Excoriation: what counselors need to know about skin picking disorder.
Skin picking was first described by William Wilson in 1875 and has been documented in medical literature for over a century (Fruensgaard, Hjorshoj, & Nielsen, 1978). It was originally viewed as a dermatological condition (Fruensgaard et al., 1978). Skin picking started gaining attention as a psychiatric condition in 1898 when the French dermatologist Brocq observed adolescent females habitually picking at their acne when emotionally distressed, producing lesions on the skin (Sneddon & Sneddon, 1983). Despite its lengthy existence, skin picking as a psychological disorder has been overlooked, and therefore has not been treated effectively by clinicians (Grant, Williams, & Potenza, 2007; Wilhelm et al., 1999). Excoriation disorder, used interchangeably with skin picking disorder (SPD), has been incorporated into the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) under obsessive compulsive and related disorders, and is defined as repetitive picking or scratching of the skin, resulting in tissue damage that causes skin lesions [American Psychiatric Association (APA), 2013], DSM-5 diagnostic criteria include: multiple attempts to reduce or cease skin picking; skin picking cannot be attributed to substance use or abuse, or any other mental or medical disorders; and that an individual experiences significant distress or functional impairment as a result of the skin picking (APA, 2013).
PREVALENCE, COURSE, ETIOLOGY
The exact prevalence rate of SPD in the general population is unknown clue to the stigma and feelings of embarrassment associated with this disorder (Neziroglu, Rabinowitz, Breytman, & Jacofsky, 2008; Wilhelm et al., 1999). Due to these factors, researchers assert that there is an underreporting of SPD, and that occurrence rates are higher than what is cited in the available literature (Neziroglu et al., 2008). Existing research has demonstrated skin picking to be a common behavior. A random sample telephone survey including 2,513 individuals revealed that 16.6% of adults in the United States have reported skin picking behaviors resulting in visible damage to the skin, and that 1.4% of those individuals met all five of the diagnostic criteria for SPD in the DSM-5 (Keuthen, Koran, Aboujaoude, Large, & Serpe, 2010; Oliveira, Leppink, Derbyshire, & Grant, 2015). Hayes, Storch, and Berlanga (2009) surveyed 354 individuals and found that 62.7% of participants acknowledged picking their skin, and 5.4% of those individuals engaged in clinically significant skin picking, meeting all five of the DSM-5 diagnostic criteria (Oliveira et al., 2015). SPD is prevalent in other populations as well. Researchers have documented excoriation occurrence rates in 2% of dermatology patients, 11.8% of adolescent psychiatric inpatients, and approximately 2%-9% of college students in the U.S., Germany, Pakistan, and Turkey (Bohne, Wilhelm, Keuthen, Baer, & Jenike, 2012; Galikusu, Kucukgoncu, Tecer, & Bestepe, 2012; Grant et al., 2007; Greisemer, 1978; Odlaug et al., 2013; Siddiqui, Naeem, Naqvi, & Ahmed, 2012). Co-occurring psychological disorders are frequently associated with this condition (Gupta & Gupta, 1996; Wilhelm et al., 1999). High rates of depressive and anxiety disorders have been reported, as well as obsessive-compulsive disorder and trichotillomania (APA, 2013; Arnold et al., 1998; Odlaug & Grant, 2008; Wilhelm et al., 1999).
Previous studies that examined gender differences in skin picking behaviors found that between 87.1% and 94.1% of individuals with SPD are female (Grant & Christenson, 2007; Wilhelm et al., 1999). Although existing literature cites high occurrence rates for SPD among women in comparison to men, it is presumed that the prevalence rates for men may be higher than initially thought (Arnold, Auchenbach, & McElroy, 2001; Flessner & Woods, 2006; Leibovici et al., 2015; Wilhelm et al., 1999). It has been posited that differences in treatment-seeking exist between genders, and the underutilization of mental health services by men may be associated with an under-reporting of SPD in males (Arnold et al., 2001; Flessner & Woods, 2006; Grant & Christenson, 2007; Leibovici et al., 2015). Although studies examining gender differences are sparse, a study by Grant and Christenson (2007) revealed that male participants who developed picking behaviors later in life had significantly higher rates of current and lifetime co-morbid disorders of generalized anxiety and social phobia, and experienced greater functional impairment from picking behaviors compared to the female subjects.
The onset of SPD can occur at any age, with existing literature reporting high occurrence rates in adolescence around the start of puberty, with the behavior often originating from the picking of dermatological conditions such as acne, psoriasis, or eczema (APA, 2013; Odlaug & Grant, 2008). Skin picking can occur on any part of the body, with previous studies noting the face, arms, legs, and hands as areas that are most commonly picked (Arnold et al., 2001; Flessner & Woods, 2006; Odlaug & Grant, 2008; Tucker, Woods, Flessner, Franklin, & Franklin, 2011). The methods used during skin picking are a matter of personal preference, with a high number of individuals reporting using their fingernails, although the implementation of instruments or objects to pick at the skin has been documented as well (Tucker et al., 2011). The amount of time spent picking can range from minutes to several hours per day, and it is not uncommon for individuals to engage in multiple picking episodes throughout the day (APA, 2013; Flessner & Woods, 2006; Gelinas & Gagnon, 2013; Odlaug & Grant, 2008). The severity and extent of SPD may produce substantial physical, social, academic, occupational, and financial consequences (Flessner & Woods, 2006; Odlaug & Grant, 2008). Flessner and Woods (2006) found that participants endorsed avoiding social and group events, and that a considerable number of subjects reported that their skin picking interfered with their ability to perform tasks at work and school. Research investigating the etiology of SPD revealed different phenomenological functions for skin picking, which has led researchers to identify three subtypes of skin picking behaviors: focused, automatic, and mixed (APA, 2013; Arnold et al., 2001; Snorrason, Smari, & Olafsson, 2010; Walther, Flessner, Conelea, & Woods, 2009). The focused style of skin picking is performed with full awareness, with many individuals reporting that they engage in this behavior when they feel anxious, bored, or depressed (Snorrason et al., 2010; Walther et al., 2009). Focused skin picking allows individuals to avoid experiencing aversive affective states, in that the act of picking helps to regulate a person's negative emotions (Snorrason et al., 2010). This cycle, known as experiential avoidance, becomes a maladaptive coping method, and is continually reinforced due to the feelings of relief and/or gratification that result from skin picking episodes (Flessner, Busch, Heideman, & Woods, 2008; Flessner & Woods, 2006; Keuthen et al., 2000; Snorrason et al., 2010; Walther et al., 2009; Wilhelm et al., 1999). Not all individuals with SPD pick their skin to regulate their emotions, as demonstrated by the automatic style of skin picking. The automatic picking subtype is characterized by individuals engaging in the behavior with little to no awareness of the action, and is commonly performed during sedentary activities like watching television (Flessner et al., 2008; Walther et al., 2009). The last subtype, mixed skin picking, consists of features from both the automatic and focused styles of skin picking (Arnold et al., 2001; Walther et al., 2009).
