192 Behav.
CASE
Res. & Therapy,
1971. Vol. 15, pp
HISTORIES
192-196.
Pergamon
AND
SHORTER
Press.
Prmted
COhfhfUNICATlONS
m Great
Bntam
Behaviour therapy for trichotillomania (Received 16 August 1976)
Hallopeau (1889) appears to have been the first to introduce the term “Trichotillomania” to describe alopecia produced by a person pulling out his or her own hair. It is quite a rare symptom although fiddling with hair is quite common and may be considered to be a normal activity in social primates (Demaret, 1973). Greenberg and Sarner (1965) could only find ten English language references on trichotillomania and details of only twenty-eight cases. They gave an account of their study of nineteen patients. Each patient was given a thorough physical investigation and psychological assessment using the WAIS, TAT, and Rorschach tests. Unfortunately, there was no indication of treatment and outcome for individual patients but the benefits of psychoanalytically based psychotherapy were generally extolled. Since then most of the literature has consisted of psychoanalytical accounts of the etiology and psychotherapeutic methods used in treating cases of trichotillomania-usually in children (e.g. Dalgaldo and Mannino 1969; Ilan and Alexander 1965; Szonn 1975). One report on the treatment of an adult is that by Munroe and Abse (1963). In this paper details were provided of the psychoanalytically based psychotherapy given to a 22-year-old woman with trichotillomania. However, it is almost incidentally that one learns that this symptom mitigated to a significant extent as “the psychotherapeutic relationship became stronger” (ibid. p. 98). From reviewing the literature it is apparent that there has never been a controlled trial of any form of treatment for this complaint. In the psychoanalytical studies there are no data to indicate the extent or duration of improvement in hair-pulling from treatment. Studies using behavioural methods of treatment are even rarer than the psychoanalytical ones. They, too, are all case-histories. This is understandable when the phenomenon of hair-pulling of a severity requiring treatment is so uncommon. There are few data on the incidence or prevalence for adults but various figures have been given from the study of children presenting for psychiatric treatment. Anderson and Dean (1956) found only 3 out of 500 cases with the symptom. Schacter (1961) found only 5 out of more than 10,000, and Mannino and Delgaldo (1969) found only 7 out of 1,368. It would, therefore, be extremely difficult to find enough cases to carry out control studies comparing the efficacy of different treatment methods. Thus, the necessity for providing quantitative data in case reports and clear specification of the relationship between any change in the symptom and treatment is of paramount importance. The scanty behaviour therapy literature meets these requirements better than the psychoanalytical studies. The earliest behavioural report seems to be that of Taylor (1963). He treated a 40-year-old woman, who had a 31-year history of compulsive eyebrow-plucking, in ten days by using a “thought stopping” technique. When her hands started to move, she simply told them, “No, stay where your are!” For whatever reasons, the technique was effective. Bayer (1972) treated a 22-year-old women, with a 2-year history of pulling out single hairs. She was embarrassed by her habit but claimed that she had managed to keep it hidden from everyone. The baseline rate of hair-pulling over 5 days was established at 20.6 per day. Following this she was instructed to keep a chart of her hair-pulling as a form of feedback in the hope of enhancing control over the symptom. This stage lasted 7 days, and mean daily hair-pulling fell to 16.6. However, the graph presented (ibid. p, 140) shows a continuous fall in hairs pulled from the beginning of this phase through to the final phase of “aversive self-control and self-monitoring”. Thus, it could be debated whether the introduction of the aversive self-control of saving the pulled hairs in a daily envelope and bringing them to the therapist once a week, added much to the undoubted effectiveness of the treatment. By day 16 of treatment the first zero score was attained, With one minor relapse on day 21. this pattern was continued until day 28. when the patient was unfortunately killed in a motor car accident. In a series of twelve patients treated for nervous habits by Azrin and Nunn (1973) one was a 31-year-old woman with compulsive eyebrow-plucking. The use of a competing response to the eyebrow plucking, viz. grasping objects, plus enhancing self awareness of the behaviour. was highly successful in removing the habit. Stabler and Warren (1974) reported the case of a 14-year-old girl with a 2-year history of trichotillomania, starting after her father’s death. Shqpulled hairs from the back and sides of her head. She was embarrassed by her appearance and referred herself for treatment. She was required to keep the hairs she pulled out and bring them to treatment sessions each week. The base line rate of hair-pulling over three weeks was 25 hairs per day. A point system was then introduced, backed up by strong positive reinforcement when she gained the target number of 140 points. She could earn 10 points by pulling out no hairs between each weekly treatment session-the contract seemed to be highly effective as she immediately ceased all hair-pulling and achieved the target score in the minimal possible time of 14 weeks. At 6-month follow-up there was no relapse nor symptom substitution. Most recently McLaughlin and Nay (1975) reported the case of a 17-year-old girl with both trichotillomania and eyelash-pulling. Again, a baseline of hair-pulling was established before actual treatment commenced by keeping a notebook and collecting the hairs pulled in a daily envelope. The eyelash-pulling responded only minimally but the hair-pulling was reduced to zero after 18 weeks. There was no relapse at 3-month follow-up. Actual treatment involved several components including training in general relaxation, and exploration of her quite marked anxieties at home and at school with suggestions as to how she might alter her patterns of social interactions. Specific use was made of positive coverants, in terms of deliberately imagining pleasant events in relation to her hair each time she successfully resisted pulling her hair. and response cost when she didn’t pull her hair. The response cost comprised recording the time, place and the conditions
CASE HISTORIES
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SHORTER
COMMUNICATIONS
193
under which the event occurred as well as collecting the hairs in envelopes. Later on, was added having to stop what she was doing to go to the bathroom to examine, in the mirror, the expact spot from which the hair had been pulled, and to record this data in a diary. As far as the author could ascertain, these behaviour therapy studies are the only ones reported in the literature, although other behaviour therapists have been encountered who have treated such patients. The review of the psychoanalytical studies is not complete but is wide enough to provide a clear idea of the nature of this approach. One important feature emerging from this review is that all the cases treated were female, ranging in age from the teens to about 40 years. In the remainder of this paper the treatment of two patients with trichotillomania, using a behavioural psychotherapy approach, is described. The first case is most unusual because, as far as can be determined, it is the only time that treatment of an adult male has been reported in the literature. The second patient is more typical, being a woman in her mid-twenties. CASE1
MR.A
