Dermatology Online Journal
StopPicking.com: Internet-based treatment for self-injurious skin picking
- Author(s): Flessner, Christopher A
- Mouton-Odum, Suzanne
- Stocker, Allison J
- Keuthen, Nancy J
- et al.
StopPicking.com: Internet-based treatment for self-injurious skin picking1. University of Wisconsin-Milwaukee
Christopher A Flessner1, Suzanne Mouton-Odum PhD2, Allison J Stocker MD3, Nancy J Keuthen PhD4
Dermatology Online Journal 13 (4): 3
2. Private Practice, Houston, TX
3. Private Practice Dermatology, San Antonio, TX
4. Massachusetts General Hospital and Harvard Medical School
StopPicking.com is an interactive self-help approach derived from an evidence-based cognitive behavioral model of treatment for skin picking (SP). We examined the development and two phases of program evaluation for an Internet-based self-help treatment for self-injurious SP. Participants included 372 individuals consecutively enrolling in StopPicking.com during a 5-month period. Results revealed significant reductions in frequency of picking episodes and symptom severity ratings from baseline to post-intervention. Treatment response rates were comparable or superior to previous research utilizing pharmacotherapy for the treatment of SP suggesting that StopPicking.com may provide an alternative or adjunctive treatment for SP. The current study is limited by lack of a control condition and use of a non-referred sample of skin pickers.
Self-Injurious skin picking (SP) currently lacks its own diagnostic classification in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). As a result, researchers have operationally defined SP as recurrent picking accompanied by visible tissue damage resulting in significant distress and/or functional impairment [2, 3, 4, 5]. Alternatively, it has also been conceptualized as a variant of other mental health concerns such as impulse control disorder not otherwise specified, body dysmorphic disorder (BDD), or obsessive-compulsive disorder (OCD) [5, 6, 7].
Reported prevalence rates for SP ranges from 2 percent to 3.8-4.6 percent in dermatology clinics and college students, respectively [3, 6, 8]. The mean age of onset has typically been around 16 years [5, 9], although recent research conducted with an Internet-based approach demonstrated a median age of onset at approximately 12 years . Skin picking occurs more commonly in females than males [2, 9, 10] with research suggesting that SP typically involves the use of fingers or tweezers and is most common on the face (although the behavior can occur on nearly all body surfaces) [2, 5, 8]. Wilhelm and colleagues found that picking may wax and wane throughout an individual's lifetime and may coincide with the menstrual cycle for some women.
Comorbid psychiatric diagnoses, including alcohol abuse or dependence, OCD, generalized anxiety disorder, and mild to moderate levels of depression or anxiety have been frequently reported in persons who pick their skin [3, 5, 9, 10, 11, 12, 13]. In a recent study, researchers found that 12 percent (n = 4) of 34 patients from an outpatient clinic reported suicidal ideation attributable to SP-related problems . Unfortunately, a dearth of literature exists examining the efficacy of specific therapeutic interventions for the treatment of SP with most extant research examining either pharmacological or cognitive-behavioral approaches.
To date, pharmacological agents have been the most frequently studied treatment approach for SP with nearly all studies examining the efficacy of serotonin reuptake inhibitors (SRIs). Recently, a group of researchers randomized 21 participants to 10 weeks of either placebo or fluoxetine for treatment of SP . After this 10-week trial, 8 of 10 participants in the fluoxetine condition were classified as much improved (n = 6) or very much improved (n = 2), while only 3 of 11 participants in the placebo condition were classified as much improved (n = 3). Similar results have been demonstrated in subsequent research examining the efficacy of fluoxetine and other SRIs (e.g., fluvoxamine, paroxetine) for the treatment of SP [12, 14, 15].
Several side effects accompanying the use of SRIs have been reported including decreased appetite, nausea, insomnia, and fatigue. Recently, researchers have reported on two clinical cases in which SRIs (e.g., fluvoxamine and paroxetine, respectively) were used to treat OCD . Results of these individual cases revealed that fluvoxamine exacerbated SP for one woman, while paroxetine induced SP in the other woman. Side effects such as those described above have led some researchers to examine alternative, nonpharmacological methods for the treatment of SP.
