by Charles S. Mansueto, PhD & Ruth G. Golomb, LCPC
Picking at one’s own skin and pulling out one’s own hair are two relatively common human behaviors. Who hasn’t removed hairs, popped a pimple, scratched at scabs or bit a jagged fingernail? But it’s when these behaviors get out of control — when they cause unwanted physical damage or personal distress and can’t be stopped — that they become disorders. Skin picking (excoriation) disorder (SPD) and trichotillomania (hair pulling disorder) (HPD) are their official names. These, along with similar behavior patterns that are not formally identified as psychological disorders, such as nail, lip and interior cheek biting, are called “body-focused repetitive behaviors,” or “BFRBs” for short. They are grouped within the diagnostic category of “obsessive compulsive and related disorders.” At one time they were believed to be relatively rare, but current estimates suggest that HPD and SPD occur in 1% to 4% of the population, meaning that roughly seven to 26 million people experience a diagnosable BFRB condition in the U.S. alone.
Luckily, BFRBs can be effectively treated. This article will focus on the therapy approach called Comprehensive Behavioral (ComB) treatment — an approach that is favored by many clinicians. As far back as 1990, the ComB approach was introduced as a method of understanding and highlighting the previously unappreciated complexity of BFRBs, the wide range of variables that contribute to the growth and persistence of these disorders, and the differing mix of factors that underlie each person’s BFRB. This article will describe how the ComB approach enables a finely tuned treatment plan to be matched to the individual needs of each BFRB sufferer.
A BRIEF HISTORY OF BFRB TREATMENT
Many treatment approaches for BFRBs have been used over the years, including psychoanalysis, hypnosis, biofeedback, acupuncture, meditation, diets, food supplements, learning-based therapies, and medications. While the search for a reliable and effective medication that directly targets BFRBs continues, none has been found as of yet. However, some may be helpful in targeting coexisting disorders like depression and anxiety and may indirectly help some people with BFRBs. Instead, behavior therapy approaches have dominated the professional literature and are currently considered treatments of choice for BFRBs (Golomb et al., 2016). Before describing ComB treatment, it is worth highlighting a well-established, learning-based treatment for BFRB–Habit Reversal Training.
Habit Reversal Training (HRT), developed by Azrin and Nunn (1973), has received the most attention to date in the BFRB research literature. It is familiar to most behaviorally oriented therapists and many BFRB sufferers, as it has been around for almost half a century and has the most empirical support of any single treatment for BFRBs. Briefly, from the HRT perspective, BFRBs were included, as tics and nail biting were, within a cluster of “nervous habits” that could occur without conscious awareness. While various treatment components were added to and deleted from HRT in response to research, all included the hallmark feature of HRT, competing response training. Competing response training involves learning and practicing movements that directly oppose the performance of problem behaviors — such as squeezing the hands into fists for a period of time — whenever the problem behavior has occurred, is likely to occur, or an urge to perform the behavior is experienced. Other treatment components associated with Azrin’s HRT included: awareness training, motivation enhancement, imaginal rehearsal, self-monitoring, and social support.
Early reports of treatments using variations of HRT for BFRBs looked very promising. However, later reports were less favorable when problems of lower effectiveness and high relapse and dropout rates were reported.
Some researchers studying HPD and SPD treatment thought that Azrin’s model upon which HRT is based failed to address key reasons why BFRB symptoms are so persistent. The researchers continued to use core parts of HRT but added on additional treatment elements intended to improve effectiveness for BFRBs. Here we will refer to these as “augmented HRT.” Some of these added elements included:
Stimulus control procedures, where the patient avoids or removes parts of their environment that trigger their BFRB (e.g., brightly lit mirrors, tweezers);
Cognitive therapy techniques to identify and replace thoughts that encourage the problem behaviors;
Emotional regulation training, in which individuals practice techniques (e.g., dialectical behavior therapy skills) to manage feelings that they may otherwise be managing by performing BFRBs;
Mindfulness training and acceptance and commitment therapy (ACT) are newer additions to HRT treatment for BFRBs.