This patient who was 42.years-old, claimed he had been pulling out hair from his head since the age of 7 years. He was also a nail-biter, and, as a child, stuttered. The compulsive hair-pulling was his main complaint but he had recently been treated for depression with desipramine hydrochloride and diazepam. At the initial session he was still taking both these drugs. He presented as rather introverted with obsessional traits. Physically, he was of average height and weight and was patchily bald as a result of his hair-pulling. He had a skilled industrial job, being the operator of complex new computer-controlled milling equipment in an engineering factory. On interview, he communicated his worries easily and rapport was good. He said that he had always been “a loner”, and was very self-conscious about his appearance. He was married and had four children aged between 4: and 15 years. There were a number of family tensions and, as his hair-pulling improved, with concomitant enhancement of self-confidence, some of these had to be treated. Eventually, the whole family was referred to a family psychotherapy unit. However, in this report attention will be focused on the treatment of trichotillomania. Treatment
Mr. A was initially seen at weekly intervals. On the first occasion he was instructed to keep a diary of his hair-pulling behaviour, recording both hairs pulled and successful resistances to the urge to pull. On the second session he reported that he felt hair-pulling had decreased by about one third. Also, instead of pulling hairs from all over his head he had concentrated on one spot, viz. behind his left ear. At the second session he was also taught relaxation by hypnosis and given the suggestion that whenever his hand touched his head to pull a hair it would become numb and weak. This procedure was repeated on sessions 3, 4 and 5, and resulted of five weeks of zero hair-pulling. During this time all medication was gradually eliminated. He continued to be seen at weekly intervals but more and more time was spent discussing his considerable family problems. Treatment session number 8 consisted of a joint interview with both him and his wife. They spent 45 minutes continuously arguing with each other. During this time it emerged that their social life was poor and that both resented this for different reasons. Also, the topic of Mr. A’s premature ejaculation was raised by his wife, who said she would like sex more often. As a short term measure some practical goals, which they both agreed upon, were drawn up; this resulted in some improvement. However, the hair-pulling worsened and in the week following session 10, hair was pulled out on 28 occasions and the urge resisted on 47. Over the next 23 weeks Mr. A was seen fourteen times, and Mrs. A twice. Family problems were the main theme and the premature ejaculation was markedly improved by using the squeeze technique (Masters and Johnson, 1970). Hair-pulling continued at between 16 and 26 per week. When it seemed that the family relationship problem had become less urgent attention was once more focused on the hair-pulling. On session 21 the relaxation/hypnotic suggestions were re-introduced. From session 26, 8 weeks later, there followed 5 months zero hair pulling. During this time his hair grew thickly and he went to a strange barber’s for a hair cut for the first time in 20 years. At this stage his father-in-law died and there were increases in family tensions again. Also, about this time, he gained promotion at work which he felt he had deserved for a long time. This promotion appeared to be resented by his wife because it meant that he had to spend more time at work as he had supervisory and apprentice training duties. All lovemaking ceased, rows became frequent and hair-pulling rose to a peak of 73, with only 20 successful resistances. in the week preceding the 39th treatment session. It was at this point that the whole family was referred for psychotherapy, with Mr. A continuing to attend alone for a concerted attack on the trichotillomania. The previous therapeutic procedure was re-instated. This produced some improvement to the extent that in the last 8 weeks of treatment the weekly total number of hairs pulled ranged from 8 to 28, and successful resistances from 10 to 18. Treatment terminated on session 48, because the therapist was leaving for overseas for 7 months, but the patient will continue to be followed up. Thus, as far as the patient’s trichotillomanis is concerned, over the 48 therapy sessions during 20 months, there had, for a time, been a marked improvement with treatment by monitoring both number of hairs pulled and successful resistances of the urge to pull, combined with relaxation and hypnotic suggestion. After a major relapse associated with family discord and work tension, the use of this treatment regime was not SO successful. However, some control over the symptom was regained and follow-up treatment is planned. CASE
2: MISS
B
was 26-years-old, had an g-year history of trichotillomania. She was also a nail-biter hut felt this to be a minor problem. The hair-pulling had apparently started when she was studying for This
Pitent,
who
194
CASE HISTORIES
AND SHORTER
COMMUNICATIONS
exams at the age of 17 years. It had continued since that time. being worse at nights before going to sleep or when sitting at a desk reading or writing. She claimed only her mother knew about her “problem”. This could well have been true since she wore a very good hair piece to cover the thin hair at the front and top of her head, from where she mostly pulled hairs. She did this by taking a single strand of hair between thumb and index finger, playing with it and eventually pulling it out. She would then inspect the root. chew it, and throw the hair away. She had attractive shoulder length wavy black hair, was well-dressed, vivacious and extroverted, and slightly above average in height and weight. She lived at home with her parents and claimed she was on good terms with them. She was a part-time primary school teacher and a part-time University student, she had a steady boyfriend and during the course of treatment married him. This was interesting because it coincided with a period of zero hair-pulling and, also, because she said she had never had sexual intercourse, even though they had slept together often. At the time treatment was terminated when the author went abroad, they had still not had sexual intercourse. However, she maintained they had very satisfying orgasms through mutual masterbation. Her family history revealed that her father had a habit of pulling out hairs from his nose and fiddling with his finger-nails. Her only sibling, a 20-year-old brother, was also a nail-biter. Treatment She was instructed to keep the diary as in the case of Mr. A. It was explained that treatment would commence by teaching her to relax and to learn to control her desire to pull out the hairs. When seen on session 2, one month later, she had not kept the diary systematically. She was asked to rectify this and given training in relaxation using an hypnotic induction technique. She found difficulty in relaxing and her latent anxiety became more manifest. Some time was thus spent in re-assuring discussion of questions she raised about normality, control of anxiety and her ambivalence to treatment. Diary records became systematic and a weekly hair pulling was in the 220’s. An example of her anxiety was seen in session 4 when the hypnotic suggestion that she would not be able to pull out the hair when her hand touched her head, was introduced. This produced mild panic and a feeling of bloodlessness in her left hand. She was then challenged to pull out a hair but adamantly refused. However, there was no effect on rate of hair-pulling over the next week, although her nail-biting ceased to the extent that she had to cut her nails with scissors for the first time in her life. Sessions 6, 7 and 8 were devoted to training in relaxation. She did become more relaxed but there was no accompanying improvement in hair-pulling. From session 9, the suggestion that her hand would go “cold. numb and paralysed”, when trying to pull out her hair was made. This had no effect on hair-pulling and made her feel worse. So, various types of post hypnotic suggestions were experimented with; but to no avail. It was