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The behavioral treatment of neurodermatitis through habit-reversal
THE
BEHAVIORAL
TREATMENT
NEURODERMATITIS
OF
THROUGH
HABIT-REVERSAL* MICHAELS. RoSENBAuM't ‘Department
and TEODCIROAYLLON’
of Pediatrics. University of South Alabama Medical Center. 2451 Fillingim Mobile. AL 36617. U.S.A.: and ‘Georgia State University. Atlanta. GA 30303. U.S.A. (Raceiurd
St.
14 Jonuary 1981)
Summary-Azrm and Nunn’s habit-reversal techmque (1973. 1977) was used to treat four clients with neurodermatitis. Following a single treatment session. scratching associated with this skin condition was markedly reduced for three clients. whereas this reduction occurred for the fourth client 4 days following treatment. Results at 6-month follow-ups showed that scratching was eliminated for the client with the mildest case. whereas this behavior remained at low levels for the other three clients.
INTRODUCTION Neurodermatitis consists of an itchy skin condition associated with and exacerbated by excessive scratching. The estimated incidence of this skin condition in the general population ranges from 2-20x (Champion and Parish, 1972). Neurodermatitis manifests itself as lesions on areas of the body which are easily accessible to the fingers, (e.g. back of the neck. arms. legs) (Robertson er uI.. 1975). This skin condition appears to begin with a minor trauma. infection or skin lesion which produces itching and subsequent scratching. Scratching relieves the itching and results in a pleasing sensation, which increases the probability of subsequent scratching in the presence of itching (Bar and Kuypers, 1973). This increased probability of scratching is reported by the client as an ‘urge’ to scratch. Thus, a cycle consisting of itching, scratching and relief is initiated and may be maintained over an extended period of time. Continuous and severe scratching can produce lichenification. a cutaneous reaction to scratching which consists of well-defined, thickened and flaky patches of skin (Robertson et ~1.. 1975). Psychoanalysis and psychotherpy, based on helping the client resolve hypothetical underlying conflicts presumably related to this skin condition. have been used in the successful treatment of neurodermatitis (Nickel. 1978; Russell. 1975). Dermatological approaches to treating neurodermatitis include the use of mild soaps, corticosteroid creams, antihistamines and dietary control (e.g. avoiding chocolate) (Lubowe, 1976). The behavioral literature offers several approaches to treating the scratching associated with neurodermatitis, including extinction (Walton, 1960), reinforcement for nonscratching behavior combined with ignoring scratching (Allen and Harris, 1966; Bar and Kuypers. 1973) graphing the scratching rate plus rewards for decreased scratching (Dobes, 1977), shock contingent on scratching combined with relaxation training (Bar and Kuypers. 1973; Ratcliff and Stein, 1968), substituting stroking and patting for scratching (Watson et al., 1972) and hypnosis (Collison, 1972; Kellner, 1975). These studies were limited methodologically due to the inclusion of only one client, a lack of reporting data and the inclusion of self-recording without assessing the reliability of self-recorded data. Focusing on habit-reversal in treating the scratching associated with neurodermatitis. the present study was designed to overcome the methodological limitations described * This research was part of the first author’s doctoral dissertation in partial fulfillment of the Ph.D. degree under the chairmanship of the second author and was presented in a paper entitled “Habit-reversal in treating neurodermatitis” at the meeting of the Southeastern Psychological Association, Washington. DC, March 1980. t To whom all reprint requests should be sent. 313
314
MICHAEL S. ROSENBAUMand TEOWJROAYLLON
above by including four clients, providing ongoing assessment of scratching throughout 6-month follow-ups and obtaining independent assessment of self-recorded data. METHOD
