavioral
target (e.g., nose, ear, point in room) is executed, preferably with
an accelerated movement (see Fig. 1). The accelerated movement
is aimed to override the previous motor sequence and create
motor irritation when impulses for the misbehavior – which is
often not available to consciousness – surface. The presumed
irritation may then reach awareness allowing initiation of active
self-control strategies. The technique has been successfully tested
in TTM and pathological nail-biting (PNB) as a self-help strategy.
The on-line administration of this technique over a period of
4 weeks led to a significant decline of TTM (Moritz & Rufer, 2010)
and PNB (Moritz, Treszl, & Rufer, 2011) relative to an active
control intervention. Despite tentative evidence for the efficacy of
DC, its theoretical rationale needs further empirical testing.
1.1. How to reach the untreated?
Patients with PSP rarely seek dermatologic or psychiatric
treatment (Grant & Odlaug, 2009). In the population investigated
by Neziroglu et al. (2008) only 30% sought specific help for PSP. In
view of the apparent large treatment gap in PSP reflecting poor
treatment motivation, shame, stigma, but also poor dissemination
of knowledge and treatment options among clinicians, many
patients attempt to cope with the symptoms themselves or turn
to other patients via internet help forums. There is preliminary
evidence that information conveyed via the internet may well
ameliorate symptoms. Flessner, Mouton-Odum, Stocker, and
Keuthen (2007) assessed the feasibility of a commercial web page
devoted to PSP called www.StopPicking.com. The web site
includes both diagnostic and intervention tools. The program first
assesses and then increases awareness of variables subserving SP
and then conveys coping skills and techniques to reduce the
frequency and severity of PSP symptoms and to maintain treat-
ment gains. The program offers education about SP and provides
links to various resources and relevant upcoming events and
publications. Uncontrolled pre–post assessments indicate that
while the majority of patients discontinue usage of the program
after some time and very few complete all of its modules, it brings
substantial symptom relief to many of its users. A total of 63%
percent of the sample showed a reduction of at least 25% on the
Skin Picking Scale (SPS; Keuthen et al., 2001).
1.2. The present study
The present study tested HRT versus DC. To reach the majority
of untreated patients with PSP an internet trial was set up. It is an
advantage of self-help interventions that they can be carried out
by patients in the privacy of their homes without fear of
 S. Moritz et al. / Journal of Obsessive-Compulsive and Related Disorders 1 (2012) 41–47
embarrassment. DC and HRT, especially CRT, are techniques that
can be easily learnt by patients and may not necessarily require a
therapist, although therapist-guided psychotherapy is usually
more successful than pure self-help (Moritz, Wittekind,
Hauschildt, & Timpano, 2011). Despite inherent methodological
limitations of internet research (i.e., no external validity of
diagnoses, possible abuse), internet studies in our view represent
an important complementary approach to clinical studies and are
especially valuable at the early stages of treatment developments,
rare illnesses/disorders or conditions for which professional
treatment is seldom sought or provided as in PSP. If certain
precautions are met (see Section 4), psychometric properties,
completion rates, and fidelity are satisfactory, even for patients
with severe psychiatric disorders (Chinman, Young, Schell,
Hassell, & Mintz, 2004; Moritz, Jelinek, Hauschildt, & Naber,
2010; Ritter, Lorig, Laurent, & Matthews, 2004; Riva, Teruzzi, &
Anolli, 2003). Moreover, sample differences between help-seeking
and non-help-seeking patients preclude the generalization of
results derived from conventional clinical studies to the entire
population (Doherty & Kartalova-O’Doherty, 2010; Vogel & Wade,
2009). Consequently, internet studies are more of a complement
rather than a suboptimal alternative to clinical trials.
For the present study, we hypothesized that HRT and DC
would create significant and similar symptom reduction on the
primary outcome measures.
