The use of pharmacologic pain sensitization in the treatment of repetitive hair-pulling

A significant problem for many individuals who engage in repetitive hair-pulling is the fact that they experience no discomfort associated with their behavior, and can thus carry on with hair-pulling outside of conscious awareness. The present case study was an attempt to address this problem through the use of a commercially available topical cream which enhances pain sensitivity. A 38-yr-old female applied the cream daily to two affected areas on her scalp. The increased pain sensitization, in conjunction with the habit reversal technique, resulted in markedly decreased hair-pulling.

Long-term use of electrical aversion treatment with self-injurious behavior

Twelve severely and profoundly mentally retarded individuals with life-threatening self-injurious behaviors were exposed to electrical aversion treatment using a remotely controlled device. Long-term effectiveness was assessed for periods ranging from 2 to 47 months for the 12 individuals, respectively. The degree of imposed physical restraint was used as the major dependent variable. With two individuals, the treatment failed to suppress self-injurious behavior. With seven individuals, however, suppression was nearly complete in that physical restraints were no longer necessary. With three individuals moderate effects were obtained, in that, although a substantial decrease of imposed physical restraint had been achieved, they still needed daily administrations of electrical aversive stimuli. The results are discussed in terms of the practical application of this procedure.

Behavioral treatment of children with autism, mental retardation, and related disabilities: ethics and efficacy

TOPIC

Ethical debates concerning the use of aversive versus nonaversive behavior management continue among those who treat children with autism, mental retardation, and related disabilities.

PURPOSE

To identify and discuss the crux of the aversive versus nonaversive debate by defining relevant terminology, examining assumptions and arguments that influence treatment approaches, and exploring the efficacy of nonaversive behavior modification techniques.

SOURCES

A case study to illustrate the use of aversive and nonaversive techniques and to compare the findings of these different approaches to treatment

CONCLUSIONS

As front-line interveners, nurses need to be aware of underlying philosophical and ethical issues if they are to implement the most effective treatment strategies while serving as advocates for the long-term welfare of children and their families.

Chronic nailbiting: a controlled comparison of competing response and mild aversion treatments

Recent studies have suggested that competing response, an abridged version of Azrin and Nunn's (1973) habit reversal method (Behaviour Research and Therapy, 11, 619-628), is a key component in the treatment of chronic nailbiting (Horne & Wilkinson, 1980, Behaviour Research and Therapy, 18, 287-291; Silber & Haynes, 1992, Behaviour Research and Therapy, 30, 15-22). This study replicated and extended the latter by adding an 8 week follow-up period and by using a non-student sample. Forty-five chronic nailbiter Ss were divided into three experimental groups. One method involved the use of mild aversion in which Ss painted a bitter substance on their nails. A second method required the subject to perform a competing response whenever they had the urge to nailbite or found themselves biting their nails. Both methods included self-monitoring of the behaviour and a third group of Ss performed self-monitoring alone as a control condition. The study lasted 12 weeks. Mild aversion resulted in significant improvements in nail length, with the competing response method just failing to show significance in this regard. There was no significant improvement for the control group. The implications for further study and the benefits of competing response in the light of these findings are discussed in terms of treatment success and use of therapist time.

A long-term follow-up of treatment for severe self-injury

One of the shortcomings in the literature is the paucity of long-term follow-up reports of the treatment of self-injury and other destructive behavior, particularly of treatment involving contingent shock. This is a report of a long-term follow-up of treatment for a woman with severe mental retardation and severe self-injurious behavior (SIB) treated initially with the Self-Injurious Behavior Inhibiting System (SIBIS) in brief clinical trials. Programmed generalization and maintenance procedures consisted of treatment throughout all waking hours in all settings as well as during brief sessions. Significant reductions attained in the SIBIS clinical trials generalized to the natural environment and the brief follow-up sessions; however, rates began to climb in the natural environment until a SIBIS pairing procedure could be applied more consistently as a consequence of self-injury. Contingent shock was discontinued after month 30 of follow-up. Overall rates of SIB episodes in the natural environment were reduced from an average of 24.6 per month in the 7 months prior to the SIBIS clinical trials to less than 2 per month during the 72 months of follow-up. Rates in brief treatment sessions remained low during the entire follow-up period. Implications of these results are discussed.