Clients Sandra. Sandra was a 34-year-old female referred by a private dermatologist for treatment of neurodermatitis. She was employed as a registered nurse in the cardiac intensive care unit at a university medical center. A few months prior to visiting the dermatologist, Sandra had been scratched on her left ankle by a cat. As the scratch was healing, the affected area began to itch and she began to scratch it. This, in turn, had produced an irritated, reddened, flaky area of skin on her ankle, which extended about 3 inches up her leg. Sandra reported that she never scratched at work but only at home. Although the dermatologist had prescribed Kenalog cream to help heal the affected skin, Sandra’s excessive scratching rendered this medication ineffective. Mary. Mary was a lbyear-old female high school student referred for treatment of neurodermatitis on the shins of both her legs by the dermatology clinic at a university medical center. She had a 2-year history of scratching her shins in response to their itching. She reported that her scratching was most severe when she worked on her homework or studied for a test. Kenalog cream prescribed by a dermatologist at the clinic had proven ineffective due to Mary’s excessive scratching. Joan. Joan was a 29-year-old female referred for treatment of neurodermatitis on her arms, legs and buttocks by the dermatology clinic at a university medical center. She reported that her current case of generalized neurodermatitis was the second occurrence of this skin condition in the past several years. Joan was employed as a secretary on a temporary basis. Her scratching typically occurred at home when she was not occupied, especially when she watched television. A dermatologist at the clinic had prescribed Kenalog cream, the effectiveness of which was markedly reduced due to Joan’s excessive scratching. Kathy. Kathy was a 22-year-old female who heard about the present research from a friend and sought treatment for neurodermatitis on both her arms and elbows. She was employed as a trainee for a local electrical manufacturing company. She reported that her job was quite anxiety-producing and that most of her scratching occurred at work. Her scratching had resulted in areas of reddened, flaky skin on each elbow extending about 2 inches on her arms.
Setting
and recording
During the initial interview with each client, the purpose of the research was explained and the client described the problem behavior in detail. Clients were also instructed in procedures for self-recording the frequency of scratching. Specifically, they were told to record a slash mark each time a target response was detected throughout the entire day on a 3 x 5” index card divided into seven columns. These recording procedures were conducted on a daily basis during baseline and throughout the first month following treatment. Baseline data were reported at the treatment session. Each client was asked to report data via phone 2 weeks following the treatment session. Data for the next 2 weeks were brought to the l-month follow-up session. Thereafter, each client recorded the frequency of scratching 1 week per month for 5 months and reported these data via monthly phone contacts. Response dejnitions Scratching. For each client this consisted of placing the hand on the affected area of skin and scratching with the fingernails for at least 5 seconds.
Habit-reversal
and neurodermatitis
315
Reliabilir)
When possible, validating reports from individuals in each client’s environment were obtained to assess reliability. These individuals (e.g. Sandra’s husband) were asked to count the number of instances of scratching. By dividing the smaller number recorded by the larger and multiplying the resulting quotient by 100, reliability was calculated on each of these occasions. Changes in the frequency of scratching were also indicated by evidence of healing in the affected skin areas (e.g. a decrease in the size of the area,.an absence of redness and flaky skin). This was based on judgments by the referring dermatologists at the 6-month follow-up sessions relative to the baseline appearance of these areas for Sandra, Mary and Joan, and at the 6-month follow-up session for Kathy by the first author.
Research design
Separate comparison designs (AB) representing a group of direct replications conducted to determine the effectiveness of treatment.
