This clinical guide describes an innovative, individualized approach to the treatment of body-focused repetitive behaviors (BFRBs), including hair pulling disorder (HPD) (also called trichotillomania) and skin picking disorder (SPD) (also called excoriation disorder). This treatment is derived from the Comprehensive Behavioral (ComB) conceptual model described more than two decades ago (Reference Mansueto, Stemberger, Thomas and GolombMansueto et al., 1997). In addition to the conceptual model, ComB treatment was first introduced in 1990 (Reference MansuetoMansueto, 1990; Reference Mansueto and GoldfingerMansueto & Goldfinger, 1990) and has been refined by Mansueto and his colleagues at the Behavior Therapy Center of Greater Washington in the ensuing years (Reference Mansueto, Golomb, Thomas and StembergerMansueto et al., 1999; Reference MansuetoMansueto, 2013, 2021; Reference Mansueto, Vavrichek and GolombMansueto, Vavrichek, & Golomb, 2019; Reference Stemberger, Thomas, MacGlashan, Mansueto, Hersen and BiaggioStemberger, Thomas, MacGlashan & Mansueto, 2000). Today, ComB is regarded as an established conceptual framework and as an assessment and treatment approach employed by scores of clinicians. ComB has served as the basis for the clinical training by the TLC Foundation for Body Focused Repetitive Behaviors’ Professional Training Institute for over two decades; it was established as a favored treatment modality by that organization’s Scientific Advisory Board; and it has influenced contemporary cognitive behavioral treatments of HPD, SPD, and other BFRBs since its introduction.
Who Should Use This Clinical Guide?
This clinical guide is intended for use by any mental health professional with a desire to help people who suffer with a BFRB. To utilize this manual most effectively, it is helpful but not essential for the treating professional to have familiarity with cognitive behavior therapy (CBT) techniques, the behavioral and cognitive principles that underlie these techniques, and experience in applying CBT to clinical problems. Although it is recommended that a therapist have some knowledge about or experience with CBT and the underlying principles thereof, it is not imperative. Anyone with an open mind and a desire to help those suffering with these disorders can benefit from reading and using this clinical guide.
Clinical Population Served by This Clinical Guide
ComB utilizes the fundamental principles of learning and cognitive theory, as well as a functional analytic approach to conceptualization and treatment of these problematic behaviors. ComB treatment was originally developed for HPD, although over the past decades it has been expanded to treat other body-focused repetitive behaviors such as SPD and those not listed individually in the fifth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (2013), such as nail biting, nail picking, lip/cheek/tongue biting, and cuticle picking that are now classified collectively as “Other Obsessive Compulsive and Related Disorders.” This clinical guide provides a broad perspective on a range of BFRBs and is intended to provide the necessary information for the conceptualization and treatment for all such disorders.
Sometimes there is some diagnostic confusion, such as when a client’s presenting concern can resemble that of a BFRB, when it is actually something else entirely. Clinical symptoms that can resemble those of a BFRB but are not served within the framework of this manual include obsessive compulsive disorder that infrequently manifests as repetitive preoccupation with, and excessive grooming of, one’s hair; body dysmorphic disorder (an obsessive concern with the appearance of one’s skin or hair that can lead to physical damage); delusional disorders such as parasitosis (a psychotic disorder where a person believes that their skin is infested with insects and may dig under their skin to remove them); or self-harm practices such as cutting or burning the skin where the damage to the body is the result of wanting to feel physical pain to divert from psychological pain. In cases such as these, it is important to differentiate these behaviors from that of a BFRB, because the treatment approach would be quite different. Diagnostic criteria for HPD and SPD, as well as how to tease out these differential diagnoses, will be discussed in greater detail in the next chapter.
