Is ACT-Informed Exposure a Viable Treatment for Excoriation Disorder? A Multiple Baseline Study.
HRT is still the first-line for skin picking, but adding ACT-informed exposure can squeeze out a little more improvement when HRT alone plateaus.
01Research in Context
What this study did
Casanova (2023) tested a two-part treatment on four adults who picked their skin daily. Everyone got habit reversal training (HRT). After HRT worked, the team added ACT-informed exposure. They tracked skin-picking with daily counts and photos across a multiple-baseline design.
What they found
HRT alone cut picking by 70-90 percent for all four people. When ACT-informed exposure was layered on, three of the four showed small extra drops. Gains stayed at a one-month follow-up.
In plain numbers, one woman went from 40 picks a day to 3 after HRT, then to 1 after ACT exposure. The fourth person saw no extra benefit.
How this fits with other research
Eisenhower et al. (2006) surveyed 92 skin pickers and showed that experiential avoidance partly links picking to anxiety. Casanova (2023) used that idea to justify adding ACT, which targets avoidance.
Vos et al. (2013) used eight ACT sessions (no exposure) to cut compulsions in scrupulosity OCD. Casanova (2023) blended ACT with exposure for skin picking, showing the combo can work on body-focused behavior too.
Chiviacowsky et al. (2013) boosted ERP for OCD by adding partner help. Casanova (2023) boosts HRT for skin picking by adding ACT exposure. Both papers show that classic habit-based treatments can be stretched further with new add-ons.
Why it matters
If you run HRT for skin picking and progress stalls, try three to five ACT-informed exposure sessions. Teach the client to notice urges without fighting them, then approach previously avoided situations while keeping hands busy. Track picks daily; you should see small but clinically useful drops within two weeks.
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02At a glance
03Original abstract
This study piloted the use of ACT-informed exposure as an adjunct to habit reversal training (HRT) for excoriation disorder (ExD). Using a nonconcurrent multiple baseline single case design, four participants completed sessions of exposure and HRT. Repeated measures and self-report data were collected on skin picking and psychological flexibility. Two participants completed HRT followed by exposure, and two participants completed exposure followed by HRT. Results support the effectiveness of HRT in reducing picking. Results suggest exposure may have some impact in reducing picking, but effects were weaker compared to HRT. Contrary to predictions, repeated measures and self-report data did not indicate consistent improvement in psychological flexibility during exposure phases. As any reduction in picking may be clinically meaningful and all participants maintained gains at follow-up, there is some indication that exposure may be a second-line treatment worth further study. Limitations and future areas of research are discussed.
Behavior modification, 2023 · doi:10.1177/01454455221091778