Treatment and extended follow-up of chronic hand mouthing

This study evaluated the relative effectiveness of differential reinforcement of other behaviors (DRO), differential reinforcement of incompatible behavior (DRI), and contingent watermist (CWM) in treating chronic self-injurious hand mouthing. The participant, a man with profound mental retardation, lived in a large residential facility. Prior to treatment he had participated in ineffective nonaversive treatments and was continuously mechanically restrained by his attending physician to promote healing of his hands. Baseline data collected in daily 30-minute sessions showed a hand mouthing rate of 1.5 responses/minute. Implementing the DRO, DRI, and CWM procedures in combination resulted in an initial 85% rate reduction. Each treatment component subsequently was withdrawn and reintroduced systematically in order to evaluate its relative effective upon hand mouthing. Only CWM plus differential reinforcement (DRO and/or DRI) had a significant effect upon hand mouthing. DRO plus DRI procedures were ineffective. In an effort to promote generalization of treatment effects, subsequent manipulations evaluated the effects of therapist proximity to the participant (one foot, 21 feet, or a random distance between one and 21 feet). Hand mouthing rates were reliably lower in the one-foot condition than in the 21-feet condition. The random proximity condition produced an intermediate performance. Direct care staff have implemented the DRI and CWM procedures throughout the participant's waking hours for nearly 3 years with almost complete elimination of hand mouthing.

Cognitive-behavioral treatment of choking phobia: 3 case studies

The present study describes 3 case examples of patients with choking phobia who were given a brief, cognitive-behavioral treatment that combined the interventions of psychoeducation, cognitive restructuring, interoceptive and in vivo exposure. This program was designed to address fears of anxiety and choking sensations as well as fears of swallowing. The patients were treated for 11-13 sessions. All 3 patients responded to the program as measured by their progression on their food hierarchy and by weight gain. Issues in the treatment of these patients are discussed.

Silver acetate mouth spray as an aid in smoking cessation: results of a double-blind trial

BACKGROUND

We studied the use of an aversive technique to improve the outcome of smoking-cessation efforts. We hypothesized that a silver acetate mouth spray, which produces a strong aversive taste when cigarettes are smoked, would increase the quit rate among smokers.

METHODS

Our study was a double-blind, placebo-controlled trial that was carried out in a private family practice office in an urban area. We studied 42 smokers, who were recruited by advertisement and who were motivated to quit by self-report. They were randomly assigned active spray or placebo spray; all were given a written list of behavioral suggestions. The spray was to be used every 2 hours for 3 weeks during which time the subjects were to keep diaries of cigarette smoking and spray use. Biochemical measures (salivary thiocyanate and cotinine) were recorded at entry, at 3 weeks, and at 3 months.

RESULTS

Thirty smokers completed the study. No differences were found between the two groups in quit rate or number of cigarettes smoked.

CONCLUSIONS

Silver acetate aversive spray did not increase quit rate among motivated smokers.

One-year follow-up after multimodal inpatient treatment for cocaine and methamphetamine dependencies

