Habit reversal training for body-focused repetitive behaviors (BFRBs) includes improving awareness and self-monitoring, controlling stimuli, and creating competing responses. Stimulus control and competing responses sound very similar. This article will talk about what they are, how they are different, and how they work in tandem to reduce body-focused repetitive behaviors.
Stimulus control refers to managing external factors, usually in one’s environment, to influence behavior. For example, someone who picks at their skin may do so in a location at home that triggers it. An area such as a well-lit bathroom with a huge mirror and a lock on the door. The bright lighting and huge mirror draw attention to every little imperfection of the skin and whenever you walk in there, you lock the door, push your face as close to the mirror as possible, start picking, and before you know it, a couple of hours have gone by.
Stimulus control prompts you to consider that environment.
First, the big mirror. What things can be done to change the giant mirror so it doesn’t “pull you in?”
Competing responses are movements or activities that are incompatible with habitual or automatic behaviors. In simple terms, if your hands are not available to use for picking at your skin, you won’t pick at your skin. In addition, think of something that is the opposite of the behavior you want to replace. It should be something you can do for longer than a couple of minutes and will be more less unnoticeable by others. It may be something challenging that you do with your hands, or something easy to do that just keeps your hands occupied.
This video transcript talks about using your smart phone as a competing response.
Hi, welcome back to Talk Therapy Channel on YouTube.
I’m Tammy Fletcher, Licensed Marriage and Family Therapist in California, and today, my friend Scooter and I are going to be talking to you about iPhone apps that can help with skin picking and hair pulling.
If you were to ask people who suffer from excoriation disorder whether hormonal changes influence the severity of their picking, they would likely say yes. Research supports this anecdotal evidence in several ways. First, the onset of excoriation disorder tends to occur during puberty. This means, the first time symptoms of skin picking start during a major hormonal change in the body. In addition, a study of 1,471 women aged 10-60 found a relationship between hormonal changes and an increase in “focused” picking behavior (Flessner et al, 2009). These women, described picking behavior as more severe when hormones were changing throughout their lives.
Has anything like this happened to you?
The scientific explanations for this phenomenon abound, however, for those who suffer from skin picking in an automated way, passive or sedentary activities can be triggers.
In simple terms, the situations described above are mild forms of dissociation. Some people refer to this as “zoning out,” while more severe versions can be diagnosed as a disorder. Think of dissociation along a continuum with mild zoning out and inattention at the less serious end and Dissociative Identity Disorder on the severe end. Dissociation can be the brain’s way of taking a break and can be caused by traumatic events or simply boredom.
There are many therapeutic interventions to help an individual focus on what is important to them. Values are those things which someone prioritizes as valuable. They can be things, ideas, people or activities and people make decisions consistent with what is important to them. Values-based therapy starts by setting up new values or reviewing existing values. This happens before discussing the problem because every step of therapy afterwards will use values as the foundation for decision making and treatment planning.
Driving is a prime environment for skin picking behavior, but competing responses can help. People who pick their skin fall into two categories:
Driving is one of those activities that many people do alone and as a private place, or it can become automatic allowing one’s thoughts to wander.
In habit reversal therapy, before considering replacement behaviors, you learn to recognize circumstances and locations that trigger picking. For many people, driving is a frequent location. Once triggers and behavior patterns are recognized, you learn and develop strategies to disrupt the behaviors you want to change. One of the strategies for disrupting behaviors is the development of competing responses.
Skin picking disorder, more formally known as excoriation disorder, is considered to be a disorder related to obsessive-compulsive disorder, but not an obsessive-compulsive disorder in itself. Skin picking can also be a symptom of obsessive-compulsive disorder, so how does one tell the difference? First, we’ll talk about the basic diagnostic criteria for each disorder, then we’ll get more specific about how to tell the difference.
(Diagnostic criteria are taken from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition published by the American Psychiatric Association.)
1. OCD is marked by the presence of obsessions, compulsions, or both.
Obsession – Recurrent or persistent thoughts, urges, or images that are intrusive, unwanted, and cause significant anxiety or distress. A person attempts to ignore or suppress them or to neutralize them with some other thought or action. Actions usually take the form of compulsions.
Scabs on the scalp are a result of cracks in the skin of the head that bleed and dry. The dried blood forms a scab and helps the wound heal. Picking at a scab constantly reopens the wound, causing it to bleed again. Then it forms another scab. It can be tempting to pick at a scab because as it forms, the skin tightens and dries out, drawing your attention to it. There are several things you can do to help facilitate quick scab healing.
A little bit of prevention goes a long way. Scalp skin is tender, sensitive, and can be damaged easily. Regardless of the cause of scabs on your scalp, if you tend to get them or already have them, take some steps to prevent them from occurring and from getting worse.
Annette Pasternak's very first stop skin picking coaching client, Carly talks about her journey and the strategies that have been most helpful to her in the long-term. Number one is logging, tracking her picking daily. She uses different methods of monitoring picking, from the SkinPick app to a simple calendar tracking method.
Tracking daily skin picking activity is a mindful practice that can help in a number of ways.
A mindful practice
What do we mean by mindful practice? Mindfulness is the process of being present in the moment, aware of thoughts, feelings, and bodily sensations without judgment. Practicing mindfulness can help you separate of the behavior of skin picking from your identity and objectively evaluate where you are and where you want to be.
The Addictive, Compulsive and Impulsive Disorders (ACID) research/clinical group of the University of Chicago has a variety of treatment services and clinical trial opportunities available in the areas of substance addiction, impulse control, and obsessive compulsive disorder. Dr. Jon Grant, onle of the leading researchers in body focused repetitive behaviors such as dermatillomania, is the director of the group. ACID strives to better understand the biological underpinnings of conditions such as substance and behavioral addictions, including alcohol, drug, and tobacco dependency, pathological gambling, compulsive shopping, kleptomania (shoplifting), pyromania (fire setting), compulsive sexual addictions, obsessive-compulsive disorder (OCD), skin picking, trichotillomania (hair pulling) and body dysmorphic disorder. It is hoped that through understanding the cause and triggers, there can be better facilitation of treatments and quality of life for clients and their families. Currently they have two studies underway. One for hair pulling, and one for both skin picking and hair pulling.
Do you pull your hair or pick your skin?