more than bad habits focused... · trichotillomania (hair-pulling) ... skin picking disorder ......
TRANSCRIPT
More Than Bad Habits:Treatment of Trichotillomania and
Body Focused Repetitive Behavior Disorders (BFRB’s)
Francine Rosenberg, Psy.D.
Morris Psychological Group, PA
50 Cherry Hill Road, Suite 305
Parsippany, N.J. 07054
(973) 257-9000 x207
Disclosure
I have no conflicts of interest to disclose.
Types of BFRB’s
◼ Trichotillomania (hair-pulling)
◼ Excoriation Disorder (skin picking)
◼ Cheek or Lip Biting
◼ Nail Biting
Prevalence for Hair Pulling and Skin Picking about
1-2% (DSM5, 2013)
Trichotillomania Impact Project (Woods et al,
2006) 1697 individuals completed an online
survey with self-reported Trich. (TIP Project)
Assessed phenomenological experiences, impact
of TTM and treatment-seeking experiences.
◼ 46% reported having never been diagnoses
◼ Of those who sought tx: 42% received medication,
31% had behavior therapy, 44% other types of
psychotherapy
Diversity
◼ Rates of hair pulling does not appear to differ
significantly among genders or ethnic backgrounds.
◼ African American women were more likely to report
pulling in response to skin irritation.
(McCarly et al, 2002)
◼ Anxiety symptoms appear to be more highly correlated
with trich than cultural messages about hair in African
American women (Neal-Barnett et al, 2011)
Habit Reversal Training
◼ Developed by Azrin and Nunn (1973)
◼ Has the most empirical support
◼ Original study 1973 included a variety of habits, tics,
thumb suckers….et. 12 subjects. 90% Habit
Reduction
◼ Azrin did two follow up studies of HRT
◼ 1980 – 34 subjects, 91% Habit reduction at 4 months,
87% habit reduction at 22 montths
◼ 1990 Tourette’s 10 subjects, 93% tic reduction
Habit Reversal Training cont’d
◼ HRT is the most studied; other researchers
includ control groups
◼ Targets motoric behaviors
◼ Theory is that the behavior reduces tension,
which is reinforcing
◼ The hair puller lacks awareness of their
actions
Steps in HRT
Awareness Training
Competing Response Training
Motivation Training
Generalization Training
Step 1: Awareness
◼Do they feel an urge or tingling?
◼Awareness essential for intervention
◼Record via index card or log: every
day for the first two weeks then
decreasing.
Awareness Training continued
◼ Look in the mirror and perform the habit
intentionally.
◼ Have a family member notify the person when
he/she engages in the target behavior.
◼ Notify the family member when engaging in the
target behavior.
Relaxation Training
◼ Not listed as one of the crucial four steps, but
Azrin noted that a brief relaxation component
can be helpful.
◼ Diaphragmatic Breathing
◼ Progressive Muscle Relaxation
Step 2: Competing Response Training
◼ Behavior that is incompatible with the target
behavior
◼ Intended to be very discrete
◼ Able to be used in a variety of situations
◼ Clenching fists by side until feeling tension in
arms and hands
◼ To be performed either before or after the habit
Step 3: Motivation Training
◼ Review in detail the inconvenience,
embarrassment and suffering that results from
the habit.
◼ Family and friends encouraged to comment
favorably when not doing the habit.
◼ Children – reward system
◼ Reminder to practice HRT when engaging in the
habit.
Step 4: Generalization Training
◼ Discuss in session the different types of habit-
eliciting situations
◼ Practice performing the competing response for
several minutes in session.
◼ Use imagery to rehearse the skills in a variety of
settings
Comprehensive Model for
Behavioral Treatment (ComB)Mansueto et al (1999)
◼ If HRT works, why another approach?
◼ Not comprehensive enough
◼ Only addresses the motoric aspect of the habit
◼ Other factors not adequately addressed
PHASE 1: ASSESSMENT AND FUNCTIONAL
ANALYSIS
PHASE 2: IDENTIFY AND TARGET MODALITIES
PHASE 3: IDENTIFY AND IMPLEMENT
STRATEGIES
PHASE 4: EVALUATION AND MODIFICATION
PHASE 1: ASSESSMENT AND
FUNCTIONAL ANALYSIS
◼ Identification of functional components
◼ Begin self-monitoring
◼ A-B-C model
◼ Antecedents
◼ Behaviors
◼ Consequences
SCAMP Model◼ Sensory: internal experiences, itchy, tingly
◼Cognitive: thoughts, beliefs, “I need to pull this
coarse hair”
◼Affective: anxiety, depression, boredom, fatigue
◼Motoric vs Awareness: discern level of
awareness of the habit
◼Places: locations, times, associated activities
(watching tv, lying bed, sitting in class,
grooming); use tools like a tweezer alone or in
front of others?
