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Treatment of eczema by EMG biofeedback and relaxation training: A multiple baseline analysis
J Behm Thvr d Erp. Rwhrur. Pnmrd m Grrnr Briram
Ixxl>7Ylwxx $3 CY,+ 0 ,x, IC IYKX Pcrgamon Prcrs plc
Vol. I’). No. 3. pp 221-127. IYXX
TREATMENT OF ECZEMA BY EMG BIOFEEDBACK AND RELAXATION TRAINING: A MULTIPLE BASELINE ANALYSIS CAROL J. McMENAMY,
ROGER C. KATZ and MARTIN GIPSON
University of the Pacific, Stockton, California Five adults who suffered from eczema for at least five years were treated in a multiple baseline design with EMG biofeedback and progressive relaxation. Treatment consisted of five weekly EMG training sessions combined with regular home practice of relaxation. Three dependent measures were used to assess treatment effects: (1) daily selfmonitoring of symptom irritation levels, (2) pre and post assessments of eczema affected areas and (3) the Spielberger Trait Anxiety Questionnaire which was also administered on a prepost basis. Results showed clinically meaningful improvements in all five participants which were maintained at a two month follow-up. A second follow-up two years later showed that three of subjects were asymptomatic. The other two subjects could not be located. Taken together, the study provides evidence that EMG biofeedback combined with home practice of progressive relaxation can help to reduce the severity of eczema and the irritation associated with the disorder. Summary
Eczema, or dermatitis as it is also called, is a chronic, inflammatory skin disease with many causes. It manifests itself by redness, swelling, sensations of heat and itching, and can be an extremely uncomfortable problem - one that carries a risk of infection from open sores due to excessive scratching, and the threat of social embarassment from the excoriation that can develop in affected areas. This is especially true when the affected area is the face (Roth and Kierland, 1964). Eczema occurs in 2-20% of the general population and is one of the most common skin disorders seen by dermatologists (Champion and Parish, 1972). There is no completely reliable treatment. What is prescribed depends on a hypothesized etiology (i.e. external irritants, allergies, trauma, infection, skin type, psychological factors) but most dermatologists will probably prescribe topical medications (e.g. corticosteroid creams) and the suggestion to remove possible allergic irritants (Haynes, Wilson, Jaffe and Britton, 1979). Because eczema is known to be affected by
emotional factors (Bethune and Kidd, 1961; Dobes, 1977; Ratliff and Stein, 1968), treatments based on psychological principles have also been tried (e.g. Brown and Bettley, 1971; Haynes et al., 1979; Nickel, 1978; Allen and Harris, 1966; Watson, Tharp and Krisberg, 1972; Ratliff and Stein, 1968; Wolpe, 1976). Encouraging results have been reported, but with few exceptions (e.g. Rosenbaum and Ayllon, 1981) most of the studies have lacked appropriate experimental controls and hence the conclusions that can be drawn from them are limited. In spite of this, there is a large body of evidence to suggest that eczema outbreaks and symptom severity are influenced by psychological stress (Allerhand, Gough and Grais, 19.50; Brown, 1970; Sulzberger, 1971). For that reason, the use of stress reduction measures offers a logical course of treatment. The present study investigated the combined effects of EMG biofeedback and progressive muscle relaxation on five patients with chronic eczema. A multiple baseline design across participants was used to evaluate the effects of
Requests for reprints should be addressed to Roger C. Katz, Psychology Department, CA 95211, U.S.A. 221
University of the Pacific, Stockton,
377 ___
CAROL
J. McMENAMY.
ROGER
treatment. Although encouraging results have been reported in similar studies (e.g. Haynes er al., 1979; Koldys and Meyer, 1979; Manuso, 1977), none has employed this combination of stress-reduction procedures or used an appropriate experimental design. The present study is most closely related to the work of Haynes et al. (1979) who reported mixed but generally positive results using EMG biofeedback. However, in their study a replicated case study design was used, and even though participants were given relaxation instructions, they were not told to practice relaxation skills daily. nor were they asked to self-monitor their symptoms to provide a more continuous and fine grain analysis of treatment effects.
