CA%
HISTORIES
AND SHORTER
217
COMMUNICATIONS
BehavRes & Therap). 0
Pcrgamon
1978. Vol. 16. pp, 217-220. Press. Ltd. Printed m Great Bwam
Multi-coqunent
behavioral treatment of trichotilbmania: A case study
(Receiued
29 September
1977)
Summary-A 21-year-old female with a 13.year history of compulsive hair pulling was treated via a multi-component behavioral intervention strategy. Dependent variables included both quasi-direct behavioral frequency counts (i.e., number of hairs pulled) and physical trace, natural erosion measures (i.e. size of bald areas). Results indicated dramatic decrease in number of hairs pulled from treatment through 40 weeks post-initiation of baseline. These findings were discussed with regard to situational-s~~fi~ty of t~chotillomania and reliance upon experimenter-derived rather than subject-controlled data collection sources.
Psychotherapeutic approaches to the treatment of trichotillomania (i.e., chronic hair pulling) have traditionally met with little success and high remission rates (Mannino and Delgado, 1969). Recently, however, behavioral interventions have been more encouraging with regard to results achieved. Successful behavioral techniques have included: interruption of the behavioral sequence of hair pulling (Taylor, 1963). simple response cost (Bayer, 1972), contingency contracting (Stabler and Warren, 1974), posit&e coverants and response cost (McLaughlin and Nay, 1975k covert sensitization (Levine, 1976k token reinforcement and time-out (Evans. 1976). suggestive hypnosis (Horne, 1977) and aversive conditioning (Home, 1977). While collectively these case studies generally support behavioral strategies in the treatment of trichotillomania, there exists a noticeable lack of direct observational measures for the problem behavior. Rather, most investigations have utilized subject recorded (e.g., self-monitored record of hair pulls) or subject-derived behaviorally-based samples (e.g, hair collection). Evans (1976) did employ the mother of an eight-year-old ~i~otillomanic as the observer of her child’s hair pulling within specified time intervals. No reliability data was reported, however, and the actual dependent variable used was simpty the number of tokens earned per week for non-hair pulting. McLaughlin and Nay (1975) attempted to obtain accurate observational data by measuring the length of their subject’s hair. The applicability of this measure is questionable, however, since it is the presence or absence of hair in trichotillomania which seems of prime importance. The purpose of the present case study was therefore to: (a) examine the effectiveness of a multi-component behavioral treatment for chronic hair pulling and (b) employ both self-monitored and more directly observable, independently-based behavioral measures of the target behavior. CASE
HISTORY
Subject
The subject, Mary B., was a 21-year-old married female, employed part-time at a local social service agency. She reported having initiated the trichotillomania at the time of her parent’s divorce 13 years ago. Aside from a one-month interval approximately nine years ago. she had been unable to abstain from performing the problem behavior since its inception. The subject was quite self-conscious of the problem; as a result, she insisted upon wearing head-scarves and refused to visit a beautician for fear of embarrassment. A detailed behavioral analysis indicated that the hair pulling was often preceded by extreme tension and anxiety (e.g., flying in airplanes); more apt to occur in particular situations (e.g., reading watching T.V., etc.) and/or when the subject was completely alone. Moreover, she indicated that hairs were only pulled from three major places on her head (viz., above left ear, right ear, and crest of scalp) and that coarse, hard, darker hairs within those areas were actively sought out and targeted as “hairs to be pulled”. Conditions Buseiine. The subject contracted the senior author by phone and arranged an initial meeting. At this time (prior to the initiation of treatment), she was asked to simply record the number of hairs pulled on a daily basis. Seljlmonitoring (pulls) plus hair collection. At the close of the first week’s session, the subject was told to continue recording the number of hairs pulled. Furthermore, she was instructed to place all hairs pulled in an envelope, returning them to the senior author at weekly intervals throughtout treatment. Relaxation training. Weekly sessions two, three, and four were devoted to relaxation training patterned after Bernstein and Borkovec (1973). Beginning with relaxation of 16, 7, and 4 muscle .,ttroum. . . the subiect > was progressively taught relaxation by recall and relaxation by counting. Cognitive Isensitizotion. Meichenbaum’s (1972) modification of the systematic desensitization procedure was implemented during weeks 5-13. Specifically, a hierarchy was constructed of anxiety-arousing situations which appeared to elicit the subject’s hair pulling behavior. The subject was then instructed to visualize herself becoming anxious and tense within these situations, coping with the anxiety by slow deep breaths paired with cognitive self-instructions. A typical scene was as follows:
“You’re sitting in your favorite chair in the bedroom reading a novel. All of a sudden you notice an urge to reach up and pull your hair. You try to pay no attention to it. As you continue reading the Requests for reprints should be sent to Philip H. Bomstein, Montana, Missoula, Montana 59812, U.S.A.