were
Procedure Baseline. The 7-day period of time between the initial interview and the treatment session constituted the baseline. Treatment (habit-reversal). As described by Azrin and Nunn (1973, 1977), the client verbally described and demonstrated scratching in the response description procedure. The first author then taught each client to detect bringing her hand toward the areas in which scratching occurred (e.g. ankle, arm, elbow) (early warning). Situation awareness training consisted of client descriptions of those situations in which scratching usually occurred or increased in frequency. Unpleasant aspects of scratching were described to increase the motivation to cease this behavior (habit inconuenience review). In the competing response practice procedure, each client was taught an isometric exercise characterized by: (a) being incompatible with scratching; (b) lasting at least 1 minute; (c) tensing the muscles used in scratching; (d) easy implementation with usual activities; and (e) preventing scratching from remaining a routine aspect of normal activities. The first author taught each client to place her hands in her lap or by the side of her body and clench her fists, until a comfortable amount of tension was produced in the hands and forearms. This response was to be performed for 2 minutes following the urge to scratch, any antecedent to scratching or any occurrence of scratching. To relieve severe itching each client was instructed to either stroke or pat the affected skin area (Watson et al., 1972). Sandra, Mary and Joan were instructed to continue using Kenalog cream. In the symbolic rehearsal procedure one situation in which scratching usually occurred was chosen. The client performing the competing response as she recalled an actual instance of scratching in that situation. Following several repetitions of this procedure. the first author engaged the client in a general discussion. The client was instructed to perform the competing response whenever an urge to scratch, antecedent to scratching, or actual scratching occurred during this discussion. The first author pointed out any instances of scratching that the client failed to detect. The entire treatment session lasted about 60 minutes. Fo//ow-up. At l- and 6-month follow-up sessions, the first author inspected the areas affected by excessive scratching, praised the client for improvement noted (e.g. a decrease in the size of the area, an absence of redness and flaky skin) and encouraged the client to continue using the treatment procedures. On each occasion that data were reported by phone, the client was praised for improvement (i.e. a decrease in the frequency of scratching or maintenance of this behavior at a low level) and was reminded to continue following the treatment procedures.
316
MICHAEL
S. ROSENEAUM
and
TEODORO
AYLLOK
B
Months
Fig. 1. The frequency of scratching for Sandra (lA), Mary (lB), Joan (IC) and Kathy (1D) on a daily basis and averaged over 1 week per month.
RESULTS
Sandra
Sandra’s mean frequency of scratching was IO.l/day during baseline and decreased markedly following treatment with habit-reversal (X = iA/day) (Fig. 1A). Following a slight increase in scratching at the 3-month follow-up, this behavior was eliminated by the 6-month follow-up. On the two occasions that Sandra’s husband recorded the frequency of his wife’s scratching (days 5 and 12), rehability averaged 7096. At the 6-month follow-up session, Sandra’s ankle had healed completely according to the referring dermatologist. Mary
During baseline the mean frequency of Mary’s scratching was 35.14/day, which decreased markedly following treatment with habit-reversal (% = “I.l/dayf {Fig. 1B). Throughout the 6-month follow-up, Mary’s mean frequency of scratching was IO&/day. On the two occasions that Mary’s sister recorded the frequency of her scratching (days 5 and lo), reliabihty averaged 80%. At the 6-month follow-up session, Mary’s shins had begun to heal (e.g. the skin was not as red or flaky as during baseline) according to the referring dermatologist. Joan
Joan’s mean frequency of scratching was 47.3/day during baseline (Fig. 1C). Treatment with habit-reversal was associated with a marked decrease in this behavior (2 = 7.l/day). At the 6-month follow-up the mean frequency of scratching was 14/day. At this session Joan’s arms and buttocks had healed completeIy and her legs showed evidence of
Habit-reversal
317
and neurodermatitis
beginning to heal (e.g. they contained fewer patches of Aaky skin reIative to baseline) according to the referring dermatologist. There were no opportunities to obtain reliability of Joan’s self-recorded data. Kathy During baseline the mean frequency of Kathy’s scratching was ZS.%/day and decreased folfowing treatment with habit-reversai (X = 13.7/dayf (Fig. ID). At the &month follow-up Kathy’s mean frequency of scratching was l~.g/day. On the two occasions~that her roommate recorded the frequency of her scratching (days 5 and 12), re~iabjlity averaged 76%. At the &month follow-up session, Kathy’s arms were almost completely healed (e,g. there was no evidence of reddened, flaky areas), whereas her elbows were stilf reddened and contained patches of flaky skin according to the first author. DISCUSSION