Clinicians treating patients with augmented HRT are likely to employ multiple treatment components like those above, as well as others like psychoeducation, reward systems, and relapse prevention strategies in a “package” format or sometimes in modular forms. Research reports indicate that, as with early forms of HRT, those treated with various combinations of cognitive behavioral techniques will benefit to some degree, at least in the short term, but long-term effectiveness remains questionable.
Obviously, there is room for improvement in treating BFRBs. Toward that goal, it is worthwhile to consider avenues for improving treatment by identifying possible shortcomings. First, is the absence of a comprehensive theoretical framework that encompasses the array of behavioral, cognitive, affective, and sensory variables that underlie BFRBs and that would guide practitioners in application of treatment techniques to each individual. Without such a conceptual framework to guide therapists, important contributors to each individual’s BFRB may be missed, and there is a risk of an unsystematic “hodgepodge” approach to therapy employed in the absence of a guiding framework. Second, the use of “package treatments” like those often employed in augmented HRT approaches may not provide the therapist with the flexibility to match therapy components to each patient’s unique combination of factors that drive and maintain the BFRB (Mansueto, 2013).
At the core of ComB treatment (Mansueto et al., 1997) is the clinician’s task of working collaboratively with the patient, first to identify and then to change relationships with factors that trigger BFRB behaviors, and variables that serve to maintain the BFRB (i.e., what is happening that is reinforcing the behaviors). Treatment begins with an in-depth structured assessment to identify an individual’s unique pattern of variables that foster the performance of their BFRB. Change is accomplished when established behavior patterns are interrupted, and non-harmful or healthy alternatives are substituted to meet the functions served by hair pulling or skin picking for a given individual. For example, a college student who “unconsciously” begins picking at dry, scabby patches of skin on her arms, legs and feet, usually while studying alone in her room, might address some triggers to picking by wearing clothing that limits access to the picking sites, and move her studying to her dormitory lounge or in the library where the presence of others would inhibit picking. She might wear finger bandages on the thumb and forefinger to trigger awareness if her fingers have drifted to potential picking sites. If the desirable consequences of picking were to produce smoothness in bumpy, dry skin areas, daily use of skin care products that soften damaged skin and help aid healing would be encouraged. If picking served to give her something to do with unoccupied hands, she might manipulate “fidget toys”, and she might employ deep breathing and take frequent breaks if picking helped sooth her when she felt restless.
Alternative behaviors are carefully chosen within five categories of factors that have been identified as relevant to each person’s unique BFRB profile. Treatment is modified, as necessary, in response to feedback regarding the usefulness of specific treatment recommendations. With practice, it is expected that triggers and reinforcers for pulling hairs or picking skin will weaken as healthy alternative habits are established.
ComB treatment encompasses a wide range of techniques drawn from standard behavioral, cognitive, and CBT practice. These are familiar to CBT practitioners as they are widely used to treat a broad range of disorders. Individual therapists are encouraged to draw upon and integrate their training, knowledge and skills into their approach to ComB as client needs become clearer over time.
As ComB treatment is uniquely tailored to the individual needs of each patient, the treatment process is expected to be both creative and fluid rather than rigidly applied. The flexible and patient-oriented nature of the treatment process results in therapy that may appear quite different from one patient to another, due to factors such as the therapist’s skill set, judgment, and decision-making as well as each patient’s preferences. The ComB approach addresses this complexity by providing a systematic framework that guides therapists as they design and implement a treatment plan that uniquely fits each patient.
