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David Baxter

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StopPicking.com: Internet-based Treatment for Self-Injurious Skin Picking
by Christopher A. Flessner, Suzanne Mouton-Odum, Allison J. Stocker, & Nancy J. Keuthen
Dermatol Online J. 2007;13(4):3.
12/10/2007

StopPicking.com is an interactive self-help approach derived from an evidence-based cognitive behavioral model of treatment for skin picking (SP). We examined the development and two phases of program evaluation for an Internet-based self-help treatment for self-injurious SP. Participants included 372 individuals consecutively enrolling in StopPicking.com during a 5-month period. Results revealed significant reductions in frequency of picking episodes and symptom severity ratings from baseline to post-intervention. Treatment response rates were comparable or superior to previous research utilizing pharmacotherapy for the treatment of SP suggesting that StopPicking.com may provide an alternative or adjunctive treatment for SP. The current study is limited by lack of a control condition and use of a non-referred sample of skin pickers.​
Self-Injurious skin picking (SP) currently lacks its own diagnostic classification in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). As a result, researchers have operationally defined SP as recurrent picking accompanied by visible tissue damage resulting in significant distress and/or functional impairment. Alternatively, it has also been conceptualized as a variant of other mental health concerns such as impulse control disorder not otherwise specified, body dysmorphic disorder (BDD), or obsessive-compulsive disorder (OCD).

Reported prevalence rates for SP ranges from 2 percent to 3.8-4.6 percent in dermatology clinics and college students, respectively. The mean age of onset has typically been around 16 years, although recent research conducted with an Internet-based approach demonstrated a median age of onset at approximately 12 years. Skin picking occurs more commonly in females than males with research suggesting that SP typically involves the use of fingers or tweezers and is most common on the face (although the behavior can occur on nearly all body surfaces). Wilhelm and colleagues found that picking may wax and wane throughout an individual's lifetime and may coincide with the menstrual cycle for some women.

Comorbid psychiatric diagnoses, including alcohol abuse or dependence, OCD, generalized anxiety disorder, and mild to moderate levels of depression or anxiety have been frequently reported in persons who pick their skin. In a recent study, researchers found that 12 percent (n = 4) of 34 patients from an outpatient clinic reported suicidal ideation attributable to SP-related problems. Unfortunately, a dearth of literature exists examining the efficacy of specific therapeutic interventions for the treatment of SP with most extant research examining either pharmacological or cognitive-behavioral approaches.

To date, pharmacological agents have been the most frequently studied treatment approach for SP with nearly all studies examining the efficacy of serotonin reuptake inhibitors (SRIs). Recently, a group of researchers randomized 21 participants to 10 weeks of either placebo or fluoxetine for treatment of SP. After this 10-week trial, 8 of 10 participants in the fluoxetine condition were classified as much improved (n = 6) or very much improved (n = 2), while only 3 of 11 participants in the placebo condition were classified as much improved (n = 3). Similar results have been demonstrated in subsequent research examining the efficacy of fluoxetine and other SRIs (e.g., fluvoxamine, paroxetine) for the treatment of SP.

[Possible] side effects accompanying the use of SRIs have been reported including decreased appetite, nausea, insomnia, and fatigue. Recently, researchers have reported on two clinical cases in which SRIs (e.g., fluvoxamine and paroxetine, respectively) were used to treat OCD. Results of these individual cases revealed that fluvoxamine exacerbated SP for one woman, while paroxetine induced SP in the other woman. Side effects such as those described above have led some researchers to examine alternative, nonpharmacological methods for the treatment of SP.

Cognitive-behavior therapy (CBT) has been the most frequently used non-pharmacological approach to the treatment of SP. Researchers have used a number of different techniques as part of CBT, including functional assessment of the problem behavior, self-monitoring, stimulus control, habit reversal training, and cognitive restructuring. For example, a client reporting thoughts such as "Nobody loves me" or "I am a complete failure and will never amount to anything" prior to picking may review these thoughts with the therapist, examine the level of truth associated with these thoughts, and practice coping skills to be used in the presence of or in situations thought to illicit these thoughts. Coping skills may include techniques such as engaging in a competing behavior that prevents picking from happening (e.g., clenching his or her fist) or developing a more objective response to these thoughts (e.g., "Well, my parents love me" or "I actually have a pretty good job").

A recent report described the use of CBT for the treatment of SP in 3 clients. Results suggested reductions in picking frequency for all 3 clients; 2 of 3 clients reported that their SP was very much improved with the use of CBT techniques. Several of the components to CBT mentioned in the preceding paragraph have shown similar efficacy in various combinations in other studies as well.

Despite these encouraging findings, several limitations to the current literature exist. First, none of the studies recruited more than three participants and nearly all of these studies were uncontrolled case histories. As a result, our ability to extend these findings to the general population may be limited. Second, because of the experimental designs implemented in several of these studies, it is impossible to infer which components of CBT were most efficacious. Lastly, many clinicians (depending upon their clinical training) may be unfamiliar with the therapeutic techniques mentioned above (e.g., functional assessment, habit reversal, stimulus control, etc.), possibly limiting the transportability of these techniques. This latter concern has led some researchers to examine the efficacy of computer-based approaches for the treatment of a variety of mental health concerns.

Computer-based approaches provide an alternative to face-to-face treatment sessions. As technology has become more advanced, researchers have incorporated the Internet, laptop computers, and portable digital assistants (PDAs) into the treatment process. These computer-based approached have been used for a variety of mental health concerns, including OCD, social phobia, panic disorder, GAD, and trichotillomania (TTM), with data generally demonstrating empirical support for the efficacy of these approaches to treatment. In addition, data suggests generally positive results with respect to client satisfaction.

Recent research provides one example of a computer-based treatment approach with particular relevance for the treatment of SP. Mouton-Odum and colleagues established an Internet-based self-help treatment strategy for TTM (StopPulling.com). These authors provided users with modules for continuous monitoring of their behavior (e.g., pulling frequency, antecedents and consequences to pulling, severity of urge to pull, etc.). Users were guided through a functional assessment and subsequently provided treatment strategies (e.g., stimulus control techniques, coping strategies, etc.) based upon data collected during a 2-5 week assessment phase. Results from 265 users of this program indicated significant improvement in symptoms of TTM (e.g., reductions in pulling frequency and self-reported pulling severity) with some evidence suggesting that duration of program use accounted for reductions in pulling severity.

Despite topographical or surface differences between TTM and SP, research suggests that these problem behaviors may serve similar functions. Specifically, both TTM and SP may reduce discomfort, tension, or some other negative feelings or states. In addition, researchers Lochner, Simeon, Niehaus, and Stein (2002) recently found that participants diagnosed with either SP or TTM showed similarities with respect to demographic characteristics, psychiatric comorbidity, and personality dimensions.

Given the documented phenomenological overlap between TTM and SP, the development of a computer-based approach to treatment similar to StopPulling.com may be advantageous for individuals who engage in a variety of picking behaviors including skin picking, cheek or lip biting, fingernail biting, and nose picking. Given that access to professionals with adequate knowledge of SP may be severely limited, a computer-based approach may provide an alternative to face-to-face therapeutic interventions for some individuals. Furthermore, shame accompanying SP may prevent some sufferers from seeking direct professional contact; accordingly, a computer-based program that affords greater privacy may offer a much-needed treatment avenue. The purpose of the current paper is to describe the development and program evaluation for StopPicking.com, an Internet-based, interactive, self-help approach for the treatment of SP.

See attached paper for more details.
 

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