Based on the results of this study, it appears that the habit-reversal’technique can be effective in eliminating or decreasing scratching associated with neurodermatjt~s. The rapid decreases obtained for the four clients in this study were maintained over an extended period of time (i.e. S-month follow-ups). Several aspects of the habit-reversal technique appeared to be related to its effectiveness. Self-recording enabled each client to become more aware of the occurrence of scratching, whiie providing feedback concerning its frequency. An alteration in the frequency of scratching may have resulted from the reactive effects associated with this feedback (e.g. Jeffrey. 1974: Kazdin, 1974; McFall. 1977: Nelson. 1977). The successful implementation of the competing response practice procedure may have been related to each client’s increased awareness of the antecedents and consequences associated with scratching, resulting from the self-recording. response description. early warning. situation awareness training and habit inconvenience review procedures. The lack of objective ratings of relative flakiness. redness or size of the affected skin areas is a timitation of this study. Ratings couid have been obtained by photographing the affected areas on a pre-treatment basis and at the &month follow-up session and having the pictures blindly rated by a dermatologist. The objective quanti~cation of neurodermatitis should be focused upon in future research in this area. Although psychoanalysis and psychotherapy have been reported to be effective in treating neurodermatitis. no studies since 1960 could be found to support this contention. The effectiveness of dermatological approaches appears to be compromised in some cases by excessive, intractable scratching behavior. In these cases. behavioral treatment appears to be a valuable adjunctive to successful therapy. The most effective behavioral treatments for the scratching associated with neurodetmatitis have involved either aversive consequences contingent on this behavior or reinforcement for nonscratching combined with ignoring scratching. In the present study habit-reversal was effective in markedly reducing scratching. but this behavior was eliminated in only one client. It appears, however. that a marked reduction in this behavior may be sufficient to allow the affected skin areas to heal. The present study. therefore. extends the generality of habit-reversal as an effective treatment for scratching associated with neurodermatitis. Component analyses to assess separately the relative contributions of self-recording. response awareness training. competing response practice and symbohc rehearsat to the effectiveness of the habit-reversal technique should be conducted in future research. Acknorr,/edgements-The authors wish to express their sincere appreciation Michael A. Milan and Robert C. I~PJWII.
to the other committee members.
REFERENCES ALLEN K. and
HARRIS
reinforcement
F.
(19661 ~lirni~alion procedures, ~~,~~~~r,Res. T/w.
of a child‘s 4. 7944.
excessive scratching
by training the mother in
318
MICHAELS. ROSENBAUM and TEOD~ROAYLLON
AZRIN N. H. and NUNN R. G. (1973) Habit-reversal: a method of eliminating nervous habits and tics. B&C. Res. Ther. 11, 619-628. AZRIN N. H. and NUNN R. G. (1977) Habir Control in a Day. Simon & Schuster. New York. BAR L. H. J. and KUYPERSB. R. M. (1973) Behavior therapy in dermatologlcal practice. Br. J. Dermur. 88, 591-598. CHAMPIONR. H. and PARISHW. E. (1972) Atopic dermatitis. In Textbook of Dermatology. Vol. I (Edited by Rook A., WILKINSOND. S. and EBLINCF. J.). Davis, Philadelphia. COLLISOND. R. (1972) Medical hypnotherapy. Med. J. Aust. 1, 643-649. DOBES R. W. (1977) Amelioration of psychosomatic dermatosis by reinforced inhibition of scratching. J. Behac. Ther. exp. Psychiat. 8, 185-187. JEFFREYD. B. (1974) Self-control: methodological issues and research trends. In Self-Control. Power to the Person (Edited by MAHONEYM. J. and THORESEN C. E.). Brooks-Cole, Monterey, Califorma. KAZDINA. E. (1974) Reactive self-monitoring: the effects of response desirability. goal setting. and feedback. J. consult. clin. Psychol. 42, 704-716. KELLNERR. (1975) Psychotherapy in psychosomatic disorders: a survey of controlled studies. Archs yen. Psychiat. 32, 1021-1028. LUBOWEI. I. (1976) Adolescent skin problems. Cutis 17, 369-374. MCFALL R. M. (1977) Parameters of self-monitoring. In Behavioral Self-Management (Edited by STUARTR. B.). Bruner/Mazel, New York. NELXINR. 0. (1977) Methodological issues in assessment via self-monitoring. In Behacioral Assessment-New Directions in Clinical Psychology (Edited by CONEJ. D. and HAWKINSR. P.). BruneriMazel. New York. NICKELW. R. (1978) Neurodermatitis: a concept. Cutis 21, 677-680. RATLIFFR. G. and STEINN. H. (1968) Treatment of neurodermatitis by behavior therapy: a case study. Behac. Res. Ther. 6. 397-399.
