Approach-Avoidance Training for Skin Picking

Dr. Dawn Ferrara
Sep 29th, 2021

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When you think about compulsive skin picking, you probably don’t think about addictions, right? After all, Skin Picking Disorder (SPD) is classified as an Obsessive-Compulsive Related Disorder in the DSM5. It was previously classified as an impulse disorder. But not everyone agrees on how to classify SPD and in fact, some research has found that SPD actually shares a number of clinical features with behavioral addictions. Those features include:

• repetitive/compulsive engagement in the behavior despite clearly adverse consequences

• diminished control over the problematic behavior

• urges prior to engagement in the problematic behavior

• pleasant sensations during the behavior

Studies have found that SPD seems to occur in part as mechanism of emotional avoidance. When triggered, one may experience intense emotion before picking and feel satisfaction or relief afterwards, alleviating emotional distress. The skin picking results in successful avoidance and feelings of relief and gratification, reinforcing the behavior. Over time, this process reinforces the skin picking, setting up the cycle to be repeated. This process is similar to that seen in behavioral addictions.

Behavioral addictions involve motivation to either approach (decrease distance) or avoid (increase distance) their desired stimulus. Actions may occur cognitively (implicit) or behaviorally (explicit) and may occur automatically. These approach and avoid behaviors are seen with skin picking as well and urges to pick can be overwhelming. When triggered, one may experience intense emotion before picking and feel satisfaction or relief afterwards, alleviating emotional distress. The skin picking results in successful avoidance and feelings of relief and gratification, reinforcing the behavior. Over time, this process reinforces the skin picking, setting up the cycle to be repeated, often automatically. This approach-avoidance process is similar to that seen in behavioral addictions.

Through A Different Lens

Viewing SPD through the lens of behavioral addictions suggests that strategies used to treat those disorders may also be helpful for people living with SPD. One strategy that has gotten a lot of attention is Approach-Avoidance Training AAT). A new study explores AAT as a potential treatment strategy for skin picking disorder and the results are intriguing.   

What Is Approach-Avoidance Training?

Approach-Avoidance Training (AAT), sometimes referred to as Approach-Avoidance Task training, is a form of cognitive bias modification (CBM) used to modify a person’s action-tendencies or their automatic approach or avoid actions associated with their issue or addiction. CBM interventions are designed to directly modify attention and interpretation biases through repeated practice on cognitive tasks.

Similar to a video game, the AAT technique uses imagery related to the person’s specific issue and employs a joystick-type apparatus to simulate approaching or avoiding a relevant stimulus such as an image of alcohol, or in the case of SPD, irregular skin, for example. The joystick movements are accompanied by a zoom-effect which increases the illusion of movement. The underlying premise of AAT is that an approach action tendency will facilitate overt approach (pull) movements and inhibit overt avoid (push) movements. And, vice versa for avoid action tendencies. Over time, these tasks reinforce more healthy, desired approach-avoidance responses, such as avoidance of alcohol or skin picking.

While AAT has most often been used with alcohol or drug addictions, it has been applied in other areas such as eating disorders and phobias. In this new study, researchers sought to determine whether the behavioral addictions model and AAT could be applied to reduce dysfunctional approach action-tendencies in individuals with skin picking, and potentially reduce their skin-picking urges.

Participants were in one of three groups, each with a specific task focus:

• Approach Training - to increase approach tendencies toward irregular skin

• Avoidance Training - to decrease approach tendencies toward irregular skin

• Placebo Training - equal training of approach and avoidance

Each group was given an Approach-Avoidance Assessment and a series of approach-avoidance tasks to complete.

Can AAT Help Skin Picking?

The study’s findings suggest that AAT can modify skin picking tendencies. As expected, the avoidance training group showed diminished approach tendencies towards picking. What was unexpected was that the placebo training group (approach and avoidance training), also demonstrated lower approach behaviors at the completion of the study and post-training. Participants in the avoidance and placebo groups also reported lower urges to pick that the approach group. No significant differences between the avoidance and placebo groups were found suggesting that both approaches may be beneficial.

It was expected that there might be changes in skin picking symptoms over time. At a 2-week follow-up, no significant changes in symptoms were reported by any of the groups. This was in contrast to urges to pick in which the approach group reported higher peak urges to pick. 

These findings support the use of the behavioral addictions model with skin picking and the application of AAT. It can help people to not only changes their approach tendencies to irregular skin stimuli, but also the urge to pick.  

Going Forward

Of course, the researchers acknowledge that there is much more to learn about AAT and its application to skin picking. What would be the results with a larger sample of participants? What might the outcomes be for people with moderate to severe symptoms of skin picking? There are many questions to be answered but the early findings suggest that AAT may hold some promise as a potential adjunctive therapy for people who live with skin picking and are faced with the challenge of how to stop skin picking.  

AAT is one of several areas that is receiving a lot of attention as researchers seek to find novel and effective treatment for SPD. Research offers hope to those living with skin picking and other BFRBs. In the meantime, there is help and support available.  


1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

2. Odlaug, B. L., & Grant, J. E. (2008). Clinical characteristics and medical complications of pathologic skin picking. General Hospital Psychiatry, 30(1), 61–66.

3. Oliveirra, E. C. B., Fitzpatrick, C. L., Kim, H. S., Gulassa, D. C. R., Amaral, R. S., de Mattos Cristiana, N., & Tavares, H. (2019). Obsessive–compulsive or addiction? Categorical diagnostic analysis of excoriation disorder compared to obsessive-compulsive disorder and gambling disorder. Psychiatry Research, 281, 112518.

4. 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 Disorders227, 463-470.

5. Odlaug, B. L., Chamberlain, S. R., & Grant, J. E. (2010). Motor inhibition and cognitive flexibility in pathologic skin picking. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 34(1), 208–211.

6. Mathew, A. S., Rech, M. A., & Lee, H. J. (2021, August 13). Evaluating the role of approach-avoidance training on action-tendencies in individuals with skin-picking disorder: A preliminary randomized experiment. Retrieved from

7. Sharbanee, J. M., Hu, L., Stritzke, W. G., Wiers, R. W., Rinck, M., & MacLeod, C. (2014). The effect of approach/avoidance training on alcohol consumption is mediated by change in alcohol action tendency. PloS one9(1), e85855.

Dr. Dawn Ferrara


With over 25 years of clinical practice, Dawn brings experience, education and a passion for educating others about mental health issues to her writing. She holds a Master’s Degree in Marriage and Family Counseling, a Doctorate in Psychology and is a Board-Certified Telemental Health Provider. Practicing as a Licensed Professional Counselor and Licensed Marriage and Family Therapist, Dawn worked with teens and adults, specializing in anxiety disorders, work-life issues, and family therapy. Living in Hurricane Alley, she also has a special interest and training in disaster and critical incident response. She now writes full-time, exclusively in the mental health area, and provides consulting services for other mental health professionals. When she’s not working, you’ll find her in the gym or walking her Black Lab, Riley.

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