J. Behav. Ther. & Exp. Psychiat.

40 (2009) 127–135

Contents lists available at ScienceDirect

Journal of Behavior Therapy

and Experimental Psychiatry
journal homepage: www.elsevier.com/locate/jbtep

The Milwaukee Inventory for the Dimensions of Adult

Skin Picking (MIDAS): Initial development and
psychometric properties
Michael R. Walther, Christopher A. Flessner, Christine A. Conelea,
Douglas W. Woods*
Department of Psychology, University of Wisconsin-Milwaukee, 224 Garland Hall, 2441 E. Hartford Avenue,
Milwaukee, WI 53211, USA

a r t i c l e i n f o a b s t r a c t

Article history: This article describes the development and initial psychometric
Received 8 December 2007 properties of the Milwaukee Inventory for the Dimensions of Adult
Received in revised form 17 June 2008 Skin picking (MIDAS), a measure designed to assess ‘‘automatic’’
Accepted 11 July 2008
and ‘‘focused’’ skin picking. Data were collected from 92 partici-
pants who completed an anonymous internet-based survey.
Keywords:
Results of an exploratory factor analysis revealed a two-factor
Automatic
solution. Factors 1 (‘‘focused’’ picking scale) and 2 (‘‘automatic’’
Focused
Psychometrics picking scale) each consisted of 6 items, and preliminary data
Skin picking demonstrated adequate internal consistency, good construct val-
idity, and good discriminant validity. The MIDAS provides
researchers with a reliable and valid assessment of ‘‘automatic’’
and ‘‘focused’’ skin picking.
Ó 2008 Elsevier Ltd. All rights reserved.

1. Introduction

Chronic skin picking (CSP) is defined as repetitive picking that results in significant tissue damage
and is accompanied by marked distress or functional impairment (e.g. Keuthen et al., 2000;
Wilhelm et al., 1999). CSP is not included as a diagnostic category in the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric
Association, 2000) but is most commonly conceptualized as an impulse control (Wilhelm et al., 1999)

* Corresponding author. Tel.: þ1 414 229 5335; fax: þ1 414 229 5219.
E-mail addresses: mwalther@uwm.edu (M.R. Walther), flessne2@uwm.edu (C.A. Flessner), cconelea@uwm.edu (C.A. Conelea),
dwoods@uwm.edu (D.W. Woods).

0005-7916/$ – see front matter Ó 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jbtep.2008.07.002
128 M.R. Walther et al. / J. Behav. Ther. & Exp. Psychiat. 40 (2009) 127–135