Cognitive-behavior therapy (CBT) has been the most frequently used non-pharmacological approach to the treatment of SP. Researchers have used a number of different techniques as part of CBT, including functional assessment of the problem behavior, self-monitoring, stimulus control, habit reversal training, and cognitive restructuring . For example, a client reporting thoughts such as "Nobody loves me" or "I am a complete failure and will never amount to anything" prior to picking may review these thoughts with the therapist, examine the level of truth associated with these thoughts, and practice coping skills to be used in the presence of or in situations thought to illicit these thoughts. Coping skills may include techniques such as engaging in a competing behavior that prevents picking from happening (e.g., clenching his or her fist) or developing a more objective response to these thoughts (e.g., "Well, my parents love me" or "I actually have a pretty good job").
A recent report described the use of CBT for the treatment of SP in 3 clients . Results suggested reductions in picking frequency for all 3 clients; 2 of 3 clients reported that their SP was very much improved with the use of CBT techniques. Several of the components to CBT mentioned in the preceding paragraph have shown similar efficacy in various combinations in other studies as well [19, 20, 21, 22].
Despite these encouraging findings, several limitations to the current literature exist. First, none of the studies recruited more than three participants and nearly all of these studies were uncontrolled case histories [18, 19, 20, 22] As a result, our ability to extend these findings to the general population may be limited. Second, because of the experimental designs implemented in several of these studies, it is impossible to infer which components of CBT were most efficacious. Lastly, many clinicians (depending upon their clinical training) may be unfamiliar with the therapeutic techniques mentioned above (e.g., functional assessment, habit reversal, stimulus control, etc.), possibly limiting the transportability of these techniques. This latter concern has led some researchers to examine the efficacy of computer-based approaches for the treatment of a variety of mental health concerns.
Computer-based approaches provide an alternative to face-to-face treatment sessions. As technology has become more advanced, researchers have incorporated the Internet, laptop computers, and portable digital assistants (PDAs) into the treatment process.[23-25] These computer-based approached have been used for a variety of mental health concerns, including OCD [23, 26], social phobia , panic disorder [28, 29], GAD , and trichotillomania (TTM) with data generally demonstrating empirical support for the efficacy of these approaches to treatment. In addition, data suggests generally positive results with respect to client satisfaction.
Recent research provides one example of a computer-based treatment approach with particular relevance for the treatment of SP . Mouton-Odum and colleagues established an Internet-based self-help treatment strategy for TTM (StopPulling.com). These authors provided users with modules for continuous monitoring of their behavior (e.g., pulling frequency, antecedents and consequences to pulling, severity of urge to pull, etc.). Users were guided through a functional assessment and subsequently provided treatment strategies (e.g., stimulus control techniques, coping strategies, etc.) based upon data collected during a 2-5 week assessment phase. Results from 265 users of this program indicated significant improvement in symptoms of TTM (e.g., reductions in pulling frequency and self-reported pulling severity) with some evidence suggesting that duration of program use accounted for reductions in pulling severity.
Despite topographical or surface differences between TTM and SP, research suggests that these problem behaviors may serve similar functions. Specifically, both TTM and SP may reduce discomfort, tension, or some other negative feelings or states [3, 9, 10, 30]. In addition, researchers Lochner, Simeon, Niehaus, and Stein (2002) recently found that participants diagnosed with either SP or TTM showed similarities with respect to demographic characteristics, psychiatric comorbidity, and personality dimensions .
Given the documented phenomenological overlap between TTM and SP, the development of a computer-based approach to treatment similar to StopPulling.com may be advantageous for individuals who engage in a variety of picking behaviors including skin picking, cheek or lip biting, fingernail biting, and nose picking . Given that access to professionals with adequate knowledge of SP may be severely limited, a computer-based approach may provide an alternative to face-to-face therapeutic interventions for some individuals. Furthermore, shame accompanying SP may prevent some sufferers from seeking direct professional contact; accordingly, a computer-based program that affords greater privacy may offer a much-needed treatment avenue. The purpose of the current paper is to describe the development and program evaluation for StopPicking.com, an Internet-based, interactive, self-help approach for the treatment of SP.
