Major Changes in the DSM-5

Transcription

1 6/17/17 Evidence-Based Treatment of Tricho=llomania, Excoria=on, and other Body-Focused Repe==ve Behaviors Caleb W. Lack, Ph.D. University of Central Oklahoma Major Changes in the DSM-5 The fiRh edi=on of the DSM included a new chapter =tled Obsessive-Compulsive and Related Disorders Pulled together both diagnoses from mul=ple previous categories and new diagnoses Obsessive-Compulsive Disorder Formerly in Anxiety Disorders Body Dysmorphic Disorder Formerly in Somatoform Disorders Hoarding Disorder Excoria=on (skin-picking) New disorders Tricho=llomania (Hair- pulling) Formerly in Impulse Control Disorders 1

2 OC&R Disorders Somewhat controversial, but reorganized for two primary reasons 1) to reflect the increasing evidence of these disorders relatedness to one another and dis=nc=on from other anxiety disorders 2) to help clinicians beaer iden=fy and treat individuals suffering from these disorders Chapter is placed next to Anxiety Disorders to reflect similari=es and overlap between these OC&R Disorders All have features in common such as an obsessive preoccupa=on and repe==ve behaviors They have enough similari=es to group them together in the same diagnos=c classifica=on But also, have enough important differences between them to exist as dis=nct disorders Outline of Workshop What are the Body-Focused Repe==ve Behavior Disorders? What are hair-pulling and skin-picking disorders? How do you treat them effec=vely? 2

3 What are Body-Focused Repe==ve Behaviors? BFRBs Repe==ve self-grooming behaviors in which pulling, picking, bi=ng or scraping of the hair, skin or nails result in damage to the body Seen to clinical levels in between 2-5% of pediatric and adult popula=ons Common BFRBs Hair pulling (of any type of hair) Skin picking (scabs, acne, or other skin imperfec=ons) Cu=cle or nail bi=ng or picking Lip or cheek bi=ng Thumb or finger sucking Nose picking 3

4 OC&R and BFRBs Two of the OC&R disorders are also BFRBs Tricho=llomania (hair-pulling disorder) Excoria=on (skin-picking disorder) Dis=nct from OCD and not the result of some deeper disorder or trauma Commonly discussed as a group, rather than really unique disorders Why Grouping? BFRBs are all Directed towards one s own body Focused on removing and/or grooming parts of your body Seem to all share emo=onal regula=on and environmental restric=on aspects Symptoms of BFRBs Pulling/picking most oren occur when sedentary Lying in bed, reading, listening to a lecture or in class, riding in or driving a car, using the bathroom, talking on the phone, using the computer or siing at a desk at work Can occur during more ac=ve =mes, though 4

5 Symptoms of BFRBs Can be planned or accidental, fully or less focused Fully focused / planned Purposefully leaving presence of others, wai=ng un=l others aren t watching Accidental / less focused Zoning out while watching TV, reading, driving, etc. Symptoms of BFRBs Some have sensa=ons that pull fingers to the sites, some do not Many report they are search for wrong hairs or skin in order to remove/fix the perceived problem For many, searching and examining behaviors are part of the process Focused & Emo=onally Regula=ng Focused BFRBs are more compulsive in nature, appear to be used to regulate nega=ve emo=ons Heightened nega=ve state (worry, anxiety, tension) causes pulling, which reduces said state 5

6 Automa=c & Environmentally Keyed Result of decreased awareness, typically very unfocused behaviors Typically seen when alone and sedentary and have a free hand E=ology Typically begin around puberty Can be seen among infants, but is less likely to develop into a long-term problem behavior Some evidence for gene=c or epigene=c component Strong environmental influence (family stress, in par=cular) What is Tricho=llomania (Hair-Pulling Disorder)? 6

7 DSM-5 Opera=onal Defini=on A. Recurrent pulling of one s hair, resul=ng in hair loss B. Repeated aaempts to decrease or stop hair pulling C. The hair pulling causes clinically significant distress in social, occupa=onal, or other important areas of func=oning DSM-5 Opera=onal Defini=on D. The hair pulling or hair loss is not aaributable to another medical condi=on E. The hair pulling is not beaer explained by symptoms of another mental disorder TTM Prevalence 1-2% in adolescents and adults Females outnumber males 10:1 in adult samples Equal number of males and females in childhood 7

