Suppression and substitution in the treatment of nailbiting

0005.7967030iOlOl-0031 SO2.WO

SUPPRESSION AND SUBSTITUTION IN THE TREATMENT OF NAILBITING*

ANNA-MARIE DAVIDSON, DOUGLAS R. DENNEY~ and CHARLES H. ELLIOTT

University of Kansas, Lawrence KS 66045, U.S.A.

(Received 3 April 1979)

Summary-The effectiveness of a package treatment for reducing nailbiting was studied. The package was composed of both positive procedures aimed at teaching adaptive behavior to substitute for nailbiting and negative procedures aimed at advancing skills for suppressing nailbiting. The design of the study permitted an analysis of the contributions of both positive and negative components of the package. Subjects assigned to combined, positive, negative and placebo groups received four weekly treatment sessions, and changes in their nailbiting behavior were compared with untreated controls. As in previous studies, nonspecific factors such as demand and attention to ones nails were found to be important determinants of outcome. In addition, positive procedures were found to be substantially more important than negative procedures in the maintenance of reductions in nailbiting over a 4-month follow-up period.

A diverse array of behavioral procedures have been reported for reducing nailbiting, including negative practice (Dunlap, 1932; Smith, 1957) self-administered shock (Bucher, 1968) behavior recording (Maletsky, 1974), self-monitoring and substitution of incompatible responses (McNamara, 1972), sequential training in self-monitoring, self-punishment, and self-reinforcement (Horan, Hoffman and Macri, 1974), habit reversal (Azrin and Nunn, 1973; Nunn and Azrin, 1976), response-cost procedures (Stephen and Koenig, 1970) cue-controlled relaxation (Barrios, 1977), and covert sensitization (Davi.dson and Denney, 1976). Methodological weaknesses in many of these studies limit the conclusions that can be drawn. However, in general all of these procedures achieved a fair measure of success in terms of the induction of changes in nailbiting among motivated adult subjects. In fact, Davidson and Denney (1976) found that an information procedure that was devised as a placebo and merely provided subjects with nonspecific information regard- ing nails and nail care produced substantial changes in nailbiting. Furthermore, although simple pre-test-post-test assessments of untreated control subjects’ nails do not appear to be sufficient (Davidson and Denney, 1976; Smith, 1957), somewhat more frequent perio- dic assessments have been shown to reduce nailbiting (McNamara, 1972; Stephen and Koenig, 1970).

The consistency in the results generated by these diverse treatment and placebo procedures suggests that nonspecific factors such as demand, expectancy, monitoring of progress, attention, and encouragement are sufficient for the induction of changes in nailbiting behavior. Given the substantial role of these nonspecific factors, it is necessary to include a placebo or nonspecific treatment group in outcome studies evaluating the effectiveness of nailbiting treatment procedures (Davidson and Denney, 1976; Lichten- stein and Keutzer, 1971).

Although a wide variety of treatments are successul in inducing changes in nailbiting over the course of treatment, several investigators (Bucher, 1968; Dunlap, 1932; Maletsky, 1974; Smith, 1957; Stephen and Koenig, 1970) also present evidence of frequent relapses following treatment. Nailbiting appears to be much like other maladaptive behavior involving ‘oral’ habits such as alcoholism, smoking and overeating. In each instance the problem is not one of inducing change, but rather one of effecting durable change which persists long after the treatment has been withdrawn. This type of change

* This study was funded by a Kansas University General Research Grant awarded to the second author. t Requests for reprints should be addressed to Douglas R. Denney, Department of Psychology, University

of Kansas. Lawrence, Kansas, 66045, U.S.A.

2 ANNA-MARIE DAVIDWN. DOUGLAS R. DENNEY and CHARLES H. ELLIOTT

is typically not achieved by means of placebo procedures or single component treatment procedures (e.g. Elliott and Denney, 1978). Several investigators have argued that broadly- based package treatments may be needed to bring about durable change in alcoholism (Denney, 1976; Hamburg, 1975), smoking (Elliott and Denney, 1978; Lando, 1977) and obesity (Mahoney, 1973). Although package treatments have been evaluated in relation to these other behavior problems, no studies evaluating the effectiveness of package treatments for bringing about durable changes in nailbiting have appeared.