Department
of Psychology,
University of
218
CASE
HISTORIES
AND
SHORTER
COMMUNICATIONS
urge seems to grow in intensity. becoming harder and harder to combat. As your hand begins to move up toward your head. you grab hold of the situation and say to yourself. ‘Mary. what the hell is wrong with you-you know you can control this-just breathe calmly. count, and relax.“’
Se/Jmoniroring (rot&es) plus goal srrting plus stimulus control. Following cognitive desensitization treatment. the subject and her husband went on an extended vacation for two months. Upon returning. she reported: (a) touching her hair with a higher frequency than desired. and that (b) some minor hair pulling had occurred at the close of the vacation period. As a result. a self-monitoring of touches and stimulus control treatment was instituted during weeks 22-30. The subject was first asked to obtain a baseline frequency of the number of touches per week. A decreasing changing criterion schedule (Hartmann and Hall. 1976) was then established. with “touching goals” sequentially modified from 133 to zero over the nine-week treatment period. Moreover, the subject was informed that when touching began. if relaxation and cognitive self-instruction failed. she was to immediately stop her ongoing activity and move to a “safe” environment [i.e.. someplace (e.g.. kitchen) or activity (e.g., piano playing) where touching was not apt to occur]. Follow-up probe data was collected by having the subject return for brief observation 34 and 40 weeks post-initiation of baseline. Dependent measures The major dependent measures used in the present investigation were: (a) a quasi-direct behavioral frequency measure (i.e., number of hairs pulled), and (b) a physical trace, natural eroston measure (Webb er al.. 1966) (i.e.. size of bald area). Since bald areas were elliptically-shaped. major and minor axes were measured prior to the utilization of the appropriate mathematical formula for computing area of an ellipse (Draper and Klingman, 1967). Data related to the self-reported frequency of hair touches was also collected during the final phase of treatment. Reliability was assessed by comparing the senior author’s measurement count with that of a second independent judge’s count for both the quasi-direct and physical erosion measures. RESULTS
ReliabilirJ 100% reliability between judges was obtained across all phases with regard to the number of hairs pulled. Reliability coefficients for size of bald areas were calculated by dividing the smaller area estimate by the larger area estimate. These coefficients ranged from 0.89 to 0.98 with a mean of 0.94 across all phases and areas. Number of hairs pulled and size of bald areas As indicated in Fig. 1, the number of hairs pulled decreased dramatically from a baseline mean of 22.6/wk to zero/wk immediately upon the introduction of treatment. A slight relapse did occur, however. during the vacation period. at which time Mary pulled out I3 scalp hairs. This. in fact. was the sole refractory incident which occurred throughout the entire investigation. Figure 1 also reveals the decreasing size of the three bald areas over the course of treatment. Correspondence between size of bald areas and number of hairs pulled tends to suggest that Mary’s hair collection data
ABC
A= Baseline B* Self monitoring (pulls)+ halr collection C = Relaxation tmlmng D= Cognitive desensitizatmn E = Vocation F= Self momtaring (touches)+ goals + stlmulus control G= Follow-up probes
Fig. I. Number
of hairs pulled
and size of bald areas
across
conditions.
