Excoriation Disorder (ExD), commonly known as skin picking disorder, presents significant challenges for those who suffer from it, often leading to severe distress and self-consciousness about their appearance. Traditional treatments, like Habit Reversal Training (HRT), have shown effectiveness in managing symptoms, but there is a growing interest in exploring how additional therapeutic approaches might enhance outcomes. A study by Brian L. Thompson, PhD, from Portland Psychotherapy, investigated the potential of using exposure therapy guided by acceptance and commitment therapy (ACT) as an adjunct to HRT for treating ExD.
The Study Design and Approach
The study employed a nonconcurrent multiple baseline design, a method that allows for analysis of individual participants over time. Four participants with ExD were recruited and randomly assigned to two conditions: one group received HRT followed by exposure therapy, while the other group received exposure therapy first, followed by HRT. During the ACT-informed exposure therapy phase, participants were oriented to the ACT model. They then practiced deliberately triggering urges to pick while being open and present with these urges, and then flexibly expanding their awareness of other sense perceptions (e.g., touch, taste, sight, sound, smell). The goal was not symptom reduction, as in traditional exposure, but of flexible responding to urges while not engaging in picking behavior. This design was chosen to assess whether exposure therapy, when informed by ACT principles, could improve psychological flexibility and reduce the severity of skin-picking behavior beyond what HRT alone could achieve.
Key Findings
The results of this study highlight several important outcomes. Results provided further evidence that HRT is effective in reducing the frequency of skin picking across participants. These findings align with previous research and supports HRT as a first-line treatment for ExD. However, the addition of ACT-informed exposure therapy yielded mixed results. While some participants reported further reductions in skin picking during the exposure phase, these reductions were generally smaller compared to those observed during the HRT phase. For example, participants who underwent exposure therapy first experienced greater reductions in skin picking during the subsequent HRT phase than during the initial exposure phase.
One of the study’s key aims was to determine if ACT-informed exposure could enhance psychological flexibility—a core process in ACT that involves accepting internal experiences while committing to actions that align with one’s values. Contrary to the researchers’ expectations, the exposure phase did not consistently lead to improvements in psychological flexibility across participants. This finding suggests that while exposure therapy might have some utility as a secondary treatment, it may not be as effective in fostering psychological flexibility as hypothesized, or psychological flexibility is less relevant as a process of change in people who struggle with skin picking. As the experimenter used broad measures of psychological flexibility, it is also possible the measures were too general and not specific enough to picking.
Implications for Treatment
Despite the mixed results, the study offers valuable insights into the treatment of ExD. All participants maintained their gains at a three-month follow-up, indicating that both HRT and ACT-informed exposure have lasting effects on symptom reduction. However, the study also raises questions about the specific role that exposure therapy should play in treating ExD. Given that HRT resulted in more robust improvements than exposure therapy, this research suggests that exposure therapy might be more effective when used as a secondary intervention.
Participant feedback indicated that exposure was an acceptable treatment. Participants who began with exposure felt that exposure therapy helped them prepare for the strategies in HRT. Some participants even endorsed a preference for exposure. For example, one participant described exposure as “more helpful overall,” and another noted that “exposure has been what really accelerated” their progress. These subjective reports highlight the potential of ACT-informed exposure to complement HRT by increasing participants’ awareness and acceptance of their urges, which might help reduce relapse rates in the long term.
Conclusion
This study, represents a pioneering effort to integrate ACT-informed exposure therapy into the treatment of Excoriation Disorder. It is also the first published experimental study of the use of exposure in treating skin picking. While the findings do not support exposure therapy as a robust standalone treatment, they suggest it may be a useful adjunct to HRT to help people further manage picking behavior. With skin picking, any additional improvements in reducing picking may be meaningful.
As the field of mental health continues to explore transdiagnostic approaches—therapies that can be applied across different disorders—the integration of ACT with traditional behavioral interventions like exposure therapy offers a promising avenue for future research. The protocol is relatively simple to implement, especially for therapists familiar with exposure therapy. This study underscores the importance of tailoring treatment to the individual, recognizing that while HRT remains the gold standard for ExD, there is room to enhance its efficacy through the thoughtful incorporation of exposure therapy.
Moving forward, larger-scale studies are necessary to determine if combining HRT and exposure therapy is more effective than HRT alone. For clinicians and researchers alike, this study offers a steppingstone toward enhancing treatments for those suffering from Excoriation Disorder and other body focused repetitive behaviors.
You can find an open access version of this article here.
Author: Portland Psychotherapy Team