The typical philosophy surrounding package treatments is first to design a complex treatment program that achieves the desired results in terms of effecting durable changes in some maladaptive behavior and then to perform analytical studies to discover the effective components operating within the package. One of the most obvious places to begin the analytical process is to compare the contributions of positive and negative components with the treatment package. Negative components encompass those procedures aimed at suppressing the maladaptive behavior itself, while positive components encompass those procedures aimed at encouraging incompatible, alternative behavior. Several writers (e.g. Tinling, 1972) have argued that suppressive treatments aimed at eliminating maladaptive behavior create a behavioral vacuum that is likely to be filled by the same response unless alternative behavior is taught. Thus one might expect that the negative components of a package treatment would be less effective than the positive components in achieving durable changes in maladaptive behavior.

Surveys (e.g. Birch, 1955; Malone and Massler, 1952; Nunn and Azrin, 1976) indicate that nailbiting is far more prevalent than many other types of maladaptive habit behavior for which package treatments have been designed and tested. One purpose of the present study was to evaluate the effectiveness of a package treatment for reducing nailbiting. Another purpose was to analyze the contributions of the positive and negative components of the package in terms of their effecting durable changes in this maladaptive behavior. The positive component of the package included applied relaxation training, hand and finger exercises, hand massage, nail and cuticle care, and self-reinforcement. The negative component included stimulus control techniques, aversive imagery. negative self-verbalization and self-punishment. Because of the importance of nonspecific factors in altering nailbiting behavior, a placebo group in addition to an untreated control group was incorporated within the design.

Subjects

METHOD

Fifty subjects (15 males and 35 females) were recruited by means of notices placed in the campus and community newspapers. The subjects ranged in age from 18 to 54 (X = 26 yr). All considered their nailbiting to be a serious problem which they were highly motivated to overcome. Virtually all subjects reported that the deteriorated condition of their nails was a source of personal shame. A number of subjects also indicated that their nailbiting habit engendered considerable conflict with their spouses and fami- lies and that they had unsuccessfully tried a variety of methods to overcome their problem. To ensure each subject’s continued participation throughout the study, subjects deposited postdated checks for 10 dollars with the experimenter. These were returned at the end of the study.

Pre-testing

An initial pre-test session was held one week before starting treatment. Subjects completed a preliminary questionnaire designed to assess their nailbiting habits and motivation for change. Two of the items embedded within this questionnaire were also included on the post-test and follow-up questionnaires. One item required subjects to rate the frequency of daily nailbiting (less than once; 1-5; 6-10; 11-15; more than 15) and the other to rate the degree of control they currently exercised over their nailbiting habit (no control, complete control). On the former item, subjects circled the correct

Treatment of nailbiting 3

alternative; on the latter, they placed an X on a continuous line scale drawn between the two anchors. These two items constituted the subjective outcome measures in the study.

After completing the preliminary questionnaire, subjects’ nails were measured to the nearest millimeter using a Vernier caliper. Measures were taken at the center of each nail, from the tip of the nail to the cuticle at the base of the nail. An overall nail length score was obtained by summing across all 10 nails. In addition, each of the subject’s nails was jndependently assessed by two judges using the Cosmetic Appearance Checklist. This checklist contained three items describing damage to the cuticles (red, swollen, or sore; ragged, cracked, or split; extension onto nail body) and three items describing damage to the nail (bitten to the nail body; bitten into the nail body; free edge of nail ragged or split). The number of damaged items observed on each nail was summed across all 10 nails. The interjudge reliability of these pre-test cosmetic appearance scores was very high, r (49) = 0.99. Thereafter, assessments by the first judge were used in all data analyses. The nail length score and cosmetic appearance score constituted the two objective outcome measures in the study.