ROBERTSON I. M., JORDANJ. M. and WHITLOCKF. A. (1975) Emotions and skin (II): the conditioning of scratch responses in cases of lichen simplex. Br. J. Dermat. 92, 407-412. RIJ~~ELLB. F. (1975) Emotional factors in skin disease. Er. J. Psychiaf. (Special No. Y) 9. 447-452. WALTOND. (1960) The application of learning theory to the treatment of a case of neuro-dermatitis. In Behaoior Therapy and the Neuroses (Edited by EYSENCKH. J.). Pergamon Press, New York. WAWN D. L., THARPR. G. and KRISBERGJ. (1972) Case study in self-modification: suppression of inflammatory scratching while awake and asleep. J. Behau. Ther. exp. Psychiat. 3, 213-215.
BEHAVIORAL
TREATMENT
NEURODERMATITIS
OF
THROUGH
HABIT-REVERSAL* MICHAELS. RoSENBAuM't ‘Department
and TEODCIROAYLLON’
of Pediatrics. University of South Alabama Medical Center. 2451 Fillingim Mobile. AL 36617. U.S.A.: and ‘Georgia State University. Atlanta. GA 30303. U.S.A. (Raceiurd
St.
14 Jonuary 1981)
Summary-Azrm and Nunn’s habit-reversal techmque (1973. 1977) was used to treat four clients with neurodermatitis. Following a single treatment session. scratching associated with this skin condition was markedly reduced for three clients. whereas this reduction occurred for the fourth client 4 days following treatment. Results at 6-month follow-ups showed that scratching was eliminated for the client with the mildest case. whereas this behavior remained at low levels for the other three clients.
INTRODUCTION Neurodermatitis consists of an itchy skin condition associated with and exacerbated by excessive scratching. The estimated incidence of this skin condition in the general population ranges from 2-20x (Champion and Parish, 1972). Neurodermatitis manifests itself as lesions on areas of the body which are easily accessible to the fingers, (e.g. back of the neck. arms. legs) (Robertson er uI.. 1975). This skin condition appears to begin with a minor trauma. infection or skin lesion which produces itching and subsequent scratching. Scratching relieves the itching and results in a pleasing sensation, which increases the probability of subsequent scratching in the presence of itching (Bar and Kuypers, 1973). This increased probability of scratching is reported by the client as an ‘urge’ to scratch. Thus, a cycle consisting of itching, scratching and relief is initiated and may be maintained over an extended period of time. Continuous and severe scratching can produce lichenification. a cutaneous reaction to scratching which consists of well-defined, thickened and flaky patches of skin (Robertson et ~1.. 1975). Psychoanalysis and psychotherpy, based on helping the client resolve hypothetical underlying conflicts presumably related to this skin condition. have been used in the successful treatment of neurodermatitis (Nickel. 1978; Russell. 1975). Dermatological approaches to treating neurodermatitis include the use of mild soaps, corticosteroid creams, antihistamines and dietary control (e.g. avoiding chocolate) (Lubowe, 1976). The behavioral literature offers several approaches to treating the scratching associated with neurodermatitis, including extinction (Walton, 1960), reinforcement for nonscratching behavior combined with ignoring scratching (Allen and Harris, 1966; Bar and Kuypers. 1973) graphing the scratching rate plus rewards for decreased scratching (Dobes, 1977), shock contingent on scratching combined with relaxation training (Bar and Kuypers. 1973; Ratcliff and Stein, 1968), substituting stroking and patting for scratching (Watson et al., 1972) and hypnosis (Collison, 1972; Kellner, 1975). These studies were limited methodologically due to the inclusion of only one client, a lack of reporting data and the inclusion of self-recording without assessing the reliability of self-recorded data. Focusing on habit-reversal in treating the scratching associated with neurodermatitis. the present study was designed to overcome the methodological limitations described * This research was part of the first author’s doctoral dissertation in partial fulfillment of the Ph.D. degree under the chairmanship of the second author and was presented in a paper entitled “Habit-reversal in treating neurodermatitis” at the meeting of the Southeastern Psychological Association, Washington. DC, March 1980. t To whom all reprint requests should be sent. 313