or obsessive-compulsive disorder spectrum disorder (Stein, Hutt, Spitz, & Hollander, 1993). CSP is
thought to occur in 2–4.6% of the population (Arnold, Auchenbach, & McElroy, 2001; Keuthen et al.,
2001) and is more prevalent among women (Flessner & Woods, 2006).
Phenomenological research suggests that those with CSP vary along different phenomenological
dimensions. In semi-structured interviews of 34 adults with CSP, 24% reported full awareness of
picking episodes, and 76% said that picking sometimes occurred out of awareness (Arnold et al., 1998).
This led Arnold et al. (2001) to categorize CSP into three styles: a ‘‘compulsive’’ style, characterized by
picking performed with full awareness and in response to aversive emotions or obsessions; an
‘‘impulsive’’ style, characterized by picking performed with minimal awareness; and a ‘‘mixed’’ style,
which shared both compulsive and impulsive features.
Similar dimensions have been proposed and studied in trichotillomania (TTM; repetitive hair
pulling), a disorder that is closely linked to CSP (Arnold et al., 1998; Lochner, Simeon, Niehaus, & Stein,
2002; Wilhelm et al., 1999). Christenson and Mackenzie (1994) identified ‘‘automatic’’ and ‘‘focused’’
pulling dimensions of TTM. ‘‘Automatic’’ pulling was characterized as pulling that occurred outside of
one’s awareness, including situations in which an individual pulled while engaged in a sedentary
activity, such as reading or watching television. ‘‘Focused’’ pulling was described as more intentional in
nature. For example, an individual engaged in ‘‘focused’’ pulling may consciously pull his or her hair in
response to an urge or other negative emotion, or as an effort to correct perceived imperfections. Initial
studies examining the phenomenology of trichotillomania offered evidence supporting the existence
of these pulling dimensions (Christenson & Mackenzie, 1994; Diefenbach, Mouton-Odum, & Stanley,
2002; du Toit, van Kradenburg, Niehaus, & Stein, 2001). However, the absence of a reliable and valid
measure to assess ‘‘focused’’ and ‘‘automatic’’ pulling limited the extent to which researchers could
examine their prevalence and associated characteristics. To address this limitation, Flessner, Woods,
Franklin, Cashin, and Keuthen (2008) developed a measure to assess ‘‘focused’’ and ‘‘automatic’’ pulling
in adults, and Flessner et al. (2007) developed a similar measure to assess pulling dimensions in
children.
Comparatively little research has been conducted to evaluate focused, automatic, and mixed
dimensions of CSP. As stated above, the Arnold et al. (1998) study suggested that three styles may exist,
and consistent with what would be expected in focused picking, there is evidence that some episodes
of picking may serve to regulate emotions (Keuthen et al., 2000; Wilhelm et al., 1999). Nevertheless, the
extent to which focused and automatic picking occurs in individuals with CSP remains unclear. Little is
known about whether demographics, onset and course of skin picking, comorbid conditions, impair-
ment, or response to treatment differ as a function of these dimensions.
In order to better understand the potential dimensions of CSP, there is a need for a reliable and valid
method of assessment. The self-report measures currently used in the assessment of CSP focus on
severity (Keuthen, Wilhelm et al., 2001) and psychosocial impact (Keuthen, Deckersbach et al., 2001),
but do not address the focused and automatic dimensions. Knowledge regarding specific dimensions of
skin picking may be particularly important, because as Flessner et al. (2008) noted when discussing
similar issues in TTM, research in this area will lead to a better characterization of the problem and will
ideally result in more effective treatments for CSP. Unfortunately, to develop such a measure requires
large sample sizes, which previous studies on CSP have found difficult to attain using traditional
subject recruitment methods (e.g. n ¼ 28, Keuthen, Wilhelm et al., 2001; n ¼ 31, Wilhelm et al., 1999).
When faced with a similar difficulty, Flessner et al. (2008) used internet sampling procedures to
develop a self-report measure of trichotillomania dimensions. This approach was supported by
research demonstrating that internet sampling procedures produce results consistent with those
obtained using traditional sampling methods (Gosling, Vazire, Srivastava, & John, 2004; Wetterneck,
Woods, Norberg, & Begotka, 2006; Woods et al., 2007).
The purpose of the current study was to develop a measure assessing the degree to which indi-
viduals with CSP engage in ‘‘focused’’ and/or ‘‘automatic’’ picking. Internet sampling procedures,
similar to those used by Flessner et al. (2008), were utilized in the current study to obtain a sufficient
sample size. The development and psychometric properties of the Milwaukee Inventory for Dimen-
sions of Adult Skin Picking (MIDAS) were established in part using an exploratory factor analysis (EFA).
To test construct validity of the instrument, it was hypothesized that ‘‘focused’’ skin picking would
positively correlate with measures of anxiety, depression, and experiential avoidance, and ‘‘automatic’’
 M.R. Walther et al. / J. Behav. Ther. & Exp. Psychiat. 40 (2009) 127–135 129

picking would not. It was also hypothesized that the ‘‘automatic’’ and ‘‘focused’’ scales would be
uncorrelated, as they were seen to reflect unique dimensions.

2. Method

2.1. Participants

The characteristics of participants in this sample have been reported elsewhere (Flessner & Woods,
2006). Individuals were recruited through a link established on the Trichotillomania Learning Center’s
(TLC’s) homepage (www.trich.org). The TLC is a national non-profit organization that provides infor-
mation and support to those affected by trichotillomania and other body focused repetitive behavior
problems such as CSP. Potential participants were informed that investigators were interested in
learning more about those who chronically pick their skin, and if interested in participating, partici-
pants were directed to the online informed consent and survey. 101 participants submitted their
responses to the survey over the course of 1 month. Of these, 92 were used in subsequent analyses. The
remaining nine were excluded from further analyses because participants did not report repetitive
picking (n ¼ 7) or were younger than 18 years of age (n ¼ 2). Of the 92 surveys used in this study, 85
(92%) were completed by females and 7 (7%) were completed by males. One participant did not provide
information about gender. Participants were primarily Caucasian (85 participants, or 92%). Other
ethnicities included 3 multiracial participants (3%), 2 Asian participants (2%), 1 African-American
participant (1%), and 1 ‘‘other’’ (1%). The median income of the sample was $30,000–49,999. Partici-
pants completed a median of 15 years of education, and the modal degree completed was a ‘‘High
School or GED equivalent.’’ Participants ranged in age from 18 to 65 years (M ¼ 30.0, SD ¼ 10.1). Forty-
five (49%) participants were single, 38 (41%) were married, and 8 were divorced (9%).
Participants reported a variety of comorbid conditions, such as trichotillomania (25%), mood
disorders (48%; e.g. depression, bipolar disorder, and dysthymic disorder), anxiety disorders (30%; e.g.
generalized anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and social
anxiety disorder), and alcohol/drug abuse (2%). Because data were collected anonymously online,
diagnoses could not be confirmed. As reported in Flessner and Woods (2006), the sample experienced
a significant amount of social, academic, and occupational impairment attributed to skin picking.
Furthermore, 80% of the sample reported tissue damage as a result of their picking.
Links to the survey were posted on the fourth author’s website (www.uwm.edu/~dwoods) and the
Trichotillomania Learning Center, Inc. website (www.trich.org). The links operated from August 1, 2004
to September 15, 2004. The internet-based survey included demographic questions (i.e. age, race,
income, etc.), questions assessing the phenomenology of the participant’s picking (i.e. ‘‘Do you expe-
rience any pleasure or gratification after picking?’’), questions assessing the social and economic
impact of skin picking (i.e. ‘‘Have you ever avoided going on vacation because of your skin picking?’’),
the Beck Anxiety Inventory (Beck, Epstein, Brown, & Steer, 1988), the Beck Depression Inventory (Beck,
Ward, Mendelson, Mock, & Erlbaugh, 1961), the Skin Picking Scale (Keuthen, Wilhelm et al., 2001), and
the Acceptance and Action Questionnaire (Hayes et al., 2004). Participants rated items on the MIDAS in
relation to how they perceived their typical pulling episodes. Prior to the administration of these
questions, participants were informed of study requirements.
The entire survey took approximately 45 min to complete, and upon completion, participants were
informed that submission indicated consent to participate. Surveys were subsequently sent via e-mail
as an ‘‘anonymous user’’ to the second author’s account.

