رفتار درمانی پیشرفته برای تریکوتیلومانیا در نوجوانان

Although several studies have examined the efficacy of Acceptance Enhanced Behavior Therapy (AEBT) for the treatment of trichotillomania (TTM) in adults, data are limited with respect to the treatment of adolescents. Our case series illustrates the use of AEBT for TTM in the treatment of two adolescents. The AEBT protocol (Woods & Twohig, 2008) is a structured treatment manual that was adapted to the individual clients’ needs and clinical progress. Both clients reported clinically significant gains in treatment as determined by at least 2 weeks of abstinence from pulling, and subjective reports of decreased distress and impairment, although one required a booster session due to relapse. AEBT is worth further exploration as a treatment for adolescents with TTM.

Trichotillomania (TTM) is characterized by the repeated pulling out of one's hair, resulting in noticeable hair loss (American Psychiatric Association, 2000). Other diagnostic criteria include a rising sense of tension or urge preceding the pulling episode and a sense of relief following a pulling episode, although children and adolescents may not readily report these symptoms (Franklin et al., 2008, Hanna, 1997 and Tolin et al., 2008). TTM predominantly occurs in women by a ratio of approximately 8:1 (Christenson, Mackenzie, Mitchell, 1991, Cohen et al., 1995 and Woods, Flessner et al., 2006a), although this gender discrepancy may be less pronounced in children (Chang et al., 1991 and Muller, 1987). Individuals with TTM may pull from any site on the body, but the most common include the scalp, eyebrows, and eyelashes (Cohen et al., 1995 and Santhanam et al., 2008). Patients with TTM may engage in pre-pulling behaviors such as hair stroking or twirling, as well as post-pulling behaviors (i.e., hair ingestion, stroking hair strands across the lips, and chewing, biting, or examining the hair root; du Toit, van Kradenburg, Niehaus, & Stein, 2001). Several studies have examined the efficacy of pharmacological and nonpharmacological interventions for TTM. Research on various selective serotonin reuptake inhibitors (SSRIs) has been mixed, with open trials showing a positive effect on pulling (Koran et al., 1992, Stanley et al., 1991 and Winchel et al., 1992) but placebo-controlled double-blind crossover studies suggesting SSRIs produce no benefit over placebo (Bloch et al., 2007, Christenson, Mackenzie, Mitchell, Callies, 1991 and Streichenwein and Thornby, 1995). Another antidepressant, clomipramine, has shown greater efficacy than SSRIs (Bloch et al., 2007). More recently, N-acetylcysteine (Grant, Odlaug & Kim, 2009) and olanzapine (Van Ameringen, Mancini, Patterson, Bennett & Oakman, 2010) have been shown to be more efficacious than pill placebo in double-blind randomized controlled studies. Unfortunately, controlled studies of medication for TTM have been conducted primarily with adults, leaving the efficacy of medications for children with TTM untested. Nonpharmacological treatments typically involve some form of behavior therapy. Various behavioral techniques have been used, either as stand-alone interventions or in combination with each other. These include relaxation training, self-monitoring, reinforcement programs, and stimulus control (Diefenbach et al., 2006, Salama and Salama, 1999 and van Minnen et al., 2003). The behavioral intervention with the strongest empirical support as a treatment for TTM is Habit Reversal Training (HRT). HRT consists of three primary techniques, including awareness, competing response, and social support training (Azrin & Nunn, 1973). HRT or HRT-based treatment packages have demonstrated efficacy in single-subject studies (Mouton and Stanley, 1996, Rapp et al., 1998, Rosenbaum, 1982 and Tarnowski et al., 1987) and in group studies utilizing waitlist (van Minnen et al., 2003 and Woods, Wetterneck et al., 2006b), alternate treatment (Azrin, Nunn, & Frantz, 1980), and pill placebo (Ninan, Rothbaum, Marstellar, Knight & Eccard, 2000) control conditions. Across these studies, HRT has been found to be more efficacious than the control conditions (Bloch et al., 2007). Although HRT has been found to be effective in reducing TTM symptoms, there are limitations. First, treatment research has rarely included children and