A variety of factors make the assessment of excoriation disorder a challenge for clinicians. For instance, individuals may view habitual skin picking behaviors simply as a bad habit, not a pathological disorder, and therefore do not actively seek out counseling for this condition (Neziroglu et al., 2008). Additionally, many individuals are often distressed about excoriation, and experience feelings of shame from the behaviors and lesions associated with skin picking, which may deter clients from bringing this topic up in counseling (Grant et al., 2007; Neziroglu et al., 2008; Simeon et al., 1997). Due to these factors, it is essential that counselors are cognizant of the physical presentation of clients, as well as the concerns clients discuss in counseling to determine if additional SPD assessments are warranted. Common physical skin picking indicators include: visible lesions or scars; wearing long pants, long-sleeved shirts, hats, or gloves, especially in warmer temperatures, to hide open wounds or scars; positioning the body at strategic angles, such as sitting on hands or placing hands on the face in effort to conceal involved areas; refusing to shake hands (if picking primarily occurs on fingers, hands, and/or arms); and avoiding well-lit areas, or requesting to change the lighting in a room prior to entry (Deckersbach, Wilhelm, & Keuthen, 2003; Flessner & Woods, 2006). In session, clients may initially disclose concerns that are related and allude to SPD such as: low self-esteem; dissatisfaction with appearance; depression; anxiety; issues associated with occupational or academic performance and productivity; impairments in social functioning such as forgoing social situations; difficulties with interpersonal relationships; and avoiding sport and leisure activities where wearing certain clothing may reveal lesions (Arnold et al., 2001; Flessner & Woods, 2006; Gelinas & Gagnon, 2013; Neziroglu et al., 2008; Simeon et al., 1997). If the client presents with the information discussed above, and excoriation is suspected, the topic of SPD should further be explored with the client (Neziroglu et al., 2008; Odlaug & Grant, 2008). Approaching the topic of excoriation should be done in a sensitive and respectful manner so that the therapeutic alliance is preserved, and the client is more receptive to receiving additional assessment measurements for SPD.
Skin Picking Scale (SPS; Keuthen, Wilhelm et al., 2001). SPS is a 6-item self-reported questionnaire that measures the severity of skin picking behaviors. Scale items consist of the following categories: frequency of urges to pick skin, intensity of skin picking urges, time spent picking, interference due to skin picking, distress, and avoidance. Items on the SPS are rated on a 5-point scale (0 = none, 4 = extremely), with a total SPS score ranging from 0 to 24. A cut-off score of 7 distinguishes self-injurious skin pickers from non-injurious skin pickers. Higher total SPS scores are indicative of more severe skin picking behaviors. A Cronbach's coefficient alpha of .80 revealed good internal consistency reliability, and significant correlations in construct validity were demonstrated between SPS total scale scores, self-reported average duration of skin picking episodes, feelings of satisfaction before skin picking, feelings of tension before picking, release of tension during skin picking, and feelings of dissatisfaction after skin picking (Keuthen, Wilhelm et al., 2001).
To further improve the psychometric properties of the SPS, Snorrason et al. (2012) created the Skin Picking Scale-Revised (SPS-R). In the revised version, the authors aimed to reduce the ambiguity of the language in one of the scale items by replacing the word "distressed" with the phrase "emotional distress." Two additional items assessing control over skin picking behaviors and the physical damage to the skin as a result of picking were also added, making the SPS-R an 8-item self-reported measurement that is more congruent with the diagnostic criteria of the DSM-5. Items on the SPS-R are rated on a 5-point scale (0 = none, 4 = extremely), producing a total score ranging from 0 to 32. Exploratory and confirmatory factor analyses were conducted, revealing two factors: a "symptom severity" subscale and an "impairment" subscale. Cronbach's coefficient alpha revealed good internal consistency for the total score of the SPS-R ([alpha] = .83) in addition to the subscales of symptom severity (a = .81) and impairment ([alpha] = .79). Steiger's method demonstrated preliminary convergent, concurrent, and discriminant validity for the two factors. Since the subscale scores demonstrate acceptable reliability and validity, Snorrason et al. (2012) recommend the two subscale scores of "symptom severity" and "impairment" be calculated separately, in addition to calculating a total SPS-R score.
Skin Picking Impact Scale (SPIS; Keuthen, Deckersbach et al., 2001). SPIS is a 10-item self-report questionnaire that is used to evaluate the psychosocial consequences that have occurred from repetitive skin picking. Scale items on the SPIS assess for avoidance behaviors, time spent concealing lesions and/or scars, social and relational challenges, and feelings of embarrassment and unattractiveness from picking one's skin. Items are rated on a 6-point scale ranging from none (0) to severe (5), resulting in a total SPIS score ranging from 0 to 50. A cut-off score of 7 distinguishes self-injurious skin pickers from non-self-injurious skin pickers. High internal consistency reliability was demonstrated for the SPIS ([alpha] = .93). Pearson product-moment correlations were computed to assess scale validity, and revealed moderate correlations between SPIS total scores, self-reported duration of time spent picking, satisfaction while picking, and intensity of shame experienced after picking episodes (Keuthen, Deckersbach et al., 2001).
