Albatross Baseline Study Synthesis

Body-Focused Repetitive Behaviors

Can tech make them go away?

Team Albatross is seeking a solution to compulsive body-focused repetitive behaviors (BFRBs, such as skin-picking/dermatillomania, or hair-pulling/trichotillomania), with the help of CS247B’s design principles focused on behavior change. We hope to design and develop a  solution, aided and improved by commodity technology to help our target audience reduce or eliminate their BFRBs.

This report details our baseline study, what we learned and who we learned it from, and our key insights that we will take to the next step in the design process.

Baseline Study

Once we decided that we wanted to work in the BFRB space, the first thing to do was do a baseline study to understand the behaviors, thoughts, and experiences of people who compulsively skin-pick/hair-pull. We wanted to understand what the phenotypical variation for BFRBs would be, what people have tried to do to stop their compulsions already, and what triggers their behaviors both emotionally and environmentally. The goal was to understand our audience and their struggles with BFRBs, and determine what kind of intervention would be most helpful, and where/when to implement it.

Rebecca, a member of the group, has dermatillomania, so we decided she would be doing most of the interactions in the baseline study due to its sensitive nature and Rebecca’s inherent empathy and understanding of the audience we are working for.

Recruitment

There is a very large community of people who struggle with BFRBs on Reddit, r/CompulsiveSkinPicking, where Rebecca wrote a post to recruit people willing to participate in our design study. This post was also cross-posted in other subreddits, like r/Trichotillomania.

In the Reddit post, Rebecca put a link to our Baseline Study Screener, which we used to determine who we would recruit for further study. On the screener, we collected data such as the respondent’s age (< 18 years were automatically disqualified), what BFRBs they do, how frequently they do them, and if they want to stop their behaviors. We also asked if the participants had a cell phone and a smart watch. Since we are hoping to design a technical intervention, having a cell phone was mandatory, but we were curious about the smart watch as well though it was not a disqualifying question.

Our Reddit post had quite a bit of reach, so we ended up with 42 responses to the screener form. After eliminating those who were disqualified due to age, did not want to participate in  further study, or did not provide a follow-up email, we sent emails to 10 possible participants.

Of the 10 email recipients, we received followup from 6 of them. One response was too late as we had already begun the diary study step, but the other 5 participants were scheduled for the pre-study interview, and completed the study all the way through with 0% attrition.

Participant demographics

We had n=5 participants, 80% women. 

Participants’ ages:

Age group (years)	Number of participants
18-24	2
25-34	2
55-56	1

Participants were also quite spread out geographically, with one participant being in California, 2 in the Midwestern United States, one on the East Coast, and one in Eastern Australia.

Every participant noted picking at their skin multiple times every day, and one participant also noted hair-pulling and nail-biting behaviors as well.

Interviews & Diary Study

Pre-study interviews were conducted for each participant, which consisted of a roughly 30-minute Zoom call to discuss details of their BFRBs such as:

• when their behaviors started,
• why they believe they do the behavior,
• what benefits they get from the behavior,
• why they want to stop,
• what they’ve tried to do in the past to stop,
• why they think their attempts were not successful,
• and to dive deeper into the emotional and habitual elements at play.

Transcripts were collected during the Zoom recordings to use, as well as Rebecca’s notes from each interview, for later analysis.

The participants then participated in a diary study for 4 days. In this study, we asked them to fill out a Google Form once per day, in the evening, telling us about their experiences with BFRBs from the day. The form asked them to describe any behaviors they did, the environment in which the behavior was occurring, whether or not they were alone, their emotions and thoughts at the time of the behavior, and whether or not they attempted to stop themselves. We asked them to record this so that we could get a better understanding of when and where they do these behaviors so that we can target those environmental and emotional factors in our intervention.

At the conclusion of the diary study, each participant also had a 15-20 minute Zoom call for a post-study interview. This interview was conducted so that we could get insights from the participants that did not come up before the diary study, and ask follow-up questions about their diary entries. Some questions we asked were:

• Did any emotions come up during the diary study that you weren’t aware of previously?
• How did your awareness of the behavior change during the study?
  • [if relevant] Was the increased awareness good or bad for you? Why?
• Were there any new triggers that you noticed during the study that you didn’t realize were triggers before?
• Did you ever successfully stop the behavior in the moment during the study? Could you tell us about that?

Lastly, we had them engage in a mini ideation session with us, where we asked them what they thought could be a helpful intervention, or what their ideal solution would be if there were no constraints.

Like the pre-study interviews, transcripts were recorded from each meeting for later analysis.

Raw Data to Grounded Theory

View our synthesis work on this FigJam Board. After breaking down our pre-study interview transcripts, diary entry data, and post-study data into ideas, we used affinity mapping to categorize our ideas into the following categories ranked by prevalence: 

• Physical Triggers

1. 1. 1. Skin-picking triggers in the physical environment e.g. location, objects, etc.

