The Use of Habit Reversal to Treat Trichotillomania Following the Surgical Removal of a Trichobezoar Jody Lieske, MA and Nancy Foster, PhD Munroe-Meyer Institute at the University of Nebraska Medical Center

Results (continued) INTRODUCTION Procedure (continued)

• Trichotillomania is rare condition that affects 1-4% of the population. In some • Self Awareness: Subject was trained to 1) look in the mirror while String and Clothing Pulling/Swallowing pretending to engage in hair/string pulling and nail biting while focusing on instances, trichophagia, or mouthing of the hair, can lead to the formation of 4 Self- how her body moved and the muscles that were used while the habit was Baseline Self-Awareness/ + trichobezoars (hairballs). Awareness/ + Competing 3.5 Competing Response + being performed; 2) identify times that she started the habit by saying “that Response + Parent/Teacher Parent/Teacher Support + Support Relaxation • Five to 18% of patients with trichotillomania also show trichophagia and was one;” and 3) record each occurrence on a 3x5 index card. 3

approximately 37.5% are at risk for forming a trichobezoar. 2.5 • Practice the Competing Response Daily: Competing responses to hair/string 2 • Trichobezoars account for 55% of all bezoars, 90% which occur in adolescent pulling and swallowing and nail biting/swallowing were generated and Per Week females. include: sitting on hands, holding a stress ball, chewing gum, and sucking 1.5 on hard candy. Frequency 1 • Behavioral interventions have been shown to be effective with treating 0.5 patients with this trichotillomania. However, additional research is needed on • The subject was encouraged to use the competing responses 1) in front of a treatments for trichotillomania when trichophagia is present. mirror for practice, 2) when she felt the urge to start her habits, 3) in 0 situations where she is likely to start her habit, and 4) for 1 minute after Session 1 Session 2 Session 3 Session 4 Session 5 • The purpose of this case study was to examine the treatment effects of habit each time she performs her habit. reversal on hair, nail, and string pulling and mouthing in a 10-year-old female who had a history of a trichobezoar. • Parental/Teacher Support: Parents and teachers were trained on how to Hair Pulling/Swallowing

identify situations when the subject engaged in her habit. They were also 4 Baseline Self-Awareness/+ Self-Awareness/+ encouraged to provide support and encouragement for efforts of the subject. Competing Competing Response 3.5 Response + + Parent/Teacher • Treatment focused on behavioral interventions without the use of a Parent/Teacher Support + Relaxation Support was encouraged at the beginning/throughout treatment. Support pharmacotherapeutic intervention. 3

2.5

Frequncy PWk • Progressive Relaxation: The subject was trained to use deep breathing along Per Week with deep muscle relaxation. She was encouraged to use strategies in 2

METHOD situations where anxiety was elevated and she felt urges to engage in habits. Frequency 1.5

Subject 1

0.5 • Archival data were examined on a 10-year-old female subject who live in a 0 rural community and was treated at an outreach behavioral health clinic RESULTS Session 1 Session 2 Session 3 Session 4 Session 5 located within a primary care setting. • Data showed a decrease in the frequency of nail biting/ swallowing and hair and string pulling/swallowing. • Prior to behavioral intervention, the subject underwent surgical removal of a trichobezoar with a 3 ½ foot long tail that extended into her small intestine. DISCUSSION/LIMITATIONS Nail Biting/Swallowing • Subject identified situations that she was more likely to engage in habits and included: 1) during academic classes and 2) at night whiled attempting to fall 12 • The case study showed decrease in the frequency of targeted habits that Baseline Self-Awareness/+ Self-Awareness/+ Competing Competing asleep, an antecedent identified was any event that created anxiety, but mostly Response + Response + previously contributed to the development of a trichobezoar. Parent/Teacher Parent/Teacher when relationship problems occurred with peers. 10 Support Support + Relaxation • Given that the subject underwent a surgical procedure prior to behavior Procedure 8 treatment, the subject could have experienced adverse effects which Frequncy PWk may have contributed to behavior change. 6 • Treatment focused on four components of habit reversal procedures: 1) an

Frequency Per Week • Treatment components were not implemented separately and it is increase in the subject’s self-awareness of the habit; 2) identification and 4 practice of a daily competing response; 3) use of relaxation techniques; and therefore difficult to attribute which component may be more

4) support from parents and teacher. 2 influential on treatment effects.

0 • Future research should examine children and adolescents who develop Session 1 Session 2 Session 3 Session 4 Session 5 trichophagia and are treated with or without behavioral interventions.