2.2. Measures

Beck Anxiety Inventory (BAI; Beck, Epstein et al., 1988) is a 21-item self-report scale designed to
assess symptoms of anxiety. Items on the BAI assess a variety of symptoms often associated with
anxiety that have occurred over the past week, including numbness or tingling, heart pounding or
racing, nervousness, trembling, and fear. Scores on the BAI range from 0 to 63, with higher scores
indicating increasingly more severe symptoms. The BAI has demonstrated high internal consistency
(a ¼ 0.92), high test–retest reliability over a 1-week period (r ¼ 0.75), good concurrent validity with
130 M.R. Walther et al. / J. Behav. Ther. & Exp. Psychiat. 40 (2009) 127–135

other self-report measures of anxiety (r ¼ 0.51), and good discriminant validity (Beck, Epstein et al.,
1988).
Beck Depression Inventory (BDI; Beck et al., 1961) is a 21-item self-report scale designed to assess
symptoms of depression. Items on the BDI assess a variety of symptoms of depression that have
occurred over the past 2 weeks, such as suicidal ideation, fatigue, weight gain/loss, and concentration.
Scores on the BDI range from 0 to 63 with higher scores indicating more severe symptoms. The BDI has
demonstrated very good internal consistency (split-half reliability, r ¼ 0.86) and good concurrent
validity (r ¼ 0.65) with a clinician’s rating of depression (Beck, Steer, & Garbin, 1988).
Acceptance and Action Questionnaire (AAQ; Hayes et al., 2004) is a 9-item self-report scale designed
to measure experiential avoidance. Experiential avoidance is one’s tendency to escape from or avoid
aversive private experiences (e.g. thoughts and emotions). Participants are asked how much each
statement applies to him/herself and to provide a rating for each item (1–7; with 1 representing ‘‘never
true’’ and 7 representing ‘‘always true’’). Scores are summed to create a total score, with higher scores
indicating higher levels of experiential avoidance. Hayes et al. (2004) reported that 38 and 42 represent
upper quartile scores in non-clinical and clinical populations, respectively. The AAQ has shown
adequate internal consistency (a ¼ 0.70) and moderate construct validity (Hayes et al., 2004).
Skin Picking Scale (SPS; Keuthen, Wilhelm et al., 2001) is a 6-item self-report scale designed to assess
the severity of skin picking. 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 5-point
scale ranging from 0 (none) to 4 (extreme) resulting in a total score ranging from 0 to 24, with higher
scores indicating greater skin picking severity. The SPS has demonstrated moderate internal consis-
tency (a ¼ 0.80) and construct validity with self-reported average duration of skin picking episodes
(Keuthen, Wilhelm et al., 2001). Research has also demonstrated that a cutoff score of 7 differentiates
severe self-injurious skin picking from non-self-injurious skin picking (Keuthen, Wilhelm et al., 2001).

