How CBT works for Excoriation Disorder?

In 2013 compulsive skin picking was included in the American Psychiatric Association (APA) Diagnostic and Statistical Manual (DSM5) for the first time as ‘Excoriation (skin picking) Disorder’. You may be one of many who has struggled with compulsive skin picking for years, not knowing that it is a clinical disorder, never finding the professional help and support you need. Where help is available for this disorder, it is often unaffordable or inaccessible. Skinpick has developed an online therapy program available at a fraction of the cost of traditional face-to-face therapy. However you may be feeling apprehensive about placing your trust in this program, especially if you are not familiar with Cognitive Behavioral Therapy (CBT), and in particular internet-based CBT. We address some of the common concerns about online CBT for excoriation disorder.

A psychotherapy approach called cognitive behavior therapy (CBT) is the treatment of choice for BFRBs.


What is CBT for Excoriation Disorder?

The Cognitive Behavioral Frame of Reference is a learning theory based in evidence that our thoughts, behaviors and emotions are invariably intertwined and therefore have a direct influence on each other. Cognitive Behavioural Therapy is a practical, problem-solving approach fundamentally rooted in an understanding of an individual’s cognitive behavioural sequence. The premise is that our thoughts and beliefs influence our interpretation of the events that we experience on a daily basis. These thoughts then create feelings, our feelings influence our behavior, and our behavior then either reinforces or refutes our thoughts and beliefs.


Figure 1: Cognitive Behavioral Sequence

When the behaviour we engage in, in response to negative thoughts and emotions, provides relief, it positively reinforces this behavioural response the next time we have a similar experience. For example people with excoriation disorder often report feeling a sense of release from stress or anxiety while engaged in skin picking. Skin picking therefore becomes a learned response to events or situations that elicit stress or anxiety. This then sets in motion an undesirable cognitive behavioural cycle. The goal of CBT for excoriation disorder is therefore to help you unlearn the reaction of skin picking in response to certain stimuli, and to replace it with more acceptable alternatives.

Figure 2: Skin Picking Cognitive Behavioral Cycle

In CBT, the therapist will help you identify the factors that trigger negative thoughts and emotions that lead to skin picking. The therapist will encourage you to develop an increased awareness of the times of day, emotional states and thought patterns during times when skin picking occurs. You will be guided in exploring and challenging “faulty” thoughts and interpretations, and the therapist will help you identify behavioural responses that interfere or compete with skin picking. CBT is thus a very hands-on treatment, often involving assignments which you complete between sessions, e.g. keeping a skin picking record, or learning to record your thoughts and looking at them more realistically.

Figure 3: Action Reflection Experiential Learning Cycle

CBT differs from other therapies in that it has a clear structure and is focussed on what you are experiencing in the present as opposed to exploring events of the past. You and your therapist will work as a team to identify goals and find practical solutions to achieving them. A large component of this is reflecting on your values and vision for your life and finding ways to engage in behaviour that is congruent with these.


Does CBT work for excoriation disorder?

CBT is recognised among health professionals as the most effective method of treatment for Body-Focussed Repetitive Behaviors such as excoriation disorder. The compulsive skin picking disorder involves two core behavioural processes: automatic and focused picking. Habit Reversal Training (HRT) and Stimulus Control (SC) are two methods of CBT used to treat automatic picking, while acceptance and commitment therapy (ACT) is employed to treat focussed picking.

One study looking at the effectiveness of ACT and HRT found that there was a significant reduction in skin picking frequency (49.5%) in the participants who received ACT/HRT compared to those who were in the control group. Another study examined the effects of brief cognitive-behaviour therapy for pathological skin picking based on measures of severity of skin picking, psycho-social impact of skin picking, strength of skin-picking-related dysfunctional cognitions, and severity of skin injury pre-, post, and two months follow-up assessment. The results showed a significantly large reduction on all measured variables, with treatment effects maintained at 2 months follow-up.

  95% of clients who finish the program say they would (and do) recommend it to others


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