christine cordle - the use of operant self-control in compulsive hair-pulling

8/11/2019 Christine Cordle - The Use of Operant Self-control in Compulsive Hair-pulling

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J. Behov. Ther. Exp. Psychior. Vol. II. pp. 127-130.

k:Pergamon Press Ltd., 1980 . Printed in Great Britain.

ooO5-7916/80/0604127 02 W/O

THE USE OF OPERANT SELF CONTROL PROCEDURES IN THE

TREATMENT OF COMPULSIVE HAIR PULLING

CHRISTINE J. CORDLE and CLIVE G. LONG

Leicester General Hospital and Walsgrave Hospital, Coventry, England

Summary-Two young female patients with a lo- and 5-year history of compulsive hair pulling

were individually treated by the same operant self-control procedure. Zero pulling was

achieved at weeks 6 and 13, and maintained at follow-up 15 months later. These findings are

discussed in the light of previous behavioural treatments, and the importance of eliciting an

appropriate aversive consequence for habit control is stressed.

The incidence of trichotillomania is extremely

difficult to ascertain, partly because reported

cases are divided between the dermatological and

psychotherapeutic literature; and partly because

many authors have made unverified estimates

on the frequency of the symptoms ranging from

rare (Philippopoulos, 1961) to commonly seen

(Monroe and Abse, 1963).

Although fiddling with hair may be considered

a normal activity among social primates (Horne,

1977), no normative data exists on the incidence

of hair pulling among the non-institutionalized

adult population. What is clear, however, is that

the phenomenon of hair pulling, of a severity

requiring treatment, is uncommon. For this

reason, perhaps, there has never been a con-

trolled trial of any form of therapy for

trichotillomania.

The benefits of psychoanalytically based

psychotherapy have been generally extolled, yet

most of these studies remark on the malignant

and chronic nature of trichotillomania with

frequent exacerbations and remissions (Green-

berg and Sarner, 1965). Generally psychoanalytic

procedures have met with little success, and in

some cases the process involving introspection

may accelerate the rate of self-destructive

symptoms.

Studies using behavioural intervention are

mostly case histories, but in terms of quantitative

data and attempts at specifying the relationship

between symptom change and treatment the

behaviour literature is undoubtedly superior.

Taylor (1963) eliminated the habit by interrupt-

ing the behavioural sequence through the

practice of an antagonistic response. Bayer

(1972) employed a technique of self-monitoring

and a mild form of aversive control (saving hairs

pulled) to treat a case of two years duration.

Unfortunately no follow-up data were presented.

Over the period 1974-1978 at least five

English language reports on the behavioural

treatment of trichotillomania in adults have

appeared with encouraging results. Techniques

used have included contingency contracting

(Stabler and Warren, 1974), positive coverants

and response cost (McLaughlin and Nay, 1975),

covert sensitization (Levine, 1976), suggestive

hypnosis (Horne, 1977), aversive conditioning

(Horne, 1977), and cognitive desensitization

(Bornstein and Rychtarik, 1978).

The six patients treated were mostly young

females with an age range of 14 to 42 years

and with a 2 to 35 year history of hair pulling.

In three cases the extent of the habit had resulted

in the wearing of a wig or headscarf and the

baseline rate of hair pulling ranged from 22.6

Requests for reprints should be sent to Miss C. J. Cordle, Senior Psychologist, Psychology Department, Leicester

General Has+*

-h

Road, Leicester LES 4PW, England.

127


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128


to 220 hairs per week. Except in the cases cited

by Horne (1977), where concurrent therapy for

sexual and family problems makes evaluation

difficult, treatment has usually been brief and

effective with no remission at up to six months

follow-up.

Unfortunately, the nature of many of these

studies precludes the possibility of isolating

active agents of therapeutic change, and con-

clusions are based on anecdotal reports by the

patients themselves. Most treatment procedures

include positive and negative reinforcement,

anxiety reduction and feedback.

While self-monitoring and hair collection

may account for initial decline in target be-

haviour, long term maintenance has been attri-

buted to the use of a cognitive desensitization

procedure (Bornstein and Rychtarik, 1978);

while Horne (1977) suggests that more effective

treatment techniques may be developed by

investigating the relationship between anxiety

and habit strength. In Levines (1976) rapid

treatment, an anxiety management technique

(relaxation) was only incidentally used as a

part of covert sensitization (imagined self-

mutilation and nausea following hair pulling).

Use of covert sensititation in altering symbolic

representations of undesired performance, how-

ever, may require determination of the natural-

istic occurrence and functional role of such

representations (Mahoney, 1974). Application

of operant self-conlrol proccdurcs lo the prob-

lems of obesity, for example, found that verbal

descriptions of aversive comcquences their

subject5 had actually experienced (social rejection,

sarcastic treatment, demeaning infcrenccs) were

more potent variables in treatment than statis-

tically probable consequences such as diabetes

(Fcrstcr, Nurnbcrgcr and Levitt, 1962).