Treatment

Subjects were randomly assigned to five conditions: combined treatment, positive treatment, negative ~eatmen~ placebo treatment, and untreated control. Ten subjects were assigned to each condition, and the male to female ratio (3:7) was held constant across conditions. All treatments were tape-recorded and administered during four weekly treatment sessions. During each session, subjects were seated in private cubicles and received all information and instructions by means of headphones. During the first session, subjects were fold that their nails would be measured again at the post-test session and were instructed not to cut their nails at any time during the course. of treatment. Subjects heard a thorough description of the specific treatment they would be receiving and its underlying rationale. They then completed an expectancy questionnaire assessing their understanding of the treatment rationale and their expectancy of success. Subjects in all of the treatment groups were asked to record the amount of time they spent thinking about their own or other people’s nails each day. In addition, subjects in the positive, negative and combined treatment groups were instructed to record the time spent each day practicing the procedure relevant to ‘their specmc treatment. These estimates were to be written down at the end of each day, using daily recording charts that were provided to the subjects each week and collected the following week. At the end of each treatment session, subjects were given transcripts of the material presented in that session which they were asked to study and put to use during the ensuing weeks.

Combined treatment. Subjects in this group heard both positive and negative treatment rationales and received both positive and negative treatment components described below. At each session, part of the negative component was administered first followed by part of the positive component. Both components were administered in their entirety, so that each session was twice as long as either the corresponding positive or negative treatment session, The average session for combined treatment lasted 45 min.

Positive r~e~rrnenr. Subjects in this group heard a positive treatment rationale stressing the importance of developing a repertoire of adaptive alternative behavior to replace nailbiting. Self-reinforcement techniques were taught as a means of adopting the alternative behavior introduced in each treatment session. During the first session, subjects were taught basic facts about the structure and function of nails, dietary aids for the nails and the equipment needed for nail care. During the second session, they were provided with detailed information concerning appropriate nail and cuticle care. During the third session, subjects were taught progressive relaxation and some additional hand and finger exercises to aid circulation. The final treatment session was devoted to hand massage and manicure techniques. Each session lasted approximately 25 min. Subjects were advised to practice each of the procedures a few times and then to adopt those that seemed most appropriate for their particular nail and cuticle problems.

4 ANNA-MARIE DAVIDSON. DOUGLAS R. DENNEY and CHARLES H. ELLIOTT

Negative treatment. Subjects in this group heard a negative treatment rationale stressing the importance of self-control techniques for suppressing their nailbiting behavior. During the first session, subjects were taught stimulus control principles wherein they might limit nailbiting to a narrowly constrained time and place. During the second session, subjects were instructed to imagine aversive scenes in which they were embar- rassed by the condition of their nails or at being seen biting their nails. The third session entailed instruction in the use of negative self-verbalizations (e.g. “It is childish of me to chew on my nails”) to be repeated whenever the subjects found themselves about to bite their nails. During the last session, subjects were taught a variety of self-punishment procedures such as burning a dollar bill or snapping a rubber band worn on their wrists whenever they bit their nails. As in the case of the positive treatment, each session lasted about 25 min. Subjects were told to practice each procedure a few times and then to adopt those that seemed most appropriate for their nailbiting problem.

Placebo treatment. Subjects in this group heard a treatment rationale stressing the importance of having thorough and veridical information about their nails and nailbiting habits. This information included facts about the structure and function of nails, nail diseases and disorders, incidence figures from surveys of nailbiting and etiological theories concerning nailbiting. A different topic was presented during the four successive weeks. The information was presented in a factual and impersonal fashion, with no attempt to relate it to the subject’s own nailbiting habit. No suggestions were made concerning methods for reducing nailbiting, substituting alternative behaviors, or caring for ones’ nails. As in the case of the positive and the negative treatments, each session of placebo treatment lasted approximately 25 mm.

Untreated connol. Subjects were told they would not receive treatment until later in the year. They completed the pre-test, post-test and follow-up sessions but received no intervening treatment. After the follow-up session, subjects were treated with the combined procedure.

Post-testing and follow-up testing

The post-test session was conducted one week after the final treatment session, and the follow-up session four months after the post-test. Post-test and follow-up questionnaires were designed to assess subjects’ reactions to the treatment and their expectancies concerning future nailbiting. Two of the items embedded in each of these questionnaires required subjects to rate the frequency of daily nailbiting and the degree of control they currently exercised over nailbiting. These were identical to items on the preliminary questionnaire.