CASE HISTORIESANI) SHORTER COMMUNICATIONS
Table
1. Changing
Week 21 22 23 24 25 26 27 28 29 30
criterion schedule and number of hair touches
Criterion
Number
219
corresponding
of hair touches 181 126 90 71 52 36 24 18 7 0
133 105 84 70 56 42 28 14 0
was a relatively accurate record of the incidence of trichotillomania. Finally. Table I indicates that self-reported frequency of hair touches covaried directly with the prescribed changing criterion schedule Implemented during the final phase of treatment.
DISCUSSION
The present case study clearly provides added support for the successful treatment of chronic trichotillomania by behavioral methods. Moreover. the methodology employed is a first attempt to assess interrater reliability and obtain experimenter-derived, rather than subject-controlled behavioral measures of trichotillomania. In that “direct recording of an individual’s behavior by some independent observer is probably the hallmark of behavioral assessment” (Ciminero, 1977. p. 10). natural erosion traces such as those developed in the present investigation would appear to be the dependent measures of choice in related future research. Unfortunately. the multi-component nature of the treatment package precluded the possibility of isolating active agents of therapeutic change. Nevertheless, anecdotal comments on the part of the subject provide some direction in this regard. Specifically, Mary reported that although she was responding favorably. she did not feel as though the early phases of treatment were capable of effecting long-term change in the problem behavior. Upon the introduction of congitive desensitization, however, Mary enthusiastically reported that she was only now beginning to feel truly capable of controlling her trichotillomania. Thus, while self-monitoring and hair collection may have accounted for initial decline in target behavior occurrence. long-term maintenance appears most attributable to the imaginal repeated exposure and situation-specific cognitive rehearsal components within the desensitization procedure. This is of some importance in that previous long-term maintenance failures (Horne. 1977) appeared directly related to situationally-specific stresses. It is therefore recommended that future treatment strategies attempt to more clearly focus upon the idiosyncratic nature of trichotillomania. Department o/Psychology, University of Montana, Missoula. Montana 59812. U.S.A.
PHIUP H. BORNSTEIN ROBERT G. RYCHTARIK
REFERENCES BAYER C. A. (1972) Self-monitoring and mild aversion treatment of trichotillomania. J. Behau. Ther. Exp. Psychiat. 3, 139-141. BERNSTEIN D. A. and BORKOVEC T. D. (1973) Progressive Relaxation Training: A Manual for the Helping Professions. Research Press, Champaign, Ill. CIMINERO A. R. (1977) Basic issues in behavioral assessment. In Handbook of Behavioral Assessmenf (Eds. A. R. CIM~NERO, K. S. CALHOUN and H. E. ADAMS). John Wiley, New York. DRAPER J. E. and KLINGMAN J. S. (1967) Mathematical analysis. Harper Row, New York. EVANSB. (1976) A case of trichotillomania in a child treated in a home token program. J. Behal;. Ther. Exp. Psychiat. I, 197-198. HARTMANN D. P. and HALL R. V. (1976) The changing criterion design. J. appl. Behac. Anal. 9. 527-532. HORNE D. J. (1977) Behaviour therapy for trichotillomania. Behao. Res. Therap. 15, 192-196. LEMNE B. A. (1976) Treatment of trichotillomania by covert sensitization. .I. Behau. Ther. Exp. Psychiat. 7, 75-76.
MANNINO F. V. and DELGAW R. A. (1969) Trichotillomania in children: A review. Am. J. Psychiat. 126, 505-511. MCLAUGHLIN J. G. and NAY W. R. (1975) Treatment of trichotillomania using positive coverants and response cost: A case report. Behau. Therap. 6, 87-91. MEICHENLIAUMD. H. (1972) Cognitive modification of test anxious college students, J. consult. C/in. psycho/. 39. 37G380.
220
CASE HISTORIESAND SHORTER COMMUNICATIONS
STABLER B. and WARREN A. B. (1974) Behavioral contracting in treating trichotillomania: Case note. Psycho/. Repts 34, 401402. TAYLOR J. A. (1963) A behavioural interpretation of obsessive-compulsive neurosis. Behar. Res. Therap. I. 237-244. WEBB E. J., CAMPBELL D. T., SCHWARTZ R. D. and SECHREST L. (1966) Unobtrusive Measures: Nonreactive Research in the Social Sciences. Rand McNally, Chicago.