2. Methods
2.1. Participants
We posted an invitation for an internet-delivered self-help trial on several
German internet self-help forums and information boards devoted to PSP or skin
problems in general. The target techniques were not described beforehand to
prevent recruitment biases. The following inclusion criteria were applied: partici-
pants had to suffer from skin picking (i.e., defined as excessive manipulation of the
skin; the symptomatology of skin picking was explained to prevent that the
invitation would attract subjects with skin conditions other than skin picking),
had sufficient time to work through the manual, and had to provide consent to
participate in two anonymous (internet-based) surveys. In view of the pilot
character of the study, no special exclusion criteria were applied, mirroring a new
trend in intervention research to collect representative (typical) samples (Hollon &
Wampold, 2009). Moreover, our aim was to learn more about factors potentially
moderating outcome. Potential participants were informed that the study was
anonymous, free of charge, and would not involve direct therapeutic support. No
compensation was offered for study participation. However, each participant
received one out of two possible treatment techniques immediately after the
baseline survey, and the other manual at the end of the second survey. Recruitment
was stopped blind to results after 70 people fulfilling inclusion criteria had been
recruited (see Table 1).
2.2. Materials and procedure
2.2.1. Baseline survey
If interested, subjects could click on the web link of the invitation directing them
to the baseline survey. The survey was constructed with uniparks and utilized
‘‘cookies’’ as a means of preventing multiple log-ons from the same computer. The
software automatically collects data upon entry but does not store IP addresses. On
the first page of the baseline survey, the text from the web page was essentially
repeated and subjects had to click a button in order to provide consent. The survey
contained the following sections: introduction, sociodemographic questions (e.g., age,
gender, and school education), medical history (e.g., previous and current treatments,
person who determined the diagnosis, time when skin picking started, comorbid
diagnoses) and a psychopathology section. The psychopathology section encom-
passed established questionnaires (see Section 2.5). At the end of the survey,
participants were required to enter their email address and a password to allow
the dispatch of one of the treatment manuals and (anonymous) identification at the
post-intervention phase. No other personal information such as the telephone
number or postal address was requested, not even optionally.
2.2.2. Treatment allocation
Participants completing the baseline survey were randomly allocated to either
HRT or DC using a fixed randomization plan according to the order of registration.
43
The treatment manual was then emailed individually as a PDF-file within 24 h, along
with brief instructions. A link was provided to download Adobe Readers in case the
PDF-documents could not be opened. Participants were provided the email address of
the first author in case of (technical) questions. However, only one patient asked for
technical advice.
HRT was described on a 5-page PDF file (free download at http://www.uke.de/
impulskontrolle). The manual first introduced the phenomenology of PSP and
described potential somatic and social consequences. The program consisted of
three steps: first, prior to the application of the core exercises, subjects were asked
to identify (contextual) triggers for skin picking, which had to be entered into a
table (e.g., watching TV, stress, boredom). Second, the theoretical rationale of HRT
was introduced. Patients were familiarized with the idea of adopting antagonistic
behaviors for 1–3 min once an urge to pick skin was sensed (competing response
training, CRT). Several examples of static behavior were provided and described
along with pictures (see Fig. 1). In the last step, the patient was instructed how to
implement the technique into his or her daily life.
DC was described on a 5(1/2)-page PDF file. The first part was identical to the
HRT manual. Subsequently, the theoretical rationale was introduced, which was
half a page longer than the description of HRT, as the technique is somewhat more
complicated than HRT. Patients were familiarized with the idea of shaping the
malbehavior into a similar but benign behavior by means of decoupling the
involved behavioral elements. Then, the core exercises were taught. Subjects were
instructed to perform a movement that resembles the previous malbehavior (e.g.,
soft movement towards skin), but then close to the prior behavioral target (i.e.,
skin) to deviate the movement and target either another part of the body or a
certain point in the room with an accelerated movement. Instructions were
illustrated by a sequence of photos depicting the different stages of DC (see
Fig. 2). DC can be exercised even in symptom-free intervals.
2.2.3. Reassessment (4 weeks later)
Four weeks after completion of the baseline assessment, participants were
recontacted via email and requested to undergo the second (final) evaluation. A
new link directed them to the posttreatment survey. Subjects were requested to
participate in the survey regardless of whether they had benefited from the
technique or had actually read the manual. In case participants did not respond,
they were reminded twice (after each 3–4 days had elapsed).