Milwaukee Inventory for the Dimensions of Adult Skin Picking (MIDAS; Walther et al., 2009). MIDAS is a 12-item self-reported assessment tool that was developed to characterize and assess two different types of skin picking: automatic (i.e., unconscious, unintentional picking) and focused (i.e., conscious, purposeful picking). Results obtained from an exploratory factor analysis revealed two factors, each containing 6 items. Factor 1 consists of questions assessing if an individual is predominately a focused skin picker (e.g., I pick my skin when I am anxious or upset), while Factor 2 comprises questions assessing if the individual is an automatic skin picker (e.g., I am usually not aware of picking my skin during the picking episode). Items are rated on a scale from 1 (not true of any of my skin picking) to 5 (true for all of my skin picking), with scores ranging between 6 and 30. Walther et al. (2009) state that the MIDAS is not intended to produce a total score, and that each subscale should be calculated separately. Adequate internal consistency for both the focused subscale (a = .81) and the automatic subscale ([alpha] = .77) was demonstrated. Correlations were calculated between SPS scores and scores from the focused and automatic subscales of the MIDAS to determine construct validity. A significant positive correlation was demonstrated between the focused scale and the SPS, but no significant correlations were established between the automatic subscale and the SPS. Additionally, correlations between the focused and automatic subscales revealed that the two subscales measure separate dimensions of SPD, and indicate evidence of discriminant validity (Walther et al., 2009).
The paucity of research on SPD has hindered the examination of efficacious treatment modalities for this condition, making the selection of appropriate treatment methods a difficult process for clinicians (Capriotti, Ely, Snorrason, & Woods, 2015; Tucker et al., 2011). Treatment for excoriation should be tailored to meet client's personal needs, as some individuals may require the utilization of multiple treatment interventions to obtain beneficial results (Capriotti et al., 2015; Grant, Chamberlain, & Odlaug, 2014). When selecting and implementing treatment methods, factors such as co-occurring disorders should be taken into account, as this may require a combination of psychological and pharmacological modalities (Grant et al., 2014). SPD subtype should also be considered when determining a client's course of treatment, as it has been suggested that focused and automatic subtypes of skin picking may respond better to specific psychotherapeutic interventions (Flessner et al., 2008; Snorrason et al., 2010; Walther et al., 2009). Existing studies on SPD treatments have primarily focused on the application of behavioral, cognitive behavioral, and pharmacological interventions, and are discussed in further detail below (Gelinas & Gagnon, 2013; Odlaug & Grant, 2010; Shuck, Keijsers, & Rinck, 2011; Tucker et al., 2011).
Habit Reversal Training
Habit reversal training (HRT) is a behavioral technique that has been used to decrease the frequency of repetitive behaviors and incorporates five components: awareness training, relaxation training, competing response training, social support, and generalization training (Azrin & Nunn, 1973). In the first part of HRT, awareness training, clients focus on all aspects associated with skin picking behaviors. Twohig and Woods (2001) had participants learn to associate specific triggers, emotions, and situations that may prompt picking episodes by openly acknowledging their picking behaviors, and describing the sequence of all steps physically executed during the picking process (Moritz, Fricke, Treszi, & Wittekind, 2012; Twohig & Woods, 2001). Competitive responses are then introduced; these are alternative behaviors that are performed whenever an urge to pick is experienced, which disrupt the habitual behavior of skin picking (Azrin & Nunn, 1973; Grant et al., 2014). The alternative behavior should be incompatible with the habitual behavior, and should be an action that draws little to no attention to the individual (Azrin & Nunn, 1973). Examples of alternative behaviors include balling up hands into a fist, having the person physically sit on their hands (if already in a seated position), or manipulating an object (that cannot penetrate the skin) to prevent the individual from engaging in picking behaviors (Twohig & Woods, 2001). Social support should also be incorporated during HRT to provide individuals with positive feedback and reminders to apply competing responses if skin picking is observed (Azrin & Nunn, 1973; Grant et al., 2014; Teng, Woods, & Twohig, 2006). During the last segment of HRT, generalization training, individuals practice their acquired skills in situations that would typically evoke picking urges, applying competing responses when necessary (Azrin & Nunn, 1973; Deckersbach et al., 2003; Grant et al., 2014).
Preliminary studies investigating the effectiveness of HRT on excoriation have shown that the intervention reduces skin picking behaviors, with maintenance of long-term treatment gains producing mixed results (Gelinas & Gagnon, 2013; Moritz et al., 2012). Using a non-concurrent multiple baseline design, Twohig and Woods (2001) found that two adult male siblings reported a decrease in the frequency of skin picking behaviors. Both participants reported that their picking behaviors never fully resolved, and a three month follow- up revealed that only one of the participants had maintained treatment gains (Twohig & Woods, 2001).
Teng et ah (2006) examined the effectiveness of HRT for SPD using an experimental wait-list controlled design involving 25 participants, and found that the treatment group had reduced picking behaviors by 77%, while the control group's picking behaviors had decreased by 16%. At follow-up, the HRT group maintained their 77% reduction of skin picking behaviors, while the control group reported a 27% decrease in picking behaviors (Teng et al., 2006).
Using a German Internet-based population of 70 participants, Moritz et ah (2012) compared the effectiveness of treating SPD with a self-help version of HRT, versus the intervention decoupling (DC). With DC, individuals carry out their typical movements of picking, however, they do not directly touch their problematic picking area, and instead touch an area that is in close proximity to where they would normally pick. Findings revealed that 50% of the HRT participants compared to 33% of the DC patients experienced significant reductions in skin picking symptoms. Significant interactions were found on frequency, severity, and distress for the HRT group (Moritz et al., 2012).
Acceptance and Commitment Therapy
Acceptance and commitment therapy (ACT) is a contextual approach to behavioral therapy that aims to break the experiential avoidance process (Capriotti et al., 2015; Flessner et al., 2008; Gelinas & Gagnon, 2013; Hayes, Strosahl, & Wilson, 1999; Snorrason et al., 2010; Twohig, Hayes, & Masuda, 2006). The goal of ACT is to increase the client's psychological flexibility by focusing on six core processes: (a) confronting the system, (b) control is the problem, (c) acceptance as an alternative agenda, (d) self as context, (e) cognitive defusion and mindfulness, and (f) a willingness and commitment to carry out valued actions (Hayes et al., 1999). During the confronting the system phase of ACT, clients identify methods they have previously used to decrease skin picking urges, and discuss their values with their counselor (Hayes et al., 1999; Woods & Twohig, 2008). The next segment of ACT, control is the problem, utilizes metaphors and experiential exercises to aid clients in realizing that experiential avoidance and previous attempts to control skin picking urges have been ineffective, and have been exacerbating their excoriation, not mitigating it. Acceptance as the alternative agenda is the next step of ACT, and involves assisting clients towards accepting skin picking urges and other negative emotions instead of trying to control them. Additional metaphors are used to illustrate how controlling strategies can have detrimental psychological effects, and the alternative to this is acceptance. Some clients may view the thought of accepting previously avoided negative thoughts and skin picking urges as threatening, so to make this process less distressing, clients are encouraged to view their negative emotions and skin picking urges separately from their identity as a person, which is known as self as context in ACT. Part of having clients learn that there is a difference between their sense of self and SPD involves the use of cognitive defusion and mindfulness exercises. With cognitive defusion, clients learn to modify the psychological function of experiencing picking urges so that it becomes a cognitive event that does not equate to a reality, and therefore, does not need to be carried out. During the last phase of ACT, willingness and commitment to valued actions, clients' values are re-examined, and they then commit to living in way that is value directed, rather than focusing on controlling skin picking urges (Hayes et al., 1999; Woods & Twohig, 2008).