HISTORIES
AND SHORTER
217
COMMUNICATIONS
BehavRes & Therap). 0
Pcrgamon
1978. Vol. 16. pp, 217-220. Press. Ltd. Printed m Great Bwam
Multi-coqunent
behavioral treatment of trichotilbmania: A case study
(Receiued
29 September
1977)
Summary-A 21-year-old female with a 13.year history of compulsive hair pulling was treated via a multi-component behavioral intervention strategy. Dependent variables included both quasi-direct behavioral frequency counts (i.e., number of hairs pulled) and physical trace, natural erosion measures (i.e. size of bald areas). Results indicated dramatic decrease in number of hairs pulled from treatment through 40 weeks post-initiation of baseline. These findings were discussed with regard to situational-s~~fi~ty of t~chotillomania and reliance upon experimenter-derived rather than subject-controlled data collection sources.
Psychotherapeutic approaches to the treatment of trichotillomania (i.e., chronic hair pulling) have traditionally met with little success and high remission rates (Mannino and Delgado, 1969). Recently, however, behavioral interventions have been more encouraging with regard to results achieved. Successful behavioral techniques have included: interruption of the behavioral sequence of hair pulling (Taylor, 1963). simple response cost (Bayer, 1972), contingency contracting (Stabler and Warren, 1974), posit&e coverants and response cost (McLaughlin and Nay, 1975k covert sensitization (Levine, 1976k token reinforcement and time-out (Evans. 1976). suggestive hypnosis (Horne, 1977) and aversive conditioning (Home, 1977). While collectively these case studies generally support behavioral strategies in the treatment of trichotillomania, there exists a noticeable lack of direct observational measures for the problem behavior. Rather, most investigations have utilized subject recorded (e.g., self-monitored record of hair pulls) or subject-derived behaviorally-based samples (e.g, hair collection). Evans (1976) did employ the mother of an eight-year-old ~i~otillomanic as the observer of her child’s hair pulling within specified time intervals. No reliability data was reported, however, and the actual dependent variable used was simpty the number of tokens earned per week for non-hair pulting. McLaughlin and Nay (1975) attempted to obtain accurate observational data by measuring the length of their subject’s hair. The applicability of this measure is questionable, however, since it is the presence or absence of hair in trichotillomania which seems of prime importance. The purpose of the present case study was therefore to: (a) examine the effectiveness of a multi-component behavioral treatment for chronic hair pulling and (b) employ both self-monitored and more directly observable, independently-based behavioral measures of the target behavior. CASE
HISTORY
Subject
The subject, Mary B., was a 21-year-old married female, employed part-time at a local social service agency. She reported having initiated the trichotillomania at the time of her parent’s divorce 13 years ago. Aside from a one-month interval approximately nine years ago. she had been unable to abstain from performing the problem behavior since its inception. The subject was quite self-conscious of the problem; as a result, she insisted upon wearing head-scarves and refused to visit a beautician for fear of embarrassment. A detailed behavioral analysis indicated that the hair pulling was often preceded by extreme tension and anxiety (e.g., flying in airplanes); more apt to occur in particular situations (e.g., reading watching T.V., etc.) and/or when the subject was completely alone. Moreover, she indicated that hairs were only pulled from three major places on her head (viz., above left ear, right ear, and crest of scalp) and that coarse, hard, darker hairs within those areas were actively sought out and targeted as “hairs to be pulled”. Conditions Buseiine. The subject contracted the senior author by phone and arranged an initial meeting. At this time (prior to the initiation of treatment), she was asked to simply record the number of hairs pulled on a daily basis. Seljlmonitoring (pulls) plus hair collection. At the close of the first week’s session, the subject was told to continue recording the number of hairs pulled. Furthermore, she was instructed to place all hairs pulled in an envelope, returning them to the senior author at weekly intervals throughtout treatment. Relaxation training. Weekly sessions two, three, and four were devoted to relaxation training patterned after Bernstein and Borkovec (1973). Beginning with relaxation of 16, 7, and 4 muscle .,ttroum. . . the subiect > was progressively taught relaxation by recall and relaxation by counting. Cognitive Isensitizotion. Meichenbaum’s (1972) modification of the systematic desensitization procedure was implemented during weeks 5-13. Specifically, a hierarchy was constructed of anxiety-arousing situations which appeared to elicit the subject’s hair pulling behavior. The subject was then instructed to visualize herself becoming anxious and tense within these situations, coping with the anxiety by slow deep breaths paired with cognitive self-instructions. A typical scene was as follows:
“You’re sitting in your favorite chair in the bedroom reading a novel. All of a sudden you notice an urge to reach up and pull your hair. You try to pay no attention to it. As you continue reading the Requests for reprints should be sent to Philip H. Bomstein, Montana, Missoula, Montana 59812, U.S.A.