On the first page of the postsurvey, participants were requested to enter either
their email address or the code word from the baseline assessment for matching
baseline and post-test data. The postintervention survey contained the same
questionnaires as the baseline survey (see Section 2.2.4). In addition, completers
were asked to indicate if they had known or practiced the respective technique
before. For participants who affirmed having read the manual, additional ques-
tions were posed relating to feasibility, subjective effectiveness, comprehensibility
of the manual, and applicability to their problem (see Table 2; 4-point likert scale:
fully agree, almost agree, somewhat agree, do not agree—the first three response
options are aggregated in Table 2 to one ‘‘yes’’ score). Subjects were also given the
option to leave comments. At the end of the assessment, a zip-file with both
techniques (HRT, DC) could be downloaded. The email address of the first author
was again displayed in case of questions or remarks. After the study was
terminated, all participants were informed about the main study results via email,
and a summary of the results was posted on the internet forums, which had
previously posted the invitation.
2.2.4. Questionnaires
A modified 10-item version of the Skin Picking Scale (SPS; Keuthen et al.,
2001) served as the primary outcome parameter (M-SPS; Bohne, in preparation).
Whereas the original version was inspired and modeled after the Yale–Brown
Obsessive-Compulsive Scale (Y–BOCS; Goodman et al., 1989), the modified version
also included aspects of the Massachusetts General Hospital (MGH) Hairpulling
Scale (Keuthen et al., 1995). The M-SPS measures the following items: 1. frequency
of the urge to pick skin, 2. intensity of the urge to pick skin, 3. control over the
urge to pick skin, 4. frequency of skin picking, 5. severity of skin picking, 6.
resistance to skin picking, 7. control over skin picking, 8. distress/suffering, 9.
impairment, 10. avoidance. Every item is scored on a 5-point likert scale from 0 to
4. For the original instrument, reliability (Cronbach’s a ¼ .8) and construct validity
(significant correlation between the total score and the self-reported duration of
skin picking episodes) have been demonstrated, which await to be established for
the modified version (see end of Section 3 for data on internal consistency).
As subjects with PSP and other impulse control disorders often display
depressive symptoms, we administered a questionnaire tapping depression: the
short form of the Beck Depression Inventory (BDI-SF; Beck & Steer, 1993;
Furlanetto, Mendlowicz, & Romildo Bueno, 2005). It has good to excellent
psychometric properties (Furlanetto et al., 2005). The 4-week retest reliability
assessed via the internet was r ¼ .84 (Moritz et al., 2010).
2.3. Strategy of data analysis
We performed both per protocol (PP) and intention-to-treat (ITT) analyses. PP
analyses only considered participants with complete data (i.e., pre–post) who had
44 S. Moritz et al. / Journal of Obsessive-Compulsive and Related Disorders 1 (2012) 41–47

accelerated movement

Fig. 2. Decoupling. In steps A and B the hand should move in direction to the skin very similar to the skin picking movement (copy of old behavioral pattern). In step C, the
hand is then either (C1, Alternative 1) directed onto a different behavioral goal (ear) or to a certain point in the room (C2, Alternative 2). The last movement should be
performed with an accelerated movement to override and counteract the prior behavioral pattern. For display purposes, the depicted decoupling movements are widely
visible but should be performed more conspicuously.

Table 1
Baseline characteristics of the sample (N ¼70).

Variable Decoupling (n¼35) HRT (n¼ 35) Statistics

Background variables
Gender (% female) 89 97 Fisher’s exact test, p 4.3
Age in years 29.54 (6.70) 28.37 (5.74) t(68)¼ .88, p 4.3
Years of school 12.74 (.85) 12.29 (1.34) t(68)¼ 1.70, p ¼ .09

Treatment
Currently on psychotropic medication in general 17% 23% w2(1) ¼.36, p 4.5
Currently on psychotropic medication for PSP 6% 3% w2(1) ¼.35, p 4.5
Prior inpatient treatment 11% 11% w2(1) ¼.00, p4 .9
Prior outpatient treatment 43% 49% w2(1) ¼.23, p 4.6
Never sought any help before 33% 20% w2(1) ¼1.49, p 4.2
Comorbid disordersa
Comorbid depression 34% 46% w2(1) ¼.95, p 4.3
Comorbid borderline personality disorder 6% 6% Fisher’s exact test, p 4.9
Comorbid obsessive-compulsive disorder 14% 6% w2(1) ¼1.43, p 4.2
Comorbid eating disorder 11% 11% Fisher’s exact test, p 4.9

Questionnaires
M-SPS total 24.54 (3.23) 24.17 (3.72) t(68)¼ .44, p 4.6
BDI-SF total score 8.71 (6.78) 10.26 (7.81) t(68)¼ .88, p 4.3

Note: BDI-SF¼ Beck-Depression Inventory, short form; M-SPS ¼ Modified Skin Picking Scale.
a
None of the patients reported a diagnosis of TTM and body dysmorphic disorder.