3. Results

The MIDAS initially consisted of 21 items (see Table 1) thought to represent ‘‘focused’’ and ‘‘auto-
matic’’ dimensions of skin picking. Items were modeled after items from a similar self-report inventory
used to assess ‘‘automatic’’ and ‘‘focused’’ hair pulling in TTM: the Milwaukee Inventory for Subtypes of
Trichotillomania – Adult Version (Flessner et al., 2008). Items constructed to assess ‘‘focused’’ picking
asked about picking in reaction to negative emotions (i.e. stress, anger, and anxiety), bodily sensations,
events, or urges, as well as using devices to pick one’s skin. Items constructed to assess ‘‘automatic’’
picking asked about being unaware of picking, concentrating on other activities while picking, and
whether or not the initiation of picking was intentional. Each item on the MIDAS was rated from 1 (‘‘not
true of any of my skin picking’’) to 5 (‘‘true for all of my skin picking’’).

3.1. Exploratory factor analysis (EFA)

Principal axis factor analysis using varimax rotation was conducted on scores from each of the 21
items of the MIDAS. Principal axis factor analysis was chosen based on the recommendation of Russell
(2002) that principal axis factor analysis, when compared to principal components analysis, yields
more accurate findings with respect to population loadings. A two-factor solution was used based upon
a priori hypotheses that individuals who pick their skin may pick in a focused (i.e. in response to
a thought, urge, desire for particular skin appearance or texture, or negative emotional state) or
automatic manner (i.e. largely out of one’s awareness). Five additional factors with eigenvalues
exceeding 1.0 (ranging from 1.193 to 1.925) were excluded given: (a) Russell’s (2002) notion that the
convention of choosing all factors with eigenvalues greater or equal to 1 often results in too many
factors, while accounting for little variance, (b) the scree plot analysis clearly indicated two predom-
inant factors, and (c) we had a priori hypotheses about the factor structure. Retaining a two-factor
solution, Factor 1 (labeled the ‘‘focused picking scale’’), with eigenvalue ¼ 4.073, accounted for 19.4% of
the total variance and consisted of 6 items that reflected picking of a more ‘‘focused’’ nature (‘‘I pick my
skin when I am anxious or upset,’’ and ‘‘I experience an intense urge to pick before I pick my skin’’).
Factor 2 (labeled the ‘‘automatic picking scale’’), with eigenvalue ¼ 3.3, accounted for 15.9% of the total
 M.R. Walther et al. / J. Behav. Ther. & Exp. Psychiat. 40 (2009) 127–135 131

Table 1
Factor structure coefficients from the principal axis factor analysis with varimax rotation of MIDAS scores

Item Structure Communality

Factor 1 Factor 2
I pick my skin when I am experiencing a negative emotion such as stress, anger, 0.673 0.008 0.716
frustration, or sadness.
I have a ‘‘strange’’ sensation just before I pick my skin. 0.656 0.022 0.588
I pick my skin when I am anxious or upset. 0.636 0.107 0.660
I experience an intense urge to pick before I pick my skin. 0.596 0.118 0.602
I pick my skin because of something that has happened to me during the day. 0.587 0.033 0.533
I am in an almost ‘‘trance-like’’ state when I pick my skin. 0.551 0.121 0.507
I have thoughts about wanting to pick my skin before I actually pick my skin. 0.462 0.413 0.592
It is difficult for me to stop picking my skin. 0.394 0.024 0.384
I use tweezers or some other device other than my fingers to pick my skin. 0.367 0.262 0.440
After I pick my skin, the urge to pick goes away or gets ‘‘better’’ for at least a short time. 0.322 0.189 0.365
I pick my skin when I am bored. 0.265 0.004 0.315
I can resist picking despite feeling the urge. 0.255 0.068 0.383
I am usually not aware of picking my skin during the picking episode. 0.100 0.762 0.667
I pick my skin when I am thinking about something unrelated to skin picking. 0.091 0.678 0.606
I don’t notice that I have picked my skin until after it’s happened. 0.306 0.659 0.683
I intentionally start picking my skin. 0.057 0.653 0.540
I pick my skin when I am concentrating on another activity. 0.006 0.562 0.584
I pick my skin while I am looking in the mirror. 0.203 0.418 0.550
I plan a time to pick during the day. 0.347 0.356 0.577
There seems to be no purpose for picking my skin. 0.028 0.178 0.329
I pick my skin based on how my skin feels (e.g. dry or rough) or how the skin looks (e.g. 0.031 0.064 0.266
scabs or soars already present.

Note. Items in bold are those items that loaded onto the respective factor using the selected criteria and thus were retained in the
final version of the scale.

variance and consisted of 6 items that reflected picking occurring out of one’s awareness (‘‘I am not
usually aware of picking my skin during a picking episode,’’ and ‘‘I pick my skin when I am concen-
trating on another activity’’). Items were categorized as fitting into Factor 1 or 2 if the item displayed
a factor structure coefficient of 0.40 or higher (Stevens, 2002; Tabachnick & Fidell, 2001). One item,
‘‘I have thoughts about wanting to pick my skin before I actually pick my skin,’’ displayed factor
structures above 0.40 for both Factors 1 and 2 (0.462 for Factor 1 and 0.413 for Factor 2) and was
excluded from the final 12-item version of the MIDAS. Factor structure coefficients are presented in
Table 1.

