MEDICINA CLÍNICA Y SOCIAL

Med. clín. soc. 2021;5(2):59-64. e-ISSN: 2521-2281 ORIGINAL

MAYO-AGOSTO. https://doi.org/10.52379/mcs.v5i2.199

The Spanish version of the Skin Picking Impact Scale (SPIS)

and its Short form (SPIS-S)
La versión en español de la Skin Picking Impact Scale (SPIS) y de su forma
abreviada (SPIS-S)
Iván Barrios 1,2, Mohammad Jafferany 3, Noelia Ruiz Díaz 1, Oscar García1, José Almirón-Santacruz 1, Marcelo
O’Higgins 1; Pamela Figueredo 1, Diego Amarilla 1, René Rojas 1, Hernando Báez 4, Rodrigo Navarro 1,
João Mauricio Castaldelli-Maia 5,6, Antonio Ventriglio 7, Jorge Villalba-Arias 1,8, Julio Torales 1,9,10
1Universidad Nacional de Asunción, Facultad de Ciencias Médicas, Cátedra de Psiquiatría, San Lorenzo, Paraguay.
2Universidad Nacional de Asunción, Facultad de Ciencias Médicas, Cátedra de Bioestadística, Santa Rosa del Aguaray, Paraguay.
3Central Michigan University, Department of Psychiatry, Mount Pleasant, Michigan, United States of America.
4Universidad Nacional de Asunción, Facultad de Ciencias Médicas, Cátedra de Pediatría, San Lorenzo, Paraguay.
5Fundação do ABC, Department of Neuroscience, Santo André, SP, Brazil.
6University of São Paulo, Department of Psychiatry, São Paulo, SP, Brazil.
7University of Foggia, Department of Clinical and Experimental Medicine, Foggia, Italy.
8Universidad Nacional de Asunción, Facultad de Ciencias Médicas, Cátedra de Psiquiatría, Santa Rosa del Aguaray, Paraguay.
9Universidad Nacional de Asunción, Facultad de Ciencias Médicas, Cátedra de Psicología Médica, San Lorenzo, Paraguay.
10Universidad Nacional de Asunción, Facultad de Ciencias Médicas, Cátedra de Socioantropología, Santa Rosa del Aguaray, Paraguay.

ABSTRACT
Introduction: The Skin Picking Impact Scale (SPIS) is a self-report rating scale that assess the psychosocial
impact of excoriation disorder. In this study the SPIS was translated into Spanish and its reliability was
measured. Similarly, its short version (SPIS-S) has been translated and tested. Methodology: The recruitment
has been performed through a survey launched on social media. All subjects were older than18 years and
Received: 21/03/2021
self-reported being diagnosed with an excoriation disorder. 281 individuals were rated for the validation
Revised: 09/04/2021
analysis. SPIS has been translated into Spanish and validated through an exploratory and confirmatory
Accepted: 19/04/2021
factorial analysis. Participants have been also scored with the Skin Picking Scale-Revised (SPS-R). Results: On
factor at the exploratory factorial analysis has a raw eigenvalue greater than 1, with 65.5% of total variance.
Corresponding author
The confirmatory analysis confirmed that the scale is one-dimensional. Cronbach’s alpha also confirmed a
good internal consistency (α=0.934 for the SPIS and α=0.882 for the SPIS-S). Scores between the two scales
Julio Torales
(SPIS and the SPS-R) have shown a good convergence (r=0.592, p<0.0001). Conclusion: The Spanish version
Universidad Nacional de Asunción
of SPIS and its short version show good psychometric properties and adequately reproduce the one-
San Lorenzo – Paraguay
dimensional model of the original English version.
[email protected] Keywords: Excoriation disorder; Validity; Reliability; Factor analysis.
Conflicts of interests