8 TTM Impact Wide variety of hair loss From small and thin patches to bald spots to total baldness of areas (head, eye brows or lashes, pubic region, legs) Can lead to chronic skin infec=ons, scalp bleeding, and carpal tunnel syndrome TTM Impact Large amounts of =me spent pulling (focused and unfocused) Up to half mouth their hair, which can lead to dental erosion 5-20% ingest hair, which can lead to GI problems like trichobezoars 8

9 TTM Impact Avoidance of common ac=vi=es Swimming, sports, sleep overs, da=ng and sex, medical exams, haircuts Time spent disguising their hair loss Wigs, styling hair, makeup, scarves, hats Feelings of isola=on, shame, embarrassment TTM Impact High levels of nega=ve affec=ve states Feeling unaarac=ve Depression Low self-esteem Irritability Higher rates of drug and alcohol use High rates of social, academic, and occupa=onal impairment found TTM Impact Very high comorbidity rates with other DSM diagnoses Mood disorders Anxiety disorders Substance use disorders 9

10 What is Excoria=on (Skin-Picking) Disorder? DSM-5 Opera=onal Defini=on A. Recurrent skin picking resul=ng in skin lesions B. Repeated aaempts to decrease or stop skin picking C. The skin picking causes clinically significant distress in social, occupa=onal, or other important areas of func=oning DSM-5 Opera=onal Defini=on D. The skin picking is not aaributable to the physiological effects of a substance another medical condi=on E. The skin picking is not beaer explained by symptoms of another mental disorder 10

11 Excoria=on Prevalence Rates of 2-5% in adults, with at least half of cases star=ng in childhood 3:1 female to male ra=o Excoria=on Sites Most commonly reported areas of picking Face Cu=cles and nails Arms Scalp Hands and feet Impact of Excoria=on Very similar to that of TTM Physical damage and scarring is oren more no=ceable and prevalent Scabs or sores that aren t give =me to heal Infec=ons are common, as is higher rate of illness 11

12 Discussion Have you seen a pa=ent with a BFRB? Which kind? How was treatment? What did you do? Treatment for BFRBs 12

13 Phases of BFRB Treatment 1. Assessment and func=onal analysis 2. Iden=fy and target modali=es 3. Iden=fy and implement strategies 4. Evalua=on and modifica=on Evidence-Based Treatments Psychosocial Habit Reversal Training Combined Behavioral Model Acceptance & Commitment Therapy (adjunc=ve) Dialec=cal Behavior Therapy (adjunc=ve) Pharmacological Liale research to support use for primary treatment, some for adjunc=ve Assessment of BFRBs 13

14 Evidence-Based Assessment Cri=cal to being able to do effec=ve diagnos=c work and treatment planning Can use a combina=on of clinician, self-, and other-ra=ngs, plus func=onal assessment and photography Different measures commonly used for different types of BFRBs see haps:// clinicalscales Hair Pulling Assessment Several different clinician ra=ng scales Psychiatric Ins=tute Tricho=llomania Scale Yale-Brown Obsessive Compulsive Scale Tricho=llomania (YBOCS-TM) Self- and parent-report measures Tricho=llomania Scale for Children Milwaukee Inventory of Subtypes of Trich Skin Picking Assessment Yale-Brown Obsessive Compulsive Scale for Neuro=c Excoria=on (Y-BOCS-NE) The only clinician rated scale, but liale psychometric data available Skin Picking Scale (SPS) Most commonly used adult self-report measure, decent psychometrics 14

15 Skin Picking Assessment Skin Picking Impact Scale Measures func=onal impairment, not severity Milwaukee Inventory of Dimensions of Adult Skin Picking (MIDAS) Assesses automa=c and focused skin picking Observa=onal Measures Self-tracked observa=ons / behavioral logs can be used for treatment monitoring across BFRBs Photography has also been used to measure severity and track treatment progress Habit Reversal Training 15

16 Habit Reversal Training Most well-researched method to date Three cri=cal components Awareness training Compe=ng response training Social support Awareness Training Involves making clients more aware of when and where the pulling/picking is most likely to occur First step is a complete opera=onal defini=on of the BFRBs Describe where it occurs, which hand(s) are used, typical loca=on(s), typical mood state(s) Awareness Training Then, any environmental func=ons of the behavior need to be iden=fied Socially mediated posi=ve reinforcement Gaining aaen=on Socially mediated nega=ve reinforcement Escaping from unwanted situa=ons/ac=ons Automa=c reinforcement Physical/emo=onal changes that happen from behavior 16