Department
of Psychology,
University of
218
CASE
HISTORIES
AND
SHORTER
COMMUNICATIONS
urge seems to grow in intensity. becoming harder and harder to combat. As your hand begins to move up toward your head. you grab hold of the situation and say to yourself. ‘Mary. what the hell is wrong with you-you know you can control this-just breathe calmly. count, and relax.“’
Se/Jmoniroring (rot&es) plus goal srrting plus stimulus control. Following cognitive desensitization treatment. the subject and her husband went on an extended vacation for two months. Upon returning. she reported: (a) touching her hair with a higher frequency than desired. and that (b) some minor hair pulling had occurred at the close of the vacation period. As a result. a self-monitoring of touches and stimulus control treatment was instituted during weeks 22-30. The subject was first asked to obtain a baseline frequency of the number of touches per week. A decreasing changing criterion schedule (Hartmann and Hall. 1976) was then established. with “touching goals” sequentially modified from 133 to zero over the nine-week treatment period. Moreover, the subject was informed that when touching began. if relaxation and cognitive self-instruction failed. she was to immediately stop her ongoing activity and move to a “safe” environment [i.e.. someplace (e.g.. kitchen) or activity (e.g., piano playing) where touching was not apt to occur]. Follow-up probe data was collected by having the subject return for brief observation 34 and 40 weeks post-initiation of baseline. Dependent measures The major dependent measures used in the present investigation were: (a) a quasi-direct behavioral frequency measure (i.e., number of hairs pulled), and (b) a physical trace, natural eroston measure (Webb er al.. 1966) (i.e.. size of bald area). Since bald areas were elliptically-shaped. major and minor axes were measured prior to the utilization of the appropriate mathematical formula for computing area of an ellipse (Draper and Klingman, 1967). Data related to the self-reported frequency of hair touches was also collected during the final phase of treatment. Reliability was assessed by comparing the senior author’s measurement count with that of a second independent judge’s count for both the quasi-direct and physical erosion measures. RESULTS
ReliabilirJ 100% reliability between judges was obtained across all phases with regard to the number of hairs pulled. Reliability coefficients for size of bald areas were calculated by dividing the smaller area estimate by the larger area estimate. These coefficients ranged from 0.89 to 0.98 with a mean of 0.94 across all phases and areas. Number of hairs pulled and size of bald areas As indicated in Fig. 1, the number of hairs pulled decreased dramatically from a baseline mean of 22.6/wk to zero/wk immediately upon the introduction of treatment. A slight relapse did occur, however. during the vacation period. at which time Mary pulled out I3 scalp hairs. This. in fact. was the sole refractory incident which occurred throughout the entire investigation. Figure 1 also reveals the decreasing size of the three bald areas over the course of treatment. Correspondence between size of bald areas and number of hairs pulled tends to suggest that Mary’s hair collection data
ABC
A= Baseline B* Self monitoring (pulls)+ halr collection C = Relaxation tmlmng D= Cognitive desensitizatmn E = Vocation F= Self momtaring (touches)+ goals + stlmulus control G= Follow-up probes
Fig. I. Number
of hairs pulled
and size of bald areas
across
conditions.