decided to use electrical aversive conditioning to break what seemed to be a very strong habit of hair-pulling only partially related to tension. It was also decided that to avoid response prevention during the aversive treatment sessions it might be more effective to administer the shocks to the patient while she was watching a videotape recording of herself pulling out her own hair. The patient co-operated fully with this procedure. The electrodes for administering the electric shock were placed on the back of either hand on different occasions, because she used both hands to pull out hairs. At treatment session 17, twelve shocks were given while she watched the pre-recorded videotape. During the following week, hairs pulled dropped from 220 to 145. At session 18, twenty-two shocks were administered with ensuing decrease in hairs pulled to 21. At session 19. fifteen shocks were given and this resulted in only five hairs being pulled in a week. At session 20, electrodes were attached but no shocks given while she watched the tape. While the electrodes were still attached the patient was asked to actually pull out a hair but, she strongly refused, saying “I can’t do that”. On session 21, she reported not having pulled out a single hair. She had also been sitting for exams during this time, and did very well in them. She was seen five more times at weekly intervals and then gradually at increasing intervals over the next four months. There were just over 5 months completely free of hair-pulling, during which time her hair grew normally and eventually she ceased wearing her hair-piece. Relapse came about when she married during the summer vacation (January). While on an aeroplane to Hawaii for her honeymoon, she pulled out some hairs. Retrospectively, she calculated that she had pulled out 50 hairs during the ensuing three weeks. On return, when she attended a follow-up appointment (session 31). some relaxation practice was given again as she appeared quite tense. She admitted that she and her husband had not had sexual intercourse since the wedding (nor before. as mentioned above). It was suggested to her that they could both well be helped in this regard but she maintained that, for the present, they would stay as they were. She was then seen four times in four weeks. Diary keeping was recommenced and training in relaxation continued. Hair-pulling fluctuated up to 20 per day but was usually much less, with a weekly average of 46.75. Mean weekly number of successful resistances was 58.0. At treatment session 36 she was given six shocks to the original videotape as the number of hairs pulled was not decreasing. This resulted in 7 months of minimal hair-pulling. Often the numbers pulled per week were zero, with increases being related to exams and general tension associated with her university study. This period ended with the final exams for the year when she asked for an appointment because her hair-pulling had increased markedly while she was studying. As she had ceased to keep a diary no precise count was available. Prior to making the appointment she had been prescribed some trifluoperazine. This had helped with the immediate crisis and, by the time she was seen. she maintained she was only pulling out up to six hairs per day. As the therapist was going abroad for some time no more could be done at this stage. However. follow-up will be maintained and major relapses treated. In summary, the introduction of aversive conditioning using an electric shock (from a 9-volt battery) have given her eighteen months of markedly reduced hair-pulling. Relapses occurred but were of limited duration, and having discarded her hair piece, she had never resumed it. In view of the fact that she had been pulling out upwards of 200 hairs per week, and her history was of S-years duration, this a probably a reasonable
CASEHISTORIES ANDSHORTER COMMUNICATIONS
19s
achievement. There were 41 treatment sessions and the patient stated that she certainly felt they were worthwhile. DISCUSSION
Behavioural psychotherapy, or behaviour therapy, approaches to treating trichotillomania have been much more explicit in stating the form of treatment carried out and monitoring the changes in the hair pulling behaviour than psychoanalytical reports. However, since treatment of the seven behaviour therapy cases reviewed was different for each individual patient, it is impossible to identify the specific factors operative in bringing about change. Nevertheless, some parameters seem to have been more important than others and to warrant further investigation. All the behavioural psychotherapy treatment programmes, except perhaps that of Taylor (1963). involved feedback of results by at least keeping a tally of the hair-pulling behaviour. Positive rewards were also used, but these varied from general praise and indulging in desired activities (e.g. Stabler and Warren. 1974) to the specific coverant positive reinforcement used by McLaughlin and Nay (1975). Aversive therapy was used, as in the case outlined above, to a video-recording of a patient pulling out her own hair, and by Bayer (1972), who felt that saving the pulled hairs in a daily envelope was an aversive procedure. The use of videotape as a form of feedback in psychiatric treatment has developed rapidly (e.g. Berger, 1970). In the case of Miss B above, the combination of a video-recording of the patient pulling her own hair combined with aversive therapy was successful, but the independent role of the videotape as feedback in its own right needs to be assessed. It may well have been that simply this form of feedback would t.ave been enought to stop her hair-pulling behaviour. There seems to be little doubt. from the cases reviewed. that whatever initially produced compulsive hairpulling behaviour, there is a strong habitual component by the time a person presents for treatment. The moderately good results from treatment by behavioural methods suggests that to tackle the symptom as a maladaptive habit is appropriate. The major elements of these methods manipulated in treating trichotillomania have been feedback to enhance knowledge and awareness of the behaviour; positive reinforcement of non-hair-pulling behaviour; negative reinforcement of hair-pulling behaviour, including response cost; general reduction of anxiety; and positive suggestion. There is no reliable information about which of these components are the most important for a particular patient. However, from the case of Miss B. above, it may be argued that when the habitual component is very strong and the behaviour is relatively independent of anxiety strong forms of feedback are required before any change can be brought about. This view concords with Azrin and Nunn’s (1973) argument that one of the difficulties in treating nervous habits is that a person with such habits often becomes relatively unaware of them because of lack of immediate adverse repercussions. Associates of such a person presumably become equally adjusted to the nervous habit and fail to read to it, after a time. Thus, an important part of treatment seems to be to increase awareness of the behaviour. In fact, the evidence from all of the cases reviewed in this paper lends weight to the crucial importance of this component. Systematic investigation of the relationships between anxiety and habit strength with the various components of treatment, even in a not strictly controlled clinical treatment setting, would be useful for developing more efficient treatment procedures. In conclusion, it can be stated that some form of direct feedback to the patient about the hair-pulling behaviour seems to be an essential, but usually not a sufficient, condition to bring about amelioration of the symptom. Acknowledgement-1
would like to acknowledge the help of Mr. M. Crewdson in suggesting the use of videotape in the case of Miss B. and in helping me to carry out this part of the treatment programme.
Department of’ Psychiatry, University of Melbourne, Royal Melbourne Hospital, Mctoria, Australia 3050
DAVIDJ.