A preliminary investigation evaluating the application and effectiveness of ACT for SPD was conducted by Twohig et al. (2006), with five participants using a pair of multiple baseline across participant designs. Post-treatment evaluations revealed reductions in picking behaviors for four of the five subjects, with one of those four participants maintaining treatment gains at a three-month follow-up (Twohig et al., 2006).
Acceptance-Enhanced Behavior Therapy
In an effort to maximize the effectiveness of treatment modalities in SPD, researchers have examined a combination of two different types of therapies, HRT and ACT (Flessner et al., 2008; Woods & Twohig, 2008; Woods, Wetterneck, & Flessner, 2006). This therapeutic approach termed acceptance-enhanced behavior therapy (AEBT) has been investigated as a treatment intervention for trichotillomania (TTM), which often co-occurs and is researched in conjunction with SPD (Flessner et al., 2008; Woods et al., 2006). Existing research examining the application of AEBT to TTM has demonstrated reductions in hair pulling behaviors, with treatment gains being maintained at follow-up (Woods et al., 2006). Given the efficacy of AEBT with TTM, Flessner et ah (2008) conducted a study investigating the application of AEBT to individuals with SPD and a clinical sample of TTM participants using a non-concurrent multiple baseline across participants design. Five female subjects participated in the study, with three of the individuals receiving previous diagnoses of TTM, and the other two participants meeting the criteria of chronic skin picking. Results revealed all five participants decreased occurrence rates of picking or pulling behaviors, with the SPD subjects experiencing a 49.5% reduction in the frequency of their skin picking behaviors (Flessner et al., 2008).
The application of AEBT for SPD was further examined by Capriotti et al. (2015) in a clinical case series involving four adults. Counseling sessions were conducted using the AEBT manual (Woods & Twohig, 2008) for TTM, which was modified to address the content and behaviors associated with skin picking. Overall, three of the four participants in this case series demonstrated reductions in excoriation symptom severity, with the fourth participant exhibiting a relapsing-remitting pattern, providing additional preliminary evidence for the use of AEBT in the treatment of SPD (Capriotti et al., 2015).
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) uses a combination of cognitive restructuring techniques and behavioral interventions to reduce skin picking behaviors in individuals (Schuck et al., 2011). Cognitive restructuring is an important feature to incorporate into the treatment of SPD, particularly for individuals who experience negative or dysfunctional cognitions, as these may elicit skin picking episodes (Schuck et al., 2011). Applying CBT to SPD generally consists of psychoeducation, cognitive interventions, behavioral interventions, and relapse prevention (Gelinas & Gagnon, 2013; Schuck et al., 2011). With psychoeducation, clients receive information explaining what SPD is, and how it manifests (Deckersbach, Wilhelm, Keuthen, Baer, & Jenike, 2002; Schuck et al., 2011). Cognitive interventions involve the identification of the automatic thoughts that activate picking behaviors (Deckersbach et al., 2002; Gelinas & Gagnon, 2013; Schuck et al., 2011). Cognitive restructuring involves clients learning to replace distorted cognitions with more realistic and positive thoughts (Deckersbach et al., 2003; Schuck et al., 2011). During cognitive restructuring, clients are encouraged to challenge and question the accuracy and credibility of their dysfunctional cognitions through the examination of evidence (including the recollection of personal experiences or hypothetical situations) to refute distorted thoughts related to skin picking (Schuck et al., 2011). Behavioral interventions are also integrated, and focus on the formulation of strategies to prevent skin picking episodes from occurring (Deckersbach et al., 2002; Schuck et al., 2011). Relapse prevention methods should also be discussed with clients, covering procedures that should be followed in the event that picking behaviors reoccur (Deckersbach et al., 2002; Deckersbach et al., 2003; Schuck et al., 2011).
To examine the application and effectiveness of CBT, Schuck et al. (2011) conducted an experiment using brief cognitive-behavior therapy (BCBT), utilizing a randomized wait-list controlled design. Post-treatment surveys revealed that the BCBT group reported experiencing substantial decreases in SPD symptoms, differing significantly from the wait-list group. An additional follow-up questionnaire was administered eight weeks later, with participants in the BCBT group reporting they had maintained their treatment gains (Shuck et al., 2011).
Deckersbach et al. (2002) further investigated the use of CBT coupled with select habit reversal techniques in three individuals with SPD. Findings from this case series revealed that one of the three subjects had ceased all picking behaviors, and that all three participants reported continuing to experience mild urges to engage in skin picking episodes (Deckersbach et al., 2002).
Various pharmacological interventions have also been investigated in the treatment of excoriation (Arnold et al., 2001; Gelinas & Gagnon, 2013; Odlaug & Grant, 2010). Existing literature indicates that selective serotonin reuptake inhibitors (SSRIs) have been studied the most, with antiepileptics, atypical antipsychotic medications, and opioid antagonists being examined as well (Arnold et al., 2001; Gelinas & Gagnon, 2013; Odlaug & Grant, 2010). Simeon et al. (1997) examined the effectiveness of Prozac for SPD using a double-blind research design involving 21 adults spanning 10 weeks. Results revealed that participants in the treatment group demonstrated statistically significant reductions in skin picking behaviors at a mean dosage of 55 mg compared to the placebo group (Simeon et al., 1997).
Bloch, Elliott, Thompson, and Koran (2001) continued the examination of Prozac in the treatment of SPD with an experiment that began as an open-label trial approach, and then transitioned to a randomized double-blind placebo-controlled study. The authors found that subjects in the Prozac group maintained their treatment gains, exhibiting a 70% decrease in symptom severity at a mean dosage of 80 mg, while the placebo group regressed back to their original pre-treatment ratings (Bloch et al., 2001).