read the manual according to self-report. The ITT approach considered all subjects reassessment despite two reminders, w2(1)¼.56, p 4.4. Comple-
with full baseline data (ITT). In the case of missing data we used the direct
ters and noncompleters did not differ on any background variable
maximum likelihood method (SAS PROC MIXED). We used the adjustment to the
standard errors and degrees of freedom derived by Kenward and Roger (1997). or questionnaire score except for age: noncompleters were older
This gives more accurate standard errors when the sample size is small and than completers (36 versus 28 years), t(68) ¼2.40, p¼.04.
corrects the default estimate of the degrees of freedom.
The study complied with the Helsinki Declaration of 1975 and followed the
standards of the local ethics committee.
3.3. Group comparisons

3.3.1. Per protocol (PP)

3. Results
3.1. Baseline characteristics
No significant baseline differences emerged between the HRT
and DC group for any psychopathological or sociodemographic
variables, or the primary outcome scale (see Table 1). The following
persons verified the presence of PSP: psychologist (n¼13), psy-
chotherapist not further specified (n¼8), psychiatrist (n¼6), gen-
eral practitioner (n¼6), dermatologist (n¼3), neurologist (n¼1),
physician not further specified (n¼1), and cosmetician (n¼1). For
23 subjects, diagnosis relied entirely on self-observation. The vast
majority of patients were never in treatment previously.
3.2. Completion
The completion rate at retest was 89%: A total of 5 subjects in
the DC (14%) and 3 in the HRT group (9%) did not take part in the
A mixed two-way ANOVA with Group as between-subject and
Time (pre, post) as within-subject factors was conducted for the
M-SPS. The effects of Group, F(1,60) ¼5.29, p¼.025, Z2partial ¼ :08,
and Time, F(1,60)¼10.25, p¼ .002, Z2partial ¼ :15, were significant,
which was qualified by a significant interaction, F(1,60) ¼4.95,
p¼.03, Z2partial ¼ :08. As can be seen in Fig. 3, improvement on the
M-SPS was stronger in the HRT group relative to the DC group.
Exploratory analysis of individual M-SPS items showed that the
significant interaction was mainly due to item 4 (frequency;
F(1,60) ¼4.40; p ¼.04, Z2partial ¼ :07), item 5 (severity;
F(1,60) ¼8.04; p ¼.006, Z2partial ¼ :12), and item 8 (control;
F(1,60) ¼5.42; p ¼.02, Z2partial ¼ :08). A total of 5 patients in the
HRT (16%) but none in the DC group showed a symptom decline
on the M-SPS of more than 50% (at least 33% improvement: 31%
versus 20%).
For the BDI-SF, the main effect of Time was significant,
F(1,60) ¼4.33, p ¼.04, Z2partial ¼ :07, indicating modest overall
improvement. The group effect was non-significant, F(1,60) ¼.06,
 S. Moritz et al. / Journal of Obsessive-Compulsive and Related Disorders 1 (2012) 41–47
p 4.8, Z2partial ¼ :00. The interaction failed to reach a conventional
level of significance, F(1,60) ¼.3.52, p¼ .07, Z2partial ¼ :05.
3.3.2. Intention to treat (ITT)
As described in Section 2.3, the ITT approach considered all
subjects with available baseline data. Missing data for eight
subjects was controlled using the direct maximum likelihood
method (SAS PROC MIXED). The group difference for the M-SPS
achieved significance (p ¼.04). Exploratory analyses revealed that
group differences for item 4 (p ¼.05), item 5 (p ¼.01), and item 8
(p¼ .03) remained significant. For the BDI-SF, the group difference
again achieved trend level (p¼.07).