DE
L. HORNE
REFERENCES
F. N. and DEAN H. C. (1956) Some Aspects of Child Guidance Intake Policy and Practices: A Study of 500 Cases at the Los Angeles Child Guidance Clinic, Los Angeles, California. Public Health Monogr No. 42. AZRIN N. H. and NUNN R. G. (1973) Habit reversal: A method of eliminating nervous habits. Behau. Res. ANDERSON
and Therapy 11, 619428.
BAYERC. A. (1972) Self-monitoring
and mild aversion treatment of trichotillomania.
J. Behau. Ther. exp.
Psychiat. 3, 139-141.
BERGERM. M. (1970) Videotape Techniques in Psychiatric Training and Treatment. Bruner/Mazel, New York. DELGAD~R. A. and MANNINOF. V. (1969) Some observations on trichotillomania in children. J. Am. Acad. Child Psychiat. 8, 229-246.
DEMARETA. (1975) Onychophagie, Trichotillomanie et Grooming. Ann. mPdico-psycho/. 131(l), 235-242. GREENBERG H. R. and SARNER C. A. (1965) Trichotillamania: symptoms and syndrome. Archs gen. Psychiat. 12, 482489.
HALLOPEAUX. (1889) Alopecia par grottage (Trichomania on Trichotillomania). Ann. Derm. Syph. 10, 440. ILAN E. and ALEXANDER E. (1965) Eyelash and eyebrow pulling (trichotillomania): Treatment of two adolescent girls. Israel Ann. Psychiat. 3, 267-281. MCLAUGHLINJ. G. and NAY W. R. (1975) Treatment of trichotillomania using positive coverants and response cost: A case report. Behar. Therap!. 6. 87-91.
CASEHISTORIES ANDSHORTER COMMUNlCATIONS
196
MANNINOF. V. and DELGAW R. A. (1969) Trichotillomania in children: A review. Am. J. Psychiat. 126, 505-511. MATTERSW. H. and JOHNSONV. E. (1970) Human Sexual Inadequacy. Churchill, London. MONROEJ. T. and ABSED. W. (1963) The psychopathology of trichotillomania and trichophagy. PsychiafrJ 26, 95-103. SCHACHTER M. (1961) Trichotillomania in children. Prux. Kinderpsychol. 10, 120-124. STABLER B. and WARRENA. B. (1974) Behavioural contracting in treating trichotillomania: Case note. Psychol. Rep. 34, 401402. SZONNG. (1975) Praxis der Kinderpsychol. Kinderpsychiat. 24, lC-18. TAYLORJ. G. (1963) A behavioural interpretation of obsessive-compulsive neurosis. Behac. Res. and Therap) 1, 237-244.
Behav. Res. & Therapy. 1977. Vol
IS. pp 196-198. Pergamon Press. Prmted m Great Bntam
Supression of a retardate’s tongue protrusion by contingent imitation:
A case study
(Receifled 13 July 1976) There is much research indicating that behaviorally handicapped children can be helped to learn appropriate behaviour by being shown models of desirable conduct (Cullinan et al., 1975). Only very recently, however, has any research attention been given to the possibility of using contingent imitation of the child’s own responses as a therapeutic tool. In previous case studies, Kauffman et al. (1975) found that mimicking severely retarded children could have quite different effects depending, apparently, on how the children perceived the adults’ behavior. In one case described by Kauffman and his colleagues, an adult’s imitation of a child’s sloppy eating dramatically improved the child’s eating habits; in another case an adult’s mimicry of the child’s animal-like yelping clearly worsened the problem. Further experimentation has shown that contingent imitation of children’s responses can accelerate the acquisition of an imitative repertoire during imitation training (Kauffman et al., in press) and that contingent imitation of children’s spelling errors can improve spelling performances (Kauffman et al. 1976). The present case study was designed to demonstrate how contingent imitation can be used to suppress a persistent inappropriate behavior and how cues associated with imitation can be used to maintain the level of suppression once the adult’s mimicry has been withdrawn. Subject and setting
The subject, Terry, was a 12-year-old retarded male (IQ 48) enrolled in a special public school class with six other retarded children. Besides the teacher, two other adults were typically present: a student teacher and a teacher aide. Terry frequently protruded his tongue far out of his mouth, making his facial appearance unpleasant. It was obvious that if he was to find social acceptance among his normal schoolmates and adults Terry would need to learn to control his tongue protrusions. His tongue was exterlded most often during activities requiring concentration, especially academic seatwork exercises. Prior to beginning the case study. the teacher had tried reminding Terry to keep his tongue in his mouth and praising him for tongue-in behavior, but to no avail. Requiring Terry to observe his protruding tongue in a mirror was not successful, as he would refuse to extend his tongue and look in the mirror at the same time. Recording and observer agreement
Tongue protrusions, defined as the tongue being visible. were recorded for 15 min each morning (during three separate 5-min intervals) while Terry was working on reading seatwork assigments at a table. Terry’s behavior was recorded by the teacher, who sat across the table from him. observed him continuously, and tallied tongue protrusions on a slip of paper. On 14 days. either the teacher aide or the student teacher independently, but simultaneously, recorded tongue protrusions. Observer agreement, calculated by dividing the lesser by the greater frequency and multiplying by 100, averaged 92% (range = 7(rlOO%) for the 14 days. Design and procedure
An ABAB design was employed in which experimental procedures were alternately applied and withdrawn. During all phases of the study, Terry was given intermittent contingent praise for keeping his tongue in his mouth. After obtaining baseline (no intervention) data for five days, the teacher gave a verbal reminder (“Terry, put your tongue in.“) each time Terry protruded his tongue. On day 12 (see Fig. 1) the teacher began contingently imitating Terry’s tongue protrusions. Each time Terry stuck his tongue out, the teacher immediately held Terry’s head so that eye contact was assured and imitated his tongue protrusion. On day 19 the teacher stopped imitating Terry and returned to reminders, and on day 25 contingent imitation was reinstated. Beginning on day 30, the teacher no longer imitated tongue protrusions but gave a physical cue (grasping Terry’s cheek) contingent on tongue-out behavior. After returning to verbal .reminders for two days. the physical cue was modified to consist of the teacher’s touching Terry’s chin lightly with her index finger (beginning on day 38). Rrsrrlts atld discussiori
Although verbal reminders had no noticeable effect on Terry’s tongue protrusions, contingent imitation immediately and dramatically reduced their frequency, as shown in Fig. 1. When contingent imitation was withdrawn, reminders failed to maintain the suppression, but reinstatement of contingent imitation quickly
CASE
Res. & Therapy,
1971. Vol. 15, pp
HISTORIES
192-196.