C. KATZ
and MARTIN
GIPSON
O-10 scale three times a day, in the morning, afternoon and evening. Zero represented no irritation, 5 represented moderate irritation, and 10 represented extreme irritation. In order to encourage accurate recording, all participants were given data sheets and carefully instructed in their use (e.g. by hypothetical examples and guided practice). The second measure was a clinical description of the subject’s symptoms in which the number of raw or open sores was counted, and notation was made of the presence of rash, skin color, oozing sores, etc. This measure was obtained immediately before and after treatment, and again at 2 month follow-up. The third dependent measure was the subject’s score on the Spielberger et al. (1970) Trait Anxiety Scale which was obtained pre and posttreatment.
METHOD Participants
Six adults (4 females, 2 males) were recruited by newspaper advertisement to participate in a research-oriented treatment program for eczema. One of them dropped out a week after the study began due to a conflict with her work schedule. The remaining subjects ranged in age from 23 to 75 years and all of them showed severe eczema symptoms on their hands, arms or feet when the study began. Each of them had been diagnosed with eczema by their physician who also verified that the condition had existed for at least the previous year - although in actuality the self-reported duration of their symptoms ranged from 5 to 20 years. None of the participants was using topical or oral medication, and none had received cortisone injection within the past year. Dependent measures and design
A multiple baseline across participants design was used, with treatment being sequentially introduced after 8, 11, 14, 17 and 20 days of baseline, respectively. Three dependent variables were used. The first consisted of daily self-monitoring of eczema irritation in which the participants rated their irritation level on a
Procedure
After an initial meeting with the therapist (CM), each subject received 5 individual onehour sessions of EMG biofeedback and progressive relaxation training. All sessions were held at the University’s Behavioral Medicine Clinic and scheduled weekly over a 5 week period. A dual channel J&J model M-53 EMG and J&J model D-200 integrator with an isolation pre-amplifier (J&J model IP-5) were used to measure muscle tension in the anterior temporalis muscle and to provide auditory feedback to the participant. During the initial meeting, participants were told about the purpose of the study, the Spielberger scale was administered, they were instructed in how to self-monitor their symptoms, and the importance of accurate and ongoing record keeping was stressed. They were given the self-monitoring data sheets and told to bring these with them to the 5 subsequent treatment sessions so that their progress could be monitored. Each treatment session began with a 5 min adaptation period before baseline measures were taken. The baseline consisted of 4 min of integrated averaged EMG readings measured
TREATMENT
OF
21-3
ECZEMA
maintained during the two month follow-up at which time four of the five participants were either symptom free or reporting only mild distress. Subjects were also asked to monitor whether they practiced relaxation at home. Each of them reported that they practiced at least once a day six days a week. This compliance rate was maintained throughout the study. Table 1 provides a summary of the participants’ eczema affected areas as recorded in the clinical descriptions at baseline, after treatment, and at follow-up. Improvement was clearly seen in all five participants. By followup, most of them had normal or near normal skin coloration, less inflammation, and far fewer lesions, which stands in contrast to their skin condition before the study began. For some participants, it was the first time in years that they had been free of eczema irritation. Mean scores on the Spielberger Trait Anxiety Scale were 42.2 (SD = 7.25) at baseline, 34.4 (SD = 5.22) after treatment, and 33.6 (SD = 4.39) at follow-up. All participants reported reductions in anxiety on this measure, F (df2,8) = 31.94, p < 0.00001. Individual comparisons showed a significant difference between the participants’ baseline mean and their
in microvolts. Biofeedback was then given for 15 min. When reductions in EMG occurred, the therapist praised the participant (e.g. “Good job, you’re getting better at relaxing”). When improvement did not occur, the therapist tried to encourage the participant by verbal prompts such as, “Now take a deep breath; I know you can do it.” The biofeedback period was followed by 24 min of progressive relaxation training which was delivered by audio tape. Afterwards, 4 min of integrated averaged EMG readings in microvolts were taken as a post-session measure. Participants were given a copy of the relaxation tape after the first treatment session along with the instruction that they should try to practice relaxation at home once a day. The self-monitoring data sheets were collected and new sheets provided at each session. RESULTS AND DISCUSSION Self-monitored data on eczema irritation levels are shown in Fig. 1. Each data point represents an average of the three daily ratings. As can be seen, irritation levels were reduced across all participants following the introduction of treatment. Moreover, this trend was Subject
*l Follow-up
Treatment
0
10
20
Days
30
40
so
ratings of eczema irritation for Subjects 1-5. Treatment Fig. 1. Self-monitored was sequentially introduced after 8, 11, 14. 17 and 20 days of baseline as per multiple baseline design requirements. Each data point represents the average of three daily ratings.