THE FOUR PHASES OF COMB TREATMENT
Phase 1 – Assessment (Functional Analysis). ComB treatment pays attention to the factors that foster and maintain BFRBs: behavioral, emotional, cognitive, and sensory variables identified in prior research on HPD (Mansueto, 1991). This approach emphasizes relationships among these categories to provide a detailed picture of the internal and external factors that make it more or less likely that a BFRB will occur, and this guides the assessment phase of treatment. Here ComB uses what is considered a traditional behavioral framework that identifies which antecedents (A) instigate and make the behaviors more likely to occur, what behaviors (B) constitute the actual pulling of hair and picking of skin, and the consequences (C) that maintain the behaviors (in other words, make the behaviors more likely to occur again in the future). We focus on those variables that appear to promote more BFRB episodes (A’s and C’s), and these are grouped into five categories:
Sensory (i.e., sensations) – Antecedents can include trigger sensations (hairs or skin that appear “wrong,” out of place or unpleasant to sight or touch, tingling, burning or itching at the site, or impulses to pick or pull in anticipation of pleasure or otherwise desirable sensations that are attained by those activities, etc.). Consequences can include pleasurable sensations experienced during or after pulling or picking. These pleasurable sensations may occur while handling hair or skin products; visually examining the hair or skin; chewing on or swallowing the hair, hair root, dry skin pieces or scabs; rubbing hair or skin across face, arm or lip, etc.
Cognitive (i.e., thoughts) – Antecedents can include ideas, thoughts, or beliefs that trigger pulling or picking, such as: “Kinky hairs are ugly and have to go,” “My pimples have to be popped to heal,” “My eyebrows or lashes must be symmetrical,” “I won’t be able to study if I don’t pull out these stubby eyelashes.” Consequences can include satisfaction gained from completing the goal (e.g., popping the pimple, eliminating unwanted hairs, finding a hair with a big root, etc.).
Affective (i.e., emotions) – Antecedents can include feelings that trigger pulling or picking behavior, such as: boredom, anxiety, frustration, depression, tension, indecisiveness, excitement, etc. Consequences can include the effect of reducing unwanted feelings, getting an energized effect when feeling bored or lethargic, or experiencing satisfaction following the action, etc.
Motor (i.e., behaviors) – Antecedents can include motor habits and body postures that encourage an individual to stroke, examine, or remove hair or pick at skin, often without full awareness (i.e., automatically). In the case of habitual behavior, Consequences can include repetition of the behaviors, establishing well-practiced movements that establish and strengthen habitual behavior.
Place (i.e., environment) – Antecedents can include cues in a particular space that trigger the behavior such as: being alone, being sedentary or not moving around much, sitting in a familiar spot where picking or pulling often occurs, the presence of mirrors, tweezers, or pins, etc. Consequences: The place domain does not typically have a reinforcing function, except for the rare attention-seeking adult, or more frequently, in children desiring attention.
In order to provide a quick and easy way to remember these domains, they are often referred to by the acronym SCAMP.
Phase 2 – Identification and Selection of Target Domains. ComB treatment emphasizes the learning and practice of strategies to target problematic behaviors as well as the thoughts, feelings, and sensations that contribute to their persistence. Each individualized plan is designed to interrupt problematic habits by providing healthier alternatives. These are organized within the five SCAMP domains and reflect the specific functions served by hair pulling or skin picking for each person. Once the BFRB has been thoroughly assessed using the SCAMP model, it becomes clearer how and why the problem behaviors show up and how they are maintained (i.e., by looking at how the antecedents and consequences are connected to the problematic behaviors). Now the therapist and the patient can work together to identify specific targets that are contributing to that individual’s pulling or picking.