3.4. Subjective appraisal
Table 2 provides data on the subjective appraisal of HRT versus
DC. None of the differences achieved significance. Every second
patient in the HRT group in contrast to every third patient in the
DC group, reported a symptom decline due to the use of the
technique. Comprehensibility of the manual, as well as appropri-
ateness for self-administration, was excellent in both groups. Still,
almost every second patient in both groups found that the method
would be more helpful in combination with psychotherapy. Less
than half of the participants in each group intend to use the
respective technique in the future. Of those whose symptoms
declined at least by one third on the M-SPS, the rate of those
who would adopt the technique in the future was slightly higher
(DC: 57%, HRT: 54%). With respect to (subjective) adherence, the
rate of patients who had used the techniques frequently (414 day
during the intervention time) was similar in the DC (53%) and the
HRT group (55%), w2(1)¼ .01, p4.9.
3.5
3 its efficacy. Against the background of two successful prior trials
DC
Difference score pre-post
HRT
2.5
2
1.5
1 cated no improvement at all. At this point we can only speculate
0.5
0 sufferers scratch at different places of their skin, whereas in
M-SPS BDI
Fig. 3. Difference scores on the Modified Skin Picking Scale (M-SPS). Participants
in the HRT group showed significantly greater symptom decline than those under
DC. For the BDI-SF, HRT was more effective than DC at statistical trend level.
Table 2
Subjective appraisal of decoupling (DC) and habit reversal training (HRT).
Item
The method is appropriate for self-administration.
My skin picking symptoms have decreased due to the method.
The manual was written comprehensively.
I was able to perform the exercises regularly.
I did not find the time to study the manual intensively.
Other persons have helped me with the exercises.
I would find the method more helpful in combination with psychotherapy.
I found the method more helpful than other self-help approaches.
Do you intend to use the method in the future?
45
3.5. Reliability
All scales showed good to excellent internal consistency at
both assessment points (M-SPS, pre: a ¼.79, post: a ¼.91; BDI,
pre: a ¼.90, post: a ¼.92). Intercorrelations across scales were
only modest (baseline: M-SPS/BDI: r ¼.26, p ¼.03).
4. Discussion
Pathological skin picking (PSP) like many other psychological
problems (Kohn, Saxena, Levav, & Saraceno, 2004) is a ‘‘hidden’’
disorder: a large subgroup of sufferers either does not seek or
receive competent help. To reach this large group of patients, we
conducted a pilot self-help trial comparing the current evidenced-
based gold standard, habit reversal training (HRT), against a new
technique entitled decoupling (DC). The results speak for the
efficacy of the former in ameliorating PSP, but against the latter,
thus replicating findings from prior (small) clinical trials on HRT.
Symptom decline under HRT was particularly pronounced for
items 4, 5, and 8 (frequency and severity of skin picking, distress/
suffering), whereby results have to be interpreted cautiously as
group differences were not corrected for multiple comparisons.
The retrospective assessment suggests that 50% in the HRT group
and 33% in the DC group experienced symptom decline, which
was attributed to the adoption of the respective method. How-
ever, less than half of the participants in each group intend to use
either technique in the future highlighting the further need
develop new and feasible treatment options. Taken together,
while the results confirm the usefulness of HRT in a subgroup of
patients, it only promises modest symptom relief when adopted
via self-help.
Why did decoupling fail? The study aimed to test the null
hypothesis, that is, that DC is no different to HRT with respect to
using DC for patients with TTM (Moritz & Rufer, 2010) and
pathological nail-biting (Moritz et al., 2011), two disorders that
are also considered impulse control disorders, we expected that
DC would also induce substantial symptom reduction in patients
with PSP. As mentioned before, at least one third of the partici-
pants attributed symptom decline to DC and half of the partici-
pants will continue to use the technique, but the primary
outcome of the pre-post comparison on the modified SPS indi-
about possible causes. First, a feature that in our view sets PSP
apart from PNB and TTM is that the behavior is less stereotyped.