Other SSRIs have been examined in the treatment of excoriation. The effectiveness of Zoloft was examined in an open-label trial involving 28 subjects in a study conducted by Kalivas, Kalivas, Gilman, and Hayden (1996). At the end of the one-month experiment, 19 of the 28 participants (68%) responded to a daily mean dose of 95 mg of Zoloft, which was demonstrated by a 50% or greater reduction in open skin lesions (Kalivas et al., 1996).
The use of Lexapro in the treatment of SPD was assessed in an open-label trial conducted by Keuthen et al. (2007) that included 19 participants and lasted 18 weeks. Results revealed that 16 of the 19 participants demonstrated full or partial responses to a mean dosage of 25 mg, which was determined by a 25% decrease in pre to post-test SPS scores (Keuthen et al., 2007).
Celexa has also been investigated in the treatment of SPD. Using a randomized double-blind placebo controlled experiment, Arbabi et al. (2008) administered 20 mg of Gelexa to 45 subjects over a four-week period. Results revealed that both the placebo and Celexa groups demonstrated a decrease in VAS scores in the second week of the experiment, however, from the second to the fourth weeks of the study, VAS scores for the Celexa group continued to decline, but there was no decline for the placebo group. Results indicated that the Celexa group experienced a greater reduction in skin picking behaviors compared to the placebo group, however, additional statistical analyses revealed that this difference was not significant (Arbabi et al., 2008).
Neurobiological studies on obsessive compulsive disorder (OCD) have accumulated evidence implicating that a glutamatergic dysfunction may be an associating factor in the pathophysiology of the disorder (Pittenger, Bloch, & Williams, 2011). Chakrabarty, Bhattacharyya, Christopher, and Khanna (2005) examined the cerebrospinal fluid (CSF) of individuals with OCD, and discovered high levels of glutamate within the CSF.
Since SPD shares similar phenomenological characteristics of OCD, Grant, Odlaug, Chamberlain, and Kim (2010) evaluated the effectiveness of the mood stabilizer and antiepileptic agent Lamictal as a potential treatment option for excoriation. A total of 32 subjects participated in a double-blind placebo-controlled study for 12 weeks. Of the 16 participants assigned to the Lamictal group, seven were considered responders to the medication, while five of the 16 subjects in the placebo group were classified as responders. This denotes that both the treatment and placebo groups experienced improvements in SPD symptoms, suggesting that Lamictal may not be an efficacious form of treatment for SPD (Grant et al., 2010).
Antipsychotic medications. Orap and Zyprexa have also been studied in the treatment of SPD. In a study by Duke (1983), two individuals with severe psychogenic excoriation received daily 4-mg dosages of Orap. After one month of treatment, both individuals reported that their skin lesions had significantly improved (Arnold et al., 2001; Duke, 1983). Garnis-Jones, Collins, and Rosenthal (2000) examined Zyprexa as a treatment option for SPD in three non-psychotic individuals with excoriation. Findings revealed that two of the three participants reported experiencing decreases in skin picking urges, while the third participant reported a complete resolution of skin picking behaviors (Arnold et al., 2001; Garnis-Jones et al., 2000). An additional examination of the use of Zyprexa in the treatment of SPD was conducted by Gupta and Gupta (2000). Two individuals with excoriation received Zyprexa on a daily basis for two to four weeks. Both individuals reported improvements in skin picking symptoms at the completion of treatment (Arnold et al., 2001; Gupta & Gupta, 2000).
A case study examined the use of the opioid antagonist naltrexone as a treatment modality for SPD (Arnold et al., 2001; Lienemann & Walker, 1989). Lienemann and Walker (1989) hypothesized that naltrexone would be effective in reducing skin picking behaviors as the medication would inhibit the pleasurable response that some individuals experience after picking episodes. The participant was instructed to take 50 mg of naltrexone once a day for 28 days. On the third day of the study, the participant reported experiencing pain when scratching at the skin, a symptom that previously had not occurred. On the eighth day of the study, the participant reported an absence of excoriation urges, and by the conclusion of experiment, the subject reported the lesions had healed (Arnold et al., 2001; Lienemann & Walker, 1989).
CASE SCENARIO AND TREATMENT CONSIDERATIONS
Laura is a 33-year-old Caucasian woman who is attending counseling to address anxiety and depression following her recent divorce. She presents with multiple lesions on her face and fingers. Laura reports that she has been a "worrier" for as long as she can remember and was treated for anxiety and depression during early adolescence. During the initial session, Laura alluded to many problems that arose during her marriage. While discussing the topic of her divorce, she began to pick the skin on her fingers. She soon realizes she is doing this and comments that she and her ex-husband would often get into fights about her "bad habit." Laura mentions that she struggled with acne as an adolescent, and would pick at the blemishes on her face causing infections and scars. She disclosed that she often missed school to avoid teasing from her classmates about her complexion. Laura then revealed that she is at risk of losing her job because she is repeatedly late in the mornings. She attributes this to spending over an hour each morning in front of the mirror picking her skin and then concealing the lesions with make-up because she feels embarrassed and self-conscious about her appearance. Laura states that she has unsuccessfully tried to control this behavior by wearing gloves to cover the affected areas on her fingers and reduce temptations to pick. She mentions that the intensity of her skin picking is more pronounced during periods of stress and worry, and indicates that feelings of sadness and periods of boredom also exacerbate her skin picking. Laura worries that she cannot control this behavior and believes it will never change, which causes her additional stress. She feels no one understands how difficult it is to stop this behavior, and believes she is the only person who struggles with this issue. She also worries that given her history and failed attempts to change this behavior, she does not believe that she will be successful, and has little confidence that any interventions will be effective.