3.2. Internal consistency

Internal consistency coefficients (Cronbach’s alphas) were obtained for scores from both the MIDAS
‘‘focused’’ and ‘‘automatic’’ scales. These scores are reported in Table 2. Results indicate that both the
‘‘focused’’ picking (a ¼ 0.805) and ‘‘automatic’’ picking (a ¼ 0.766) scales demonstrate adequate
internal consistency (Nunnally & Bernstein, 1994). Although deletion of one item of the ‘‘automatic’’
picking scale (‘‘I pick my skin while I am looking in the mirror’’) resulted in a higher Cronbach’s alpha,
the change was minimal and did not affect the scale’s construct validity. Thus, the final version of the
MIDAS retained this item. These results suggest a 12-item version of the MIDAS consisting of a 6-item
‘‘focused’’ picking scale and a 6-item ‘‘automatic’’ picking scale, each with scores ranging from 6 to 30.
Higher scores indicate increasingly ‘‘focused’’ or ‘‘automatic’’ picking, respectively.

3.3. Means and standard deviations

The MIDAS was not intended to yield a total score, but rather, distinct scores from each of the two
subscales. Subscale scores were calculated by summing the individual item scores corresponding to the
appropriate subscale. Two of the items (‘‘I intentionally start picking my skin’’ and ‘‘I pick my skin while
I am looking in the mirror’’) on the ‘‘automatic’’ scale were reverse scored. The average score on the
132 M.R. Walther et al. / J. Behav. Ther. & Exp. Psychiat. 40 (2009) 127–135

Table 2
Internal consistency coefficients (Cronbach’s alphas) for both the ‘‘focused’’ and ‘‘automatic’’ picking scales of the MIDAS

Scale a Corrected-item a with

correlation item deleted
‘‘Focused’’ picking scale 0.805
1. I pick my skin when I am experiencing a negative emotion, such as stress, anger, 0.658 0.754
frustration, or sadness.
2. I have a ‘‘strange’’ sensation just before I pick my skin. 0.568 0.776
3. I pick my skin when I am anxious or upset. 0.636 0.759
4. I experience an intense urge to pick before I pick my skin. 0.499 0.789
5. I pick my skin because of something that has happened to me during the day. 0.577 0.774
6. I am in an almost ‘‘trance-like’’ state when I pick my skin. 0.469 0.795

‘‘Automatic’’ picking scale 0.766

1. I am usually not aware of picking my skin during the picking episode. 0.613 0.706
2. I pick my skin when I am thinking about something unrelated to skin picking. 0.589 0.712
3. I don’t notice that I have picked my skin until after it’s happened. 0.498 0.734
4. I intentionally start picking my skin. 0.555 0.719
5. I pick my skin when I am concentrating on another activity. 0.532 0.726
6. I pick my skin while I am looking in the mirror. 0.320 0.789

‘‘automatic’’ picking scale of the MIDAS was 17.09 (SD ¼ 4.60), and the average score on the ‘‘focused’’
picking scale of the MIDAS was 18.93 (SD ¼ 5.15).
The sample means and standard deviations for the AAQ, BAI, BDI, and SPS were as follows: AAQ:
M ¼ 39.0 (SD ¼ 8.5); BAI: M ¼ 18.0 (SD ¼ 12.5); BDI: M ¼ 22.8 (SD ¼ 11.6); SPS: M ¼ 14.5 (SD ¼ 4.7,
Range ¼ 3–23) (as reported in Flessner & Woods, 2006). The clinical cutoff score for the SPS is 7.0,
indicating the present sample’s skin picking severity was in the clinical range and comparable to
a recent samples of individuals with CSP participating in an open trial of escitalopram (Keuthen et al.,
2007).