According to an investigation by Arnold et al. (1998), 82% of the
people with PNB and TTM, the movement pattern is rather
confined to a particular area (i.e., fingers—head; fingers—
mouth). While Arnold and coworkers counted a mean of 2.8
(SD¼ 1.6) different picking sites in their sample, a large study on
DC (%) HRT (%) Statistics
73 84 w2(1) ¼ 1.14, p 4.2
33 50 w2(1) ¼ 1.77, p 4.1
93 100 w2(1) ¼ 2.20, p 4.1
67 56 w2(1) ¼ .71, p 4.3
27 19 w2(1) ¼ .55, p 4.4
3 16 w2(1) ¼ 2.68, p 4.1
48 52 w2(1) ¼ 1.07, p 4.3
43 41 w2(1) ¼ .05, p 4.8
45 41 w2(1) ¼ .11, p 4.7
46 S. Moritz et al. / Journal of Obsessive-Compulsive and Related Disorders 1 (2012) 41–47
N ¼760 participants meeting criteria of PSP even had a mean of
4.7 (SD ¼2.9) different picking places (Tucker et al., 2010). The
phenomenological differences between PSP and, for example,
TTM may be very relevant as DC, in short, does not eliminate
the behavior sequence as does HRT, but attempts to mimic and
alter it. However, if no consistent motor pattern emerges, it is
unlikely that the prior dysfunctional behavior is overlearnt. In
fact, some of the subjects commented that their individual PSP
did not involve a typical chain of events. Second, PSP might be
more sensory driven (bottom-up) than PNB and TTM (e.g., itching
scalp). Third, the act of picking is not always haptic in that many
patients use devices such as pins and even razors, which may also
play a role, especially as recent evidence tentatively suggests that
this type of behavior is more prevalent in internet-recruited than
clinical samples (Tucker et al., 2010). Fourth, DC requires more
instruction to master than a simple competing response. Thus,
while less efficacious with internet dissemination, it deserves to
be tested whether the technique is more successful when con-
veyed via a therapist. Clearly, these are speculations that await
direct testing in future studies.
The study has some limitations, rendering its findings pre-
liminary. First, one may object that data was obtained over the
internet and relied on self-report. We do not know to what extent
participants had engaged in other therapies during the study.
Moreover, objective parameters of treatment integrity are lacking.
Perhaps most importantly, a diagnosis of PSP was not formally
verified. Whereas clinical studies with expert ratings are the
undisputed gold standard, patients with PSP are rarely seen in
the hospital due to shame, perceived stigma on the side of the
patients, or to poor awareness and treatment competence on the
side of the mental health system. Therefore, in our view, online
studies are the best alternative to ‘‘treat the untreated’’. From
other disorders (Besiroglu, Cilli, & Askin, 2004) we know that
help-seeking patients differ markedly from non-help seeking
patients. Therefore, findings from clinical trials and populations
may not be fully representative (for differences between clinical
and online-recruited samples see also Tucker et al., 2010). Clinical
interviews in a psychiatric hospital environment would have
discouraged many potential participants (Moritz, Wittekind
et al., 2011). In addition, we met several precautious to ensure
good data quality: 1. cookies were set to prevent multiple log-ons,
2. the invitation was posted on specialized forums, 3. we recruited
a large sample, and 4. we employed reliable instruments. Recent
studies have also asserted the reliability and validity of data
obtained via the internet, even with psychiatric patients
(Chinman et al., 2004; Coles, Cook, & Blake, 2007; Meyerson &
Tryon, 2003; Moritz & Laroi, 2008; Ritter et al., 2004; Riva et al.,
2003). Psychometric properties in the present study were good to
excellent. Future studies may ask participants’ consent to contact
therapists in order to formally verify diagnosis (for a review on
procedure for validating online-obtained diagnoses see Moritz,
Wittekind et al., 2011). Second, no follow-up was undertaken,
so we do not know if the effects shown for HRT are maintained
for longer periods of time. It should also be tested whether
clinician-administered HRT exerts a larger effect, as many
participants deemed HRT more helpful when conveyed in the
framework of a conventional psychotherapy (see Table 2).
While our HRT protocol contained its core components
(Woods & Miltenberger, 1995), CRT and an abbreviated form of
awareness training, other common features of HRT (e.g., relaxa-
tion and social support) were not included, so that the obtained
effects may somewhat underestimate the potential of HRT.
Finally, studies are needed that replicate the present results with
clinically well-defined subjects, or perform telephone interviews
in order to verify the diagnosis and the creditability of the
subjects.
To conclude, self-help HRT emerged as an efficacious techni-
que for the treatment of PSP. The manual is currently available in
German and can be downloaded at no cost from www.uke.de/
impulskontrolle. An English translation is underway. As pre-
viously acknowledged, it awaits further investigation if the
technique is more effective when applied by a clinician, and
whether symptom changes last over a larger follow-up period.