CAROL
221
J. McMENAMY,
ROGER
C. KATZ
and MARTIN
GIPSON
Subject ‘2 Follow-up
Treatment
I
IO
f
20
30
40
50
60
Days
SubJect *3 6
0
10
20
3o
Days
4
50
60
Fig. 1. Subjects 2 and 3.
treatment, t = 2.74, p < t = 2.74, p < 0.05. Significant reductions were also noted on the session EMG scores from baseline to followup, F (u”3,12) = 19.40, p C 0.0001. The mean and standard deviations for the participants were 4.89 (SD = 1.10) 4.04 (SD = l.Ol), 2.26 (SD = 1.21), and 2.40 (SD = 0.98) during the initial baseline, pretest, posttest, and follow-up phases, respectively. Three of the subjects (#s 2, 3 and 5) were mean
scores
after
0.05, and at follow-up
interviewed by phone two years after the study was completed in order to assess the long term effects of treatment. Unfortunately, the remaining two subjects had left the area and could not be contacted. Results of this informal follow-up were generally encouraging. Thus, all three of the subjects were asymptomatic and reported an irritation level of zero at the time they were interviewed. Their scores on the Spielberger Trait Anxiety Scale were at or below the level they were during the two
TREATMENT
Subject
OF ECZEMA
*4 Treatment
10
0
40
30
20
Days SubJect
I
Follow-up
R
b,pBp
50
60
=5
b
7
0
10
20
30
40
50
60
Days Fig. 1. Subjects 4 and 5.
month follow-up. All of them were still using the relaxation exercises they had learned earlier and none of them was under a dermatologist’s care or using any prescription medications. One of the subjects (#2) reported a single outbreak of eczema lesions since the last follow-up which responded well to topical medication. Another subject (#5) reported having about three outbreaks of skin irritation per year which she rated as 3 on the eczema irritation scale - well below the sevens and
eights she assigned to her symptoms during baseline. She said she treated these flare-ups herself by trying to reduce the stressors in her life, practicing relaxation and not exacerbating the lesions by scratching them. The last subject had no further skin problems. Taken together, the results show that EMG biofeedback in combination with regular home practice of progressive relaxation can help to reduce the severity of eczema and the irritation associated with the disorder. The results were
226
CAROL
J. McMENAMY.
ROGER
C. KATZ and MARTIN GIPSON
Table 1. Eczema affected areas at baseline, follow-up
2
Post
4 sores;
oozing sores inflammation skin color
5 sores; no scabs or rash no Yes red
* left foot/ankle lesion type
6 sores;
no sores; large scabs; no rash no no red
no no red
no lesions
no lesions
no no normal
no no normal
no lesions
no lesions
no ;E,k
no no normal
rash only
rash only
no no pink/normal
no no pink/normal
*hands lesion type
large scabs; no rash oozing sores inflammation skin color 3
* arms/hands lesion type
oozing sores inflammation skin color 4
* arms lesion type oozing sores inflammation skin color
5
and
Baseline
Subject 1
posttreatment
* hands lesion type oozing sores inflammation skin color
yes no red 7 sores; no scabs or rash no ;ik/red rash; no sores/scabs no yes red rash; no sores/scabs no no pink/red
Follow-up
no
scabs or rash no no normal
4 sores; no scabs or rash no no normal small scabs; no sores/rash
* Primary lesion site.