The authors declare that there is RESUMEN

no conflict of interest.
Introducción: la Skin Picking Impact Scale (SPIS) es una escala autoaplicada de que evalúa el impacto
Funding psicosocial del trastorno de excoriación. En este estudio se tradujo la SPIS al español y se midió su
confiabilidad. Asimismo, se tradujo y se evalúo su versión corta (SPIS-S). Metodología: el reclutamiento se
The authors received no financial realizó a través de una encuesta distribuida a través de redes sociales. Todos los sujetos participantes fueron
support for the research, mayores de 18 años e informaron haber sido diagnosticados con trastorno de excoriación. 281 individuos
authorship, and/or publication of calificaron para el análisis de validación. La SPIS fue traducida al español y validada a través de análisis
this article. factorial exploratorio y análisis factorial confirmatorio. Los participantes también fueron evaluados con la
versión revisada de la Skin Picking Scale – Revised (SPS-R). Resultados: en el análisis factorial exploratorio,
This article is published under un valor tenía un valor propio bruto mayor que 1, con 65,5 % de la varianza total. El análisis confirmatorio
Creative Commons Attribution 4.0 determinó que la escala es unidimensional. El alfa de Cronbach también confirmó una buena consistencia
International License. interna (α = 0,934 para la SPIS y α = 0,882 para la SPIS-S). Las puntuaciones entre las dos escalas (SPIS y SPS-
R) mostraron una buena convergencia (r = 0,592, p <0,0001). Conclusión: la versión en español de la SPIS y
de su versión abreviada muestran buenas propiedades psicométricas y reproducen adecuadamente el
modelo unidimensional de la versión original en inglés.
Palabras clave: Trastorno de excoriación; Validez; Fiabilidad; Análisis factorial

How to cite this article: Barrios I, Jafferany M, Ruíz-Díaz N, García O, Almirón-Santacruz J, O'Higgins M, et al. The Spanish version of the Skin
Picking Impact Scale (SPIS) and its Short form (SPIS-S). Med. clín. soc. 2021;5(2):59-64
 The Spanish version of the Skin Picking Impact Scale (SPIS) and its Short form (SPIS-S)

INTRODUCTION METHODOLOGY
Excoriation disorder (ED) is also well-known as Participants
compulsive skin-picking, pathological skin-picking,
Participants were recruited through an Internet-based
psychogenic excoriation, or dermatillomania (1–3).
survey, spread through social media, during December
This condition is characterized by a recurrent picking of
2020. All participants received complete information
skin, leading to skin lesions and significant distress or
about the aim of the study, privacy and data-
functional impairment (3,4). Affected patients may
processing. No payment has been foreseen for
show typical injuries, or report bleeding and pain after
completing the survey. Subjects were older than18
picking their skin (3). Even though the patient is aware
years and self-reported being diagnosed with an
of the self-destructiveness of this behavior, he/she
excoriation disorder, according to the criteria of the
shows poor control about it (5), despite having made
American Psychiatric Association, and accepted to
repeated attempts to decrease or interrupt it.
participate in the study.
ED is also associated with relevant impairment in the
The sample size was calculated using the Epidat
occupational, social and personal functioning.
epidemiological package. Assuming an expected ED
Symptoms cannot be better explained by the presence
frequency of 5% (15), a confidence level of 95%, and a
of another mental disorder, medical condition or
precision of 2.6%, the minimum sample was
substance use (6). The repetitive behavior may be
established in 270 participants. Finally, 637 subjects
carried out with nails or instruments (tweezers,
were surveyed. Of them, 281 subjects were selected as
needles, among others) and causes tissue damage,
reporting current symptoms of ED.
cellulite, deforming scars, in addition to significant
aesthetic and emotional distress (7). Current symptoms were detected as the presence of
positive answers to the following two questions: a) At
ED was considered as an impulse control disorder (8),
present, do you perform recurrent skin picking, that
although, according to the fifth edition of the
causes tissue damage, bleeding, or pain? And, b) Do
Diagnostic and Statistical Manual of Mental Disorders
you experience discomfort or impairment resulting
of the American Psychiatric Association (DSM 5), it is
from this behavior? The Internet-based survey
currently included in the obsessive-compulsive
approach was used taking into account that there is
disorder and other related disorders section (6).
supporting evidence that responses to online surveys
The assessment of ED is based on clinician- may provide similar findings to those reported through
administered and self-report rating scales. Self- “in person” samples (16).
administered scales reported a high psychometric
In this research, all measures, conditions, data
validity (9,10). Skin Picking Scale (SPS) and Skin Picking
exclusions, and procedure for the determination of the
Impact Scale (SPIS) are self-administered scales for ED,
sample size, to the best of our knowledge, have been
and measure its clinical severity and related
reported.
psychosocial impact, respectively (10,11). Nonetheless,
both of them are not validated in Spanish. In this study Measures
the Skin Picking Impact Scale (SPIS) and its short The Skin Picking Impact Scale (SPIS)
version (SPIS-S) have been translated into Spanish and
their reliability have been measured. The SPIS is a self-administered rating scale that
assesses the severity of ED in terms of psychosocial
The assessment of ED is based on clinician- impact. The scale is composed of 10 items. Each item
administered and self-report rating scales (9,10,12). reports a score ranging from 0 to 5, with a total score
Among the clinician-administered rating scales, the ranging from 0 to 50 points. A score of 7 has been
Yale-Brown Obsessive-Compulsive Scale modified for determined as the cut-off point from which the
neurotic excoriation and the Skin Picking Treatment existence of a significant psychosocial impact is
Scale are available (13). Skin Picking Scale (SPS) and considered (10). The SPIS-S includes questions 2, 5, 6
Skin Picking Impact Scale (SPIS) are self-administered and 7 of the original version, with the same scores as
scales for ED, measuring the clinical severity of the the extended version and good psychometric
disorder and the psychosocial impact of it, respectively properties (17).
(12,14). Self-administered scales report a high
psychometric validity (13). It is noteworthy that a The SPIS has demonstrated good internal consistency
correct assessment of ED patients may lead to tailored in previous research (α = 0.93) (15). Cronbach's alpha
therapeutic options. for the current sample is described in the results
section of the present study.
Med. clín. soc. 2021;5(2):59-64 60
 The Spanish version of the Skin Picking Impact Scale (SPIS) and its Short form (SPIS-S)