StopPicking.com Development—StopPicking.com was created to provide adults with an affordable, accessible, and confidential approach to treatment for SP. Key components include interactive behavioral programs that (1) assess and increase awareness of variables controlling SP (e.g., antecedents and consequences to picking); (2) teach coping skills to reduce the frequency and severity of symptoms; and (3) provide users with a tool for maintaining treatment gains. The program also offers education about SP and provides links to various resources and relevant "current events" such as conferences, workshops, recent publications and media events focused on SP. Consequently, the website includes a Self-Injurious Skin Picking Education section summarizing relevant literature on SP, a Resources page listing available books, and a Links page providing links to relevant organizations (e.g., the Trichotillomania Learning Center, Obsessive Compulsive Foundation, and the American Psychological Association).
|Figure 1||Figure 2|
|Figure 1. Example of a Daily Record form.|
|Figure 2. Example of a Personal Analysis form|
|Figure 3. Example of Personal Data Summary (My Page)|
Prior to beginning the program, users are evaluated for symptoms associated with SP. Specifically, the program screens for major depression, psychotic processes (specifically delusions of parasitosis), suicidality, obsessive-compulsive disorder, severe anxiety, and substance abuse. If the user responds positively to any of these symptoms, referral sources are offered and participants are encouraged to seek alternate help before initiating the program.
StopPicking.com includes three Modules: Assessment, Intervention, and Maintenance, that are similar to modules from StopPulling.com (Mouton-Odum et al., in press). The Assessment Module focuses on gathering information about possible variables controlling SP, such as antecedents and consequences to SP. Participants are asked to record situations, precipitating behaviors, and thoughts and feelings experienced before, during, and after picking. Participants are asked to enter information on a "Daily Record" every time they pick or have an urge to pick their skin (Fig. 1). Participants enter (by clicking fields) the date, time of day, urge severity (on a scale of 1-5), location and activity at the time, picking behavior (e.g., squeezing a pimple, lip biting, scab picking, etc.), body surface from which the skin was picked, and time spent picking for that episode. StopPicking.com compiles each user's data over time, and the number of times picked is presented to the user in graphic form to facilitate visual tracking of progress.
Four subsections of the Assessment Module ask for progressively more detailed information, including type of picking behavior (e.g., biting cuticles, peeling the skin, picking a scab, etc.), specific triggers for that episode (e.g., scab feels "crusty" or ripe for picking, itching or skin discomfort, etc.), feelings experienced before, during, and after picking (e.g., feeling tired, overwhelmed, angry at self for picking, embarrassed at being seen in public, etc.), and thoughts associated with picking, and post-picking behaviors. The Assessment Module takes approximately 3-5 weeks to complete, depending on the frequency of data entry. At the end of the Assessment Module, each user is presented with an individualized behavioral Personal Analysis, which is a summary of all relevant data previously entered (Fig. 2). This analysis provides the information necessary for the selection of coping skills to be presented during the intervention phase. All data are recorded for the user and summarized in graphic form on My Page (Fig. 3). Subscribers may also view their entries, edit past entries, and navigate through the program via My Page.
The Intervention Module utilizes information from the Assessment Module to select relevant coping strategies. Nineteen coping strategies derived from the literature,[32-34] are available for use (see Table 1). These strategies are linked to a corresponding matrix that directs the program about how and when to offer them. For example, if a user enters "looking in the mirror" as a common activity that leads to picking, he or she is then instructed to do specific things such as "Avoid mirrors," "Dim the lights," and "Stand three feet from the mirror" to help reduce associated visual triggers. Users are presented with three unique coping strategies each week. During the Intervention Module, in addition to recording data about each urge/episode as in the Assessment Module, they also record which (if any) coping strategies were used and how strong the urges were after using the coping strategy(ies). During the Intervention Module, users also set weekly goals and give themselves rewards for having attained their goals. When a user has successfully met a goal for 4 consecutive weeks, he/she advances to the third module, Maintenance.
The goal of the Maintenance Module is to maintain gains made during active treatment. Although research is unclear as to the rate of relapse for individuals who pick their skin, continued monitoring of behavior and reminders to use coping skills may serve to prevent relapse and promote recovery. During the Maintenance Module, participants continue to record all urges/episodes on the Daily Record. If situational correlates change and new high-risk situations are noted, the program incorporates the changes into the Personal Analysis and additional coping strategies may be offered. Users continue to rate the strength of their urges before and after use of coping strategies and continue to set weekly goals. If goals are not met for 4 consecutive weeks, the program defines this as a relapse and the user is directed to return to the Intervention Module to review coping strategies and re-evaluate high risk situations. During the Maintenance Module, users are presented with weekly Activities intended to assist with recovery and relapse prevention. These activities include specific exercises to aid users in defining for themselves what recovery means, how to accept urges without responding to them, and long term approaches to affective and sensory regulation (e.g., how to reinforce oneself for positive changes; how to continue to remind oneself to use coping strategies, etc.).