3.4. Construct validity

Correlations between scores on the ‘‘automatic’’ and ‘‘focused’’ subscales and the SPS were calcu-
lated. Results showed a significant positive correlation between scores on the ‘‘focused’’ subscale and
SPS scores (r (81) ¼ 0.505, p < 0.001), and no significant correlation between the ‘‘automatic’’ subscale
and SPS scores (r (82) ¼ 0.089, p ¼ 0.425). These results indicate that higher levels of ‘‘focused’’
picking are associated with greater skin picking severity.
Relationships between scores on the ‘‘focused’’ and ‘‘automatic’’ scales and scores on the AAQ, BAI,
and BDI were calculated. Results showed a moderate significant correlation (r (79) ¼ 0.340, p ¼ 0.002)
between the AAQ and ‘‘focused’’ scale, but not the ‘‘automatic’’ scale (r (80) ¼ 0.130, p ¼ 0.251).
Moderate significant correlations were also found between scores on the BAI and the ‘‘focused’’ scale
(r (76) ¼ 0.489, p < 0.001), but not the ‘‘automatic’’ scale (r (74) ¼ 0.024, p ¼ 0.838), indicating that
increased ‘‘focused,’’ but not ‘‘automatic,’’ picking is associated with greater anxiety. Finally,
moderate significant correlations between total scores on the BDI and scores on the ‘‘focused’’ scale
(r (76) ¼ 0.343, p ¼ 0.002), but not the ‘‘automatic’’ scale (r (78) ¼ 0.056, p ¼ 0.626) were found,
indicating that greater ‘‘focused,’’ but not ‘‘automatic,’’ picking is associated with greater depression. As
hypothesized, no significant relationship was found between the ‘‘automatic’’ subscale and the AAQ
and BDI (AAQ: r (67) ¼ 0.117, p ¼ 0.339); BDI: (r (67) ¼ 0.004, p ¼ 0.974).
Because higher levels of ‘‘focused’’ picking were associated with greater skin picking severity, partial
correlations between scores on the ‘‘focused’’ scale and the BAI, BDI, and AAQ were re-run controlling
for SPS scores. A positive correlation between ‘‘focused’’ scores and BAI scores remained significant
(r (67) ¼ 0.264, p ¼ 0.028), but correlations between ‘‘focused’’ scores and the AAQ and BDI were no
longer significant (AAQ: r (67) ¼ 0.071, p ¼ 0.562; BDI: r (67) ¼ 0.004, p ¼ 0.974).
The hypothesis that ‘‘focused’’ and ‘‘automatic’’ dimensions would be unrelated was supported
(r (78) ¼ 0.008, p ¼ 0.942), suggesting that the two scales measure separate dimensions of CSP.
 M.R. Walther et al. / J. Behav. Ther. & Exp. Psychiat. 40 (2009) 127–135 133

4. Discussion

The current study investigated the development, factor structure, and psychometric properties of
a measure designed to assess ‘‘focused’’ and ‘‘automatic’’ skin picking in a sample of adult participants
reporting CSP. An exploratory factor analysis revealed a 12-item, two-factor solution. Both the
‘‘focused’’ and ‘‘automatic’’ scales of the MIDAS demonstrated adequate internal consistency and good
construct validity. In addition, the two scales demonstrated no significant relationship to one another,
providing evidence that the two scales measure separate dimensions of CSP.
These findings are potentially useful for a number of reasons. First, the current study confirms the
existence of separable dimensions of CSP. Second, the current study provides a potentially useful tool in
assessing and characterizing those with CSP. Third, results of this study may be useful in tailoring
treatments for individuals with CSP. For example, in a similar study targeting a TTM sample, Flessner
et al. pointed out that ‘‘automatic’’ hair pulling may be particularly responsive to habit reversal (HR;
Azrin & Nunn, 1973), which aims to increase one’s awareness and disrupt a chain of habitual
responding, whereas ‘‘focused’’ hair pulling may be more responsive to techniques that aid in the
management of negative emotions, such as Cognitive Behavior Therapy (CBT), Dialectical Behavior
Therapy (DBT; Linehan, 1993) or Acceptance and Commitment Therapy (ACT; Hayes, Stroshal, & Wilson,
1999). A similar approach may be helpful for those clinicians treating individuals with CSP. That is,
individuals whose skin picking is primarily ‘‘automatic’’ may benefit from HR, while individuals’ whose
skin picking is primarily ‘‘focused’’ may benefit from CBT, DBT, or ACT. Individuals who demonstrate
aspects of both ‘‘focused’’ and ‘‘automatic’’ skin picking may benefit from a combination of HR and
other techniques, such as HR and ACT (Flessner, Busch, Heideman, & Woods, in press; Franklin, Tolin, &
Diefenbach, 2006; Woods, Wetterneck, & Flessner, 2006;).
Despite these potential contributions to its work on CSP, a number of limitations exist. First, it is
important to note that after controlling for skin picking severity, the relationships between ‘‘focused’’
picking scores and the AAQ and BDI no longer remained significant. This is consistent with previous
literature indicating a relationship between levels of skin picking severity and affective distress
(Keuthen et al., 2000). It is also interesting to note that in trichotillomania, a disorder thought to be
related to CSP, AAQ scores have been found to correlate significantly with ‘‘focused’’ hair pulling
independent of pulling severity (Flessner et al., 2008). The fact that the relationship between experi-
ential avoidance and ‘‘focused’’ picking did not hold up in the current study (i.e. after controlling for
severity) may point to a difference between the two disorders. Both CSP and TTM are currently clas-
sified in the DSM-IV-TR as impulse control disorders (CSP is usually diagnosed as impulse control
disorder not otherwise specified), but the current results suggest that different processes may underlie
skin picking and hair pulling, at least as they relate to ‘‘focused’’ picking or pulling.
Second, the finding that scores on the ‘‘focused’’ subscale, but not the ‘‘automatic’’ subscale, of the
MIDAS correlated significantly with scores on the SPS needs to be considered. A few possible expla-
nations exist. First, its differential relationship could be a measurement artifact. Two of the six items on
the SPS assess the urge to pick (one assessing the frequency of urges, and the other assessing the
intensity of urges). As a result, individuals who display elevated rates of ‘‘focused’’ picking may simply
report more urges. In contrast, individuals who display picking more ‘‘automatic’’ in nature may not
endorse the presence of an urge, or at least an urge with similar frequency or intensity as those who
pick in a more ‘‘focused’’ manner. As a second explanation, other items on the SPS assess the domains of
impairment, distress, and avoidance related to skin picking. Given the findings that the ‘‘focused,’’ but
not the ‘‘automatic,’’ subscale of the MIDAS correlated significantly with scores on the BDI and BAI, it is
possible that the presence of co-occurring anxiety or depression in the ‘‘focused’’ group may be
inflating SPS scores differentially. More research on these issues should be conducted in the future.
As a third limitation, the internet sampling procedure used in the current study yields particular
interpretive issues. Although SPS data indicated that picking was occurring at above threshold levels, it
was not possible to confirm any diagnoses (both comorbid and diagnoses related to skin picking), verify
that skin picking was the participants’ primary concern, or rule out various medical or psychiatric
causes. Fourth, questions remain about whether the sample recruited for this study would differ from
clinical samples (i.e. those who are treatment seeking). Nevertheless, recent research has demon-
strated similarity between internet samples and samples obtained using face-to-face methods in the
134 M.R. Walther et al. / J. Behav. Ther. & Exp. Psychiat. 40 (2009) 127–135