After completion of the post-test and the follow-up questionnaire, subjects’ nails were measured and a judge assessed the condition of subjects’ nails and cuticles using the Cosmetic Appearance Checklist. Post-test and follow-up sessions were conducted by an experimenter who had no knowledge of the groups to which subjects had been assigned during treatment. After completing the follow-up session, all subjects were debriefed and their deposits returned. A schedule was established for subjects in the untreated control group to receive treatment.

RESULTS

A complete set of preliminary analyses revealed the following: (a) there were no significant main effects or interactions involving sex on any of the four outcome measures, therefore allowing sex to be eliminated as a factor in all subsequent analyses; (b) there were no differences between the five groups in terms of general characteristics assessed by the preliminary questionnaire, such as age at which nailbiting began, number and duration of previous attempts to stop nailbiting, motivation for treatment, and propor- tion of nailbiting attributed to habit or tension; (c), there were no differences between the four treatment groups in terms of their understanding of the treatment rationale, confidence in the treatment program, or expectation of success as indicated on the


Table 1. Residual&d post-test and follow-up scores for the objective outcome measures

Combined Positive Negative treatment treatment treatment Placebo Control F(4,44) P

Nail length Post-test x 9.93, 10.07. 9.71, 9.92, 8.56,

S.D. 2.91 2.07 2.33 2.14 1.33 3.88 <0.009 Follow-up X

SD. Cosmetic armearance

9.80, 9.98, 9.36,~ 9.90, 8.61, 2.92 1.78 1.93 3.41 1.43 2.24 co.08

. . Ratings Post-test

Follow-up

X 16.05, 16.04~ 23.55b 23.03,,b 37.14, SD. 10.96 7.29 13.28 15.13 8.50 to.001

X 21.17,Vb 17.02, 27.22b 26.33,,b SD. 12.13 8.64 14.92 18.19 5.03 <0.002

Note: means which do not share a common subscript were significantly different (p < 0.05) from each other on the basis of the appropriate paired comparisons test.

expectancy questionnaire; (d) there were no initial differences between the five groups on any of the outcome measures.

Although no significant initial differences existed between the five groups, it was nevertheless advisable to correct for nonsignificant initial differences. To do so, subjects’ post-test and follow-up scores for each of the four outcome measures were residualized using their corresponding pre-test score, in accordance with the procedure recommended by Cronbach and Furby (1970). The residualized post-test and residualized follow-up scores were then each subjected to two analyses of variance: (a) a one-way analysis of variance which included all five groups in the study; and (b) a 2 (Positive Component) x 2 (Negative Component) analysis of variance which included the combined treatment,

positive treatment, negative treatment and untreated control groups. The overall main effects for treatment in the one-way analyses of variance are shown

in Table 1 for each of the objective outcome measures and in Table 2 for each of the subjective outcome measures. The treatment main effect failed to attain significance in two instances: (a) on the residualized follow-up scores for the nail length measures, p < 0.08, and (b) on the residualized follow-up scores for the subjects reported frequency of nailbiting, p < 0.12. When the overall treatmeni main effect attained significance, paired comparisons were performed using simple t tests for independent means.* In the two instances in which the treatment main effect failed to reach significance, paired comparisons using the Duncan multiple range test were performed, as recommended by Carmer and Swanson (1973).

Objective outcome measures

Residualized post-test and residualized follow-up scores for the nail length measures and the cosmetic appearance scores are presented in Table 1.

The 2 x 2 analysis of the residualized post-test nail length measures revealed a significant main effect for the positive component, F (1,35) = 8.96, p < 0.05. Treatments which included the positive component were significantly more effective than those lacking this component. The same was not true in the case of the negative component, indicating that this latter component made no significant contribution to treatment outcome. Pairwise t tests revealed that subjects in all treatment groups, including the placebo group, had significantly longer nails than untreated control subjects at the time of the post-test (all p’s < 0.01). There were no differences between the four treatment groups.

The 2 x 2 analysis of the residualized follow-up measures of nail length revealed only a significant main effect for the positive component, F (1,35) = 8.51, p < 0.006. Once

*The use of the r test as a paired comparison test for analyzing overall significance F’s obtained through analyses of variance has recently been supported on the basis of Monte Carlo studies reported by Bernhardson (1975) and Carmer and Swanson (1973).

