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Utilizing DBT Skills to Augment Traditional CBT for Trichotillomania: An Adult Case Study

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Abstract

Traditional cognitive-behavioral interventions for trichotillomania have had modest acute treatment outcomes and poor maintenance of gains over time. Techniques adopted from dialectical behavior therapy (DBT) can potentially enhance treatment outcomes by specifically addressing issues of impulsivity, emotion regulation, and distress tolerance. In this paper we discuss the application of a DBT-enhanced treatment and its outcome in a single-case study.

Section snippets

Emotion Regulation and TTM

Considerable evidence exists to suggest that affect regulation may be an important function of hair pulling behavior. The DSM-IV-TR criteria for TTM (American Psychiatric Association [APA], 2000) include tension prior to pulling or when attempting to resist pulling (Criteria B), as well as pleasure, relief, or gratification upon pulling (Criteria C). In addition, other affective states, including anger, anxiety, embarrassment, boredom, frustration, and depression, have also been identified as

TTM Pulling Styles

One hypothesis for the limited acute and poor follow-up results with traditional HRT is the failure of these techniques to adequately address the heterogeneity of hair pulling phenomenology. Many years ago Christenson, Mackenzie, and Mitchell (1991) proposed two types of hair pulling: (a) “automatic” or habitlike pulling out of awareness and (b) “focused” pulling often secondary to uncomfortable inner experiences. In a subsequent analysis of cue profiles, these authors provided further

DBT-Enhanced CBT Protocol for TTM

Recognizing these recent advances in our understanding of TTM phenomenology, we sought to amplify existing CBT approaches by including instruction in skills to further enhance awareness and address problematic emotion regulation and distress tolerance. Our treatment protocol (Keuthen et al., 2010) consists of 11 weekly hour-long sessions with elements of both traditional CBT (habit reversal training and stimulus control) and DBT assessed to be relevant to the treatment of TTM. We chose DBT

Case Study

Jenny B. is a 46-year-old married female who is employed full-time as a marketing executive for a national pharmaceutical company. She met DSM-IV-TR criteria for TTM with a history of pulling since the age of 11 years old. Her pulling caused significant distress due to limitations in leisure activities (especially camping and swimming) and time spent engaged in the behavior. She sought treatment due to her fear that the pulling behavior would cause physical damage to her eyes. She had recently

Measures

Table 1 reports scale scores on measures of hair-pulling severity and impairment, depression and anxiety severity, and emotion regulation throughout treatment and at 3- and 6-month follow-up.

At baseline evaluation, administration of the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID; First, Spitzer, Gibbon, & Williams, 1995) revealed a lifetime history of recurrent major depressive episodes and panic disorder without agoraphobia. In addition to TTM, Jenny currently satisfied

Course of Treatment

Below we provide a session-by-session review of the content and outcome of the acute and maintenance treatment sessions.

In Session 1, a treatment overview was provided along with psychoeducation regarding TTM. A cognitive-behavioral model for TTM was presented emphasizing that positive and negative reinforcement from pulling maintains the behavior. Functional analysis of behavior and chain analysis were introduced to identify her unique pulling sequences including triggers, setting events and

Discussion

This case study illustrates the potential benefits of augmenting traditional CBT interventions for TTM with selected DBT skills. This patient was able to reduce both the severity and impact of her hair pulling during acute treatment and to maintain these gains during a 3-month maintenance period with limited therapist contact. Similarly, substantial improvement in her emotion regulation capacity was reported over the same time period.

It is noteworthy that this patient had pulled hair for the

Acknowledgments

Contract grant sponsor: David Judah Fund.

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