study of trichotillomania (Wetterneck et al., 2006). Likewise, internet sampling procedures have
seldom been found to be limited by false data or repeat responders, and internet-derived data
generally provide results consistent with traditional methods (Gosling et al., 2004). Also, it is unclear if
the proposed dimensions of ‘‘automatic’’ and ‘‘focused’’ dimensions are the best dimensions to capture
CSP. As we learn more about CSP, other dimensional or subtyping models may be proposed that prove
to be more accurate or clinically useful. Finally, the sample size used in this study is relatively small and
limits the strength of the conclusions somewhat. For example, variability in this data set may have
a larger effect (e.g. skewness) on the results than if a larger data set had been used. Also, because of the
small sample size, we were unable to investigate the potential differences in the MIDAS factor structure
as a function of skin picking severity. Thus, it remains possible that the factor structure of the MIDAS
may be different in individuals with varying levels of severity.
Future research should aim to address these limitations and conduct a confirmatory factor analysis
with the MIDAS to replicate its factor structure with larger samples. Future research should also
attempt to validate the subscales of the MIDAS in a clinically identified sample of individuals who
engage in CSP. In addition, a similar measure designed to assess CSP in children should be developed.
Although similar dimensions of pulling have been found in children (Flessner et al., 2007) it remains
unclear whether children have similar dimensions of skin picking. Finally, as discussed earlier,
researchers should begin to determine if the MIDAS can be useful in guiding treatment selection.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, fourth edition, text revision.
Washington, DC: American Psychiatric Association.
Arnold, L. M., Auchenbach, 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.
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.
Azrin, N. H., & Nunn, R. G. (1973). Habit reversal: a method of eliminating nervous habits and tics. Behaviour Research and
Therapy, 11, 619–628.
Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: psychometric properties.
Journal of Consulting and Clinical Psychology, 56, 893–897.
Beck, A. T., Steer, R. A., & Garbin, M. G. (1988). Psychometric properties of the Beck Depression Inventory: twenty-five years of
evaluation. Clinical Psychology Review, 8, 77–100.
Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General
Psychiatry, 4, 561–571.
Christenson, G. A., & Mackenzie, T. B. (1994). Trichotillomania. In M. Hersen, & R. T. Ammerman (Eds.), Handbook of prescriptive
treatment for adults (pp. 217–235). New York, NY: Plenum Press.
Diefenbach, G. J., Mouton-Odum, S., & Stanley, M. A. (2002). Affective correlates of trichotillomania. Behaviour Research and
Therapy, 40, 1305–1315.
Flessner, C. A., Busch, D., Heideman, P., & Woods, D. W. Acceptance-enhanced behavior therapy: exploring components of
sequencing. Behavior Modification, in press.
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.
Flessner, C. A., Woods, D. W., Franklin, M. E., Cashin, S. E., & Keuthen, N. J. (2008). The Milwaukee Inventory for Subtypes of
Trichotillomania (MIST-A): development of an instrument for the assessment of ‘‘focused’’ and ‘‘automatic’’ hair pulling.
Journal of Psychopathology and Behavioral Assessment, 30, 20–30.
Flessner, C. A., Woods, D. W., Franklin, M. E., Keuthen, N. J., Piacentini, J., Cashin, S. E., et al. (2007). The Milwaukee Inventory for
Styles of Trichotillomania-Child Version (MIST-C): initial development and psychometric properties. Behavior Modification,
31, 896–918.
Franklin, M. F., Tolin, D. F., & Diefenbach, G. J. (2006). Trichotillomania. In E. Hollander, & D. J. Stein (Eds.), Clinical manual of
impulse control disorders (pp. 149–173). Washington, DC: American Psychiatric Publishing, Inc.
Gosling, S. D., Vazire, S., Srivastava, S., & John, O. P. (2004). Should we trust web-based studies? A comparative analysis of six
preconceptions about internet questionnaires. American Psychologist, 59, 93–104.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior
change. New York, NY: Guilford Press.
Hayes, S. C., Strosahl, K. D., Wilson, K. G., Bissett, R. T., PistorelloToarmino, J., et al. (2004). Measuring experiential avoidance:
a preliminary test of a working model. The Psychological Record, 4, 553–578.
Keuthen, N. J., Deckersbach, T., Wilhelm, S., Engelhard, I., Forker, A., O’Sullivan, R. L., et al. (2001). The Skin Picking Impact Scale
(SPIS): scale development and psychometric analyses. Psychosomatics, 42, 397–403.
Keuthen, N. J., Deckersbach, T., Wilhelm, S., Hale, E., Fraim, C., Baer, L., et al. (2000). Repetitive skin-picking in a student pop-
ulation and comparison with a sample of self-injurious skin-pickers. Psychosomatics, 41, 210–215.
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.
 M.R. Walther et al. / J. Behav. Ther. & Exp. Psychiat. 40 (2009) 127–135 135