Following the analysis of Fcrstcr e/ (I/. (1962)

an individual will manipula(c the factor\ which

dctcrminc the frequency and amount of an

undesired behaviour if this control is reinforcing

to him-if it cnablcs him to ejcapc from the

ultimate avcrsivc con\equcnces (U.A.C..). In

scvcrc cases of tricllotillornania, whcrc basc-

lint rates of hair-pulling are very high and where

the aversive results of the habit are covered by a

wig or headscarf, it would seem that the

pa ient is

protected

from the social con-

sequences of the habit (e.g. embarrassment,

anxiety) as well as from social reinforcement

for habit reduction. It seems likely that penetra-

tion of this disguise is for many extremely

aversive and it is surprising that no treatment

procedure has dealt with manipulation of this

variable.

In accordance with these considerations, the

present study reports the results of two cases ot

severe trichotillomania treated (one by each

author) within an operant self-control regime.

METHOD

ub jec ts

Client A was a 25year-old married woman who described

a IO-year history of hair pulling which she had never been

able completely to inhibit. She reported that she had

started pulling her hair out when she was bullied at school.

Eyelash pul ling occurred for a short period but spon-

taneously remitted. The usual pattern was for the hair to be

played with pulled out examined for root removal

chewed and finally discarded. Hair was pulled from the

top of her head and above the right and left ear. In all 3

areas the hair was thin and patchy. Diary recordings

revealed that hair was usually pulled in the evenings last

thing at night and first thing in the morning. The habit

occurred most typically when she was alone and the fre-

quency increased when she was angry depressed or worried.

Over the years she disguised her problem with a variety of

hair styles a scarf and eventually for the last 3 years a wig.

Embarrassment and shame led to constant worry that her

problem which she hid from everyone except her husband

and mother would be discovered. The client reported that

her husband was very supportive and willing to help her in

any way possible.

Client B was an attractive 19-year-old girl with a 5.year

history of trichotillomania which started soon after the

death of her mother. Prior to this she had been in the habit

of fiddling with her hair a great deal. The hair pul ling had

persisted with only a 2-week period of abstinence which

followed a hurtful comment made about her hair. Hairs

were singly pulled from the top of her scalp back of her

head and above both ears where the hair was very patchy.

She would chew the hair before discarding it. The habit was

most likely to occur when working at her desk or at home

when she was reading or watching T.V. The frequency

increased when she was anxious. Her state of mind when

she performed the hair pulling seemed to vary from absent-

mindedness when she would suddenly discover that she had

been pulling her hair without thinking about it to a state

in which she felt the urge to pull her hair and did so in

spite of some sense of resistance. She was self-conscious

and embarrassed by her problem and had attempted to


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THE TREATMENT OF COMPULSIVE HAIR-PULLING

129

disguise it with various hairstyles and a headscarf. Nail

biting apart she showed no other neurotic features.

Procedure

Basel ine.

After the initial assessment interview each

client was asked to record daily the number of hairs pulled

out over a 2-week period.

Treafmenl.

The clients were then seen once a week for

% hourly treatment sessions. Client A was treated by one

of the authors and Client B by the other, using the same

treatment techniques:

(I) Feedback to increase awareness of behaviour including

self-monitoring by weekly collection of hairs in an envelope

(following Bayer, 1972) and visual display of progress via a

graph in the therapists office.

(2) Self-targeting: Client and therapist agreed on the

maximum number of hairs to be pulled each week. This was

to decrease each time the target was achieved.

(3) Stimulus control: The use of incompatible responses

when the urge to pull hair occurred (a prepotent repertoire

including knitting, isometric and relaxation exercises) and,

in the case of Client A, removal to a predetermined safe

environment, e.g. the room in which her husband was

working.

(4) Escalating response cost: (a) After each occasion

of hair-pulling the client was instructed to examine a

photograph of herself which showed very clearly the results

of her trichotillomania. (b) Use of the U.A.C. should the

client pull more than the self-targeted number of hairs per

week. In both cases this was found to be removal of their

respective disguises and a scalp examination by a young

male member of the hospital staff.

(5) Positive reinforcement consisting of coffee and

general pratre at each session when the stated target was

achieved.

(6) Phasing out of wig and scarf wearing as control was

achieved and hair grew back.

Fol low up

After 4 weeks of zero hair pulling, each client was

followed up every month for 6 months and at 3-monthly

intervals thereafter for a total of 15 months.

RESULTS

The number of hairs pulled decreased dramatic-

ally in the case of Client A from a baseline mean

of 515/week to zero/week after 5 treatment

sessions. In the case of Client B the number of

hairs pulled decreased more gradually from a

baseline mean of 692/week to zero/week over a

period of 13 weeks (see Table 1). Phasing out

the wig and headscarf in the case of Client A

was gradually achieved over a period of 12

months. Initially, 5 months after zero hair

pulling, she was able to discard the wig at

Table

I.