Pergamon
AND
SHORTER
Press.
Prmted
COhfhfUNICATlONS
m Great
Bntam
Behaviour therapy for trichotillomania (Received 16 August 1976)
Hallopeau (1889) appears to have been the first to introduce the term “Trichotillomania” to describe alopecia produced by a person pulling out his or her own hair. It is quite a rare symptom although fiddling with hair is quite common and may be considered to be a normal activity in social primates (Demaret, 1973). Greenberg and Sarner (1965) could only find ten English language references on trichotillomania and details of only twenty-eight cases. They gave an account of their study of nineteen patients. Each patient was given a thorough physical investigation and psychological assessment using the WAIS, TAT, and Rorschach tests. Unfortunately, there was no indication of treatment and outcome for individual patients but the benefits of psychoanalytically based psychotherapy were generally extolled. Since then most of the literature has consisted of psychoanalytical accounts of the etiology and psychotherapeutic methods used in treating cases of trichotillomania-usually in children (e.g. Dalgaldo and Mannino 1969; Ilan and Alexander 1965; Szonn 1975). One report on the treatment of an adult is that by Munroe and Abse (1963). In this paper details were provided of the psychoanalytically based psychotherapy given to a 22-year-old woman with trichotillomania. However, it is almost incidentally that one learns that this symptom mitigated to a significant extent as “the psychotherapeutic relationship became stronger” (ibid. p. 98). From reviewing the literature it is apparent that there has never been a controlled trial of any form of treatment for this complaint. In the psychoanalytical studies there are no data to indicate the extent or duration of improvement in hair-pulling from treatment. Studies using behavioural methods of treatment are even rarer than the psychoanalytical ones. They, too, are all case-histories. This is understandable when the phenomenon of hair-pulling of a severity requiring treatment is so uncommon. There are few data on the incidence or prevalence for adults but various figures have been given from the study of children presenting for psychiatric treatment. Anderson and Dean (1956) found only 3 out of 500 cases with the symptom. Schacter (1961) found only 5 out of more than 10,000, and Mannino and Delgaldo (1969) found only 7 out of 1,368. It would, therefore, be extremely difficult to find enough cases to carry out control studies comparing the efficacy of different treatment methods. Thus, the necessity for providing quantitative data in case reports and clear specification of the relationship between any change in the symptom and treatment is of paramount importance. The scanty behaviour therapy literature meets these requirements better than the psychoanalytical studies. The earliest behavioural report seems to be that of Taylor (1963). He treated a 40-year-old woman, who had a 31-year history of compulsive eyebrow-plucking, in ten days by using a “thought stopping” technique. When her hands started to move, she simply told them, “No, stay where your are!” For whatever reasons, the technique was effective. Bayer (1972) treated a 22-year-old women, with a 2-year history of pulling out single hairs. She was embarrassed by her habit but claimed that she had managed to keep it hidden from everyone. The baseline rate of hair-pulling over 5 days was established at 20.6 per day. Following this she was instructed to keep a chart of her hair-pulling as a form of feedback in the hope of enhancing control over the symptom. This stage lasted 7 days, and mean daily hair-pulling fell to 16.6. However, the graph presented (ibid. p, 140) shows a continuous fall in hairs pulled from the beginning of this phase through to the final phase of “aversive self-control and self-monitoring”. Thus, it could be debated whether the introduction of the aversive self-control of saving the pulled hairs in a daily envelope and bringing them to the therapist once a week, added much to the undoubted effectiveness of the treatment. By day 16 of treatment the first zero score was attained, With one minor relapse on day 21. this pattern was continued until day 28. when the patient was unfortunately killed in a motor car accident. In a series of twelve patients treated for nervous habits by Azrin and Nunn (1973) one was a 31-year-old woman with compulsive eyebrow-plucking. The use of a competing response to the eyebrow plucking, viz. grasping objects, plus enhancing self awareness of the behaviour. was highly successful in removing the habit. Stabler and Warren (1974) reported the case of a 14-year-old girl with a 2-year history of trichotillomania, starting after her father’s death. Shqpulled hairs from the back and sides of her head. She was embarrassed by her appearance and referred herself for treatment. She was required to keep the hairs she pulled out and bring them to treatment sessions each week. The base line rate of hair-pulling over three weeks was 25 hairs per day. A point system was then introduced, backed up by strong positive reinforcement when she gained the target number of 140 points. She could earn 10 points by pulling out no hairs between each weekly treatment session-the contract seemed to be highly effective as she immediately ceased all hair-pulling and achieved the target score in the minimal possible time of 14 weeks. At 6-month follow-up there was no relapse nor symptom substitution. Most recently McLaughlin and Nay (1975) reported the case of a 17-year-old girl with both trichotillomania and eyelash-pulling. Again, a baseline of hair-pulling was established before actual treatment commenced by keeping a notebook and collecting the hairs pulled in a daily envelope. The eyelash-pulling responded only minimally but the hair-pulling was reduced to zero after 18 weeks. There was no relapse at 3-month follow-up. Actual treatment involved several components including training in general relaxation, and exploration of her quite marked anxieties at home and at school with suggestions as to how she might alter her patterns of social interactions. Specific use was made of positive coverants, in terms of deliberately imagining pleasant events in relation to her hair each time she successfully resisted pulling her hair. and response cost when she didn’t pull her hair. The response cost comprised recording the time, place and the conditions
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under which the event occurred as well as collecting the hairs in envelopes. Later on, was added having to stop what she was doing to go to the bathroom to examine, in the mirror, the expact spot from which the hair had been pulled, and to record this data in a diary. As far as the author could ascertain, these behaviour therapy studies are the only ones reported in the literature, although other behaviour therapists have been encountered who have treated such patients. The review of the psychoanalytical studies is not complete but is wide enough to provide a clear idea of the nature of this approach. One important feature emerging from this review is that all the cases treated were female, ranging in age from the teens to about 40 years. In the remainder of this paper the treatment of two patients with trichotillomania, using a behavioural psychotherapy approach, is described. The first case is most unusual because, as far as can be determined, it is the only time that treatment of an adult male has been reported in the literature. The second patient is more typical, being a woman in her mid-twenties. CASE1
MR.A
