by Dr. Dawn Ferrara

26 Feb, 2021

When it comes to mental health disorders, one thing is true. While there are specific diagnostic criteria used to make a diagnosis, how those behaviors and traits are manifested can vary. Rarely is a diagnosis a “one-size-fits-all.” Skin picking disorder (SPD) is no exception. It has not gone unnoticed by the clinical community that picking behavior and its associated traits don’t always look the same from person to person. In fact, research has looked at how people engage in picking and, it turns out that there is not a single type of picking but rather distinct subtypes.

• Some people experience intense, irresistible urges to pick and do so compulsively to relieve emotional distress or address some perceived imperfection. This behavior is classified as compulsive or emotional/reward picking.
• Others engage in impulsive/automatic or functional picking. They seem to pick almost automatically, with little awareness of the behavior in the moment.
• Still others experience both compulsive and automatic or mixed episodes.

Subsequent research has supported the presence of subtypes and identified the emotional underpinnings that seem to trigger this behavior. Taking a closer look at the subtypes, this recent study found that each subtype is associated with distinct characteristics that include emotion, trait impulsiveness, inattention, and hyperactivity.

• Focused or compulsive pickers, tend to struggle with emotional regulation. Their picking is reward-based and focused on alleviating negative emotions.  This is the most common form of SPD and can cause significant impairment. Individuals in this subtype tend to score high on measures of ADHD and report a high degree of perfectionism.
• Automatic or functional pickers tend to experience milder symptoms of SPD and lower urges to pick. People in this group tend to experience some degree of sensory sensitivity and a lowered tolerance to stress. Impairment is generally low.

The presence of subtypes suggests that each type of picking and each individual has a unique set of traits that may respond to different treatment approaches. A new study suggests that these traits may be due to early maladaptive schemas (EMS) and understanding which EMS are associated with subtypes may support the use of schema therapy for treating SPD.    

Schema Theory and SPD

Schema theory holds that early maladaptive schema (EMS) develops when basic psychological needs of childhood are not met. Those early needs include secure attachment, autonomy, realistic limits, self-directedness, and playfulness. These EMS are essentially trait-like characteristics that develop in response to early childhood experiences. They are broad, pervasive, dysfunctional patterns of memories, emotions, thoughts, feelings, and attributions that develop over time and carry through into adulthood.

Through the lens of schema theory, the maladaptive behaviors of picking develop as a result of the triggering of EMS from traumatic or toxic early childhood experiences. These experiences serve as a framework or “schema” for the development of traits and behaviors to cope, in the case of SPD, skin picking. When the EMS is triggered, a person may respond with maladaptive coping behaviors such as compensation, avoidance, or surrender.  Understanding a person’s EMS and how it is related to their skin picking can help to guide treatment.

The Study

The study focused on identifying the specific EMS and core domains associated with each subtype of skin picking. Study participants completed questionnaires that identified their SPD subtype and assessed for the 18 EMS domains. These domains are related to the early basic childhood psychological needs and include:

Disconnection and rejection

• Abandonment/instability

• Mistrust/abuse
• Emotional deprivation
• Defectiveness/shame
• Social Isolation/alienation

Impaired autonomy and performance

• Dependence/incompetence
• Vulnerability to harm or illness
• Enmeshment/underdeveloped self
• Failure

Impaired limits

• Entitlement/grandiosity
• Insufficient self-control/self-discipline

Other-directedness

• Subjugation
• Self-sacrifice
• Approval-seeking/recognition-seeking

Overvigilance and inhibition

• Negativity/pessimism
• Overcontrol/emotional inhibition
• Unrelenting standards/hypercriticalness
• Punitiveness

Results of the study found that the three subtypes of SPD were each associated with common EMS. Higher dependence/Incompetence EMS was a predictor for both the automatic and focused subtypes. Lower emotional derivation was associated with all three subtypes.

Higher approval/Recognition Seeking was a specific predictor for the automatic subtype. Higher mistrust/Abuse, Lower social isolation/Alienation and Enmeshment/Undeveloped self were specific predictors for the focused subtype. Higher Failure to Achieve and male gender were predictive of the mixed subtype.

Treatment Implications for SPD

The results of this study confirm that SPD subtypes are associated with specific EMS and support the use of schema theory to understand the role of EMS in skin picking subtypes. These findings highlight the possibility that schema therapy may be an option for tailoring treatment to the unique needs of the person.

Schema-focused Therapy is an integrated approach to treatment that combines key elements of cognitive-behavioral therapy (CBT), experiential therapy, interpersonal therapy and psychoanalytic therapies into one unified approach to treatment. It is a highly effective therapeutic approach that helps people change their maladaptive patterns of coping.  

Schema-focused Therapy targets those enduring, self-defeating schema developed early in life that results in maladaptive coping. Sometimes referred to as “life traps”, these self-defeating patterns keep you stuck in negative patterns of thinking, feeling, and behaving.  Schema-focused Therapy helps break these negative patterns and opens the way for more positive ways of coping.

This approach to treatment occurs in three phases. In the assessment phase, EMS operating is identified. Next, in the experiential phase, the person increases their emotional awareness learns to recognize when their schema has been activated in their day-to-day life.  The final phase is changing behavior. During this phase, the person learns to replace those pervasive, negative patterns and replace them with healthier coping choices.

Currently, Habit Reversal is the most used treatment approach for SPD. Habit Reversal requires the person to focus on the behavior or urge by resistance, avoidance or competing response. While effective at least in the short-term, over time, this can be quite challenging, especially if urges are particularly intense. Schema-focused therapy may offer an alternative to focusing on the maladaptive coping behavior, in this case picking, and focus on changing the thought patterns associated with the response.

If EMSs are indeed perpetuating picking behavior as the study seems to suggest, then changing the schema may indeed result in healthier coping responses. Clearly, much more research is needed but schema theory and schema-focused therapy may offer hope and more targeted treatment options for people living with SPD.

References

1. Arnold, L. M., McElroy, S. L., Mutasim, D. F., Dwight, M. M., Lamerson, C. L., & Morris, E. M. (1998). Characteristics of 34 adults with psychogenic excoriation. The Journal of Clinical Psychiatry, 59(10), 509-514. doi:10.4088/jcp.v59n1003
2. Grant, J. E., Peris, T. S., Ricketts, E. J., Lochner, C., Steins, D. J., Chamberlain, S. R., … Keuthin, N. J. (2020). Identifying subtypes of trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder using mixture modeling in a multicenter sample. Journal of Psychiatric Research, in press. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0022395620310578?via%3Dihub
3. Pozza, A., Albert, U. & Dèttore, D. (2020). Early maladaptive schemas as common and specific predictors of skin picking subtypes. BMC Psychol 8, 27. https://doi.org/10.1186/s40359-020-0392-y
4. Young JE, Klosko JS, Weishaar ME. (2003). Schema therapy: a practitioner’s guide. New York: Guilford Press; 2003. p. 7–8.https://www.guilford.com/books/Schema-Therapy/Young-Klosko-Weishaar/9781593853723/contents

About the author

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.