across five participants in a multiple baseline design. The design showed that improvement was not a function of selfmonitoring per se or the passage of time. Subjects did not improve until treatment began which is the best evidence that the treatment was responsible for the improvement. The results also show that decreases in skin irritation were accompanied by visible healing in eczema affected areas. This finding was previously reported by Haynes et al. (1979) who used similar treatment procedures, but in their study reductions in skin irritation (itching) replicated
occurred only within and not between treatment sessions as they did in this experiment. Since the main difference between the two studies was an instruction that participants practice relaxation daily at home (which our results suggest they did), the home practice would seem to be very important in reducing the subject’s discomfort. One reason for this is that the relaxation exercises may interfere with a “scratch and itch” cycle that can easily lead to further inflammation and irritation. Reductions in EMG and self-reported anxiety provide another line of evidence that skin
TREATMENT
changes occurred because of improved autonomic control and/or reductions in felt distress. This interpretation would be consistent with the hypothesis that eczema outbreaks and the severity of eczema symptoms are mediated by psychological factors (Brown, 1970; Nickel, 1978; Sulzberger, 1971). As encouraging as these results might be, the study is not without its problems. Chief among them are questions concerning the reliability of self-monitored data as well as data derived from a visual examination of eczema affected areas. There is also the possibility that the participants may have been reacting to demand characteristics in order to please the therapist or to confirm their own expectations that they should feel better once treatment began. None of these rival hypotheses can be ruled out using the present experimental design. An additional question concerns the confounding of treatment variables. In short, there is no way of knowing from this study whether both EMG biofeedback and home relaxation training are necessary for improvement or whether either one alone would be sufficient. This is an issue that awaits further study, preferably by means of a factorial design using a much larger number of participants. A final question concerns the relative effectiveness of psychological versus traditional dermatological treatments for eczema (e.g. topical ointments), and/or how psychological approaches can be used in a supplemental role by practicing physicians. The significance of this issue is underscored by the fact that all of the participants in this study had suffered from eczema for many years, had been treated by conventional therapies and had never achieved lasting relief. Some participants volunteered that the improvement they experienced during the study was better than any improvement they had experienced before.
227
OF ECZEMA REFERENCES
Allerhand M. E., Gough H. G. and Grais M. L. (1950) Personality factors in neurodermatitis: A preliminary studv. Psvckosomatic Med. 12, 386-391. Allen ‘K. E: and Harris, F. R. (1966) Elimination of a child’s excessive scratching by training the mother in reinforcement procedures. Bekav. Res. Ther. 4, 79-8-l. Bethune H. C. and Kidd C. B. (1961) Psychophysiological mechanisms in skin diseases. The Luncet 2, 1419-1422. Brown D. G. (1970) A study of the significance of psychological symptoms in eczema. Unpublished M.D. thesis. University of Leeds. Brown G. and Bettley F. R. (1971) Psychiatric treatment of eczema: A controlled trial. Br. Med. J. 2, 729-734. Champion R. H. and Parish W. E. (1972) Atopic dermatitis. In Book of Dermatitis. Vol. 1. Davis Publishers, Philadelphia. Dobes R. W. (1977) Amelioration of psychosomatic dermatitis by reinforced inhibition of scratching. J. Bekav.
Tker.
Exper.
Psyckiat. 8. 185-187.
Haynes S. N., Wilson C. C., Jaffe P. G. and Britton B. T. (1979) Biofeedback treatment of atopic dermatitis. Biofeedback Self Regularion 4, 195-209. Koldys K. W. and Meyer R. P. (1979) Biofeedback training in the therapy of dyshidrosis. Curie 24, 219-221. Manuso J. (1977) The use of biofeedback assisted hand warming training in the treatment of chronic eczematous dermatitis of the hands: A case study. J. Bekav. Tker. Exper.