314
MICHAEL S. ROSENBAUMand TEOWJROAYLLON
above by including four clients, providing ongoing assessment of scratching throughout 6-month follow-ups and obtaining independent assessment of self-recorded data. METHOD
Clients Sandra. Sandra was a 34-year-old female referred by a private dermatologist for treatment of neurodermatitis. She was employed as a registered nurse in the cardiac intensive care unit at a university medical center. A few months prior to visiting the dermatologist, Sandra had been scratched on her left ankle by a cat. As the scratch was healing, the affected area began to itch and she began to scratch it. This, in turn, had produced an irritated, reddened, flaky area of skin on her ankle, which extended about 3 inches up her leg. Sandra reported that she never scratched at work but only at home. Although the dermatologist had prescribed Kenalog cream to help heal the affected skin, Sandra’s excessive scratching rendered this medication ineffective. Mary. Mary was a lbyear-old female high school student referred for treatment of neurodermatitis on the shins of both her legs by the dermatology clinic at a university medical center. She had a 2-year history of scratching her shins in response to their itching. She reported that her scratching was most severe when she worked on her homework or studied for a test. Kenalog cream prescribed by a dermatologist at the clinic had proven ineffective due to Mary’s excessive scratching. Joan. Joan was a 29-year-old female referred for treatment of neurodermatitis on her arms, legs and buttocks by the dermatology clinic at a university medical center. She reported that her current case of generalized neurodermatitis was the second occurrence of this skin condition in the past several years. Joan was employed as a secretary on a temporary basis. Her scratching typically occurred at home when she was not occupied, especially when she watched television. A dermatologist at the clinic had prescribed Kenalog cream, the effectiveness of which was markedly reduced due to Joan’s excessive scratching. Kathy. Kathy was a 22-year-old female who heard about the present research from a friend and sought treatment for neurodermatitis on both her arms and elbows. She was employed as a trainee for a local electrical manufacturing company. She reported that her job was quite anxiety-producing and that most of her scratching occurred at work. Her scratching had resulted in areas of reddened, flaky skin on each elbow extending about 2 inches on her arms.
Setting
and recording
During the initial interview with each client, the purpose of the research was explained and the client described the problem behavior in detail. Clients were also instructed in procedures for self-recording the frequency of scratching. Specifically, they were told to record a slash mark each time a target response was detected throughout the entire day on a 3 x 5” index card divided into seven columns. These recording procedures were conducted on a daily basis during baseline and throughout the first month following treatment. Baseline data were reported at the treatment session. Each client was asked to report data via phone 2 weeks following the treatment session. Data for the next 2 weeks were brought to the l-month follow-up session. Thereafter, each client recorded the frequency of scratching 1 week per month for 5 months and reported these data via monthly phone contacts. Response dejnitions Scratching. For each client this consisted of placing the hand on the affected area of skin and scratching with the fingernails for at least 5 seconds.