17 Awareness Training For homework, clients are to keep an ongoing log of all pulling/picking episodes Typically includes severity, dura=on, triggers, emo=ons, sensa=ons, thoughts, loca=on Compe=ng Response Training In this phase, you teach and prac=ce doing behaviors that are physically incompa=ble with the picking/pulling behavior Ul=mate goal is to desensi=ze client to the urges that oren occur, as well as con=nue to raise awareness 17

18 Compe=ng Response Training CRT is very similar to doing EX/RP for OCD it s all about preven=on of typical responses and leing discomfort naturally dissipate May need to get highly crea=ve to develop appropriate compe=ng responses Compe=ng Response Training Typically begins by doing prac=ce phase where spend 30 minutes a day prac=cing pulling and doing CRs Iden=fy the most problema=c behavior and resultant picking/pulling site to target first Compe=ng Response Prac=ce 1) Based on prior opera=onal defini=ons, you begin the picking/pulling behavior 2) Start the behavior, but do not complete it 3) Do CR immediately 4) Hold the CR for 1 minute or un=l urge goes away, whichever is longer 5) Rinse and repeat 18

19 Social Support Involves bringing loved ones and family members into the therapy process to: Provide posi=ve feedback when the individual engages in compe=ng responses Cue the person to employ these strategies Provide encouragement and reminders when the individual is in a trigger situa=on Session Breakdown for HRT Session 1 - Interview Session 2 - Awareness training Session 3 Compe=ng Response Training Session 4 CR Generaliza=on Session 1 - Interview Func=onal assessment of BFRBs Assessment of comorbid issues Establish ongoing assessment plan Discuss treatment outline 19

20 Session 2 - Awareness training Provide ra=onale for awareness training Get detailed descrip=on of pulling/picking Discuss warning signs of pulling, establish 1-3 Therapist simulates pulling, client has acknowledge BFRBs Session 2 - Awareness training Repeat process with warning signs Homework is to do self-monitoring of pulling/ picking behavior for the next week 20

21 Session 3 Compe=ng Response Training Review monitoring HW Choose a compe=ng response Clinician models CR Address concerns about CR Situa=ons it will not possible, worries about it feeling uncomfortable Session 3 Compe=ng Response Training Teach client the CR Social support training Iden=fy support person Have client demonstrate CR Have support person praise (based on therapist modeling) Homework is to prac=ce CR for minutes daily and con=nue self-monitoring Session 4 CR Generaliza=on Review HW, troubleshoot as needed Assess self-monitoring data Review CR to ensure it s being done correctly Ask support person about any problems 21

22 Session 4 CR Generaliza=on Introduce use of CR outside of prac=ce Determine how support person(s) will let client know when to do the CR (if they don t catch it themselves) Prac=ce in session Homework con=nue self-monitoring and prac=ce, implement general CR use Sessions 5+ Review and troubleshoot progress using CR and prac=cing Repeat awareness and CR process for other BFRBs Space sessions out to provide contact as needed Comprehensive Behavioral Model 22

23 Comprehensive Behavioral Treatment ComB was developed to individualize BFRB treatment Combines HRT with other CBT techniques to maximize generalizablity Differs from HRT in that uses not just CRs, but also sensory subs=tutes ComB Sensory Subs=tutes All about finding items that achieve the sensa=on desired when engaging in BFRBs If itching at picking/pulling area, use wide tooth comb to provide relief but not have fingers touch skin/hair If searching for coarse hair to pull, might roll twine between fingers ComB Other Aspects Cogni=ve restructuring and correc=ng faulty thinking Interpersonal work due to shame, isola=on, and low self-esteem that is oren seen in people with BFRBs 23

24 Adjunc=ve Treatments Adjunc=ve Therapies Small scale trials have shown that supplemen=ng HRT with ACT or DBT can have increased benefits Using ACT has been found to help address focused/planned behaviors DBT enhances awareness of triggers and teaches distress tolerance Pharmacological Treatments More adjunc=ve than primary, no FDA approved meds specifically for the BFRBs SSRIs show mixed results, at most may cause a mild improvement but effects seem to decrease across =me Tranquilizers some=mes prescribed PRN to help prevent behaviors in stressful situa=ons 24

25 Pharmacological Treatments An=histamines or topical steroids some=mes used to decrease feelings of itching Prophylac=c use of an=-acne meds to decrease triggers Topical analgesics to decrease physical sensa=ons Ques=ons? 25