In working with Laura, the counselor wants to be sensitive to the embarrassment she has experienced from her picking behaviors. It might be helpful for the counselor to help normalize her experience by educating her about SPD including the prevalence, course, and etiology. During the intake, the counselor may consider administering several skin picking assessments to acquire additional information that Laura may not have disclosed to better understand the extent of the behavior. The SPS-R may be a preferred assessment as it is congruent with the diagnostic criteria of the DSM 5, and assesses the severity of skin picking behaviors. The SPIS could be used to assess the psychosocial implications for Laura. Given the information gathered during the intake, it appears that Laura engages in a focused-style skin picking pattern. Administering the MIDAS could confirm if Laura demonstrates a preponderance for the focused picking subtype. Combining SPD assessment information on the severity of Laura's picking behaviors, her picking subtype, and a detailed psychosocial history helps the counselor not only establish a diagnosis, but also assists in navigating treatment options. Treatment for Laura should focus on addressing her SPD, in addition to her co-occurring disorders of anxiety and depression, since these have been long-standing issues that seem to exacerbate Laura's skin picking behaviors. A combination of psychotherapy and pharmacotherapy would likely improve treatment outcomes. Psychotherapy should focus on Laura's maladaptive coping methods of experiential avoidance, dysfunctional behavioral patterns, and distorted cognitions. An option would be to integrate acceptance-enhanced behavior therapy with elements from cognitive behavioral therapy. Techniques such as psychoeducation, cognitive restructuring, competitive responses, relaxation training, along with developing support systems to help reinforce gains made in treatment, and relapse prevention could all be used with this approach. Using SSRIs may help with Laura's underlying anxiety and depression, and may also help to reduce her symptoms associated with skin picking.
IMPLICATIONS FOR CLINICIANS
Since SPD is new to the DSM-5, it is important that clinicians understand the various aspects that are involved with this disorder. Being knowledgeable about the etiology, course of the disorder, precursors, presentation, and co-occurring disorders can lead to a proper diagnosis and treatment for those who have been impacted by this condition. Many individuals may have experienced emotions of shame, guilt, and embarrassment associated with their picking behaviors. Therefore, they may be reluctant to discuss their symptoms or are unaware that treatment options exist. When the topic of SPD is discussed, it is essential that clinicians are respectful, sensitive, supportive, and empathetic to facilitate additional disclosure from the client, which will help to enhance the quality of the working alliance and strengthen the therapeutic bond.
Treatment plans should be formulated to best fit clients' individual needs. If applicable, co-occurring disorders should be addressed during treatment since symptoms from other conditions may exacerbate skin picking urges and behaviors for some individuals. As stated, SPD subtype should be considered when selecting treatment interventions, and may influence the progression of treatment. Certain techniques may be more effective in treating focused skin picking compared to automatic skin picking and vice versa, so clinicians may have to adapt treatment plans and methods accordingly. Generally, treatment will involve the integration of different behavioral techniques, and in some instances, cognitive components may need to be incorporated as well. Regression and relapse of picking behaviors may occur during or following the completion of therapy, so clinicians should prepare clients for this possibility, and have plans clients can apply should this occur.
Skin picking is a complex behavior that has historically been overlooked as a psychological disorder despite its prevalence rates and the negative physical and emotional impacts that individuals with this condition experience. The inclusion of SPD into the DSM-5 can better aid clinicians in the identification, assessment, and diagnosis of this condition. The etiology of SPD varies across individuals and can occur at any age in life, but it generally manifests at the start of puberty in adolescence. Three subtypes of skin picking behaviors have been identified (focused, automatic, and mixed), and are posited to contribute to the phenomenological function and continuation of the disorder.
Some empirically supported treatments for SPD have produced encouraging clinical outcomes for habit reversal training, acceptance and commitment therapy, acceptance-enhanced behavior therapy, cognitive behavioral therapy, and pharmacological interventions. Even though studies examining treatment modalities for SPD exist, sample sizes were generally small, convenience samples were often used, and few studies utilized longitudinal methods to evaluate the long-term maintenance of treatment gains. Additionally, the diagnosis and treatment of SPD using culturally and ethnically diverse populations has not been extensively studied. Furthermore, research examining the treatment of SPD using a combination of psychotherapy and pharmacological therapy has not been conducted. Investigating these variables and replicating previous studies could allow for a better understanding of this condition, and provide additional evidence in determining which interventions are the most effective for treating SPD.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed.) Washington, DC: Author.
Arbabi, M., Farnia, V., Balighi, K., Mohammadi, M. R., Nejati-Safa, A. A., Yazdchi, K., ... Darvish, F. (2008). Efficacy of citalopram in treatment of pathological skin picking, a randomized double blind placebo controlled trial. Acta Medica Iranica, 46, 367-372. Retrieved from http://acta. tums.ac.ir/index.php/acta
Arnold, L. M., Auchenback, M. B., & McElroy, S. L. (2001). Psychogenic excoriation: Clinical features, proposed diagnostic criteria, epidemiology, and approaches to treatment. Central Nervous System Drugs, 15, 351-359. doi: 10.2165/00023210-200115050-00002
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. Journal of Clinical Psychiatry, 59, 509-514. doi: 10.4088/jcp.v59nl003
Azrin, N. H., & Nunn, R. G. (1973). Habit reversal: A method of eliminating nervous habits and tics. Behavior Research andTherapy, 11, 619-628. doi: 10.1016/000 5-7967(73)90119-8
Bloch, M. R., Elliot, M., Thompson, H., & Koran, L. M. (2001). Fluoxetine in pathological skin picking. Psychosomatics, 42, 314-319. doi: 10.1176/appi.psy.42.4.314
Bohne, A., Wilhelm, S., Keuthen, N. J., Baer, L., & Jenike, M. A. (2012). Skin picking in German students. Prevalence, phenomenology and associated characteristics. Behavior Modification, 26, 320-329. doi:10.1177/0145445502026003002
Calikusu, C., Kucukgoncu S., Tecer, O., & Bestepe, E. (2012). Skin picking in Turkish students: Prevalence, characteristics and gender differences. Behavior Modification, 36, 49-66. dohlO.l 177/0145445511420282