In addition to behavioral methods like HRT we deem that the
investigation of further cognitive interventions is fruitful (Schuck
et al., 2011), as PSP in part may represent a dysfunctional emotion
regulation strategy.
Acknowledgment
The authors would like to thank Amanda Brooks for helpful
comments.
References
Arnold, L. M., Auchenbach, M. B., & McElroy, S. L. (2001). Psychogenic excoriation.
Clinical features, proposed diagnostic criteria, epidemiology and approaches to
treatment. CNS Drugs, 15, 351–359.
Arnold, L. M., McElroy, S. L., Mutasim, D. F., Dwight, M. M., Lamerson, C. L., &
Morris, E. M. (1998). Characteristics of 34 adults with psychogenic excoriation.
Journal of Clinical Psychiatry, 59, 509–514.
Azrin, N. H., & Nunn, R. G. (1973). Habit reversal: A method of eliminating nervous
habits and tics. Behaviour Research and Therapy, 11, 619–628.
Beck, A. T., & Steer, R. A. (1993). Beck Depression Inventory manual. San Antonio:
Psychological Corporation.
Besiroglu, L., Cilli, A. S., & Askin, R. (2004). The predictors of health care seeking
behavior in obsessive-compulsive disorder. Comprehensive Psychiatry, 45,
99–108.
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.
Chinman, M., Young, A. S., Schell, T., Hassell, J., & Mintz, J. (2004). Computer-
assisted self-assessment in persons with severe mental illness. Journal of
Clinical Psychiatry, 65, 1343–1351.
Coles, M. E., Cook, L. M., & Blake, T. R. (2007). Assessing obsessive compulsive
symptoms and cognitions on the internet: Evidence for the comparability of
paper and Internet administration. Behavior Research and Therapy, 45,
2232–2240.
Deckersbach, T., Wilhelm, S., Keuthen, N. J., Baer, L., & Jenike, M. A. (2002).
Cognitive-behavior therapy for self-injurious skin picking. A case series.
Behavior Modification, 26, 361–377.
Doherty, D. T., & Kartalova-O’Doherty, Y. (2010). Gender and self-reported mental
health problems: Predictors of help seeking from a general practitioner. British
Journal of Health Psychology, 15, 213–228.
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, 579–594.
Flessner, C. A., Mouton-Odum, S., Stocker, A. J., & Keuthen, N. J. (2007). StopPick-
ing.com: Internet-based treatment for self-injurious skin picking. Dermatology
Online Journal, 13, 3.
Fruensgaard, K., Hjortshøj, A., & Nielsen, H. (1978). Neurotic excoriations. Inter-
national Journal of Dermatology, 17, 761–767.
Furlanetto, L. M., Mendlowicz, M. V., & Romildo Bueno, J. (2005). The validity of the
Beck Depression Inventory-short form as a screening and diagnostic instru-
ment for moderate and severe depression in medical inpatients. Journal of
Affective Disorders, 86, 87–91.
Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L., & Hill,
C. L., et al. (1989). The Yale-Brown Obsessive Compulsive Scale. I. Develop-
ment, use, and reliability. Archives of General Psychiatry, 46, 1006–1011.
Grant, J. E., & Odlaug, B. L. (2009). Update on pathological skin picking. Current
Psychiatry Reports, 11, 283–288.
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.
Hollon, S. D., & Wampold, B. E. (2009). Are randomized controlled trials relevant to
clinical practice?. Canadian Journal of Psychiatry, 54, 637–643.
Kent, A., & Drummond, L. M. (1989). Acne excoriée—A case report of treatment
using habit reversal. Clinical and Experimental Dermatology, 14, 163–164.
Kenward, M. G., & Roger, J. H. (1997). Small sample inference for fixed effects from
restricted maximum likelihood. Biometrics, 53, 983–997.
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.
 S. Moritz et al. / Journal of Obsessive-Compulsive and Related Disorders 1 (2012) 41–47
Keuthen, N. J., O’Sullivan, R. L., Ricciardi, J. N., Shera, D., Savage, C. R., & Borgmann,
A. S., et al. (1995). The Massachusetts General Hospital (MGH) Hairpulling
Scale: 1. Development and factor analyses. Psychotherapy and Psychosomatics,
64, 141–145.