This patient who was 42.years-old, claimed he had been pulling out hair from his head since the age of 7 years. He was also a nail-biter, and, as a child, stuttered. The compulsive hair-pulling was his main complaint but he had recently been treated for depression with desipramine hydrochloride and diazepam. At the initial session he was still taking both these drugs. He presented as rather introverted with obsessional traits. Physically, he was of average height and weight and was patchily bald as a result of his hair-pulling. He had a skilled industrial job, being the operator of complex new computer-controlled milling equipment in an engineering factory. On interview, he communicated his worries easily and rapport was good. He said that he had always been “a loner”, and was very self-conscious about his appearance. He was married and had four children aged between 4: and 15 years. There were a number of family tensions and, as his hair-pulling improved, with concomitant enhancement of self-confidence, some of these had to be treated. Eventually, the whole family was referred to a family psychotherapy unit. However, in this report attention will be focused on the treatment of trichotillomania. Treatment
Mr. A was initially seen at weekly intervals. On the first occasion he was instructed to keep a diary of his hair-pulling behaviour, recording both hairs pulled and successful resistances to the urge to pull. On the second session he reported that he felt hair-pulling had decreased by about one third. Also, instead of pulling hairs from all over his head he had concentrated on one spot, viz. behind his left ear. At the second session he was also taught relaxation by hypnosis and given the suggestion that whenever his hand touched his head to pull a hair it would become numb and weak. This procedure was repeated on sessions 3, 4 and 5, and resulted of five weeks of zero hair-pulling. During this time all medication was gradually eliminated. He continued to be seen at weekly intervals but more and more time was spent discussing his considerable family problems. Treatment session number 8 consisted of a joint interview with both him and his wife. They spent 45 minutes continuously arguing with each other. During this time it emerged that their social life was poor and that both resented this for different reasons. Also, the topic of Mr. A’s premature ejaculation was raised by his wife, who said she would like sex more often. As a short term measure some practical goals, which they both agreed upon, were drawn up; this resulted in some improvement. However, the hair-pulling worsened and in the week following session 10, hair was pulled out on 28 occasions and the urge resisted on 47. Over the next 23 weeks Mr. A was seen fourteen times, and Mrs. A twice. Family problems were the main theme and the premature ejaculation was markedly improved by using the squeeze technique (Masters and Johnson, 1970). Hair-pulling continued at between 16 and 26 per week. When it seemed that the family relationship problem had become less urgent attention was once more focused on the hair-pulling. On session 21 the relaxation/hypnotic suggestions were re-introduced. From session 26, 8 weeks later, there followed 5 months zero hair pulling. During this time his hair grew thickly and he went to a strange barber’s for a hair cut for the first time in 20 years. At this stage his father-in-law died and there were increases in family tensions again. Also, about this time, he gained promotion at work which he felt he had deserved for a long time. This promotion appeared to be resented by his wife because it meant that he had to spend more time at work as he had supervisory and apprentice training duties. All lovemaking ceased, rows became frequent and hair-pulling rose to a peak of 73, with only 20 successful resistances. in the week preceding the 39th treatment session. It was at this point that the whole family was referred for psychotherapy, with Mr. A continuing to attend alone for a concerted attack on the trichotillomania. The previous therapeutic procedure was re-instated. This produced some improvement to the extent that in the last 8 weeks of treatment the weekly total number of hairs pulled ranged from 8 to 28, and successful resistances from 10 to 18. Treatment terminated on session 48, because the therapist was leaving for overseas for 7 months, but the patient will continue to be followed up. Thus, as far as the patient’s trichotillomanis is concerned, over the 48 therapy sessions during 20 months, there had, for a time, been a marked improvement with treatment by monitoring both number of hairs pulled and successful resistances of the urge to pull, combined with relaxation and hypnotic suggestion. After a major relapse associated with family discord and work tension, the use of this treatment regime was not SO successful. However, some control over the symptom was regained and follow-up treatment is planned. CASE
2: MISS
B
was 26-years-old, had an g-year history of trichotillomania. She was also a nail-biter hut felt this to be a minor problem. The hair-pulling had apparently started when she was studying for This
Pitent,
who
194
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exams at the age of 17 years. It had continued since that time. being worse at nights before going to sleep or when sitting at a desk reading or writing. She claimed only her mother knew about her “problem”. This could well have been true since she wore a very good hair piece to cover the thin hair at the front and top of her head, from where she mostly pulled hairs. She did this by taking a single strand of hair between thumb and index finger, playing with it and eventually pulling it out. She would then inspect the root. chew it, and throw the hair away. She had attractive shoulder length wavy black hair, was well-dressed, vivacious and extroverted, and slightly above average in height and weight. She lived at home with her parents and claimed she was on good terms with them. She was a part-time primary school teacher and a part-time University student, she had a steady boyfriend and during the course of treatment married him. This was interesting because it coincided with a period of zero hair-pulling and, also, because she said she had never had sexual intercourse, even though they had slept together often. At the time treatment was terminated when the author went abroad, they had still not had sexual intercourse. However, she maintained they had very satisfying orgasms through mutual masterbation. Her family history revealed that her father had a habit of pulling out hairs from his nose and fiddling with his finger-nails. Her only sibling, a 20-year-old brother, was also a nail-biter. Treatment She was instructed to keep the diary as in the case of Mr. A. It was explained that treatment would commence by teaching her to relax and to learn to control her desire to pull out the hairs. When seen on session 2, one month later, she had not kept the diary systematically. She was asked to rectify this and given training in relaxation using an hypnotic induction technique. She found difficulty in relaxing and her latent anxiety became more manifest. Some time was thus spent in re-assuring discussion of questions she raised about normality, control of anxiety and her ambivalence to treatment. Diary records became systematic and a weekly hair pulling was in the 220’s. An example of her anxiety was seen in session 4 when the hypnotic suggestion that she would not be able to pull out the hair when her hand touched her head, was introduced. This produced mild panic and a feeling of bloodlessness in her left hand. She was then challenged to pull out a hair but adamantly refused. However, there was no effect on rate of hair-pulling over the next week, although her nail-biting ceased to the extent that she had to cut her nails with scissors for the first time in her life. Sessions 6, 7 and 8 were devoted to training in relaxation. She did become more relaxed but there was no accompanying improvement in hair-pulling. From session 9, the suggestion that her hand would go “cold. numb and paralysed”, when trying to pull out her hair was made. This had no effect on hair-pulling and made her feel worse. So, various types of post hypnotic suggestions were experimented with; but to no avail. It was decided to use electrical aversive