Psyckiat. 8, 445-446.
Nickel W. R. (1978) Neurodermatitis - a concept. Cutis 21, 677680. Ratliff R. G. and Stein N. H. (1968) Treatment of neurodermatitis by behavior therapy: A case study. Bekav. Res.
Tker. 6. 397-399.
Rosenbaum M. S. and Ayllon T. (1981) The treatment of neurodermatitis through habit reversal. Beknv. Res. Tker. 19, 313-318. Roth H. L. and Kierland R. R. (1964) The natural history of atopic dermatitis: A 20 year follow-up study. Arch. Dermatol.
89, 209-21.5.
Spielberger C. D., Gorsuch R. L. and Lushene R. G. (1970) The State-Trait Anxiefy Inventorv. Consulting Psychologists Press, Palo Alto, California. Sulzberger M. H. (1971) Atopic dermatitis. Dermarology in General Medicine. McGraw Hill. New York. Watson D. L., Tharp R. G. and Krisberg J. (1972) Case study in self-modification suppression of inflammatory scratching while awake and asleep. J. Bekav. Tker. Exper.
Psych&
3, 213-215.
Wolpe J. (1959) The treatment of a case of neurodermatitis. In Burton A. (Ed.) Case Sfudies in Counseling and Psychotherapy. Prentice-Hall Englewood Cliffs, New Jersey. Reprinted in Wolpe J. (1976) Theme and Vuriations: A Behavior Therapy Casebook. Pergamon Press, Oxford.
Ixxl>7Ylwxx $3 CY,+ 0 ,x, IC IYKX Pcrgamon Prcrs plc
Vol. I’). No. 3. pp 221-127. IYXX
TREATMENT OF ECZEMA BY EMG BIOFEEDBACK AND RELAXATION TRAINING: A MULTIPLE BASELINE ANALYSIS CAROL J. McMENAMY,
ROGER C. KATZ and MARTIN GIPSON
University of the Pacific, Stockton, California Five adults who suffered from eczema for at least five years were treated in a multiple baseline design with EMG biofeedback and progressive relaxation. Treatment consisted of five weekly EMG training sessions combined with regular home practice of relaxation. Three dependent measures were used to assess treatment effects: (1) daily selfmonitoring of symptom irritation levels, (2) pre and post assessments of eczema affected areas and (3) the Spielberger Trait Anxiety Questionnaire which was also administered on a prepost basis. Results showed clinically meaningful improvements in all five participants which were maintained at a two month follow-up. A second follow-up two years later showed that three of subjects were asymptomatic. The other two subjects could not be located. Taken together, the study provides evidence that EMG biofeedback combined with home practice of progressive relaxation can help to reduce the severity of eczema and the irritation associated with the disorder. Summary
Eczema, or dermatitis as it is also called, is a chronic, inflammatory skin disease with many causes. It manifests itself by redness, swelling, sensations of heat and itching, and can be an extremely uncomfortable problem - one that carries a risk of infection from open sores due to excessive scratching, and the threat of social embarassment from the excoriation that can develop in affected areas. This is especially true when the affected area is the face (Roth and Kierland, 1964). Eczema occurs in 2-20% of the general population and is one of the most common skin disorders seen by dermatologists (Champion and Parish, 1972). There is no completely reliable treatment. What is prescribed depends on a hypothesized etiology (i.e. external irritants, allergies, trauma, infection, skin type, psychological factors) but most dermatologists will probably prescribe topical medications (e.g. corticosteroid creams) and the suggestion to remove possible allergic irritants (Haynes, Wilson, Jaffe and Britton, 1979). Because eczema is known to be affected by
emotional factors (Bethune and Kidd, 1961; Dobes, 1977; Ratliff and Stein, 1968), treatments based on psychological principles have also been tried (e.g. Brown and Bettley, 1971; Haynes et al., 1979; Nickel, 1978; Allen and Harris, 1966; Watson, Tharp and Krisberg, 1972; Ratliff and Stein, 1968; Wolpe, 1976). Encouraging results have been reported, but with few exceptions (e.g. Rosenbaum and Ayllon, 1981) most of the studies have lacked appropriate experimental controls and hence the conclusions that can be drawn from them are limited. In spite of this, there is a large body of evidence to suggest that eczema outbreaks and symptom severity are influenced by psychological stress (Allerhand, Gough and Grais, 19.50; Brown, 1970; Sulzberger, 1971). For that reason, the use of stress reduction measures offers a logical course of treatment. The present study investigated the combined effects of EMG biofeedback and progressive muscle relaxation on five patients with chronic eczema. A multiple baseline design across participants was used to evaluate the effects of
Requests for reprints should be addressed to Roger C. Katz, Psychology Department, CA 95211, U.S.A. 221