Hair Pulling Log
Date Time Location/
Activity
Strength
of Urge
(1-10)
Notable
Thoughts
Notable
Feelings/
Sensations
# of Hairs
Pulled/ Site
(scalp, lashes
….etc)*
*For other BFRB’s change the last column to Behavior (picked skin, bit lip…etc)
PHASE 2: IDENTIFY AND
TARGET MODALITIES
◼ Identification of potential modalities to be
targeted (SCAMP) and train the patient in using
them.
◼ Sensory: scratch the sensory itch
◼ Stress ball, silly putty
◼ Pick dried glue off
◼ Sequin pillow
Phase 2 cont’d
◼ Cognitive
◼ Identify cognitive distortions
◼ Cognitive restructuring
◼ Affective:
◼ Relaxation Training
◼ Exposures for feared situations
◼ Sleep issues
Phase 2 cont’d
◼ Motoric Modality
◼ Avoid sitting in certain positions
◼ Competing Response
◼ Environmental
◼ Disrupt the chain of events
◼ Barriers to picking and pulling
Phase 3: Implement Strategies
◼ Instruct the patient in using the strategies
◼ Identify the strategies most likely to be used
◼ Instruct them to practice for at least a week
before making any judgements
PHASE 4: EVALUATION AND
MODIFICATION
◼ Evaluate the effectiveness of the strategies
employed
◼ Further refinements
◼ Maintaining some of the selected interventions
◼ Modify interventions before replacing them
◼ Include others that had been previously discussed
Is Comb empirically supported?
◼ Not tested in its entirety. Small uncontrolled
study by Falkenstein et al (2016) created a
manual and a therapist adherence measure.
Results demonstrated efficacy. Will be used for
future randomized controlled studies.
◼ Expected to be successful, because it’s just
taking HRT and expanding it to be more
comprehensive
Other Treatment Options
◼ Medication:
◼ No medications are FDA approved for BFRB’s
◼ Most Commonly Used
◼ SSRI’s: can be helpful sometimes
◼ SNRI’s: can increase pulling in some people
◼ Clomipramine (Tricyclic)- good drug, several side effects
◼ Lithium has been used for impulsivity
◼ Naltrexone is showing some early success, needs more
study (commonly used to treat addiction).
◼ Riluzole works on glutamate some early promise (typically
used to treat ALS/Lou Gehrig’s Disease).
Other Treatment Options cont’d
◼ Schumer et al (2016) Systematic Review of
Pharmacological and Behavioral Treatments for
Skin Picking Disorder
◼ Meta-analysis of 11 studies revealed no evidence that
SSRI’s were superior to placebo.
◼ Only behavioral interventions demonstated
significant benefits compared with inactive control
groups.
Other Treatment Options
◼ Inositol: considered a B vitamin
◼ N-Acetylcysteine (NAC): a neutraceutical that
modulates the amino acid glutamate in the body
or brain. Some uncontrolled studies to support
it’s effectiveness in treating BRFB’s. Lochner et
al (2017)
Other Treatment Options cont’d
◼ Research is inconsisent; some demonstrate
effectiveness, some don’t.
◼ CBT/HRT demonstrated better than medication
in a number of studies Schumer et al (2016)
◼ Conclusion: if even medication is effective,
some form of CBT is necessary for lasting
results.
References
Azrin N.H & Nunn R.G. (1973). Habit –reversal: A method of eliminating nervous habits
and tics. Behaviour Research and Therapy. Volume 11, Issue 4, pp 619-628.
Falkenstein, M. J., Mouton-Odum, S., Mansueto, C. S., Golomb, R. G., & Haaga, D. A. F.
(2016). Comprehensive behavioral treatment of trichotillomania: A treatment development
study. Behavior Modification, 40(3), 414-438.
Lochner, C., Roos, A., & Stein, D. J. (2017). Excoriation (skin-picking) disorder: A
systematic review of treatment options., 13 Article ID 1867-1872. Neuropsychiatric
Disease and Treatment
McCarly N.G, Spirrison CL & Ceminsky JL. (2002) Journal of Psychopathology and
Behavioral Assessment September 2002, Volume 24, pp 139–144.
References cont’d
Mansueto C, Golumb R, Thomas A & Stemberger R (1999). A Comprehensive Model for
Behavioral Treatment of Trichotillomania (ComB) Cognitive and Behavioral Practice, 6,
23-43.
Neal-Barnett A, Statom D., & Stadulis R. (2011). Trichotillomania Symptoms in African
American Women: Are they Related to Anxiety and Culture? CNS Neuroscience &
Therapeutics, 17(4):207-13.
Schumer, M. C., Bartley, C. A., & Bloch, M. H. (2016). Systematic review of
pharmacological and behavioral treatments for skin picking disorder. Journal of Clinical
Psychopharmacology, 36(2), 147-152.
Woods DW, Flessner CA, Franklin ME, Keuthen NJ, Goodwin RD, Stein DJ & Walther
MR. (2006). The Trichotillomania Impact Project (TIP): exploring phenomenology,
functional impairment, and treatment utilization. Journal of Clinical Psychiatry, 67(12):
1877-88.
Resources
The TLC Foundation for BFRB’s
www.bfrb.org
International Obsessive Compulsive Foundation
www.iocdf.org