Participants—StopPicking.com members were included in this study if they registered for the program between August 28, 2003 and January 31, 2006, provided at least 2 data points (e.g., reported at least 2 episodes of picking in the Assessment Module), and were 19 years of age or older1. A total of 372 participants met inclusion criteria, and demographic information was available for 332 to 372 of these participants. The majority of these individuals were women (83.6%, n = 311). Age distribution was as follows: 19 - 24 years (19.1%, n = 71), 25 – 30 years (26.1%, n = 97), 31 – 40 years (35.5%, n = 132), 41 – 50 years (14.5%, n = 54); 51 – 60 years (3.2%, n = 12); 61 – 70 years (3.2%, n = 5), and over 70 (0.3%, n = 1). Most participants were Caucasian (92.5%, n = 344), African-American (2.7%, n = 10), "other" (2.2%, n = 8), Hispanic (1.1%, n = 4), and Asian (1.1%, n = 4). The most common primary picking site was the face (54.3% n = 202), although the scalp (8.6%, n = 32), legs (6.7%, n = 25), and arms (6.5%, n = 24) were also commonly endorsed as primary picking locations. The mean self-reported age at picking onset was 14.4 years (SD = 9.14). These demographic characteristics are similar to what has been reported in previous research using both Internet-based and clinical samples [5, 9].
The Skin Picking Scale (SPS) is a 6-item self-report scale designed to assess the severity of SP. The scale consists of items assessing frequency of urges, intensity of urges, time spent picking, interference due to picking, distress, and avoidance. All items are rated on a five-point scale ranging from 0 (none) to 4 (extreme). The scores are summed to create a total score ranging from 0 to 24, with higher scores indicating greater picking severity. The SPS has demonstrated moderate internal consistency (alpha = 0.80) and construct validity with self-reported average duration of SP episodes. Research has also demonstrated that a cutoff score of 7 differentiates severe self-injurious SP from non-self-injurious SP .
Additional Outcome Measures—Participants were asked to record each picking episode, duration of episodes, and average severity of urges to pick. These measures were derived from data entered at each episode on the Daily Record. Each time an episode was entered, participants reported the duration of the picking episode. Severity of the urge to pick prior to picking was rated at each episode on a 0 (no urge) to 5 (strongest urge) scale. The frequency of picking episodes was totaled for each module, and duration and severity of urge to pick were averaged across each module to create duration and urge severity scores.
Procedure and Data Analysis— Participant responses across all program modules were stored in a dedicated server in a secure database and compiled for analysis in SPSS 13.0. Preliminary descriptive analyses examined duration of program use and relation with demographic and clinical variables. Other descriptive analyses compared demographic and clinical characteristics of active users (those using StopPicking.com at the time of outcome analyses) and inactive users (participants who had previously discontinued program use) with reasons for discontinuing the program. Because data from the Maintenance Module were available for only 15 participants, subsequent analyses were conducted for only those participants who met inclusion criteria and reported at least 2 post-intervention data points (i.e., 2 data points during the Intervention Module; n = 159 to 183). Two sets of outcome analyses were conducted: (1) One-way repeated measures analysis of covariance (ANCOVA) evaluated change across time by comparing baseline (Assessment Module) and post-intervention (Intervention Module) ratings on SPS scores, frequency and duration of picking episodes, and urge severity using duration of program use as a covariate. (2) Response rates based on SPS scores were calculated according to the following criteria: responder = 25 percent or greater improvement in symptoms from baseline to post-intervention ratings; worsened = 25 percent or greater worsening in symptoms from baseline to post-intervention ratings; and no change = less than 25 percent change in either direction .
Duration of Program Use—Participants used StopPicking.com on average for 11.7 weeks (SD = 12.3; n = 323). Duration of program use was not significantly correlated with number of picking episodes (r = 0.07, p = 0.19), SPS total score (r = -0.10, p = 0.08), duration of picking episodes (r = -0.01, p = 0.91), or baseline urge severity (r = -0.05, p = 0.40), nor did duration of program use differ across gender, age, or ethnicity (all p > 0.28).