University of the Pacific, Stockton,
377 ___
CAROL
J. McMENAMY.
ROGER
treatment. Although encouraging results have been reported in similar studies (e.g. Haynes er al., 1979; Koldys and Meyer, 1979; Manuso, 1977), none has employed this combination of stress-reduction procedures or used an appropriate experimental design. The present study is most closely related to the work of Haynes et al. (1979) who reported mixed but generally positive results using EMG biofeedback. However, in their study a replicated case study design was used, and even though participants were given relaxation instructions, they were not told to practice relaxation skills daily. nor were they asked to self-monitor their symptoms to provide a more continuous and fine grain analysis of treatment effects.
C. KATZ
and MARTIN
GIPSON
O-10 scale three times a day, in the morning, afternoon and evening. Zero represented no irritation, 5 represented moderate irritation, and 10 represented extreme irritation. In order to encourage accurate recording, all participants were given data sheets and carefully instructed in their use (e.g. by hypothetical examples and guided practice). The second measure was a clinical description of the subject’s symptoms in which the number of raw or open sores was counted, and notation was made of the presence of rash, skin color, oozing sores, etc. This measure was obtained immediately before and after treatment, and again at 2 month follow-up. The third dependent measure was the subject’s score on the Spielberger et al. (1970) Trait Anxiety Scale which was obtained pre and posttreatment.
METHOD Participants
Six adults (4 females, 2 males) were recruited by newspaper advertisement to participate in a research-oriented treatment program for eczema. One of them dropped out a week after the study began due to a conflict with her work schedule. The remaining subjects ranged in age from 23 to 75 years and all of them showed severe eczema symptoms on their hands, arms or feet when the study began. Each of them had been diagnosed with eczema by their physician who also verified that the condition had existed for at least the previous year - although in actuality the self-reported duration of their symptoms ranged from 5 to 20 years. None of the participants was using topical or oral medication, and none had received cortisone injection within the past year. Dependent measures and design
A multiple baseline across participants design was used, with treatment being sequentially introduced after 8, 11, 14, 17 and 20 days of baseline, respectively. Three dependent variables were used. The first consisted of daily self-monitoring of eczema irritation in which the participants rated their irritation level on a
Procedure
After an initial meeting with the therapist (CM), each subject received 5 individual onehour sessions of EMG biofeedback and progressive relaxation training. All sessions were held at the University’s Behavioral Medicine Clinic and scheduled weekly over a 5 week period. A dual channel J&J model M-53 EMG and J&J model D-200 integrator with an isolation pre-amplifier (J&J model IP-5) were used to measure muscle tension in the anterior temporalis muscle and to provide auditory feedback to the participant. During the initial meeting, participants were told about the purpose of the study, the Spielberger scale was administered, they were instructed in how to self-monitor their symptoms, and the importance of accurate and ongoing record keeping was stressed. They were given the self-monitoring data sheets and told to bring these with them to the 5 subsequent treatment sessions so that their progress could be monitored. Each treatment session began with a 5 min adaptation period before baseline measures were taken. The baseline consisted of 4 min of integrated averaged EMG readings measured
TREATMENT
OF
21-3
ECZEMA