The Skin Picking Scale-Revised (SPS-R) Translation process and validation

The SPS-R is a revised version of the Skin Picking Scale The translation process was divided in three phases: (a)
(SPS). It is self-administered and assesses the severity the original English version (v1) was translated into
of ED in the 7 days prior to the evaluation. The scale is Spanish (v2); (b) a bilingual expert translated back the
composed of 8 items. Each item gets a score ranging Spanish version (v2) into English (v3); (c) finally, a
from 0 to 4, with a total score ranging from 0 to 32 native English speaker compared, sentence by
points. SPS-R explores two dimensions: (a) severity of sentence, the new translation (v3) with the original
symptoms (frequency and intensity of the urge to pick, English version (v1), in order to verify if they were
time spent picking, and ability to control it); and, (b) the equivalent in meaning. Some changes or
impairment due to skin picking (emotional distress, improvements were made after the comparison was
social avoidance, and skin damage due to skin picking) made and the Spanish version was administered to 20
(9,14). In this study, the Spanish version of the SPS-R individuals, as a pilot test, in order to verify if the
was used, which has demonstrated good validity and questionnaire was understandable. After the pilot test,
internal consistency (α = 0.884; 0.889) in previous the final Spanish version was obtained (Table 1).
samples (12,18). Cronbach's alpha for the current
sample is described in the results section of the present
study.
TABLE 1. THE SPANISH VERSION OF THE SPIS.

1. No miro a los ojos a las personas a causa de mi rascado

(I don’t look people in the eye because of my skin picking)

2. Creo que mi vida social podría ser mejor si no rascase mi piel

(I think my social life would be better if I didn’t pick my skin)

3. Odio la forma en la que me veo a causa de mi rascado

(I hate the way I look because of my skin picking)

4. Me toma más tiempo salir a causa de mi rascado

(It takes me longer to go out because of my skin picking)

5. Me siento avergonzado a causa de mi rascado

(I feel embarrassed because of my skin picking)

6. Hay algunas cosas que no puedo hacer por mi rascado

(There are some things I can’t do because of my skin picking)

7. No me siento atractivo a causa de mi rascado

(I feel unattractive because of my skin picking)

8. Me toma más tiempo que a otros estar listo por las mañanas a causa de mi rascado
(It takes me longer than others to get ready in the morning because of my skin picking)

9. No me gusta que la gente me mire a causa de mi rascado

(I don’t like people looking at me because of my skin picking)

10. Mis relaciones han sufrido a causa de mi rascado

(My relationships have suffered because of my skin picking)

Statistical analysis with the afore-mentioned software and confirmatory

factorial analysis was performed with JASP statistical
To test the construct validity, the pertinence of
software (version 0.10.2.0). Exploratory factorial
performing an exploratory factor analysis was
analysis aimed to obtain the factorial structure, to be
preliminary assessed using the Kaiser-Meyer-Olkin
confirmed with confirmatory analysis. Exploratory
(KMO; SPSS software - version 23) test for sample
factorial analysis was made using principal axis
adequacy and the Bartlett's Test of Sphericity. The
factoring with promax rotation, with a kappa value of
sample was randomly divided into two subsamples, in
4. Confirmatory analysis was made through diagonally
which exploratory factorial analysis was performed