Capriotti, M. R., Ely, L. J., Snorrason, I., & Woods, D. W. (2015). Acceptance-enhanced behavior therapy for excoriation (skin-picking) disorder in adults: A clinical case series. Cognitive and Behavioral Practice, 22, 230-239. doi: 10.1016/j.cbpra.2014.01.008
Chakrabarty, K., Bhattacharyya, S., Christopher, R., & Khanna, S. (2005). Glutamatergic dysfunction in obsessive compulsive disorder. 14 europsychopharmacology, 30, 1735-1740. doi: 10.1038/sj.npp. 1300733
Deckersbach, T., Wilhelm, S., Keuthen, N. J., Baer, L., & Jenike, M. A. (2002). Cognitive-behavior therapy for self-injurious skin picking. A case-series. Behavior Modification, 26, 361-377. doi:10.1177/0145445502026003004
Deckersbach, T., Wilhelm, S., & Keuthen, N. (2003). Self-injurious skin picking: Clinical characteristics, assessment methods, and treatment modalities. Brief Treatment and Crisis Intervention, 3, 249-260. doi:10.1093/brief-treatment/mhg018 Duke, E. E. (1983). Clinical experience with pimozide: Emphasis on its use in postherpetic neuralgia. Journal of the American Academy of Dermatology, 8, 845-850. doi: 10.1016/s01909622(83)80015-2
Flessner, C. A., Busch, A. M., Heideman, P. W., Woods, D. W. (2008). Acceptance-enhanced behavior therapy (AEBT) for trichotillomania and chronic skin picking: Exploring the effects of component sequencing. Behavior Modification, 32, 579-594. doi: 10.1177/0145445 507313800
Flessner, C. A., & Woods, D. W. (2006). Phenomenological characteristics, social problems, and the economic impact associated with chronic skin picking. Behavior Modification, 30, 944-963. doi: 10.1177/0145445506294083
Fruensgaard, K., Hjortshoj, A., & Nielsen, H. (1978). Neurotic excoriations. International Journal of Dermatology, 17, 761-767. doi: 10.1111/j. 1365-4362.1978.tb05976.x
Garnis-Jones, S., Collins, S., & Rosenthal, D. (2000). Treatment of self-mutilation with olanzapine. Journal of Cutaneous Medicine and Surgery, 4, 161-163. Retrieved from http://cms.sagepub.com
Gelinas, B. L., & Gagnon, M. M. (2013). Pharmacological and psychological treatments of pathological skin-picking: A preliminary meta-analysis. Journal of Obsessive-Compulsive and Related Disorders, 2, 167-175. doi: 10.1016/j.jocrd.2013.02.003
Grant, J., Chamberlain, S., & Odlaug, B. L. (2014). Clinical guide to obsessive compulsive and related disorders. Oxford, UK: Oxford University Press.
Grant, J. E., & Christenson, G. A. (2007). Examination of gender in pathologic grooming behaviors. Psychiatric Quarterly, 78, 259-267. doi: 10.1007/sl 1126-007-9045-z
Grant, J. E., Odlaug, B. L., Chamberlain, S. R, & Kim, S. W. (2010). A double-blind, placebo-controlled trial of lamotrigine for pathological skin picking: Treatment efficacy and neurocognitive predictors of response. Journal of Clinical Psychopharmacology, 30, 396-403. doi: 10.1097/)CP.0b013e3181e617a1
Grant, J. E., Williams, K. A., & Potenza, M. N. (2007). Impulse control disorders in adolescent psychiatric inpatients: Co-occurring disorders and sex differences. Journal of Clinical Psychiatry, 68, 1584-1592. doi:10.1016/j psychres.2009.04.006
Greisemer, R. D. (1978). Emotionally triggered disease in a psychiatric practice. Psychiatric Annals, 8, 407-412. Retrieved from http://www.healio.com/psychiatry/journals/psycann
Gupta, M. A., & Gupta, A. K. (1996). Psychodermatology: An update. Journal of the American Academy of Dermatology, 34, 1030-1046. doi: 10.1016/sO 190-9622(96)90284-4
Gupta, M. A., & Gupta, A. K. (2000). Olanzapine is effective in the management of some self-induced dermatoses: Three case reports. Cutis, 66, 143-146. Retrieved from http://www.cutis. com/
Hayes, L. S., Storch, E. A., & Berlanga, L. (2009). Skin picking behaviors: An examination of the prevalence and severity in a community sample. Journal of Anxiety Disorders, 23, 314-319. doi: 10.1016/j.janxdis.2009.01.008
Hayes, L. S., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York, NY: Guilford Press.
Kalivas, J., Kalivas, L., Gilman, D., & Hayden, C. T. (1996). Sertraline in the treatment of neurotic excoriation and related disorders. Archives of Dermatology, 132, 589-590. doi: 10.1001/ archderm. 1996.03890290131022
Keuthen, N. J., Deckersbach, T., Wilhelm, S., Engelhard, I., Forker, A., O'Sullivan, R. L., ... Baer, L. (2001). The Skin Picking Impact Scale (SPIS): Scale development and psychometric analyses. Psychosomatics, 42, 397-403. dohlO.l 176/appi.psy.42.5.397
Keuthen, N. J., Deckersbach, T., Wilhelm, S., Hale, E., Fraim, C., Baer, L., O'Sullivan, R. L., ... Jenike, M. A. (2000). Repetitive skin-picking in a student population and comparison with a sample of self-injurious skin-pickers. Psychosomatics, 41, 210-215. doi: 10.1176/appi.psy.41.3.210
Keuthen, N. J., Jameson, M., Loh, R., Deckersbach, T., Wilhelm, S., & Dougherty, D. D. (2007). Open-label escitalopram treatment for pathological skin picking. International Clinical Psychopharmacology, 22, 268-274. doi: 10.1097/yic.0b013e32809913b6
Keuthen, N. J., Koran, L. M., Aboujaoude, E., Large, M. D., & Serpe, R. T. (2010). The prevalence of pathological skin picking in US adults. Comprehensive Psychiatry, 51, 183-186. doi: 10.1016/j. comppsych.2009.04.003
Keuthen, N. J., Wilhelm, S., Deckersbach, T., Engelhard, I. M., Forker, A. E., Baer, L., & Jenike, M. A. (2001). The Skin Picking Scale (SPS): Scale construction and psychometric analysis. Journal of Psychosomatic Research, 50, 337-341. doi: 10.1016/S00223999(01)00215-X
Leibovici, V., Koran, L. M., Murad, S., Siam, I., Odlaug, B. L., Mandelkorn, U., ... Keuthen, N. J. (2015). Excoriation (skin-picking) disorder in adults: A cross-cultural survey of Israeli Jewish and Arab samples. Comprehensive Psychiatry, 58, 102-107. doi:10.1016/j.comppsych.2014.12.008
Lienemann, J., & Walker, F. D. (1989). Reversal of self-abusive behavior with naltrexone. Journal of Clinical Pharmacology, 9, 448-449. doi: 10.1097/00004714-198912000-00022
Moritz, S., Fricke, S., Treszi, A., & Wittekind, C. E. (2012). Do it yourself! Evaluation of self-help habit reversal training versus decoupling in pathological skin picking: A pilot study. Journal of Obsessive-Compulsive and Related Disorders, 1,41-47. doi: 10.1016/j.jocrd.2011.001
Neziroglu, F., Rabinowitz, D., Breytman, A., & Jacofsky, M. (2008). Skin picking phenomenology and severity comparison. Primary Care Companion Journal of Clinical Psychiatry, 10, 306-312. doi:10.4088/PCC.vl0n0406
Odlaug, B. L., & Grant. J. E. (2008). Clinical characteristics and medical complications of pathologic skin picking. General Hospital Psychiatry, 30, 61-66. doi:10.1016/j.genhosppsych.2007.07.009
Odlaug, B. L., & Grant, J. E. (2010). Pathological skin picking. The American Journal of Drug and Alcohol Abuse, 36, 296-303. doi: 10.3109/0095299100374754T
Odlaug B. L., Lust K., Schreiber L. R., Christenson G., Derbyshire K., & Grant J. E. (2013). Skin picking disorder in university students: Health correlates and gender differences. General Hospital Psychiatry, 35, 168-173. doi:10.1016/j.genhosppsych.2012.08.006
Oliveira, E. C., Leppink, E. W., Derbyshire, K. L., & Grant, J. E. (2015). Excoriation disorder: Impulsivity and its clinical associations. Journal of Anxiety Disorders, 30, 19-22. doi: 10.1016/j. janxdis.2014.12.010.