6 ANNA-MARIE DAVIDSON. DOUCLAS R. DENNEY and CHARMS H. ELLIOTT

Table 2. Residualized post-test and follow-up scores for the subjective outcome measures

Combined Positive Negative treatment treatment treatment Placebo Control F(4, 4.4) P

Estimated frequency of nailbitinn

- Post-test x 2.00, 1.74 1.70, 1.80, 2.90, S.D. LOO 1.00 0.70 0.90 1.30 2.59 <0.05

Foltow-up R 2.~O*,tJ 1.70. 2.3%, I.60, 2.50, SD. 0.80 0.70 f-20 1.00 I.@ 1.99 <O.f2

Estimated Control over Nailbiting Post-test x 57.30, n.oo, 67.7@* 56.40~ 17.70,

SD‘ 24.60 29.00 32.60 30.80 19.00 6.05 to.001 Follow-up x 48.3%,, 69.00, 49.4%& 52.%& 26.30,

SD. 25.80 29.50 29.60 36.70 30.00 2.58 < 0.05

Note: means which do not share a common subscript were significantly different (p < 0.05) from each other on the basis of the appropriate paired comparisons test.

again, treatments including the positive component were significantly more effective than those failing to include this component. A Duncan multiple range test revealed that the positive treatment, combined treatment, and placebo groups each differed ~i~i~~a~tly

from untreated controls (all p’s < 0.05). However, subjects in the negative treatment were no longer different from controls.

The analysis of residualized post-test scores on the Cosmetic Appearance Checklist yielded significant main effects for the positive component, F (1,351 = 32.77, p < 0.001, and the negative component, F (1,35) = 7.40, p < 0.01, and a significant positive x negative interaction, F (1,35) = 6.65, p < 0.02. Pairwise E tests showed that each treatment group, including the placebo group, differed significantly from the control (all p’s < 0.01). In addition, both the positive treatment group and the combined treatment group differed from the negative treatment group (both p’s c 0.05) and the placebo group (both p’s < 0.10).

The analysis of resid~l~d follow-up scores on the Cosmetic Appearance Checklist revealed a significant main effect for the positive component, F.(l, 35) I 19.19, p < 0,001, and a significant positive x negative interaction, F (I, 35) = 6.12, p < 0.02. As in the case of the post-test scores, the four treatment groups each differed significantly from the control (all p’s < 0.05). Also, subjects in the positive treatment group (but not in the combined treatment group) had better cosmetic appearance scores than subjects in either the negative treatment group (p K 0.05) or the placebo group Cp < 0.10).

Subjective outcome measures

The patterns of results observed in the case of objective outcome measures were essentially replicated with subjective outcome measures as welt. Table 2 presents the residualized post-test and residualized follow-up scores for subjects’ estimates of their frequency of n~lbit~~g and their control over naj~b~ting.

The 2 x 2 analysis of residualized post-test estimates of nailbiting frequency revealed a significant interaction involving the positive and negative treatment components, F (1,351 = 4.85 p < 0.05. Pairwise t: tests indicated that all four treatment groups differed si~~fi~ntly from the controls (all p’s 2 0.05).

A similar 2 x 2 analysis performed on the residualized follow-up estimates of nailbiting frequency revealed only a main effect for the positive treatment component falling just short of significance, F (1,3S) = 3.01, p < 0.10. A Duncan multiple range test indicated that the positive treatment and the placebo groups estimated their nailbiting frequency to be significantly lower than the untreated controls (both p’s < 0.05); however, the negative and combined treatment groups were not significantly different from controls.

The 2 x 2 analysis of the residuaiized post-test estimates of subjects’ control over


nailbiting yielded significant main effects for the positive treatment component, F (1,35) = 6.60, p < 0.02, and the negative treatment component, F (1,35) = 4.22, p c 0.05, and a significant positive x negative interaction, F (1,35) = 14.30, p < 0.001. Each of the four treatment groups rated their control over nailbiting to be significantly greater than the control group (all p < 0.05). There were no differences.between the four treatment groups.

