Journal of Behavior Therapy and Experimental Psychiatry
Implicit processes in pathological skin picking: Responses to skin irregularities predict symptom severity and treatment susceptibility
Highlights
► We examine the role of implicit processes in pathological skin picking (PSP). ► We assess automatic responses to skin irregularities in PSP patients and controls. ► PSP patients display distraction and avoidance in response to skin irregularities. ► Distraction by skin irregularities uniquely predicts symptom severity at post-measurement. ► Responses to skin irregularities seem relevant in severity and maintenance of PSP.
Introduction
Within recent literature, a growing body of research is currently examining the role of implicit cognitive processes in various behaviours. The general assertion underlying these lines of research implicates the existence of two distinct processes which govern our behaviour and through which behavioural change can occur. Controlled processes, on one hand, are supposed to rely on knowledge about facts and values and encompass active goal construction. Traditionally, these processes are assessed using self-report measures. Implicit processes, on the other hand, are supposed to encompass fast activation and efficient resolution. Recently, these processes are assessed using indirect measures. While deliberate self-control and meta-cognition are thought to be major determinants in controlled processes, associative links and motivational orientations are assumed to constitute driving forces in implicit processes (for an overview see Strack & Deutsch, 2004).
In recent literature, indirect measures are applied with increasing frequency to a variety of domains and populations. This interest originates from the idea that indirect measures are helpful in understanding the more automatic processes involved in cognition and behaviour, which may be less readily accessible to introspection. Particular interest in these measures can be observed in the domain of pathological and dysfunctional behaviours (e.g., Heuer et al., 2007, Teachman et al., 2001, Teachman and Woody, 2003, Wiers et al., 2009), as indirect measures promise to provide more insight into the representations and mechanisms involved in psychopathology.
The present study investigated implicit processes in pathological skin picking (PSP). PSP is characterized by recurrent and excessive picking or scratching of skin, skin lesions, and minor surface irregularities up to the point of causing severe tissue damage (Odlaug & Grant, 2008). Negative consequences can be profound and include lesions, infections, pigmentations, and scarring. Research indicates that skin picking is a common behaviour which can range from benign to self-injurious (Bohne, Wilhelm, Keuthen, Baer, & Jenike, 2002). In previous research, criteria used to define PSP have been diverse (Arnold, Auchenbach, & Elroy, 2001; Odlaug & Grant, 2007; Keuthen, Jameson, Loh, Deckersbach, Wilhelm, & Dougherty, 2007 Odlaug & Grant, 2008; Snorrason, Smari, & Olafsson, 2010), but recommendations for a uniform definition of PSP, in line with related disorders such as trichotillomania (hair pulling disorder) and stereotypic movement disorder, were recently proposed (Stein et al., 2010). Clinical levels of skin picking, as defined by substantial emotional distress or functional impairment, appear to be a problem with significant prevalence, estimated to occur in approximately 1.4–5.4% of the general population (Bohne et al., 2002, Grant and Odlaug, 2009, Hayes et al., 2009, Keuthen et al., 2000, Keuthen et al., 2010).
At least two features of PSP render evaluation of implicit processes particularly interesting. First, individuals with PSP often report impulsivity or an inability to control the urge to engage in picking behaviour (Odlaug, Chamberlain, & Grant, 2010). Second, skin picking behaviour is often reported to occur automatically or unconsciously (Arnold et al., 1998, Walther et al., 2009). Therefore, the employment of indirect measures appears particularly promising in a more comprehensive understanding of the processes involved in the execution of dysfunctional skin picking behaviour.
To assess automatic response tendencies, we used an Approach–Avoidance Task (AAT; Rinck & Becker, 2007) which assesses stimulus-response associations in terms of affective behavioural reactions. Approach and avoidance tendencies are regarded as critical processes in the maintenance of dysfunctional behaviour in various disorders (Field et al., 2008, Palfai and Ostafin, 2003, Turk et al., 2001), and altered response tendencies have been repeatedly observed in social anxiety, spider phobia, and heavy drinking (Heuer et al., 2007, Lange et al., 2008, Rinck and Becker, 2007, Wiers et al., 2009). Importantly, previous research showed critical discrepancies between direct and indirect measures (Heuer et al., 2007). Indirect measures have been shown to explain unique variance in behaviour assessments over and above direct measures, thereby predicting more aspects of behaviour than could be predicted from self-report alone (Rinck & Becker, 2007).
In the present study, we investigated automatic response tendencies in response to varying types of stimuli in PSP. We distinguished between pictures of skin irregularities, pictures of healthy skin, and pictures of control stimuli. Odlaug and Grant (2008) reported that the majority of skin picking episodes is preceded by clear triggers, mostly by sight or feel of the skin. Therefore, the employment of stimuli that are visual or tactile in nature seems particularly interesting in assessing skin picking-related processes. We hypothesized that PSP patients display altered response tendencies in comparison to a control sample, and we expected this effect to be specific for skin picking-relevant stimuli (i.e., pictures of skin irregularities). Furthermore, we hypothesized that altered response tendencies are not only associated with current skin picking behaviour, but also predictive of prospective skin picking behaviour, thereby characterising a relevant process in the maintenance of symptom severity in PSP.
Section snippets
Participants and procedure
For the present study, we used data of 34 participants suffering from PSP who participated in a treatment study aimed at reducing skin picking behaviour (for more detailed information see Schuck, Keijsers, & Rinck, 2011). All participants were randomly assigned to either a four-session cognitive-behavioural treatment (n = 17) or a waiting-list condition (n = 17).
Of the 34 participants, 30 were female. Participants satisfied the following inclusion criteria: repetitive skin picking resulting in
Descriptives
With regard to skin picking severity, PSP patients (M = 9.48, SD = 3.49) differed significantly from the control sample (M = 1.76, SD = 1.76), t (81) = 12.65, p < 0.001.
For PSP patients, a repeated-measures analysis of skin picking severity from pre- to post-measurement showed a significant interaction effect between time and treatment condition, F(1,27) = 15.09, p < 0.01, ηp2 = 0.36, indicating stronger improvements in skin picking severity for the treatment condition (M = 5.43, SD = 3.41)
Discussion
The present study investigated the role of implicit processes in pathological skin picking behaviour. Results demonstrate altered response tendencies towards skin picking-related stimuli in individuals who suffer from PSP. First, PSP patients generally responded more slowly to pictures of skin irregularities compared to pictures of healthy skin and pictures of control stimuli. The control sample did not differ in reaction times across picture types. Second, PSP patients were slower to pull
Conclusions
In conclusion, individuals suffering from PSP display altered response tendencies towards skin picking-related stimuli, which are associated with current skin picking severity and predictive of prospective skin picking severity. While affective distraction in response to skin irregularities seems detrimental in untreated participants, it appears to be a favourable condition when PSP is treated. Future research needs to confirm and extend insight into the role of implicit processes in symptom
Conflict of interests
None.
Acknowledgements
This work was supported by the Behavioural Science Institute, Radboud University Nijmegen.
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