How to Use This Guide
This clinical guide is designed to be a standalone tool for the conceptualization, assessment, and treatment of BFRBs. Because BFRBs are idiosyncratic behaviors in that they are experienced somewhat differently for each individual, understanding the unique clinical phenomenology of each BFRB sufferer is important and ultimately lays the foundation for the treatment plan. The rationales for the approach to conceptualization, assessment, and treatment in this guide will be offered, followed by descriptions of how to evaluate, understand, and intervene in cases that have their own unique underlying features and presentations. Clinical worksheets will be provided to assist in the evaluation process. Detailed descriptions of treatment strategies and tactical interventions will be offered. A complex case, “Emily’s Story,” will be introduced later in this chapter and returned to at numerous points throughout this guide. The case will be used to illustrate and highlight concepts and techniques of ComB treatment as applied to a complex case, from start to finish.
We will begin by providing an overview of BFRBs in Chapter 1, so that the reader has a basic understanding of the diagnostic, phenomenological, and clinical presentation of BFRBs. Chapter 2 will detail the clinical characteristics of HPD and SPD as related to the ComB conceptual model to provide a foundation for understanding how these behaviors are best understood. Chapter 3 will delve into the history of treatments for BFRBs and will describe current approaches to decreasing BFRB symptomatology, including an overview of ComB treatment. Chapter 4 provides a blueprint for getting started with a client utilizing ComB and setting the stage for successful ComB treatment. Chapter 5 will provide direction on conducting the assessment, functional analysis, and case conceptualization of an individual’s BFRB practices. Chapter 6 addresses both the identification of relevant domains and the selection and implementation of targeted interventions. Chapter 7 will outline how to evaluate client progress, work toward treatment termination, and prevent relapse. Chapter 8 will provide self-care strategies to help support clients during their ongoing treatment and after termination. Chapter 9 will describe work with children and families when BFRBs are present in younger clients. And finally, Chapter 10 will give an overview of working with comorbidities and other complicating factors that can influence treatment, and summarize the ComB approach and thoughts about moving forward in light of recent research findings. We anticipate that readers will find this clinical guide to be the most comprehensive resource available for treating individuals struggling with BFRBs.
Now we will introduce you to Emily, a young woman who has suffered with a complex problem that involves a combination of hair pulling and skin picking features. This combined form of BFRB disorder is not typical but also not uncommon in the population of people with BFRBs. Please read it carefully as it will contain many of the critical pieces of information that will illustrate points covered in the ensuing chapters. Plan to return to Emily’s story from time to time as you read relevant sections of the guide to reconnect with information provided in her initial case description. As you will see, the experience of living with an established BFRB encompasses suffering across a broad range of human dimensions with highly complex interconnectedness. Now meet Emily and share in her life’s story.
It was everything that Emily thought she wanted, the start of a new life at college, with her own private room and all the freedom to shape the next phase of her young life. But just three months into her college career, things had gone terribly wrong. Instead of the joy and freedom she had hoped for, she spent much of her time alone, flooded with sadness, sobs, and tears so deeply felt that she was constantly exhausted from crying, fatigue, and growing despair. Instead of sleeping and living a normal college life, she was pulling out her hair and picking her skin for hours each day and night. Not long after freshman orientation she had withdrawn from socializing. Soon dormmates gave up on her and stopped inviting her to join them in routine college activities. Worse yet, she was no longer attending classes, and, to her horror, she had to accept the possibility that she might have to admit to failure to her parents and return home in disgrace. Things had gone terribly wrong in what seemed no time at all.
She knew that she had problems before she left home. As an only child, she had resented her mother’s intense scrutiny and daily comments on all aspects of her behavior and appearance. It obviously had some advantages, Emily had to acknowledge, because without those intrusions and with so much time alone, her “attacks” on her body now went unchecked and were occurring with a vengeance. She was trapped in her single dorm room, afraid to show her face to her dorm mates, or anyone else for that matter – a pretty face, now bruised, swollen, and oozing blood and lymph fluid. Only weeks ago, she had arrived on campus with excitement and great hopes for her new life. The blackheads around her nose and cheeks, and the few unremarkable zits on her chin and forehead bothered her some, but with a little makeup she could almost forget about them most of the time.