Reasons for Discontinuing Program Use—Participants reported discontinuing StopPicking.com for one of four possible reasons including, "do not access the Internet enough" (41.2%, n = 129), "other" (20.8%, n = 65), "symptoms decreased" (15.7%, n = 49), and "program is too expensive" (15.0%, n = 47). To examine a possible explanation for the small sample of participants completing all three modules of the program (n = 15), frequency counts were computed for only those participants who discontinued use of StopPicking.com and provided at least 2 data points during the Intervention Module (n = 141). Results demonstrated similar findings to those described above, including "do not access the Internet enough" (36.8%, n = 56), "other" (21.1%, n = 32), "symptoms decreased" (20.4%, n = 31), and "program is too expensive" (14.5%, n = 22).
Active versus Inactive Users—At the time of our analyses, 59 users were actively using StopPicking.com and 313 users had discontinued the program. No statistically significant differences existed between baseline SPS scores (t (354) = 0.69, p = 0.49), frequency of picking episodes (t (370) = 0.54, p = 0.59), duration of picking episodes (t (369) = 0.84, p = 0.40), or urge severity scores (t (370) = 0.17, p = 0.86). Similarly, chi-square analyses revealed no statistically significant differences in gender, age, or ethnicity (all p > 0.04) . As a result, active and inactive users were combined for all subsequent analyses. However, active (M = 25.7, SD = 17.7) and inactive (M = 11.20, SD = 11.8) users did demonstrate significant differences with respect to duration of program use (t (321) = 3.75, p < 0.001). As a result, duration of program use was used as a covariate for the repeated measures ANCOVAs reported below.
Baseline versus Post-Intervention Ratings—Means and standard deviations at baseline and post-intervention are reported in Table 2. Because of the number of analyses conducted (n = 4) an alpha level of 0.013 was used to determine statistical significance. Repeated measures ANCOVA demonstrated a main effect of Time for frequency of picking episodes (F (1, 157) = 29.41, p < 0.001, λ2 = 0.16) and a significant Time x Weeks (duration of program use) interaction (F (1, 157) = 35.84, p < 0.001, λ2 = 0.19) indicating that duration of program use accounted for reductions in the frequency of self-report picking episodes. No statistically significant differences were found for either duration of picking episodes (F (1, 157) = 5.71, p = 0.018, λ2 = 0.04) or urge severity (F (1, 157) = 1.050, p = 0.307, λ2 = 0.01). A final repeated measures ANCOVA revealed a statistically significant main effect of Time for SPS total score (F (1, 149) = 71.70, p < 0.001, λ2 = 0.33). The Time x Weeks interaction was not statistically significant (F (1, 149) = 2.83, p = 0.10, λ2 = 0.02) indicating that reduction in picking severity occurred independent of program duration.
Response Rates and Predictors—According to SPS scores, 62.8 percent of participants (n = 115) were classified as responders, 1.6 percent as worsened (n = 3), and 27.9 percent (n = 51) as unchanged. In order to examine the potential role of treatment response predictors, the relationship between demographic variables and responses status (0 = worsened; 1 = no change; 2 = responder) were examined and indicated that neither age (r = -0.15, p = 0.06), gender (r = 0.04, p = 0.63), nor ethnicity (r = -0.09, p = 0.25) were significantly related to response status. Subsequently, a multiple regression analysis was performed to examine the role of baseline picking severity (SPS scores), duration of program use (reported in weeks), and user status (active vs. inactive). Results indicated that only duration of program use was a significant predictor of SPS response status. However, the total amount of variance accounted for was small (see Table 3).
This paper describes the initial development and evaluation of StopPicking.com, an Internet-based, self-help approach for the treatment of self-injurious SP. This program was modeled after an existing Internet-based, self-help approach (e.g., StopPulling.com) with demonstrated efficacy for the treatment of TTM . Despite topographical difference between TTM and SP, research suggests that these behaviors may serve similar functions and share similarities with respect to demographic characteristics, comorbid mental health concerns, and personality dimensions [3, 10, 30, 31].