• Emotional Triggers

1. 1. 1. Skin-picking triggers related to mental well-being

• Personal Prevention

1. 1. 1. Skin-picking prevention techniques that are specific to the person

• Emotional Response

1. 1. 1. Emotional response before, during, and after skin-picking session
   2. Medication Prevention
      1. Skin-picking prevention through medication
      2. Not addressed due to limited medical and medication expertise 

• Environmental Prevention

1. 1. Skin-picking prevention techniques that change the context/environment
2. Knowledge of Habit
   1. Knowledge of skin-picking disorder / history / awareness
   2. Not addressed due to limited participant subset
3. Frequency
   1. Frequency and duration of skin-picking sessions during the diary study

We will dive into the insights for our top 5 categories [bolded above], as well as discuss an overview of the trends and contradictions in the data.

Physical Triggers

Grounded Theory: Most skin-picking sessions occur when idle in private spaces (e.g. couch at home, bathroom, car, etc.), especially when people are alone.

Evidence: All of the participants in our diary study logged skin-picking sessions in private spaces, whether that be at home or in the work bathroom. Given this observation, it seems that people are more prone to skin-pick in spaces that are more familiar and personal to them. One participant noted that sessions start at home: “Sometimes when I’m working from home…I’ll start messing with my arms.”

Tension: Bathroom spaces can make people hyper aware of their skin because of the mirrors, which can incite skin-picking.

Evidence: One participant noted every single day they would start skin-picking in front of the bathroom mirror. Once the mirror brings forward skin imperfections, the participant picks their skin in hopes of removing those imperfections. It’s a destructive cycle.

Emotional Triggers

Grounded Theory: Anxiety and stress triggered by other actions can exacerbate skin-picking sessions in duration, frequency, and severity. To understand skin-picking triggers, we need to understand anxiety triggers.

Evidence: It is consistent across the participants that anxiety triggers skin-picking, however, anxiety occurs in different areas for the different participants. Multiple participants cited feeling anxious/stressed during work which made them want to relieve that feeling by skin-picking. One participant feels anxious scrolling on social media. To understand skin-picking triggers, we need to understand anxiety triggers.

Contradiction: People pick their skin in hope of removing skin imperfections, but end up exacerbating them. “I want to get rid of the bumps on my skin…which obviously are there because I keep picking them,” said one participant in the pre-study interview. They are aware of this contradiction but having good skin is such a strong motivator. It seems as if the participant doesn’t realize the consequences of skin-picking until after the motivator subsides.

Personal Prevention

Grounded Theory: Solutions that cover the skin (e.g. creams, gels, gloves) are only effective if the person embeds the solution consistently in routine.

Evidence: Insect bite gel and skin moisturizer are examples of effective solutions for preventing skin-picking as cited by participants. We assume these are effective because they change the texture of the skin and provide a different physical sensation. However, most participants have trouble routinizing such solutions: either they forget to use it before incidents, the solution doesn’t stay on skin, or they relapse into pattern.

Tension: Physical solutions eliminate skin texture (e.g. gloves, acne patches, silicone patches) but they also may be ineffective long-term if solutions come off or are removed. 

Evidence: A lot of physical solutions are temporary. Gloves and band-aids aren’t worn 24/7. Acne or silicone patches fall off due to sweat. Gels and moisturizers come off in the shower. “I’ve tried sticking things over them and what have you but they just sweat off… If they stuck on, I think they would help,” said one participant. Physical solutions are only effective when consistently used even after solutions fall off temporarily.

Emotional Response

Grounded Theory: The longer and more severe the skin-picking sessions are, the more aware the person will be about the habit. This will kick in more motivation to use prevention techniques.

Evidence: Most skin-picking sessions are very subconscious with quick durations and high frequencies. But, the harmful effects of long, severe skin-picking sessions can kick in awareness much faster. Another participant said they felt the worst after a long 1-hour session when they usually have sessions that are 15 minutes. It can be frustrating to be more aware that the skin-picking is severe while in the moment.

Contradiction: People feel ashamed and embarrassed in front of people due to severe skin-picking episodes, especially when scars or imperfections are visible. But, some say that external accountability could be effective.

Evidence: A story that stuck out to our team was the nurse participant who was shamed by her own patient. The patient did not want to be helped by the nurse because she was “covered in sports.” The participant told us that the patient was deemed to be mentally unstable, but the comment is hurtful nonetheless. The visible scars from skin-picking sessions can make people feel ashamed about the habit and this discrimination can be discouraging. 

One participant said, however, that having someone they trust point out skin-picking could be effective: “In that moment I suppose, … if my best friend or my partner says, oh, just stop picking that. I will.” This could imply that people may have not had external accountability that is effective and not shameful. 