Of a randomly selected sample of 214 patients treated with aversion therapy for cocaine dependence in four chemical dependency units operated by Schick Shadel Hospitals, 156 were followed up 12 to 20 months posttreatment (average 15.2 months). Significant other validation was obtained in 33%. Total abstinence from cocaine for the group overall was 53% at one year post treatment, and current abstinence of at least 6 months at follow-up was 68.6%. Those treating with aversion for cocaine alone had a one-year abstinence of 39% and a current abstinence of 62.4%. Those treating with aversion for alcohol and cocaine had a one-year total abstinence from cocaine of 69% and a current abstinence of 76%. Those treating with aversion for cocaine and marijuana had a one-year total abstinence from cocaine of 50% and a current abstinence of 65%. Those treating with aversion for alcohol, cocaine, and marijuana had a one-year total abstinence from cocaine of 73% and a current abstinence of 73%. One-year total abstinence from alcohol was 54% for those receiving aversion for both alcohol and cocaine and 77% for those receiving aversion for alcohol, cocaine, and marijuana. Current abstinence from alcohol at follow-up was 68% and 81%, respectively. One-year total abstinence from marijuana was 42% for those treating with aversion for cocaine and marijuana and 64% for those treating with aversion for alcohol, cocaine, and marijuana. Current abstinence at follow-up from marijuana was 61% and 81%, respectively. The use of aversion therapy for both alcohol and cocaine in alcoholics who were also using cocaine was associated with higher total abstinence rates (88% vs. 55%) from cocaine when compared with alcoholics who used cocaine but received no aversion as part of their program. The conclusion is tentative since the follow-up rate in this study was lower than that of the previous study (64% vs. 84%). Being around other users accounted for 49% of relapse situations. Family/Work stress was associated with relapse in 33% of cases and unpleasant feelings in 24% of cases. The use of both reinforcement treatments and the use of support following treatment were associated with improved abstinence rates from cocaine. Those patients who reported losing all urges for cocaine after treatment had a total abstinence from cocaine of 90%, those who reported losing all the uncontrollable urges had a total abstinence of 64%, and those who reported still having the urge reported only 33% total abstinence from cocaine.

Development of a program of behavior modification directed to the rehabilitation of drug-dependent patients: treatment and follow-up of 223 cases

The study reports treatment and follow-up of compulsive drug-consuming patients (mainly of coca paste). The program used was based on a behavioral cognitive and instructional model. The traditional functional analysis was modified to include the therapeutical work in seven behavioral areas: (1) drug use; (2) behavior during free time; (3) behavior at work; (4) social behavior; (5) self- and environmental management behaviors; (6) problem solving and decision-making behaviors; (7) recognition, evaluation, and modification of irrational beliefs. For each area objectives, therapeutical procedures, control and evaluation methods, and termination criteria were determined. Patients engaged in a multiple activity program and received individual and group therapy. Out of 223 male patients, 130 were discharged (that is, they fulfilled all the conditions stated by the program) and 93 patients abandoned treatment. For evaluation purposes a test was used to determine the accomplishment of the behavioral objectives. Follow-up interviews after 6 to 72 months showed that although 24 patients relapsed to drug use, 106 (81.48%) of the patients who had finished the program restrained from using drugs and obtained high scores in all seven behavioral areas.

Gentle teaching and applied behavior analysis: a critical review

In recent years, there has been a growing controversy surrounding gentle teaching. This paper explores the nature of this controversy with particular reference to the relationship between gentle teaching and applied behavior analysis. Advantages and disadvantages of this approach are discussed, and it is suggested that gentle teaching and applied behavior analysis need not be regarded as mutually exclusive approaches to working with persons with mental retardation.

Treating nailbiting: a comparative analysis of mild aversion and competing response therapies

This study compared two methods of treating nail-biting. One method involved the use of a mild aversive stimulus in which subjects painted a bitter substance on their nails, and the other required the subject to perform a competing response whenever they had the urge to bite or found themselves biting their nails. Both methods included self-monitoring of the behaviour, and a third group of subjects performed self-monitoring alone as a control condition. The study lasted four weeks. Twenty-one subjects, seven per group, participated. Both methods resulted in significant improvements in nail length, with the competing response method showing the most beneficial effect. There was no significant improvement for the control group. The competing response condition also yielded significant improvements along other dimensions such as degree of skin damage and subjects own ratings of their control over their habit. These were not seen for the other two conditions. The benefits of this abridged version of Azrin and Nunn's (Behaviour Research and Therapy, 11, 619-628, 1973) habit reversal method in terms of treatment success, use of therapist time and client satisfaction, are discussed.