The analysis of residualized follow-up estimates of subjects’ control over nailbiting revealed a significant main effect for the positive treatment component, F (1,35) = 5.35, p < 0.03, and a significant positive x negative interaction, F (1,35) = 6.06, p < 0.02. Pairwise t tests demonstrated that only the positive treatment group was significantly different from controls at the time of the follow-up, p -z 0.01.

On the daily recording charts, subjects in each of the four treatment groups were asked to record the amount of time spent attending to their own or other people’s nails over the course of the 4-week treatment program. These recordings were grouped into 7-day blocks and subjected to a 4 (Treatments) x 4 (Weeks) mixed factorial analysis of variance. This analysis revealed significant main effects for treatments, F (3,36) = 4.93, p < 0.006, and for weeks, F (3,108) = 5.26, p < 0.002. Subjects in all four treatment groups paid less attention to their own or other people’s nails as treatment progressed. However, subjects in the positive and combined treatment groups paid significantly more attention to their nails throughout the ~eatment period than subjects in the negative treatment or placebo groups (all p’s -z 0.05). Subjects whose treatment included the positive treatment component reported spending an average of 44 min per week attending to their nails, whereas subjects whose treatment did not include this component reported spending an average of only 19 min per week.

Subjects in the combined, positive and negative treatment groups were also asked to record the amount of time spent practicing their respective procedure each day, on the daily recording charts. Data reflecting the amount of time that the subjects in the negative and the combined treatment groups spent practicing negative procedures were subjected to a 2 (Treatments) x 4 (Weeks) mixed factorial analysis of variance. A significant main effect for treatment was found, F (1,18) = 4.95, p e 0.05, indicating that the combined treatment group spent more time practicing the negative procedure (X = 15 mm per day) than the negative treatment group (x = 6 min per day). A similar 2 (Treat- ments) x 4 (Weeks) analysis was performed on the data reflecting the amount of time that subjects in the positive and the combined treatment groups spent practicing positive procedures. No significant main effects or interactions occurred in this latter analysis. Thus the combined treatment group and the positive treatment group spent comparable amounts of time practicing positive procedures (x’s = 12 and 13 min per day).

DISCUSSION

As in the case of previous studies (Davidson and Denney, 1976; McNamara, 1972; Stephen and Koenig, f970), it appears that nonspecific factors were highly influential in reducing nailbiting over the course of treatment. The placebo group was si~i~cantly better than the untreated control group on all four outcome measures at the time of the post-test. Surprisingly, the placebo group maintained much of its effectiveness during the 4-month follow-up period as well. Subjects in the placebo group were still significantly better than untreated control subjects in terms of nail length and estimated nailbiting frequency. The fact that nonspecific factors are such powerful determinants of outcome underscores the necessity of including placebo groups in future studies designed to evaluate the effectiveness of treatments for nailbiting.

Although both positive and negative treatment procedures were found to be effective at the time of the post-test, the results generally indicate that subjects who received the positive treatment component maintained their gains to a greater extent than those who received the negative treatment component. This superiority is most clearly evident in the results of the 2 x 2 analyses performed on the follow-up measures. The main effect of the positive component was si~~c~t for all four outcome measures, while the main effect

8 ANNA-MARIE DAMWON, DOUGLAS R. DENNEY and CHARLES H. ELLIOTT

for the negative component never attained significance. Furthermore, at the time of the follow-up, subjects in the positive treatment group had significantly better cosmetic

appearance scores than subjects in the negative treatment group. Subjects in the positive treatment group were also significantly better than untreated controls on all four follow-up measures, while subjects in the negative ~eatment group exceeded controls on only the cosmetic appearance scores. Finally, it should be noted that the means for all four follow-up measures indicated that the negative treatment group was less effective than the placebo group on these measures.

The combined treatment, using both positive and negative treatment components ~mult~eously, was expected to effect the largest and most durable changes in nailbiting, However, neither the effectiveness nor the durability of this treatment was enhanced, even though treatment sessions for the combined procedure lasted almost twice as iong as for the positive, negative or placebo procedures. indeed, post-test and follow-up means for all four outcome measures indicated that the combined treatment was slightly less effective than the positive treatment alone. Clearly, the addition of suppressive, negative procedures contributed nothing to the electiveness of the combined treatment and may have even detracted slightly from its overall effectiveness. Similar results were found by Davidson and Denney (1976) when a negative procedure, covert sensitization, was combined with a neutral procedure wherein subjects were provided with general information about nails and nail care. The negative procedure detracted from the effectiveness of the neutral procedures alone.