Environmental Prevention

Grounded Theory: People are less aware of how to utilize environmental cues or friction to decrease their skin-picking habit long-term.

Evidence: Fortunately, some of our participants became more aware of their environment participating in our diary study. One participant in particular knew how consistent the bathroom mirror was in inciting skin-picking and tried to remove themselves from the mirror. But, it’s difficult when you have to use the bathroom regularly. Another participant knew that removing tools like tweezers from the environment would prevent skin-picking but still had the compulsion to find the tools. One participant contemplated having external accountability from people they trust but didn’t implement it in their life. These participants attempted changing their environment, had short-term success, but were more uncertain about how to utilize friction to prevent skin-picking long-term. We wonder what it would take to find the most effective friction for each participant.

24-Hour Timeline Mapping

Here we map some of our insights on a 24-hour timeline to see when the likelihood of skin-picking is highest and when prevention techniques may be the most useful. We note here that stress and anxiety induced from work tends to incite the most severe and long-lasting skin-picking sessions, especially for those who work from home. Additionally, after work hours, people tend to be more idle, bored, and alone, which can induce skin-picking sessions. Finally, there are more prevention techniques happening in the beginning of the day, but not so much in the middle or evening. This means that prevention techniques have the potential to wear off at the end of the day. We also shouldn’t underestimate the idle moments that happen during commutes when people are sitting idle in the car. There are many potential contexts for intervention throughout the work day.

Summary

1. Physical space: Most skin-picking sessions occur when idle in private spaces (e.g. couch at home, bathroom, car, etc.), especially when people are alone.
   1. Bathroom spaces can make people hyper aware of their skin because of the mirrors, which can incite skin-picking.
2. Emotional Triggers: Anxiety and stress triggered by other actions can exacerbate skin-picking sessions in duration, frequency, and severity. To understand skin-picking triggers, we need to understand anxiety triggers.
   1. People pick their skin in hope of removing skin imperfections, but end up exacerbating them.
3. Prevention: Solutions that cover the skin (e.g. creams, gels, gloves) are only effective if the person embeds the solution consistently in routine.
   1. Physical solutions eliminate skin texture (e.g. gloves, acne patches, silicone patches) but they also may be ineffective long-term if solutions come off or are removed.
4. Emotional Response: The longer and more severe the skin-picking sessions are, the more aware the person will be about the habit. This will kick in more motivation to use prevention techniques.
   1.  People feel ashamed and embarrassed in front of people due to severe skin-picking episodes, especially when scars or imperfections are visible. But, some say that external accountability could be effective
5. Environment: People are less aware of how to utilize environmental cues or friction to decrease their skin-picking habit long-term.

Given these insights, we see that people have already identified short-term solutions for preventing skin-picking sessions like utilizing creams, insect gel, gloves, etc. However, there is frustration because these solutions depend on the willpower of the person to enact it, which is unreliable. Our data shows that anxiety and idleness are consistent triggers for skin-picking behavior. If people are more aware of when and what contexts trigger these emotional states for them (like during work or after work), it’ll make for more sustained and personalized prevention. We believe there is potential to combine these short-term solutions with environmental cues for long-term behavior change.

System Models

Secondary Research

From the literature, we found that pharmaceutical interventions are very effective, and surprisingly, anxiety medications can elicit symptoms of skin-picking that either require abstention or additional medication (6). However, since we do not feel comfortable prescribing medication or overseeing an intervention like that, we’ve sought out alternatives. Alternatives that require reflection and comprehension of the disorder have been found to help. The German site savemyskin.de provided helpful information about skin-picking and fostered a supportive environment that users reported as helpful in their journey to quit skin-picking (7). Moreover, virtual cognitive behavioral therapy offered to users of the site was quite effective (7). In another research paper, cognitive-behavioral therapy, habit reversal training, and acceptance commitment therapy were all found to significantly reduce skin-picking behaviors across multiple studies (9). Another research study combined the savemyskin.de approach of providing skin-picking awareness content with a wearable device that vibrates when the user tries to skin-pick (11). This study was conducted over 214 days and significantly reduced skin-picking. However, users complained that the vibrating wearable was distracting, especially during the high times of stress when they would subconsciously pick (11). Due to this complaint and some of the complaints issued by our users in user testing, I explored less invasive alternatives. Expressive writing about participants’ urges to skin-pick produced a short-term reduction in the urge to pick the skin and increased feelings of relief immediately after the writing session (8). Mid-term effects showed that focused skin-picking behaviors decreased. Participants that free-painted felt less of an urge to manipulate their skin in the short-term (8). Skin barriers were also explored as a worthy method of harm reduction (5). The only issue with this approach was finding different materials for different areas of the skin that would be picked to ensure practicality.