conditioning to break what seemed to be a very strong habit of hair-pulling only partially related to tension. It was also decided that to avoid response prevention during the aversive treatment sessions it might be more effective to administer the shocks to the patient while she was watching a videotape recording of herself pulling out her own hair. The patient co-operated fully with this procedure. The electrodes for administering the electric shock were placed on the back of either hand on different occasions, because she used both hands to pull out hairs. At treatment session 17, twelve shocks were given while she watched the pre-recorded videotape. During the following week, hairs pulled dropped from 220 to 145. At session 18, twenty-two shocks were administered with ensuing decrease in hairs pulled to 21. At session 19. fifteen shocks were given and this resulted in only five hairs being pulled in a week. At session 20, electrodes were attached but no shocks given while she watched the tape. While the electrodes were still attached the patient was asked to actually pull out a hair but, she strongly refused, saying “I can’t do that”. On session 21, she reported not having pulled out a single hair. She had also been sitting for exams during this time, and did very well in them. She was seen five more times at weekly intervals and then gradually at increasing intervals over the next four months. There were just over 5 months completely free of hair-pulling, during which time her hair grew normally and eventually she ceased wearing her hair-piece. Relapse came about when she married during the summer vacation (January). While on an aeroplane to Hawaii for her honeymoon, she pulled out some hairs. Retrospectively, she calculated that she had pulled out 50 hairs during the ensuing three weeks. On return, when she attended a follow-up appointment (session 31). some relaxation practice was given again as she appeared quite tense. She admitted that she and her husband had not had sexual intercourse since the wedding (nor before. as mentioned above). It was suggested to her that they could both well be helped in this regard but she maintained that, for the present, they would stay as they were. She was then seen four times in four weeks. Diary keeping was recommenced and training in relaxation continued. Hair-pulling fluctuated up to 20 per day but was usually much less, with a weekly average of 46.75. Mean weekly number of successful resistances was 58.0. At treatment session 36 she was given six shocks to the original videotape as the number of hairs pulled was not decreasing. This resulted in 7 months of minimal hair-pulling. Often the numbers pulled per week were zero, with increases being related to exams and general tension associated with her university study. This period ended with the final exams for the year when she asked for an appointment because her hair-pulling had increased markedly while she was studying. As she had ceased to keep a diary no precise count was available. Prior to making the appointment she had been prescribed some trifluoperazine. This had helped with the immediate crisis and, by the time she was seen. she maintained she was only pulling out up to six hairs per day. As the therapist was going abroad for some time no more could be done at this stage. However. follow-up will be maintained and major relapses treated. In summary, the introduction of aversive conditioning using an electric shock (from a 9-volt battery) have given her eighteen months of markedly reduced hair-pulling. Relapses occurred but were of limited duration, and having discarded her hair piece, she had never resumed it. In view of the fact that she had been pulling out upwards of 200 hairs per week, and her history was of S-years duration, this a probably a reasonable
CASEHISTORIES ANDSHORTER COMMUNICATIONS
19s
achievement. There were 41 treatment sessions and the patient stated that she certainly felt they were worthwhile. DISCUSSION
Behavioural psychotherapy, or behaviour therapy, approaches to treating trichotillomania have been much more explicit in stating the form of treatment carried out and monitoring the changes in the hair pulling behaviour than psychoanalytical reports. However, since treatment of the seven behaviour therapy cases reviewed was different for each individual patient, it is impossible to identify the specific factors operative in bringing about change. Nevertheless, some parameters seem to have been more important than others and to warrant further investigation. All the behavioural psychotherapy treatment programmes, except perhaps that of Taylor (1963). involved feedback of results by at least keeping a tally of the hair-pulling behaviour. Positive rewards were also used, but these varied from general praise and indulging in desired activities (e.g. Stabler and Warren. 1974) to the specific coverant positive reinforcement used by McLaughlin and Nay (1975). Aversive therapy was used, as in the case outlined above, to a video-recording of a patient pulling out her own hair, and by Bayer (1972), who felt that saving the pulled hairs in a daily envelope was an aversive procedure. The use of videotape as a form of feedback in psychiatric treatment has developed rapidly (e.g. Berger, 1970). In the case of Miss B above, the combination of a video-recording of the patient pulling her own hair combined with aversive therapy was successful, but the independent role of the videotape as feedback in its own right needs to be assessed. It may well have been that simply this form of feedback would t.ave been enought to stop her hair-pulling behaviour. There seems to be little doubt. from the cases reviewed. that whatever initially produced compulsive hairpulling behaviour, there is a strong habitual component by the time a person presents for treatment. The moderately good results from treatment by behavioural methods suggests that to tackle the symptom as a maladaptive habit is appropriate. The major elements of these methods manipulated in treating trichotillomania have been feedback to enhance knowledge and awareness of the behaviour; positive reinforcement of non-hair-pulling behaviour; negative reinforcement of hair-pulling behaviour, including response cost; general reduction of anxiety; and positive suggestion. There is no reliable information about which of these components are the most important for a particular patient. However, from the case of Miss B. above, it may be argued that when the habitual component is very strong and the behaviour is relatively independent of anxiety strong forms of feedback are required before any change can be brought about. This view concords with Azrin and Nunn’s (1973) argument that one of the difficulties in treating nervous habits is that a person with such habits often becomes relatively unaware of them because of lack of immediate adverse repercussions. Associates of such a person presumably become equally adjusted to the nervous habit and fail to read to it, after a time. Thus, an important part of treatment seems to be to increase awareness of the behaviour. In fact, the evidence from all of the cases reviewed in this paper lends weight to the crucial importance of this component. Systematic investigation of the relationships between anxiety and habit strength with the various components of treatment, even in a not strictly controlled clinical treatment setting, would be useful for developing more efficient treatment procedures. In conclusion, it can be stated that some form of direct feedback to the patient about the hair-pulling behaviour seems to be an essential, but usually not a sufficient, condition to bring about amelioration of the symptom. Acknowledgement-1
would like to acknowledge the help of Mr. M. Crewdson in suggesting the use of videotape in the case of Miss B. and in helping me to carry out this part of the treatment programme.
Department of’ Psychiatry, University of Melbourne, Royal Melbourne Hospital, Mctoria, Australia 3050
DAVIDJ.