Keuthen, N. J., Wilhelm, S., Deckersbach, T., Engelhard, I. M., Forker, A. E., & Baer, L.,
et al. (2001). The Skin Picking Scale: Scale construction and psychometric
analyses. Journal of Psychometric Research, 50, 337–341.
Kohn, R., Saxena, S., Levav, I., & Saraceno, B. (2004). The treatment gap in mental
health care. Bulletin of the World Health Organisation, 82, 858–866.
Meyerson, P., & Tryon, W. W. (2003). Validating internet research: A test of the
psychometric equivalence of internet and in-person samples. Behavior
Research Methods, Instruments, and Computers, 35, 614–620.
Miltenberger, R. G., & Fuqua, R. W. (1985). A comparison of contingent versus non-
contingent competing response practice in the treatment of nervous habits.
Journal of Behavior Therapy and Experimental Psychiatry, 16, 195–200.
Moritz, S., Jelinek, L., Hauschildt, M., & Naber, D. (2010). How to treat the
untreated: Effectiveness of a self-help metacognitive training program
(myMCT) for obsessive-compulsive disorder. Dialogues in Clinical Neuros-
ciences, 12, 209–220.
Moritz, S., & Laroi, F. (2008). Differences and similarities in the sensory and
cognitive signatures of voice-hearing, intrusions and thoughts. Schizophrenia
Research, 102, 96–107.
Moritz, S., & Rufer, M. (2010). Movement decoupling: A self-help intervention for
the treatment of trichotillomania. Journal of Behavior Therapy and Experimental
Psychiatry, 42, 74–80.
Moritz, S., Treszl, A., & Rufer, M. (2011). A randomized controlled trial of a novel
self-help technique for impulse control disorders: A study on nail-biting.
Behavior Modification, 35, 468–485.
Moritz, S., Wittekind, C. E., Hauschildt, M., & Timpano, K. R. (2011). Do it yourself?
Self-help and online therapy for people with obsessive-compulsive disorder.
Current Opinion in Psychiatry, 24, 541–548.
Neziroglu, F., Rabinowitz, D., Breytman, A., & Jacofsky, M. (2008). Skin picking
phenomenology and severity comparison. Journal of Clinical Psychiatry
10, 306–312.
47
O’Sullivan, R. L., Phillips, K. A., Keuthen, N. J., & Wilhelm, S. (1999). Near-fatal skin
picking from delusional body dysmorphic disorder responsive to fluvoxamine.
Psychosomatics, 40, 79–81.
Ritter, P., Lorig, K., Laurent, D., & Matthews, K. (2004). Internet versus mailed
questionnaires: A randomized comparison. Journal of Medical Internet Research,
6, e29.
Riva, G., Teruzzi, T., & Anolli, L. (2003). The use of the internet in psychological
research: Comparison of online and offline questionnaires. CyberPsychology
and Behavior, 6, 73–80.
Schuck, K., Keijsers, G. P., & Rinck, M. (2011). The effects of brief cognitive-
behaviour therapy for pathological skin picking: A randomized comparison to
wait-list control. Behaviour Research and Therapy, 49, 11–17.
Snorrason, I., Smari, J., & Olafsson, 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.
Stein, D. J., Garner, J. P., Keuthen, N. J., Franklin, M. E., Walkup, J. T., & Woods, D. W.
(2007). Trichotillomania, stereotypic movement disorder, and related disor-
ders. Current Psychiatry Reports, 9, 301–302.
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, 411–422.
Tucker, B. T., Woods, D. W., Flessner, C. A., Franklin, S. A., & Franklin, M. E. (2010).
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.
Twohig, M. P., & Woods, D. W. (2001). Habit reversal as a treatment for chronic
skin picking in typically developing adult male siblings. Journal of Applied
Behavior Analysis, 34, 217–220.
Vogel, D. L., & Wade, N. G. (2009). Stigma and help-seeking. The Psychologist, 22, 20–23.
Wilhelm, S., Keuthen, N. J., Deckersbach, T., Engelhard, I. M., Forker, A. E., & Baer, L.,
et al. (1999). Self-injurious skin picking: Clinical characteristics and comor-
bidity. Journal of Clinical Psychiatry, 60, 454–459.
Woods, D. W., & Miltenberger, R. G. (1995). Habit reversal: A review of applica-
tions and variations. Journal of Behavior Therapy and Experimental Psychiatry,
26, 123–131.