Austin Trich Support Group

1. Austin Trich Support Group Overview of BFRBs By Suzanne Mouton-Odum, Ph.D. Private Practice, Houston Texas Baylor College of Medicine University of Houston, Department of Psychology

2. Congratulations! • You are here taking the first step to change. • Being here today takes courage. • Being here today promotes readiness. • Being here today will lead to hope. • You are no different from anyone else. • BFRBs are adaptive. • BFRBs are common. • BFRBs are no different from a variety of other problematic behaviors. • Qualities of people with BFRBs. • So, why does it feel so different?

3. TYPES OF BFRBs Trichotillomania Face Picking/Squeezing Severe Nail/Cuticle Biting Severe Nose Picking Lip/Cheek/Tongue Biting Knuckle Cracking Tooth Grinding

4. Clinically Significant BFRBs • They lead to distress or impairment. • A person has tried, unsuccessfully, to stop. • They are not accounted for by another medical or psychological disorder.

5. IMPACT AND PERSONAL TOLL Cosmetic Medical Emotional Social- Relationships Shame- Self-Esteem, Insecurity Education/Career Implications

6. WHY DO PEOPLE PULL AND PICK? It feels good! Raise your hand… “I like the way it feels when the hair is plucked” “I can’t stand the coarse, thick, darker, lighter, kinkier hairs” “It helps me relax” “I like my skin to feel smooth, not bumpy” “I have to get all of the gunk out of my skin” “I like to look at the bulb at the end of the hair” “I do it when I am upset, it just makes me feel better” “It helps me fall asleep”

7. What are BFRBs???(unofficial description) • BFRBs are repetitive behaviors that serve a person by helping them in some way: • they soothe the nervous system, or • they provide relief from some discomfort, or • they increase a pleasurable feeling, or • they satisfy an irrational belief, or • they are behaviors that, over time, become associated with certain activities or environments, or • some combination of one or more of the above statements.

8. BFRB Quiz • BFRBS are “self-inflicted,” therefore under a person’s direct control. • People are often blamed for their BFRB behavior. • BFRBs always occur in response to stress. • Behaviors are often hidden or “secret.” • BFRBs are the result of abuse/trauma. • BFRBs often lead to self-mutilation such as cutting. • BFRBs can be managed and a person can stop their behavior.

9. BFRB Quiz • BFRBS are “self-inflicted,” therefore under a person’s direct control. (False) • People are often blamed for their BFRB behavior. (True) • BFRBs always occur in response to stress. (False) • Behaviors are often hidden or “secret.”(True) • BFRBs are the result of abuse/trauma. (False) • BFRBs often lead to self-mutilation such as cutting. (False) • BFRBs can be managed and a person can stop their behavior. (True)

10. Therapy for BFRBsComprehensive Behavioral Model (ComB) Step 1: Target Modalities for that person Sensory:Visual, Tactile, Physical Urges, homeostasis Cognitive:Thoughts and beliefs about hair/skin Affective:Emotions before, during and after Motor Habits / Awareness:Automatic vs. Focused, postures Place and Other Environmental Factors: Locations, Times, Activities, Implements, Presence/Absence of other people

11. Therapy for BFRBsComprehensive Behavioral Model (ComB) Step 2:Identify Potential Treatment Strategies Within The Targeted Modalities: Each person is unique and has individual triggers and reinforcers. Which of these apply to you? Sensory Cognitive Affective Motor Habits /Awareness Place and other Environmental Factors

12. Therapy for BFRBsComprehensive Behavioral Model (ComB) Sensory: Can involve all of the 5 senses and can help with the integration of sensory information into the brain. • Substitution: string, dental floss, doll hair, glue, bubble wrap • Sensory objects: koosh balls, goo, soft brushes, smooth items, feathers, pipe cleaners, head massagers, fabric swatches • Pictures of follicles, things that make noise, • Scented lotion • Chew gum, peppermints • Hot bath, mindfulness, deep breathing, meditation, exercise, some medications (all require recognizing when this sensory overload is happening)