DE
L. HORNE
REFERENCES
F. N. and DEAN H. C. (1956) Some Aspects of Child Guidance Intake Policy and Practices: A Study of 500 Cases at the Los Angeles Child Guidance Clinic, Los Angeles, California. Public Health Monogr No. 42. AZRIN N. H. and NUNN R. G. (1973) Habit reversal: A method of eliminating nervous habits. Behau. Res. ANDERSON
and Therapy 11, 619428.
BAYERC. A. (1972) Self-monitoring
and mild aversion treatment of trichotillomania.
J. Behau. Ther. exp.
Psychiat. 3, 139-141.
BERGERM. M. (1970) Videotape Techniques in Psychiatric Training and Treatment. Bruner/Mazel, New York. DELGAD~R. A. and MANNINOF. V. (1969) Some observations on trichotillomania in children. J. Am. Acad. Child Psychiat. 8, 229-246.
DEMARETA. (1975) Onychophagie, Trichotillomanie et Grooming. Ann. mPdico-psycho/. 131(l), 235-242. GREENBERG H. R. and SARNER C. A. (1965) Trichotillamania: symptoms and syndrome. Archs gen. Psychiat. 12, 482489.
HALLOPEAUX. (1889) Alopecia par grottage (Trichomania on Trichotillomania). Ann. Derm. Syph. 10, 440. ILAN E. and ALEXANDER E. (1965) Eyelash and eyebrow pulling (trichotillomania): Treatment of two adolescent girls. Israel Ann. Psychiat. 3, 267-281. MCLAUGHLINJ. G. and NAY W. R. (1975) Treatment of trichotillomania using positive coverants and response cost: A case report. Behar. Therap!. 6. 87-91.
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MANNINOF. V. and DELGAW R. A. (1969) Trichotillomania in children: A review. Am. J. Psychiat. 126, 505-511. MATTERSW. H. and JOHNSONV. E. (1970) Human Sexual Inadequacy. Churchill, London. MONROEJ. T. and ABSED. W. (1963) The psychopathology of trichotillomania and trichophagy. PsychiafrJ 26, 95-103. SCHACHTER M. (1961) Trichotillomania in children. Prux. Kinderpsychol. 10, 120-124. STABLER B. and WARRENA. B. (1974) Behavioural contracting in treating trichotillomania: Case note. Psychol. Rep. 34, 401402. SZONNG. (1975) Praxis der Kinderpsychol. Kinderpsychiat. 24, lC-18. TAYLORJ. G. (1963) A behavioural interpretation of obsessive-compulsive neurosis. Behac. Res. and Therap) 1, 237-244.
Behav. Res. & Therapy. 1977. Vol
IS. pp 196-198. Pergamon Press. Prmted m Great Bntam
Supression of a retardate’s tongue protrusion by contingent imitation:
A case study
(Receifled 13 July 1976) There is much research indicating that behaviorally handicapped children can be helped to learn appropriate behaviour by being shown models of desirable conduct (Cullinan et al., 1975). Only very recently, however, has any research attention been given to the possibility of using contingent imitation of the child’s own responses as a therapeutic tool. In previous case studies, Kauffman et al. (1975) found that mimicking severely retarded children could have quite different effects depending, apparently, on how the children perceived the adults’ behavior. In one case described by Kauffman and his colleagues, an adult’s imitation of a child’s sloppy eating dramatically improved the child’s eating habits; in another case an adult’s mimicry of the child’s animal-like yelping clearly worsened the problem. Further experimentation has shown that contingent imitation of children’s responses can accelerate the acquisition of an imitative repertoire during imitation training (Kauffman et al., in press) and that contingent imitation of children’s spelling errors can improve spelling performances (Kauffman et al. 1976). The present case study was designed to demonstrate how contingent imitation can be used to suppress a persistent inappropriate behavior and how cues associated with imitation can be used to maintain the level of suppression once the adult’s mimicry has been withdrawn. Subject and setting
The subject, Terry, was a 12-year-old retarded male (IQ 48) enrolled in a special public school class with six other retarded children. Besides the teacher, two other adults were typically present: a student teacher and a teacher aide. Terry frequently protruded his tongue far out of his mouth, making his facial appearance unpleasant. It was obvious that if he was to find social acceptance among his normal schoolmates and adults Terry would need to learn to control his tongue protrusions. His tongue was exterlded most often during activities requiring concentration, especially academic seatwork exercises. Prior to beginning the case study. the teacher had tried reminding Terry to keep his tongue in his mouth and praising him for tongue-in behavior, but to no avail. Requiring Terry to observe his protruding tongue in a mirror was not successful, as he would refuse to extend his tongue and look in the mirror at the same time. Recording and observer agreement
Tongue protrusions, defined as the tongue being visible. were recorded for 15 min each morning (during three separate 5-min intervals) while Terry was working on reading seatwork assigments at a table. Terry’s behavior was recorded by the teacher, who sat across the table from him. observed him continuously, and tallied tongue protrusions on a slip of paper. On 14 days. either the teacher aide or the student teacher independently, but simultaneously, recorded tongue protrusions. Observer agreement, calculated by dividing the lesser by the greater frequency and multiplying by 100, averaged 92% (range = 7(rlOO%) for the 14 days. Design and procedure
An ABAB design was employed in which experimental procedures were alternately applied and withdrawn. During all phases of the study, Terry was given intermittent contingent praise for keeping his tongue in his mouth. After obtaining baseline (no intervention) data for five days, the teacher gave a verbal reminder (“Terry, put your tongue in.“) each time Terry protruded his tongue. On day 12 (see Fig. 1) the teacher began contingently imitating Terry’s tongue protrusions. Each time Terry stuck his tongue out, the teacher immediately held Terry’s head so that eye contact was assured and imitated his tongue protrusion. On day 19 the teacher stopped imitating Terry and returned to reminders, and on day 25 contingent imitation was reinstated. Beginning on day 30, the teacher no longer imitated tongue protrusions but gave a physical cue (grasping Terry’s cheek) contingent on tongue-out behavior. After returning to verbal .reminders for two days. the physical cue was modified to consist of the teacher’s touching Terry’s chin lightly with her index finger (beginning on day 38). Rrsrrlts atld discussiori
Although verbal reminders had no noticeable effect on Terry’s tongue protrusions, contingent imitation immediately and dramatically reduced their frequency, as shown in Fig. 1. When contingent imitation was withdrawn, reminders failed to maintain the suppression, but reinstatement of contingent imitation quickly