Keuthen, N. J., Wilhelm, S., Deckersbach, T., Engelhard, I. M., Forker, A. E., Baer, L., et al. (2001). The skin picking scale: scale
construction and psychometric analysis. Journal of Psychosomatic Research, 50, 337–341.
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: The Guilford Press.
Lochner, C., Simeon, D., Niehaus, D. J. H., & Stein, D. J. (2002). Trichotillomania and skin-picking: a phenomenological
comparison. Depression and Anxiety, 15, 83–86.
Nunnally, J. C., & Bernstein, I. H. (1994). Psychometric theory (3rd ed.). New York: McGraw-Hill.
Russell, D. W. (2002). In search of underlying dimensions: the use (and abuse) of factor analysis in Personality and Social
Psychology Bulletin. Personality and Social Psychology Bulletin, 28, 1629–1646.
Stein, D. J., Hutt, C. S., Spitz, J. L., & Hollander, E. (1993). Compulsive picking and obsessive-compulsive disorder. Psychosomatics,
34, 177–181.
Stevens, J. P. (2002). Applied multivariate statistics for the social sciences (4th ed.). Hillsdale, NJ: Erlbaum.
Tabachnick, B. G., & Fidell, L. S. (2001). Using multivariate statistics (4th ed.). Boston, MA: Allyn and Bacon.
du Toit, P. L., van Kradenburg, J., Niehaus, D. J. H., & Stein, D. J. (2001). Characteristics and phenomenology of hair-pulling: an
exploration of subtypes. Comprehensive Psychiatry, 42, 247–256.
Wetterneck, C. T., Woods, D. W., Norberg, M. M., & Begotka, A. M. (2006). The social and economic impact of trichotillomania:
results from two nonreferred samples. Behavioral Interventions, 21, 97–109.
Wilhelm, S., Keuthen, N. J., Deckersbach, T., Engelhard, I. M., Forker, A. E., Baer, L., et al. (1999). Self-injurious skin picking:
clinical characteristics and comorbidity. Journal of Clinical Psychiatry, 60, 454–459.
Woods, D. W., Flessner, C. A., Franklin, M. E., Keuthen, N. J., Stein, D., Goodwinn, R. G., et al. (2007). Trichotillomania Impact
Project (TIP): exploring the functional impact of Trichotillomania and its treatment in adults. Journal of Clinical Psychiatry,
67, 1877–1888.
Woods, D. W., Wetterneck, C. T., & Flessner, C. A. (2006). A controlled evaluation of acceptance and commitment therapy plus
habit reversal for Trichotillomania. Behaviour Research and Therapy, 44, 639–656.