Contains Video1Utilizing DBT Skills to Augment Traditional CBT for Trichotillomania: An Adult 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.
References (36)
- et al.
Systematic review: Pharmacological and behavioral treatment for trichotillomania
Biological Psychiatry
(2007) - et al.
The identification of trichotillomania cue profiles
Behaviour Research and Therapy
(1993) - et al.
Affective correlates of trichotillomania
Behaviour Research and Therapy
(2002) - et al.
Emotion regulation and trichotillomania: A comparison of clinical and nonclinical hair pulling
Journal of Behavior Therapy and Experimental Psychiatry
(2008) - et al.
Styles of pulling in trichotillomania: Exploring differences in symptom severity, phenomenology, and functional impact
Behaviour Research and Therapy
(2008) - et al.
Current treatment practices for children and adults with trichotillomania
Cognitive and Behavioral Practice
(2010) - et al.
Behavioural treatment of trichotillomania: Two-year follow-up results
Behaviour Research and Therapy
(2006) - et al.
Effectiveness of a cognitive behavioral treatment program for trichotillomania: An uncontrolled evaluation
Behavior Therapy
(1998) - et al.
Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder
Drug and Alcohol Dependence
(2002) - et al.
Trichotillomania: A comprehensive behavioral model
Clinical Psychology Review
(1997)
Affective regulation in trichotillomania: Evidence from a large-scale internet survey
Behaviour Research and Therapy
Nonclinical hair pulling: Affective correlates and comparison with clinical samples
Behavior Research and Therapy
A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania
Behaviour Research and Therapy
Diagnostic and statistical manual of mental disorders
An inventory for measuring clinical anxiety: Psychometric properties
Journal of Consulting and Clinical Psychology
Comparison of Beck Depression Inventories Ia and IIa in psychiatric outpatients
Journal of Personality Assessment
Measuring generalized expectancies for negative mood regulation: Initial scale development and implications
Journal of Personality Assessment
Reduced brain white matter integrity in trichotillomania
Archives of General Psychiatry
Cited by (0)
- 1
Video patients/clients are portrayed by actors.