Habit-reversal
and neurodermatitis
315
Reliabilir)
When possible, validating reports from individuals in each client’s environment were obtained to assess reliability. These individuals (e.g. Sandra’s husband) were asked to count the number of instances of scratching. By dividing the smaller number recorded by the larger and multiplying the resulting quotient by 100, reliability was calculated on each of these occasions. Changes in the frequency of scratching were also indicated by evidence of healing in the affected skin areas (e.g. a decrease in the size of the area,.an absence of redness and flaky skin). This was based on judgments by the referring dermatologists at the 6-month follow-up sessions relative to the baseline appearance of these areas for Sandra, Mary and Joan, and at the 6-month follow-up session for Kathy by the first author.
Research design
Separate comparison designs (AB) representing a group of direct replications conducted to determine the effectiveness of treatment.
were
Procedure Baseline. The 7-day period of time between the initial interview and the treatment session constituted the baseline. Treatment (habit-reversal). As described by Azrin and Nunn (1973, 1977), the client verbally described and demonstrated scratching in the response description procedure. The first author then taught each client to detect bringing her hand toward the areas in which scratching occurred (e.g. ankle, arm, elbow) (early warning). Situation awareness training consisted of client descriptions of those situations in which scratching usually occurred or increased in frequency. Unpleasant aspects of scratching were described to increase the motivation to cease this behavior (habit inconuenience review). In the competing response practice procedure, each client was taught an isometric exercise characterized by: (a) being incompatible with scratching; (b) lasting at least 1 minute; (c) tensing the muscles used in scratching; (d) easy implementation with usual activities; and (e) preventing scratching from remaining a routine aspect of normal activities. The first author taught each client to place her hands in her lap or by the side of her body and clench her fists, until a comfortable amount of tension was produced in the hands and forearms. This response was to be performed for 2 minutes following the urge to scratch, any antecedent to scratching or any occurrence of scratching. To relieve severe itching each client was instructed to either stroke or pat the affected skin area (Watson et al., 1972). Sandra, Mary and Joan were instructed to continue using Kenalog cream. In the symbolic rehearsal procedure one situation in which scratching usually occurred was chosen. The client performing the competing response as she recalled an actual instance of scratching in that situation. Following several repetitions of this procedure. the first author engaged the client in a general discussion. The client was instructed to perform the competing response whenever an urge to scratch, antecedent to scratching, or actual scratching occurred during this discussion. The first author pointed out any instances of scratching that the client failed to detect. The entire treatment session lasted about 60 minutes. Fo//ow-up. At l- and 6-month follow-up sessions, the first author inspected the areas affected by excessive scratching, praised the client for improvement noted (e.g. a decrease in the size of the area, an absence of redness and flaky skin) and encouraged the client to continue using the treatment procedures. On each occasion that data were reported by phone, the client was praised for improvement (i.e. a decrease in the frequency of scratching or maintenance of this behavior at a low level) and was reminded to continue following the treatment procedures.
316
MICHAEL
S. ROSENEAUM
and
TEODORO
AYLLOK
B
Months
Fig. 1. The frequency of scratching for Sandra (lA), Mary (lB), Joan (IC) and Kathy (1D) on a daily basis and averaged over 1 week per month.
