Implicit processes in the treatment of titillomania

Titillomania (TiTM) is an impulse control disorder characterized by recurrent
and excessive picking or scratching of the skin and skin irregularities, often
resulting in severe tissue damage.

Behaviour therapy (BT) has shown to be effective, however, relapse rates after
successful treatment are high in these disorders (see Keijsers et al., 2006).
It seems that certain processes or conditions below the manifest behavioural
level remain largely unaffected by treatment and maintain the likelihood of
symptom reoccurrence.

Bargh (1990, 1997) proposed that these processes below the manifest behavioural
level consisting of mental processes, such as the implicit effects of goal
setting and implicit approach-avoidance tendencies, mediate the
stimulus-response chain. Several studies have shown that these implicit
processes are indeed related to unwanted bahaviour.

Interestingly, these implicit biases can be retrained by specific computer
tasks, called cognitive bias modification (CBM) training. Another way to target
these mediating mental processes is cognitive therapy (CT). Cognitive therapy
is first designed to help people to identify and challenge automatic thoughts
and second, to train the activation of helpful alternative beliefs and
long-term goals.

In sum, there are different treatments suited to target underlying implicit
mental processes that are believed to play a crucial role in habit disorders.
Both CBM training and CT have been shown to be effective. We propose to add
these treatments to standard BT to improve long-term treatment outcomes.

The objective of this study is to investigate whether adding either CBM
training or CT to standard treatment can improve long-term treatment effects in
patients suffering from TiTM.

The second goal of this study is to investigate how several implicit processes
are related and thus examine the mechanisms underlying the relatively high
relapse rates in habit disorders such as TiTM. The acquired findings may help
us improve the long-term results of psychological treatments.

This study is a randomized waiting-list controlled study.

Patients receive either:

4 weeks waiting-list
4 weeks/sessions of computer training
4 weeks/sessions of cognitive therapy

after which they all receive manual-based behaviour therapy. After one and
three months, follow-up sessions will take place.

Patients all receive the first choice of treatment for titillomania (4 sessions
of approximately one hour). Patients in the cognitive therapy condition and
cognitive bias modification condition receive additional treatment (4
additional sessions of approximately one hour) of which we expect positive
outcomes. In our view there are no risks involved in participation.