Number of hairs pulled out

Week

Client A

Client B

Baseline mean 515

692

I

17

531

2

16

487

3

10

455

4 7 420

5 1

22

6 0

I90

7

0

86

8 0

58

9 0

52

IO

0

50

II 0

39

12 0

35

13

0

0

16

0

0

home, substituting it for a headscarf. After a

further 2 months she was able to go out in the

evenings and then at weekends with only a

headscarf and after another month she paid her

first visit for 11 years to the hairdressers. By

this time, there had been substantial hair-growth

at the back and sides of her head but the hair on

the top of her scalp remained very thin and

patchy. After 12 months she was able to go to

work without a wig or headscarf, with her hair

styled to cover the bald patches. Since then the

wig has been completely discarded and she

and her husband reported strong negative

feelings towards it.

Client Bs disguise was less total than Client A

and the phasing out process was therefore

quicker. Three months after zero hair pulling,

she only used a headscarf on very windy days

and after a further three months she no longer

used any form of disguise.

At 15 months follow-up there had been no

relapse with either client.

DISCUSSION

The present study provides support for the

use of operant self-control procedures in the

treatment of two severe cases of trichotillo-

mania. The length of follow-up, which greatly

exceeded that of previous studies, was sufficient

to monitor phasing out of habit disguise, which

was particularly difficult for Client A. As a


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130


result of treatment, both clients were able to

engage in activities previously restricted, such

as swimming and various other outdoor pursuits.

They both reported an increase in self-confidence

and assertiveness, and Client B initiated her first

serious relationship. Her embarrassment con-

cerning her hair had previously led her to

avoid such contact. The differential rate of

reduction in hair pulling between the 2 clients

was thought to reflect the greater support Client

A received from her husband. Further, the

U.C.A (wig removal) was possibly a greater

deterrent than that for Client B whose disguise

was less total.

Observation and the clients own report

showed a number of factors to be of importance

in treatment success. The cases support Hornes

(1977) hypothesis that where a strong habitual

component exists, strong forms of feedback

(hair collection and photograph examination)

are required. As in previous studies (McLaughlin

and Nay, 1975; Levine, 1976) both patients

commented on increased feelings of self-control

made possible by self-targeting; using a margin

of error of I or 2 hairs per week clients felt

safe and more capable of maintaining zero

pulling. Habit-related anxiety was minimal in

both cases. The most important treatment

component identified by the clients was threat

she clearly found the process extremely stressful,

she felt it was the critical factor in continued

abstinence. In the case of Client A, the threat

alone of the U.A.C. was a sufficient deterrent.

This study suggest that a self-control pro-

cedure combining feedback with appropriate

negative reinforcement can be a potent and

lasting form of intervention for trichotillomania.

REFERENCES

Bayer C. A. (1972) Self-monitoring and mild aversion

treatment of trichotillomania, J. Behov. T/w. & Exp.

Psychiut. 3, 139-141.

Bornstein P. H. and Rychtarik R. G. (1978) Multi-

component behavioural treatment of trichotillomania:

A case study, Behav. Res. Ther. 16, 217-220.

Ferster C. B.. Nurnberger J. E. and Levitt E. B. (1962)

The control of eating, J.

Math.

1 87-100.

Greenberg H. R. and Sarner C. A. (1965) Trichotillomania:

Symptoms and syndrome,

Ar chs Gen. Psychiat. 12,

482-489.

Horne D. J. (1977) Behaviour theraov for trichotiliomania.

Behuv. Rei. Thtb. I S, 192-196.

.

Levine B. A. (1976) Treatment of trichotillomania bv covert

sensitization,

J. Behav. Ther. Exp. Psychiat. 7; 75-76.

Mahoney M. J. (1974)

Cogniti on and Behaviour Modifica-

tion,

Ballinger, Cambridge, Massachusetts.

McLaughlin J. G. and Nay W. R. (1975) Treatment of

trichotillomania using positive coverants and response

cost: A case report,

Behuv. Ther. 6, 87-91.

Monroe J. T. and Abse D. W. (1963) The psychopathology

of trichotillomania and trichophagy,

Psychiatry 26,

95-103.

of exposure or disguise penetration as a result

Philippopoulos G. S. (1961) A case of trichotillomania

of failure to achieve their weekly goal. This

(hair pulling),

Aclu Psychorher. Psychosom. Orthopued.

aversive consequence, carefully identified prior

(Basef) 9,30 3 12.

to treatment, was in fact only used with Client B

Stabler B. and Warren A. B. (1974) Behavioural contracting

in treating trichotillomania: Case note,

Psycho/. Rep. 34,

and its employment resulted in a dramatic

4OL402.

reduction in hair pulling that was maintained

Seager C. P.

(1970)

Treatment of compulsive gamblers

by

electrical aversion,

Er . J. Psychiut. 117. 545-553.

through treatment. During scalp examination,

Taylor J. A. (1963) A behavioural interpretation

the observer was informed that the condition

obsessive-compulsive neurosis,

Behuv. Rex Ther.

was not a medical one and on occasion the client

237-244.

stated that she pulled out her hair. Although

of

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christine cordle - the use of operant self-control in compulsive hair-pulling

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