maintained during the two month follow-up at which time four of the five participants were either symptom free or reporting only mild distress. Subjects were also asked to monitor whether they practiced relaxation at home. Each of them reported that they practiced at least once a day six days a week. This compliance rate was maintained throughout the study. Table 1 provides a summary of the participants’ eczema affected areas as recorded in the clinical descriptions at baseline, after treatment, and at follow-up. Improvement was clearly seen in all five participants. By followup, most of them had normal or near normal skin coloration, less inflammation, and far fewer lesions, which stands in contrast to their skin condition before the study began. For some participants, it was the first time in years that they had been free of eczema irritation. Mean scores on the Spielberger Trait Anxiety Scale were 42.2 (SD = 7.25) at baseline, 34.4 (SD = 5.22) after treatment, and 33.6 (SD = 4.39) at follow-up. All participants reported reductions in anxiety on this measure, F (df2,8) = 31.94, p < 0.00001. Individual comparisons showed a significant difference between the participants’ baseline mean and their
in microvolts. Biofeedback was then given for 15 min. When reductions in EMG occurred, the therapist praised the participant (e.g. “Good job, you’re getting better at relaxing”). When improvement did not occur, the therapist tried to encourage the participant by verbal prompts such as, “Now take a deep breath; I know you can do it.” The biofeedback period was followed by 24 min of progressive relaxation training which was delivered by audio tape. Afterwards, 4 min of integrated averaged EMG readings in microvolts were taken as a post-session measure. Participants were given a copy of the relaxation tape after the first treatment session along with the instruction that they should try to practice relaxation at home once a day. The self-monitoring data sheets were collected and new sheets provided at each session. RESULTS AND DISCUSSION Self-monitored data on eczema irritation levels are shown in Fig. 1. Each data point represents an average of the three daily ratings. As can be seen, irritation levels were reduced across all participants following the introduction of treatment. Moreover, this trend was Subject
*l Follow-up
Treatment
0
10
20
Days
30
40
so
ratings of eczema irritation for Subjects 1-5. Treatment Fig. 1. Self-monitored was sequentially introduced after 8, 11, 14. 17 and 20 days of baseline as per multiple baseline design requirements. Each data point represents the average of three daily ratings.
CAROL
221
J. McMENAMY,
ROGER
C. KATZ
and MARTIN
GIPSON
Subject ‘2 Follow-up
Treatment
I
IO
f
20
30
40
50
60
Days
SubJect *3 6
0
10
20
3o
Days
4
50
60
Fig. 1. Subjects 2 and 3.
treatment, t = 2.74, p < t = 2.74, p < 0.05. Significant reductions were also noted on the session EMG scores from baseline to followup, F (u”3,12) = 19.40, p C 0.0001. The mean and standard deviations for the participants were 4.89 (SD = 1.10) 4.04 (SD = l.Ol), 2.26 (SD = 1.21), and 2.40 (SD = 0.98) during the initial baseline, pretest, posttest, and follow-up phases, respectively. Three of the subjects (#s 2, 3 and 5) were mean
scores
after
0.05, and at follow-up
interviewed by phone two years after the study was completed in order to assess the long term effects of treatment. Unfortunately, the remaining two subjects had left the area and could not be contacted. Results of this informal follow-up were generally encouraging. Thus, all three of the subjects were asymptomatic and reported an irritation level of zero at the time they were interviewed. Their scores on the Spielberger Trait Anxiety Scale were at or below the level they were during the two
TREATMENT
Subject
OF ECZEMA
*4 Treatment
10
0
40
30
20
Days SubJect
I
Follow-up
R
b,pBp
50
60
=5
b
7
0
10
20
30
40
50
60
Days Fig. 1. Subjects 4 and 5.