CASE HISTORIESANI) SHORTER COMMUNICATIONS
Table
1. Changing
Week 21 22 23 24 25 26 27 28 29 30
criterion schedule and number of hair touches
Criterion
Number
219
corresponding
of hair touches 181 126 90 71 52 36 24 18 7 0
133 105 84 70 56 42 28 14 0
was a relatively accurate record of the incidence of trichotillomania. Finally. Table I indicates that self-reported frequency of hair touches covaried directly with the prescribed changing criterion schedule Implemented during the final phase of treatment.
DISCUSSION
The present case study clearly provides added support for the successful treatment of chronic trichotillomania by behavioral methods. Moreover. the methodology employed is a first attempt to assess interrater reliability and obtain experimenter-derived, rather than subject-controlled behavioral measures of trichotillomania. In that “direct recording of an individual’s behavior by some independent observer is probably the hallmark of behavioral assessment” (Ciminero, 1977. p. 10). natural erosion traces such as those developed in the present investigation would appear to be the dependent measures of choice in related future research. Unfortunately. the multi-component nature of the treatment package precluded the possibility of isolating active agents of therapeutic change. Nevertheless, anecdotal comments on the part of the subject provide some direction in this regard. Specifically, Mary reported that although she was responding favorably. she did not feel as though the early phases of treatment were capable of effecting long-term change in the problem behavior. Upon the introduction of congitive desensitization, however, Mary enthusiastically reported that she was only now beginning to feel truly capable of controlling her trichotillomania. Thus, while self-monitoring and hair collection may have accounted for initial decline in target behavior occurrence. long-term maintenance appears most attributable to the imaginal repeated exposure and situation-specific cognitive rehearsal components within the desensitization procedure. This is of some importance in that previous long-term maintenance failures (Horne. 1977) appeared directly related to situationally-specific stresses. It is therefore recommended that future treatment strategies attempt to more clearly focus upon the idiosyncratic nature of trichotillomania. Department o/Psychology, University of Montana, Missoula. Montana 59812. U.S.A.
PHIUP H. BORNSTEIN ROBERT G. RYCHTARIK
REFERENCES BAYER C. A. (1972) Self-monitoring and mild aversion treatment of trichotillomania. J. Behau. Ther. Exp. Psychiat. 3, 139-141. BERNSTEIN D. A. and BORKOVEC T. D. (1973) Progressive Relaxation Training: A Manual for the Helping Professions. Research Press, Champaign, Ill. CIMINERO A. R. (1977) Basic issues in behavioral assessment. In Handbook of Behavioral Assessmenf (Eds. A. R. CIM~NERO, K. S. CALHOUN and H. E. ADAMS). John Wiley, New York. DRAPER J. E. and KLINGMAN J. S. (1967) Mathematical analysis. Harper Row, New York. EVANSB. (1976) A case of trichotillomania in a child treated in a home token program. J. Behal;. Ther. Exp. Psychiat. I, 197-198. HARTMANN D. P. and HALL R. V. (1976) The changing criterion design. J. appl. Behac. Anal. 9. 527-532. HORNE D. J. (1977) Behaviour therapy for trichotillomania. Behao. Res. Therap. 15, 192-196. LEMNE B. A. (1976) Treatment of trichotillomania by covert sensitization. .I. Behau. Ther. Exp. Psychiat. 7, 75-76.
MANNINO F. V. and DELGAW R. A. (1969) Trichotillomania in children: A review. Am. J. Psychiat. 126, 505-511. MCLAUGHLIN J. G. and NAY W. R. (1975) Treatment of trichotillomania using positive coverants and response cost: A case report. Behau. Therap. 6, 87-91. MEICHENLIAUMD. H. (1972) Cognitive modification of test anxious college students, J. consult. C/in. psycho/. 39. 37G380.
220
CASE HISTORIESAND SHORTER COMMUNICATIONS
STABLER B. and WARREN A. B. (1974) Behavioral contracting in treating trichotillomania: Case note. Psycho/. Repts 34, 401402. TAYLOR J. A. (1963) A behavioural interpretation of obsessive-compulsive neurosis. Behar. Res. Therap. I. 237-244. WEBB E. J., CAMPBELL D. T., SCHWARTZ R. D. and SECHREST L. (1966) Unobtrusive Measures: Nonreactive Research in the Social Sciences. Rand McNally, Chicago.