RESULTS
Sandra
Sandra’s mean frequency of scratching was IO.l/day during baseline and decreased markedly following treatment with habit-reversal (X = iA/day) (Fig. 1A). Following a slight increase in scratching at the 3-month follow-up, this behavior was eliminated by the 6-month follow-up. On the two occasions that Sandra’s husband recorded the frequency of his wife’s scratching (days 5 and 12), rehability averaged 7096. At the 6-month follow-up session, Sandra’s ankle had healed completely according to the referring dermatologist. Mary
During baseline the mean frequency of Mary’s scratching was 35.14/day, which decreased markedly following treatment with habit-reversal (% = “I.l/dayf {Fig. 1B). Throughout the 6-month follow-up, Mary’s mean frequency of scratching was IO&/day. On the two occasions that Mary’s sister recorded the frequency of her scratching (days 5 and lo), reliabihty averaged 80%. At the 6-month follow-up session, Mary’s shins had begun to heal (e.g. the skin was not as red or flaky as during baseline) according to the referring dermatologist. Joan
Joan’s mean frequency of scratching was 47.3/day during baseline (Fig. 1C). Treatment with habit-reversal was associated with a marked decrease in this behavior (2 = 7.l/day). At the 6-month follow-up the mean frequency of scratching was 14/day. At this session Joan’s arms and buttocks had healed completeIy and her legs showed evidence of
Habit-reversal
317
and neurodermatitis
beginning to heal (e.g. they contained fewer patches of Aaky skin reIative to baseline) according to the referring dermatologist. There were no opportunities to obtain reliability of Joan’s self-recorded data. Kathy During baseline the mean frequency of Kathy’s scratching was ZS.%/day and decreased folfowing treatment with habit-reversai (X = 13.7/dayf (Fig. ID). At the &month follow-up Kathy’s mean frequency of scratching was l~.g/day. On the two occasions~that her roommate recorded the frequency of her scratching (days 5 and 12), re~iabjlity averaged 76%. At the &month follow-up session, Kathy’s arms were almost completely healed (e,g. there was no evidence of reddened, flaky areas), whereas her elbows were stilf reddened and contained patches of flaky skin according to the first author. DISCUSSION
Based on the results of this study, it appears that the habit-reversal’technique can be effective in eliminating or decreasing scratching associated with neurodermatjt~s. The rapid decreases obtained for the four clients in this study were maintained over an extended period of time (i.e. S-month follow-ups). Several aspects of the habit-reversal technique appeared to be related to its effectiveness. Self-recording enabled each client to become more aware of the occurrence of scratching, whiie providing feedback concerning its frequency. An alteration in the frequency of scratching may have resulted from the reactive effects associated with this feedback (e.g. Jeffrey. 1974: Kazdin, 1974; McFall. 1977: Nelson. 1977). The successful implementation of the competing response practice procedure may have been related to each client’s increased awareness of the antecedents and consequences associated with scratching, resulting from the self-recording. response description. early warning. situation awareness training and habit inconvenience review procedures. The lack of objective ratings of relative flakiness. redness or size of the affected skin areas is a timitation of this study. Ratings couid have been obtained by photographing the affected areas on a pre-treatment basis and at the &month follow-up session and having the pictures blindly rated by a dermatologist. The objective quanti~cation of neurodermatitis should be focused upon in future research in this area. Although psychoanalysis and psychotherapy have been reported to be effective in treating neurodermatitis. no studies since 1960 could be found to support this contention. The effectiveness of dermatological approaches appears to be compromised in some cases by excessive, intractable scratching behavior. In these cases. behavioral treatment appears to be a valuable adjunctive to successful therapy. The most effective behavioral treatments for the scratching associated with neurodetmatitis have involved either aversive consequences contingent on this behavior or reinforcement for nonscratching combined with ignoring scratching. In the present study habit-reversal was effective in markedly reducing scratching. but this behavior was eliminated in only one client. It appears, however. that a marked reduction in this behavior may be sufficient to allow the affected skin areas to heal. The present study. therefore. extends the generality of habit-reversal as an effective treatment for scratching associated with neurodermatitis. Component analyses to assess separately the relative contributions of self-recording. response awareness training. competing response practice and symbohc rehearsat to the effectiveness of the habit-reversal technique should be conducted in future research. Acknorr,/edgements-The authors wish to express their sincere appreciation Michael A. Milan and Robert C. I~PJWII.
to the other committee members.
REFERENCES ALLEN K. and
HARRIS
reinforcement
F.
(19661 ~lirni~alion procedures, ~~,~~~~r,Res. T/w.
of a child‘s 4. 7944.
excessive scratching
by training the mother in
318
MICHAELS. ROSENBAUM and TEOD~ROAYLLON
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