Phase 3 – Implementation of Specific Interventions. At this point in treatment, individuals will explore the use of a variety of specific interventions designed to decrease their BFRB symptoms. Interventions are chosen based upon their ability to affect the targets identified in Phase 2 by modifying the antecedents and consequences that trigger and maintain the BFRB. As stated above, many of the interventions include standard behavioral and cognitive strategies previously described in the cognitive behavioral literature, but there are others that address targets not typically emphasized in behavioral interventions (e.g., the sensory components). Examples of standard CBT techniques used and less familiar ones that address the targets include:
Cognitive restructuring, coping self-statements, and mindfulness and acceptance strategies to address cognitive targets
Relaxation, controlled breathing, positive visualization, and dialectical behavior therapy skills to address affective/emotional targets
Awareness training, competing response training,
and response prevention to address motoric/behavioral targets
Stimulus control and contingency management to address place/environmental targets
Sensory substitution techniques (i.e., activities that do not require the removal of hair or skin) are used to address sensory needs previously addressed in the individual’s BFRB, and sensory distraction techniques are taught in order to provide alternatives to soothe, invigorate, and provide pleasing sensations impacting the nervous system in ways that divert the individual from pulling hair or picking skin
When potentially useful interventions have been identified, the individual, in consultation with the therapist, chooses several to try out over the next week focusing on high-risk situations. For example, while driving to work the client might wear driving gloves (stimulus control, response prevention), listen to relaxing music (sensory distraction), breathe deeply and slowly (controlled breathing), and keep both hands gripped to the steering wheel (competing response). Other situations in which pulling is probable will likely require a different set of interventions, for example, while working on the computer at the office. Choices of interventions should be carefully fitted to the lifestyle and preferences of the client. The usefulness of the interventions will be determined once they have been tried and their impact on hair pulling has been reviewed. During each session, the client and therapist decide together how to modify the intervention to maximize control of hair pulling.
Phase 4 – Evaluation, Termination, and Relapse Prevention. In the final phase of formal treatment, the client is encouraged to continue with ongoing assessments of progress and to modify the use of interventions as needed. A shift is made from reliance on therapist guidance toward self-management and utilization of skills and techniques learned during formal treatment. The focus is on maintenance, extension of the gains achieved during formal therapy, and preparation for setbacks that are common during the recovery process. Relapse prevention training provides a systematic approach to minimizing setbacks and keeping them from leading to a full-blown resumption of hair pulling or skin picking.
EVIDENCE IN SUPPORT OF COMB TREATMENT
The ComB conceptual model comes from established behavioral principles and decades of laboratory and clinical research, and employs proven behavioral, cognitive, and CBT techniques. As the first stage of a three-part research program, a ComB treatment manual was developed and tested (Falkenstein, Mouton-Odum, Mansueto, Golomb & Haaga, 2016). In the second stage (currently underway), subjects treated with ComB treatment are being compared with those receiving minimal-attention placebo treatment. The final stage will compare subjects treated with ComB to others who are treated with HRT. Through this research program we hope to acquire the scientific foundation that demonstrates the utility and benefits of ComB treatment.
For more than a decade, The TLC Foundation for Body-Focused Repetitive Behaviors (BFRBs), a national, nonprofit service organization devoted to serving sufferers of trichotillomania (hair pulling) and excoriation (skin picking) disorders worldwide, has provided formal certification training in ComB therapy through their Professional Training Institute or by viewing a ComB DVD training series — TLC’s Virtual Professional Training Institute. Many other clinicians have adopted the ComB approach after having acquired informal training in various professional settings or by reading accounts in the professional literature. As a result, hundreds of therapists around the world are employing ComB in their clinical practice to treat BFRBs.
The last several decades have seen much progress toward understanding and treating BFRBs. The ComB treatment model guides assessment across a broad range of features for a comprehensive view of each individual’s BFRBs. When used as a guide, it points to a broad range of potential treatment avenues that might be unavailable with a more limited view of the disorder. While outcome research on ComB and other CBT therapies for BFRBs continues to clarify the effectiveness, efficiency, and acceptability of these approaches, decades of informal clinical observation and testimonials by numerous expert clinicians employing ComB treatment for BFRBs support the following conclusions regarding ComB:
It provides a unique and likely more effective alternative to existing CBT treatment approaches;
It addresses the diverse nature of elements that foster hair pulling in each individual;
It guides the assessment of relevant information and organizes that information into important domains of human experience;
It generates a broad variety of possible therapeutic interventions;
It guides the therapist through the process of clinical decision-making to ensure that therapeutic interventions fit well with the unique characteristics of each patient;
It has been adapted for use with children and adolescents (Golomb and Vavrichek, 2000) and for self-help applications (Mansueto, Vavrichek & Golomb, In Press).
At this time no other single treatment formulation provides these features within an integrated conceptual framework and treatment model.
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