13. Therapy for BFRBsComprehensive Behavioral Model (ComB) Cognitive: How do you think about pulling and picking? Do you have thoughts and beliefs about your behavior? Do you have irrational thought patterns in general? • Thoughts about how your behavior is helpful, or lack of behavior is harmful • Permission-giving thoughts • How do you deal with slips? Relapse? • Cognitive Restructuring: Recognize and replace thoughts with new, more appropriate ones, e.g. “I deserve to have all of my hair!” • Test your beliefs: Do experiments to test your beliefs, e.g. if you don’t pick, does it still heal? • Address irrational thought patterns, e.g. worry, black and white thinking, fortune telling, all or nothing thinking, catastrophic thinking. • Teach alternate coping: Assertiveness, self-care or anti-procrastination strategies!

14. Therapy for BFRBsComprehensive Behavioral Model (ComB) Affective: If your behavior tends to be driven by emotional factors, then you want to address these emotions. Negative pre- or positive during/post • How to deal with negative emotions?: • Relaxation • Exercise • Meditation/Mindfulness • Assertiveness • Journaling • Distress tolerance exercises, acceptance of negative emotions ACT. DBT • Do NOT procrastinate! Daily goals, break large goals down into smaller ones • Social support • Medication for depression or anxiety if needed • Increase positive emotions!!!! Hobbies, pleasurable activities, fun!

15. Therapy for BFRBsComprehensive Behavioral Model (ComB) Motor Habits / Awareness: How aware of you of your behavior as it is happening? Focused vs. Automatic pulling/picking…or BOTH! • Postural changes • Awareness Training: • Self-monitoring- write down every urge and episode • Reminders to self • Barriers (hats, BandAids, medical tape, sticky notes, lotion, Caution signs) • Wash hair • Cover sores, blemishes • Wear protective clothing (socks, gloves, long pants/sleeves) • Competing Response Training, e.g. Do something else! • Mindfulness exercises • Social support

16. Therapy for BFRBsComprehensive Behavioral Model (ComB) Place and other Environmental Factors: Where, when, associated activities, presence or absence of people, implements (tweezers, needles) or things (mirrors). • Stimulus Control: Modify your environment to reduce triggers/ability to pull/pick, e.g. turn off TV, read in the family room, change where you sit, cover the mirrors, where gloves while driving, dim the lights. • Reduce pulling and picking implements: • Get rid of magnifying mirrors • Freeze, throw away tweezers, razors, needles, etc. • Change HOW you do things: • Take breaks while reading • Wear Band Aids/gloves to bed • Put a timer in the bathroom

17. Therapy for BFRBsComprehensive Behavioral Model (ComB)Step 3 Step 3: Putting it all together!!!! • Integrate what you have learned • Know your high-risk situations? • What things make pulling/picking more or less likely to happen? • What strategies do you think might be helpful in different environments? • Based upon the 5 modalities, pick 3 strategies to commit to using every day, in high risk situations, for one week.

18. Therapy for BFRBsComprehensive Behavioral Model (ComB) It takes commitment! • May require purchasing items at the store. • May require talking to friends and family to garner support/approval. • May help to give yourself rewards for using strategies. • Track your progress and adherence (what works and what does not?). • It WILL require persistence, energy, readiness, and a willingness to suffer.

19. Therapy for BFRBsComprehensive Behavioral Model (ComB) Step 4: Evaluate the Effectiveness of Each Strategy • Monitor daily urges and episodes, triggers, strategies used and of hairs pulled/time spent picking. • Use each strategy for at least a week…give each one a chance to work. • Try strategies, even if you think that they won’t work. • The strategies DO WORK, but you have to use them!!!!!!! • Be self/other encouraging, not discouraging! • Expect setbacks and slips!

20. Daily Self-Monitoring Form