month follow-up. All of them were still using the relaxation exercises they had learned earlier and none of them was under a dermatologist’s care or using any prescription medications. One of the subjects (#2) reported a single outbreak of eczema lesions since the last follow-up which responded well to topical medication. Another subject (#5) reported having about three outbreaks of skin irritation per year which she rated as 3 on the eczema irritation scale - well below the sevens and
eights she assigned to her symptoms during baseline. She said she treated these flare-ups herself by trying to reduce the stressors in her life, practicing relaxation and not exacerbating the lesions by scratching them. The last subject had no further skin problems. Taken together, the results show that EMG biofeedback in combination with regular home practice of progressive relaxation can help to reduce the severity of eczema and the irritation associated with the disorder. The results were
226
CAROL
J. McMENAMY.
ROGER
C. KATZ and MARTIN GIPSON
Table 1. Eczema affected areas at baseline, follow-up
2
Post
4 sores;
oozing sores inflammation skin color
5 sores; no scabs or rash no Yes red
* left foot/ankle lesion type
6 sores;
no sores; large scabs; no rash no no red
no no red
no lesions
no lesions
no no normal
no no normal
no lesions
no lesions
no ;E,k
no no normal
rash only
rash only
no no pink/normal
no no pink/normal
*hands lesion type
large scabs; no rash oozing sores inflammation skin color 3
* arms/hands lesion type
oozing sores inflammation skin color 4
* arms lesion type oozing sores inflammation skin color
5
and
Baseline
Subject 1
posttreatment
* hands lesion type oozing sores inflammation skin color
yes no red 7 sores; no scabs or rash no ;ik/red rash; no sores/scabs no yes red rash; no sores/scabs no no pink/red
Follow-up
no
scabs or rash no no normal
4 sores; no scabs or rash no no normal small scabs; no sores/rash
* Primary lesion site.
across five participants in a multiple baseline design. The design showed that improvement was not a function of selfmonitoring per se or the passage of time. Subjects did not improve until treatment began which is the best evidence that the treatment was responsible for the improvement. The results also show that decreases in skin irritation were accompanied by visible healing in eczema affected areas. This finding was previously reported by Haynes et al. (1979) who used similar treatment procedures, but in their study reductions in skin irritation (itching) replicated
occurred only within and not between treatment sessions as they did in this experiment. Since the main difference between the two studies was an instruction that participants practice relaxation daily at home (which our results suggest they did), the home practice would seem to be very important in reducing the subject’s discomfort. One reason for this is that the relaxation exercises may interfere with a “scratch and itch” cycle that can easily lead to further inflammation and irritation. Reductions in EMG and self-reported anxiety provide another line of evidence that skin
TREATMENT
changes occurred because of improved autonomic control and/or reductions in felt distress. This interpretation would be consistent with the hypothesis that eczema outbreaks and the severity of eczema symptoms are mediated by psychological factors (Brown, 1970; Nickel, 1978; Sulzberger, 1971). As encouraging as these results might be, the study is not without its problems. Chief among them are questions concerning the reliability of self-monitored data as well as data derived from a visual examination of eczema affected areas. There is also the possibility that the participants may have been reacting to demand characteristics in order to please the therapist or to confirm their own expectations that they should feel better once treatment began. None of these rival hypotheses can be ruled out using the present experimental design. An additional question concerns the confounding of treatment variables. In short, there is no way of knowing from this study whether both EMG biofeedback and home relaxation training are necessary for improvement or whether either one alone would be sufficient. This is an issue that awaits further study, preferably by means of a factorial design using a much larger number of participants. A final question concerns the relative effectiveness of psychological versus traditional dermatological treatments for eczema (e.g. topical ointments), and/or how psychological approaches can be used in a supplemental role by practicing physicians. The significance of this issue is underscored by the fact that all of the participants in this study had suffered from eczema for many years, had been treated by conventional therapies and had never achieved lasting relief. Some participants volunteered that the improvement they experienced during the study was better than any improvement they had experienced before.
227
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