Med. clín. soc. 2021;5(2):59-64 61

 The Spanish version of the Skin Picking Impact Scale (SPIS) and its Short form (SPIS-S)

weighted least squares (DWLS) estimation procedure, treated with confidentiality, equality, and justice,
taking into consideration the sample size. respecting the Helsinki principles. Participants who
required a feedback from the survey were invited to
Chi square test was performed, and the following fit
write down their email address and received
indices were used to assess the model: CFI, NFI, and
information or specific helpful suggestions.
RMSEA. For the validity of model, CFI and NFI values
had to be at least 0.90 and RMSEA value below 0.05 RESULTS
(19).
Kaiser-Meyer-Olkin (KMO) test was adequate
Reliability was measured with Cronbach’s alpha. Alpha (KMO=0.919) and sphericity tested significantly
values are described as excellent (0.93–0.94), strong (p<0,0001). These results confirmed that the sample
(0.91–0.93), reliable (0.84–0.90), robust (0.81), fairly was adequate for a factorial analysis. Secondly, the
high (0.76–0.95), high (0.73–0.95), good (0.71–0.91), sample was randomly divided into two subsamples
relatively high (0.70–0.77), slightly low (0.68), (subsample 1, n=142; subsample 2, n=139), in order to
reasonable (0.67–0.87), adequate (0.64–0.85), perform exploratory and confirmatory factorial
moderate (0.61–0.65), satisfactory (0.58–0.97), analysis.
acceptable (0.45–0.98), sufficient (0.45–0.96), not
Factorial analysis
satisfactory (0.4–0.55), and low (0.11) (20). Convergent
validity was measured between the scores of the SPIS Since only the first factor had a raw eigenvalue greater
and the SPS-R. than the parallel random values, thus one factor was
retained. Before extraction, this factor explained 65.5%
Ethical considerations
of total variance. After extraction, this factor explained
The study was approved by the Department of 62.3% of total variance. Communality values were
Psychiatry of the National University of Asunción, acceptable, except for item 1 (Table 2).
School of Medical Sciences (Paraguay). Data were

TABLE 2. RESULTS FROM THE EXPLORATORY FACTOR ANALYSIS WITH PROMAX ROTATION ON THE SPANISH
VERSION OF THE SPIS.

Items Communality
1.No miro a los ojos a las personas a causa de mi rascado 0.114
(I don’t look people in the eye because of my skin picking)
2. Creo que mi vida social podría ser mejor si no rascase mi piel 0.546
(I think my social life would be better if I didn’t pick my skin)
3. Odio la forma en la que me veo a causa de mi rascado 0.656
(I hate the way I look because of my skin picking)
4. Me toma más tiempo salir a causa de mi rascado 0.716
(It takes me longer to go out because of my skin picking)
5. Me siento avergonzado a causa de mi rascado 0.824
(I feel embarrassed because of my skin picking)
6. Hay algunas cosas que no puedo hacer por mi rascado 0.715
(There are some things I can’t do because of my skin picking)
7. No me siento atractivo a causa de mi rascado 0.754
(I feel unattractive because of my skin picking)
8. Me toma más tiempo que a otros estar listo por las mañanas a causa de mi rascado 0.712
(It takes me longer than others to get ready in the morning because of my skin picking)
9. No me gusta que la gente me mire a causa de mi rascado 0.644
(I don’t like people looking at me because of my skin picking)
10. Mis relaciones han sufrido a causa de mi rascado 0.548
(My relationships have suffered because of my skin picking)

The one-factor model, as found in the exploratory reproduce the same one-dimensionality found in the
factorial analysis performed on subsample 1, was original English version of the scale.
assessed with confirmatory factorial analysis in
Internal consistency and correlation between factors
subsample 2. The model adjustment was valid,
according to all fit indices (S-B 2=978.119, df=45, For the SPIS, Cronbach’s alpha showed a valid internal
p>0,05; RMSEA=0; CFI=1, NFI= 0.986). This may confirm consistency (α=0.934). It is of note that the deletion of
that the model of the Spanish version of SPIS can the first item of the scale would rise Cronbach's alpha
Med. clín. soc. 2021;5(2):59-64 62
 The Spanish version of the Skin Picking Impact Scale (SPIS) and its Short form (SPIS-S)