Pittenger, C., Bloch, M. H., & Williams, K. (2011). Glutamate abnormalities in obsessive compulsive disorder: Neurobiology, pathophysiology, and treatment. Pharmacology and Therapeutics, 132, 314-332. doi: 10.1016/j.pharmthera.2011.09.006
Schuck, K., Keijsers, G. P., & Rinck, M. (2011). The effects of brief cognitive-behaviour therapy for pathological skin picking: A randomized comparison to wait-list control. Behaviour Research and Therapy, 49, 11-17. doi: 10.1016/j.brat.2010.09.005
Siddiqui, E. U., Naeem, S. S., Naqvi, H., & Ahmed, B. (2012). Prevalence of body-focused repetitive behavior in three large medical colleges of Karachi: A cross-sectional study. BMC Research Notes, 5, 614-619. doi: 10.1186/1756-0500-5-614
Simeon, D., Stein, D. J., Gross, S., Islam, N., Schmeidler, J., & Hollander, E. (1997). A double-blind trial of fluoxetine in pathologic skin picking. Journal of Clinical Psychiatry, 58, 341-347. doi: 10.4088/jcp.v58n0802
Sneddon, J., & Sneddon, I. (1983). Acne excoriee: A protective device. Clinical and Experimental Dermatology, 8, 65-68. doi: 10.1111/j. 1365-2230.1983.tbO 1746.x
Snorrason, I., Olafsson, R. P., Flessner, C. A., Keuthen, N. J., Franklin, M. E., & Woods, D. W. (2012). The Skin Picking Scale-Revised: Factor structure and psychometric properties. Journal of Obsessive-Compulsive and Related Disorders, 1, 133-137. doi: 10.1016/j.jocrd.2012.03.001.
Snorrason, I., Smari, J., & Olafsson, R. P. (2010). Emotion regulation in pathological skin picking: Findings from a non-treatment seeking sample, journal of Behavior Therapy and Experimental Psychiatry, 41, 238-245. doi: 10.1016/j.jbtep.2010.01.009
Teng, E.J., Woods, D.W.,& Twohig, M.P. (2006). Habit-reversal asa treatment for chronic skin picking: Apilot investigation. Behavior Modification, 30,411-422. doi: 10.1177/0145445504265707.
Tucker, B. T., Woods, D. W., Flessner, C. A., Franklin, S. A., & Franklin, M. E. (2011). The skin picking impact project: Phenomenology, interference, and treatment utilization of pathological skin picking in a population-based sample, journal of Anxiety Disorders, 25, 88-95. doi: 10.1016/j. janxdis. 2010.08.007
Twohig, M. P., Hayes, S. C., & Masuda, A. (2006). A preliminary investigation of acceptance and commitment therapy as a treatment for chronic skin picking. Behaviour Research and Therapy, 44, 1513-1522. doi: 10.1016/j.brat.2005.10.002
Twohig, M. P., & Woods, D. W. (2001). Habit reversal as a treatment for chronic skin picking in typically developing adult male siblings, journal of Applied Behavior Analysis, 34, 217-220. doi: 10.1901/jaba.2001.34-217
Walther, M. R., Flessner, C. A., Conelea, C. A., & Woods, D. W. (2009). The Milwaukee inventory for the dimensions of adult skin picking (MIDAS): Initial development and psychometric properties, journal of Behavior Therapy and Experimental Psychiatry, 40, 127-135. doi: 10.1016/j. jbtep.2008.07.002
Wilhelm, S., Keuthen, N. J., Deckersbach, T., Engelhard, I. M., Forker, A. E., Baer, L., .. Jenike, M. A. (1999). Self-injurious skin picking: Clinical characteristics and comorbidity, journal of Clinical Psychiatry, 60, 454-459. doi:10.4088/jcp.v60n0707
Woods, D. W., & Twohig, M. P. (2008). Trichotillomania: An ACT'-enhanced behavior therapy approach therapist guide. New York, NY: Oxford University Press.
Woods, D. W., Wetterneck, C. T., & Flessner, C. A. (2006). A controlled evaluation of acceptance and commitment therapy plus habit reversal as a treatment for trichotillomania. Behaviour Research andTherapy, 44, 639-656. doi: 10.1016/j .brat. 2005.05.006
Gina E. Jagger and William R. Sterner
Gina E. Jagger and William R. Sterner, Department of Counseling, Marymount University. Correspondence concerning this article should be addressed to William Sterner, Department of Counseling, Marymount University, 2807 N. Glebe Road, Arlington, VA, 22207. E-mail: wsterner@ marymount.edu
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|Author:||Jagger, Gina E.; Sterner, William R.|
|Publication:||Journal of Mental Health Counseling|
|Date:||Oct 1, 2016|
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