Experimentally induced taste aversions in humans: effects of overshadowing on acquisition

This study used vection-induced symptoms of motion sickness as an unconditioned stimulus to condition food aversions in humans and to evaluate the efficacy of an overshadowing agent (novel flavored candy: CS2) to attenuate acquisition of the aversion. Subjects unfamiliar with a target food (CS1) were assigned to one of the following three groups which were identical except for order of exposure to stimuli: Taste Aversion Group (CS1-US-CS2-Test), Control Group (US-CS1-CS2-Test), and Overshadowing Group (CS1-CS2-US-Test). Subjects were tested on aversion ratings and consumption of the target flavor and ratings of the overshadowing agent. Subjects in the Taste Aversion group rated the target flavor as significantly more aversive and consumed less of it, although not significantly so, that did those in the Control group. The Overshadowing group consumed significantly more of the target food than did the Taste Aversion Group. Considering only subjects unfamiliar with the overshadowing agent, those in the Overshadowing group rated the agent (CS2) as significantly more aversive than the Taste Aversion and Control groups. Implications of these findings to taste aversions in humans are discussed.

Chemical aversion treatment of alcohol dependence

Developments in the application of chemical aversion therapy to the treatment of alcohol dependence are discussed. Historical factors leading to the early use of chemical aversion therapies are delineated and the theoretical underpinnings of chemical aversion interventions are evaluated. Ethical and procedural considerations are addressed and an assessment of the efficacy of the therapy is attempted. Future research activities that would lead to refinement of chemical aversion therapy protocols are highlighted. The effectiveness of chemical aversion treatment of alcohol dependence is discussed vis-a-vis production of condition alcohol-aversion and treatment outcome.

The use of contingent water misting in the treatment of self-choking

A 25-year-old, deaf-blind, mentally retarded male was treated for chronic self-choking using water mist treatment and positive reinforcement. During pre-treatment baseline, self-chokes occurred at a rate of 2.09 per minute. During treatment sessions each self-choke was followed by water misting of the subject's face paired with a forceful "No!". Periods of 20 sec absent of self-chokes were positively reinforced with liquids and/or social contacts. Treatment procedures were generalized from the initial therapists, location, and absence of other clients and staff to other locations, and the presence of other clients and staff. Water mist treatment was associated with at least a 10-fold and as much as a 100-fold reduction of self-choking (i.e. to 0.02-0.20 self-chokes per min) across treatment and generalization phases. Eight-month follow-up observations showed that self-choke rates were at zero.

Comparison of imaginal desensitisation with other behavioural treatments of pathological gambling. A two- to nine-year follow-up

Of 120 pathological gamblers randomly allocated to imaginal desensitisation (ID) or to other behavioural procedures (60 to each group, all procedures administered over one week) 63 subjects were contacted two to nine years later. Twenty-six of the 33 who received ID reported control or cessation of gambling compared with 16 of 30 who received other behavioural procedures. This difference was significant, indicating ID had a specific effect additional to that of the other behavioural procedures. It is suggested the other procedures could be regarded as placebos. As the response at a mean of over five years to one week of ID is comparable with that reported to more intensive therapies, after briefer follow-up, it is suggested ID is a cost-effective therapy for pathological gambling, and is worth considering when resources are limited.

Long-term use of aversive drugs in outpatient alcoholism treatment

In a 2-year outpatient treatment programme for alcoholics, 90% of the patients used aversive drugs during some part of the treatment period. Long-term use was significantly related to a favourable drinking outcome during 2 years subsequent to treatment compared with short-term use. Long-term and short-term users did not differ in background data. Continued use of aversive drugs after the first 6 months might have been critical for favourable outcome.