Study Notes on Concurrent Treatment of Intimate Partner Violence and Trichotillomania

Abstract

  • Survivors of intimate partner violence (IPV) face numerous emotional and behavioral consequences, including challenges with emotion regulation and comorbid psychological diagnoses.

    • Studies have indicated that a modified version of Dialectical Behavior Therapy (DBT) may be effective in treating these survivors, particularly in alleviating symptoms of depression and emotional dysregulation.

    • However, there is limited research on the treatment of comorbid disorders within this population, specifically Body Focused Repetitive Behaviors (BFRB), such as trichotillomania.

    • The case study presented demonstrates an approach to effectively treat comorbid diagnoses of truichotillomania among IPV survivors.

Theoretical and Research Basis for Treatment

  • Definition of Intimate Partner Violence (IPV)

    • Includes physical violence, sexual violence, stalking, and psychological harm inflicted by a present or former partner (CDC, 2008).

  • Mental Health Consequences of IPV

    • Survivors often experience mental health issues such as depression, PTSD, and difficulties with emotion regulation (Kaufman et al., 2016; Resnick et al., 1997).

    • Emotion dysregulation is seen as a core feature affecting multiple internalizing and externalizing problems.

  • Evidence for DBT in IPV Situations

    • A modified version of DBT has been observed to diminish psychiatric distress, depression, and hopelessness among IPV survivors.

    • Initial studies, however, have yet to explore the treatment of comorbid conditions among this demographic.

  • Emotion Dysregulation Model (Theoretical Framework)

    • Iverson et al. (2009) assert that IPV's function often lies in its capacity to invalidate the victim's feelings.

    • Patterns of invalidation lead to shame and guilt, increasing emotional sensitivity and creating difficulty in returning to emotional homeostasis.

Definition of Comorbid Disorders

  • Body Focused Repetitive Behaviors (BFRB)

    • BFRBs are behaviors focused on the body, such as nail-biting and hair-pulling, conceptualized as maladaptive coping mechanisms for regulating dysregulated emotions (Roberts et al., 2013).

  • Trichotillomania Defined

    • Classified under Obsessive-Compulsive and Related Disorders in the DSM-5 (APA, 2013).

    • Characterized by recurrent hair pulling leading to noticeable hair loss and significant distress or impairment, despite multiple attempts to stop (American Psychiatric Association, 2013).

  • Correlation Between Trichotillomania and Anxiety

    • Several studies link the severity of trichotillomania to heightened anxiety (Hajcak et al., 2006; Lootens & Nelson-Gray, 2016; Roberts et al., 2013).

    • Research indicates a significant positive correlation between cognitive anxiety (worry and fear) and symptom severity, while no significant relationship exists for somatic anxiety symptoms (Alexander et al., 2017).

  • Emotion Regulation and Hair-Pulling

    • Evidence indicates that hair-pulling acts as a method of altering emotional experiences (Gross, 2008).

    • High rates of comorbidity (34%-82%) exist between trichotillomania and mood disorders, further indicating emotion regulation difficulties (Roberts et al., 2013).

Effectiveness of Acceptance-Based Therapies

  • Overview of Acceptance-Based Therapies

    • Acceptance and Commitment Therapy (ACT) and DBT-enhanced cognitive behavioral therapy show promise for treating trichotillomania (Boppana & Gross, 2019; Keuthen et al., 2010, 2011, 2012).

  • Efficacy Studies

    • Case studies and randomized trials indicate significant reductions in hair pulling and increases in emotion regulation through these therapies.

  • Connection to IPV Treatment

    • Integrating treatments for IPV and trichotillomania can result in improved outcomes by addressing both conditions concurrently.

Case Study Introduction

  • Patient Profile

    • "Le": pseudonym of a 23-year-old Asian American female referred for treatment due to feelings of unhappiness related to IPV.

  • Diagnostic Criteria

    • Meets DSM-5 criteria for Trichotillomania (history of pulling since age 4) and is diagnosed with PTSD and Generalized Anxiety Disorder.

  • Current IPV Scenario

    • Le experiences psychological and physical control from her partner; she faces challenges regarding safety and overcoming trauma-related symptoms.

Presenting Complaints

  • Initial Complaints

    • Negative feelings about self, intrusive memories, hyperarousal symptoms, anxiety management difficulties leading to hair-pulling.

    • Reports a consistent pattern of hair-pulling linked to both internal (stress) and external (conflict) cues, along with feelings of relief and satisfaction following episodes but embarrassment afterwards.

Personal History

  • Background context

    • Early life in Southeast Asia with a tumultuous family environment that included physical and emotional violence.

    • Immigrated to the U.S. at age 10, living with relatives while parents remained in her home country.

    • Previous intimate partner relationships marked by violence.

Assessment

  • Diagnostic Tools Utilized:

    • Generalized Anxiety Disorder-7 (GAD-7)\n - PTSD Checklist for DSM-5 (PCL-5)

    • Milwaukee Inventory for Subtypes of Trichotillomania (MIST-A)

    • NIMH Trichotillomania Scale (TTS)

    • Distress Tolerance Scale (DTS)

    • Difficulties in Emotion Regulation Scale (DERS)

    • Five Facet Mindfulness Questionnaire (FFMQ)

    • Acceptance and Action Questionnaire-II (AAQ-II)

  • Baseline findings indicated severe anxiety, provisional PTSD diagnosis, and high levels of hair pulling.

Case Conceptualization

  • Foundational Theories

    • Le's invalidating home environment led to her emotion regulation struggles and established patterns of hair-pulling coping.

Treatment Course and Progress Assessment

  • Treatment Structure and Modality

    • Conducted via telehealth/telephone due to COVID-19.

    • Individual interventions based on habit reversal and group therapy focusing on DBT skills targeting IPV.

  • Treatment goals updated throughout sessions based on effectiveness and situational changes.

  • Summary of Skill Training Sessions

    • Session content incorporated mindfulness, safety planning, emotional regulation, distress tolerance, and interpersonal skills.

Outcomes and Improvements

  • Notable Treatment Outcomes

    • Significant symptom reduction in PTSD and anxiety, emotional regulation improvements and reductions in hair-pulling behavior reported.

    • Clinically significant changes were recorded across multiple assessment measures.

    • Improvements observed in the context of independence from ongoing IPV after leaving the relationship.

Complicating Factors

  • Ongoing IPV during initial treatment resulted in high stress and fluctuation in treatment progress.

  • Compounded difficulties due to the COVID-19 pandemic affecting therapy accessibility and execution.

  • Individual/group treatment discrepancies due to lack of participation in group sessions.

Access and Barriers to Care

  • Treatment provided at a free, specialty clinic due to socioeconomic factors impacting Le.

  • Telehealth services limited by physical and logistical barriers, such as needing privacy and safety during sessions.

Treatment Implications

  • Highlights the need for further examination of DBT applications for IPV survivors, focusing on concurrent treatment of comorbid conditions.

  • Emphasizes mantra of holistic treatment, addressing both symptom behavior and underlying emotion regulation deficits.

Recommendations for Clinicians

  • Continued integration of cultural considerations to improve treatment relevancy and efficacy.

  • Importance of flexibility and adaptations based on cultural backgrounds during therapy sessions.

  • Engage in culturally informed practices to optimize client contributions to treatment.

Conclusion

  • This case study underscores the efficacy of combining DBT with habit reversal therapy to effectively treat IPV survivors with comorbid trichotillomania based on emotion regulation deficits. Integrating cultural perspectives in treatment significantly enhances the effectiveness and adherence to treatment methods.