to α=0.941. SPIS-S Cronbach’s alpha showed a valid reported. The same applies for the short version of the
internal consistency too (α=0.882). SPIS’s mean score scale (10,17).
and standard deviation were 11.5±12.4.
Finally, good convergence was found between the
For the SPS-R, Cronbach’s alpha showed a valid internal scores of the SPIS and the SPS-R, which indicates a
consistency too (α=0.889), the average score of the direct and strong relationship between both scales and
scale was 1.083, with a standard deviation of 0.907. a good validity of the Spanish version of the SPIS. These
The average correlation between items was 0.505. results are consistent with the existing literature
Scores between the two scales (SPIS and the SPS-R) (15,24).
have shown a good convergence (r = 0.592, p <0.0001),
Limitations of this research may include the lack of data
which indicates a direct and strong relationship
in order to determine if there were any other
between both scales and a good validity of the Spanish
difference in sociodemographic factors (e.g., race,
version of the SPIS.
ethnicity, education level, employment, etc.) or clinical
DISCUSSION characteristics (e.g., comorbidity, urge to pick skin,
etc.) that might be present between the included
Three elements are invariably observed in patients
participants and the excluded subjects. Furthermore,
with ED (3,21): a) Recurrent skin picking, that causes
the scope of this article could have been greater if
tissue damage, bleeding, or pain; b) Significant
additional data had been available (e.g., information on
discomfort or impairment resulting from skin picking;
discriminant association with other obsessive-
and, c) The behavior is not due to other medical or
compulsive related disorders or emotional disorders).
psychiatric illnesses or substance use (e.g., body
Another limitation may include the fact that we
dysmorphic disorder, amphetamine use,
completely relied on self-report measures in order to
dermatological diseases, respectively).
include/exclude participants. Finally, test-retest
The self-inflicted nature of skin lesions and the lack of reliability was not calculated, since contact information
delusions and/or hallucinations differentiate ED from of recruited subjects were not collected for a second
other psychiatric conditions (such as delusional assessment.
infestation) or dermatological diseases (such as
A strength point of this research is the measurement of
dermatitis artefacta), which may lead to skin damage
psychometric properties of the Spanish version of SPIS:
or mutilation (3).
this might suggest a valuable assessment tool for
Skin picking is characterized by acute episodes with Spanish-speaking patients affected by ED. In fact, if not
skin scratching, "digging" and damaging (22). The correctly assessed, diagnosed and successfully treated,
behavior may cause clinically significant injuries with ED may evolve into a chronic form with severe
preceding psychosocial stress in up to 90% of patients psychosocial impairment and serious medical
(22). Skin picking can be also ritualized, often at complications. Clinicians would need an assessment
bedtime, and patients may feel unhappy and guilty for instrument for ED (such as SPIS, possibly standardized
the disfigurement caused. according to the international guidelines). Also,
therapeutic approaches should address the control of
These negative feelings increase progressively as the
this repetitive behavior (picking), in order to improve
skin picking continues (4). Stress, sadness, anger,
patients’ quality of life in the long-term (25).
anxiety, or specific situations like talking on the phone,
being in bed, reading, or watching television can Finally, we believe that the assessment of ED patients
facilitate skin picking episodes (23). is useful to tailor therapeutic options on the base of
patients’ needs. It is also recommended that,
Our results show that the Spanish version of SPIS
whenever possible, patients are assessed with more
reports acceptable psychometric properties and
tools, in order to guarantee an integral assessment
validity in terms of reliability and internal consistency.
over all stages of illness (13,18).
As in the original English version (14), in the Spanish
version one well defined factor was found, with good AUTHORS CONTRIBUTION
factorial weights.
IB: Conceptualization, Methodology, Formal analysis,
Regarding the confirmation analysis, all indices give Writing-original draft. MJ: Conceptualization,
acceptable values that confirm the model, which Methodology, Formal analysis, Writing-original draft.
implies that the scale fully reproduces the original NRD: Methodology, Writing-original draft. OG:
model of the authors. Internal consistency was correct Methodology, Writing-original draft. JAS:
and concordant with what the original authors Methodology, Writing-original draft. MO:

Med. clín. soc. 2021;5(2):59-64 63

 The Spanish version of the Skin Picking Impact Scale (SPIS) and its Short form (SPIS-S)

Methodology, Writing-original draft. PF: Methodology, https://dx.doi.org/10.1016/j.jocrd.2020.100586

13. Keuthen N, Siev J, Reese H. Assessment of
Writing-original draft. DA: Methodology, Writing- trichotillomania, pathological skin picking, and stereotypic
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RN: Methodology, Writing-original draft. JMCM: N, editors. Trichotillomania Skin Pick. Body-Focus.
Writing-Review & Editing, Validation. AV: Writing- Repetitive Behav., Washington, D.C.: American Psychiatric
Publishing; 2012, p. 129–50.
Review & Editing, Validation. JVA: Methodology,
14. Snorrason I, Ólafsson RP, Flessner CA, Keuthen NJ,
Writing-original draft. JT: Conceptualization, Franklin ME, Woods DW. The Skin Picking Scale-Revised:
Methodology, Formal analysis, Writing-original draft, Factor structure and psychometric properties. J Obsessive-
Supervision. Compuls Relat Disord.2012;1(2):133–7.
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