References

1. Grant, J. E., Odlaug, B. L., Chamberlain, S. R., Keuthen, N. J., Lochner, C., & Stein, D. J. (2016). N-Acetylcysteine in the treatment of excoriation disorder: A randomized clinical trial. JAMA Psychiatry, 73(5), 490-496. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2500041
2. Grant, J. E., Odlaug, B. L., & Chamberlain, S. R. (2022). Double-blind placebo-controlled study of memantine in trichotillomania and skin-picking disorder. American Journal of Psychiatry, 179(7), 465-474. https://psychiatryonline.org/doi/10.1176/appi.ajp.20220737
3. Flessner, C. A., Lochner, C., Stein, D. J., Woods, D. W., Franklin, M. E., Keuthen, N. J., & Grant, J. E. (2023). Self-help habit replacement in individuals with body-focused repetitive behaviors. Journal of Psychiatric Research, 163, 215-223. https://pmc.ncbi.nlm.nih.gov/articles/pmid/36856701
4. Woods, D. W., Miltenberger, R. G., & Carr, J. E. (2023). Reducing skin picking via competing activities: A single-case analysis. Journal of Applied Behavior Analysis, 56(2), 340-352. https://pmc.ncbi.nlm.nih.gov/articles/PMC8001957
5. Patel, S., Chavan, M., & Singh, S. (2023). Dermatillomania: Strategies for developing protective biomaterials/cloth. Biomaterials and Biomechanics, 5(3), 43. https://www.mdpi.com/2624-8611/5/3/43
6. van Amerongen, A. N., van der Meer, A. S., & Hoekzema, R. (2019). Bridging the gap between dermatology and psychiatry: Prevalence and treatment of excoriation disorders secondary to neuropsychiatric medications. Journal of Medical Internet Research, 21(9), e15011. https://www.jmir.org/2019/9/e15011
7. Weidt, S., Haag, T., & Laireiter, A. R. (2023). An internet-based self-help intervention for skin picking (SaveMySkin): Pilot randomized controlled trial. JMIR Mental Health, 10(4), e10508252. https://pmc.ncbi.nlm.nih.gov/articles/PMC10508252
8. Köteles, F., Kiss, K., & Szamosközi, S. (2024). Reduction of pathological skin-picking via expressive writing. Clinical and Experimental Dermatology, 50(2), 299-310. https://academic.oup.com/ced/article/50/2/299/7746452
9. Franklin, M. E., Zaidel, E., Woods, D. W., & Piacentini, J. (2021). A systematic review of nonpharmacological treatment options for skin picking disorder. arXiv preprint arXiv:2106.10970. https://arxiv.org/abs/2106.10970
10. Maleki, D., Hollon, S. D., & Wenze, S. J. (2023). Anticipatory detection of compulsive body-focused repetitive behaviors using wearable technology. Journal of Behavioral Addictions, 12(4), 315-332. https://pubmed.ncbi.nlm.nih.gov/37731870
11. Gatzonis, S., Meyer, B., & Rüsch, N. (2022). Short-term intervention complemented by wearable technology improves trichotillomania – A naturalistic single-case report. Journal of Psychiatric Research, 160, 45-53. https://pmc.ncbi.nlm.nih.gov/articles/PMC9063575
12. Lochner, C., Grant, J. E., & Stein, D. J. (2021). Trichotillomania and skin-picking disorder: An update. Frontiers in Psychiatry, 12, 732717. https://www.frontiersin.org/journals/psychiatry/articles/10.3389/fpsyt.2021.732717/full
13. Snorrason, I., Ricketts, E. J., & Woods, D. W. (2021). Pathological skin picking: Phenomenology and associations with emotions, self-esteem, body image, and subjective physical well-being. Clinical Psychology Review, 85, 101972.

Proto-Personas and Journey Maps

Disclaimer: we tried multiple ways of exporting the journey maps from FigJam and this is the best quality we could get. Please refer to the FigJam link for better quality journey maps.

Key Insights

• For Perfect Ben, we see that there are attempts of prevention at the beginning and end of the day, but not in the middle of the day
  • Prevention techniques may wear off at the end of the day
• For Anxious Emily, we see that when she is surrounded by her partner and kids, there is no need for prevention. But, when she is alone and idle, skin-picking will occur.
  • Skin-picking is consistently triggered in the car, which she uses consistently to drive her kids to and from school
• Both personas do not attempt prevention in the middle of the day
• Both personas have an increase of skin-picking sessions when they are the most idle i.e. either at home or working at a desk
• Both personas have existing short-term solutions but have yet to routinize them effectively for long-term habit change
  • Anxious Emily forgets gloves for the car
  • Perfect Ben’s skin patches fall off by the end of the day