In middle school and high school, it wasn’t her complexion that was most challenging. At first it had been her eyebrows that she had fussed with. She hadn’t a clue why, but she would occasionally pull out eyebrow hairs, one by one, that is, until her mother noticed the damage and responded with intense emotion and disapproval. That was enough to end that behavior quickly. Her eyebrows quickly grew back and were never a problem again. But she had a secret. Though she had stopped pulling from her eyebrows, instead she was targeting hairs on her legs, mainly from her thighs, where the damage could be more easily hidden. But soon a complication became apparent, because many of her leg hairs were frustratingly hard to grasp, especially the short ones and ingrown ones that caused her the most bother, she began to use tweezers to dig beneath the skin to pull them out. She would go at the more deeply buried hairs with the sharp tweezer points, causing irritation, bleeding, and unsightly lesions. Scabs began to multiply on her legs, and they became irresistible targets for picking and scraping with her fingernails.
Before college, her chronic hair pulling and skin picking clearly was an inconvenience, and shaving her legs became very difficult with all of the irregularities on her skin. She wasted a lot of time engaged in secret and shameful activities of hair removal, and a lot more time than that in efforts to keep the damage concealed from others. Wearing shorts, bathing suits, and other clothes that bared her legs were impossible when the damage was at its worst – and that meant missing out on some fun events. Still, partly out of fear of her mother’s wrath if she knew, Emily managed to limit the damage she caused and to keep it mostly concealed from others as best she could. Now her world had crumbled in a matter of weeks. What had been an inconvenience was now a crippling condition that dominated her life.
Maybe all of this privacy, freedom, and excitement about college was just too much for her to handle. It was during orientation week that she realized something that she should have thought about and taken more seriously. Having chosen a college in New Orleans meant hot, humid weather, and that translated to revealing outfits as de rigueur in the local scene. Moreover, she had met a nice guy, Josh, who under any other circumstances would have been a major plus in her life. But after three straight days of getting together with him, she realized that things had moved too fast. She was blind-sided by his insistence that she be his date for a swim party being thrown for new students. Scrutiny of her legs via her wall mirror made it clear that she wasn’t nearly ready for daylight exposure of her tortured limbs. In fact, she was so distraught in her realization that not only going to the party but more intimacy with Josh was out of the question. Worse yet, the self-examination of her bared legs had led to the most severe incident of pulling and picking that had ever occurred up to that point. More damage than ever, more invitations turned down, and a call to Josh in which she ended their involvement. She lied when she had told him that she “just wasn’t into him in that way”. That pushed her into the deep pit of despair in which she now felt trapped. Emily wondered at what point she should return home and end her college dream that now felt like a nightmare. She dreaded having to face her mother and admit that it was her own weakness that led to this humiliating circumstance.
With her mother phoning her daily, it was increasingly difficult to pretend that everything was fine. She was always probing and intrusive, insisting on providing Emily with unwanted advice. The phone calls just added fuel to the fires that ignited Emily’s shameful activities. During these calls, her frustration would mount, and her composure would wane. Her tension would increase as the conversations became more one-sided. It was after one of those calls that she realized to her horror that, for the first time, she had pulled out hair from her scalp. Within a week, she had a growing bald spot the size of a fifty-cent piece behind her left ear. Now there was enough hair missing from several spots on her scalp that it became challenging to camouflage them, even with clever hairstyling. That’s what led Emily to begin to skip classes, to start eating alone in her room, and to give up on any involvement with potentially friendly dorm mates.
Desperate and alone, after a terribly damaging episode where she attacked her legs and scalp with unchecked pulling and picking, Emily tearfully searched online for any kind of help. She discovered an organization, the TLC Foundation for BFRBs. With information from their website she found a therapist trained to treat hair pulling and skin picking right in New Orleans. She quickly scheduled an appointment in the hopes of finding a way out of her horrible dilemma. She felt a flicker of hope.
Throughout this book we will return to Emily’s case and describe her experiences throughout the course of her treatment.