Statistical analyses demonstrated significant reductions in the frequency of picking episodes and symptom severity ratings (as measured by the SPS) from baseline to post-intervention. Results also indicated that the aforementioned reductions in picking episodes were accounted for by duration of program use. That is, participants using StopPicking.com for longer periods of time demonstrated greater reductions in frequency of picking episodes. Conversely, reductions in symptom severity ratings (SPS scores) were not influenced by duration of program use. That is, participants using StopPicking.com for longer periods of time did not evidence greater reductions in perceived picking severity.
Based upon SPS scores, approximately 63 percent of the current sample (n = 115) was classified as treatment responders (e.g., 25% reduction in SPS scores from baseline to post-intervention). This percentage of treatment responders is comparable to findings from clinical trials of fluoxetine (80%) and fluvoxamine (50%) and is substantially larger than the 32 percent response rate reported for StopPulling.com . These results suggest that StopPicking.com is an easily accessible and private treatment option for individuals who pick their skin with demonstrated reductions in symptom severity comparable or superior to existing pharmacological treatment approaches. Due to the small sample of participants recruited for studies examining CBT for the treatment of SP, meaningful treatment response rate comparisons cannot be made.
Despite these encouraging findings, several limitations should be noted. First, the lack of a control condition limits the conclusions that can be drawn from this study. It is possible that the symptom reduction reported by participants may have been due to a variety of treatment factors (e.g., self-monitoring, use of appropriate coping strategies, etc.). Second, the limited number of participants completing all three modules (e.g., Assessment, Intervention, and Maintenance) makes it impossible to examine the utility of the Maintenance Module. Lastly, data from the current study were collected from a non-referred sample of skin pickers and may not represent an accurate picture of SP in a clinical population. However, demographic information from the current sample is comparable to published findings in the SP literature [5, 10, 37]. In addition, the average symptom severity rating (SPS score) for participants whose data were used as part of outcome analyses were nearly 5 points higher than the previously established cutoff score differentiating self-injurious from non-self-injurious skin pickers [4, 5]
Future research is necessary to systematically examine the utility of the Assessment, Intervention, and Maintenance Modules and specific components within each module (e.g., self-monitoring alone vs. self-monitoring + coping strategies, specific coping strategies, etc.). In addition, research should compare the efficacy of StopPicking.com to other interventions such as self-help manuals, self-monitoring alone, individualized CBT, or computer-assisted CBT (e.g., the use of PDAs in conjunction with individual therapy) [28, 29].
The most frequent reason for discontinuing use of StopPicking.com was the infrequency with which participants reported accessing the Internet; the duration of program use was the only variable found to predict treatment response. As such, StopPicking.com may not be well-suited for individuals with limited access to a computer or the Internet. As the frequency of Internet use increases, the development and further examination of Internet-based, self help programs for skin picking (and related disorders) will become of increasing importance, particularly for those individuals unable to access services regularly. The data from the current study are encouraging and provide preliminary evidence supporting the efficacy of StopPicking.com for the reduction in frequency and severity of a variety of skin picking behaviors and as an alternative or adjunctive treatment for self-injurious SP.
Author conflict of interest statement:
Suzanne Mouton-Odum PhD is co-owner of PsycTech, Ltd., which owns and markets StopPicking.com. Nancy J Keuthen PhD received consultant fees from PsycTech, Ltd.
1 The total number of participants who signed onto the program from August 28, 2003 to January 31, 2006 was 526 but only participants 18 years of age or older and with at least 2 data points were included in subsequent analyses. Results revealed no statistically significant differences between these two groups with respect to age, gender, or ethnicity (Chi-square analyses; p > 0.12). In addition, the groups demonstrated no statistically significant differences between baseline SPS scores, t (475) = 0.133, p = 0.894. However, participants with at least 2 data points tended to report significantly more picking episodes at baseline (M = 38.08, SD = 36.78) than participants not meeting inclusion criteria (M = 19.98, SD = 30.02; t (507) = -5.16, p < 0.001).
2 Mouton-Odum et al. (in press) used a response cutoff of 25% to examine whether participants in their study improved, worsened, or did not change via the use of the StopPulling.com. As a result, the current study used similar response cutoff criterion.
3 Due to the number of chi-square analyses conducted (n = 3), and alpha level of 0.017 was required to achieve statistical significance.
4 The average symptom severity rating (SPS score) for all participants meeting inclusion criteria (n = 356) was 12.22 (SD = 3.13).
5 Drs. Mouton-Odum and Keuthen are the owner and consultant to StopPicking.com, respectively.
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