adolescents, although the one published open trial in children suggests that HRT in conjunction with stimulus control (i.e., a group of techniques designed to prevent pulling and provide alternative tactile reinforcement) can be effective in this population (Tolin, Franklin, Diefenbach, Anderson, & Meunier, 2007). Second, there is little evidence to suggest that complete elimination of pulling is a standard outcome. Reasons are unclear, but may have to do with the different styles of pulling believed to be present in many with TTM. One style, automatic pulling, is a habitual pattern that often occurs out of awareness and is likely maintained by the sensory consequences of the hair pulling act itself. HRT plus stimulus control has been suggested as particularly well-suited to treat this style of pulling (Walther, Ricketts, Conelea, & Woods, 2010). Focused pulling, on the other hand, appears more purposeful and is believed to serve an emotional regulatory function. Unfortunately, there is evidence suggesting HRT does not significantly impact negative emotions (Teng, Woods, & Twohig, 2006), and thus may be less effective in treating the focused style of pulling. Because both styles of pulling are believed to be present in most adolescents and adults who pull (Flessner, Woods, Franklin, Keuthen, & Piacentini, 2009), when only HRT and stimulus control are used, our clinical experience indicates that treatment gains may be incomplete if a person also engages in focused pulling. To address this concern in adults, a combined Acceptance and Commitment Therapy (ACT) and HRT approach, labeled Acceptance Enhanced Behavior Therapy (AEBT) for TTM was developed. ACT is based on the assumption that psychological problems are brought about, in large part, by experiential avoidance (Hayes, Strosahl, & Wilson, 1999), or the person's tendency to avoid, control, or escape from unwanted private experiences such as thoughts, urges, or emotions. In TTM, it is believed that the act of pulling regulates these internal experiences and as such, the pulling itself is used to avoid or escape from unwanted private events (Wetterneck & Woods, 2007). Indeed, data exist showing a link between TTM severity and experiential avoidance (Begotka, Woods, & Wetterneck, 2004), and other evidence suggests that experiential avoidance mediates the relationship between thoughts and emotions and pulling severity (Norberg, Wetterneck, Woods, Conelea, 2007). Researchers have begun to examine the efficacy of this combined approach in adult samples with TTM. A preliminary investigation of AEBT using a multiple baseline design showed that treatment was effective in reducing the number of hairs pulled to rates approaching zero in 80% of the participants (Twohig & Woods, 2004). In a follow-up study comparing AEBT to a waitlist control, AEBT was found to be effective in decreasing hair-pulling severity, number of hairs pulled, overall impairment, experiential avoidance, and symptoms of anxiety and depression (Woods, Wetterneck, et al., 2006). Evidence was provided for the differential impact of the ACT and HRT components on TTM symptoms in a study by Flessner, Busch, Heideman, and Woods (2008). Although several studies have examined the efficacy of AEBT for the treatment of TTM in adults, data are limited with respect to the treatment of adolescents, despite the fact that both focused and automatic pulling occur commonly in adolescents with TTM. Our case series illustrates the use of AEBT for TTM in the treatment of two adolescents with TTM. These cases were selected from a larger set to illustrate varying presentations of TTM. Protocol adaptations for the adolescents were made throughout treatment based on the specific needs of each adolescent.

Trichotillomania is believed to serve multiple behavioral functions, including both tactile/sensory and emotional regulation functions. AEBT, a treatment designed to address both sets of controlling variables, has been developed (Woods & Twohig, 2008) and tested in adult TTM samples (Twohig and Woods, 2004 and Woods, Wetterneck et al., 2006b) but not in younger samples, despite the fact that the onset of TTM typically occurs in adolescence (Christensen, Mackenzie, & Mitchell, 1991). The current case series was a downward extension of AEBT to two adolescents with TTM.