The results ob&ned in the present study support Tinling’s (1972) hypothesis that aversive procedures which aim only at the suppression of maladaptive behavior do not typically produce durable behavioral changes. Measures from the daily recording charts kept by each subject suggest two explanations for the relative ineffectiveness of negative treatment procedures. First, subjects who are exposed to negative treatment procedures practice the procedures they have learned in treatment to a lesser extent than subjects exposed to positive treatment procedures or to combinations of positive and negative procedures. Obviously, the usefulness of procedures such as those examined in the present study is limited by the willingness of subjects to incorporate the procedures into their daily lives, both during and after treatment. Second, negative treatment procedures which attempt to suppress nailbiting behavior may, in a more generalized fashion, suppress subjects’ attention to their nails and their nailbiti~g habit, whereas positive treatment procedures which attempt to instill alternative behaviors to replace nailbiting appear to be more effective at sustaining subjects’ attention. Several studies (Davidson and Denney, 1976; McNamara, 1972; Stephen and Koenig, 1970) have indicated that a necessary and sufficient condition for effecting changes in naifbiting is the focussing of subjects’ attention upon their nails. Such an outcome is more likely to follow from positive rather than negative treatment procedures.

REFERENCES AZR~N N. H. and NWN R. G. (1973) Ha&t reversal: A method of eliminating nervous habits and tics.

B&W. RPS. Tker. If, 619-628. BARIUOS 3. A. (1977) Cue-controlled relaxation in reduction of chronic nervous habits. Psycho!. Rep. 41,

m-706.

ONION C. S. (1975) Type I error rates when mukiple comparison procedures follow a significant F test of ANOVA. Biometrics 31,229-232.

BIRCH L. 8. (1955) The incidence of nail biting among school children. Br. J. e&c. Ps~c~~~. 25, 123-128. BUCWR 8. R. (1968) A ~ket-enable shock device with appli~tion to naiibit~ng. Be&u. Res. Ther. 6,

389-392. CARMER S. G, and SWANSON M. R. (1973) An evaluation of ten pairwise multiple comparison procedures by

Monte Carlo methods. J. Am. srutist. Ass. 58, 66-74. CROWIWH L. J. and FURBY L. (1970) How we should measure change-or should we? Psychol. Butt. 74,68-X0. ~AYIKXWN A. and DEX~Y D. R. 119761 Covert sensitizatian and information in the reduction of nailbitina.

Bettou. Ther. 7,512-518. ~ DENWT D. R. (1976) Behavioral approaches to the treatment of alcoh&m. In Experimental Studies in Afcoho-

lism (Edited by 6. Goldstein and C. Neuringer). Ballinger, Cambridge, Mass. DUNLAP K. (1932) Habits: Their Making and Unmaking. Liveright, New York.


ELLIOTT C. I-I., and DENNEY D. R. (1978) A multiple component treatment approach to smoking. J. consult. c/in. Psycho/. 46, 1330-1339.

HAMBURG S. (1975) Behavior therapy in alcoholism: A critical review of broad spectrum approaches. J. Stud. Alcohol. 36, 69-87.

HORAN J. J., HOFFMAN A. M. and MACRI M. (1974) Self-control of chronic fingernail biting. J. Behao. Ther. exp. Psychiat. 5, 307-309.

LANDO H. A. (1977) Successful treatment of smokers with a broad-spectrum behavioral approach. J. consult. c/in. Psycho/. 45. 361-366.

LICHTENSTEIN E. and KEU~ZER C. S. (1971) Modification of smoking behavior: A later look. In Aduances in Behavior Therapy (Edited by R. D. Rubin, H. Fensterheim. A. A. Lazarus and C. M. Franks). Academic Press, New York.

MAHONEY M. J. (1973) Clinical issues in self-control training. Paper presented at the 81st Annual Convention of the American Psychological Association, Montreal, Canada.

MALETSKY B. M. (1974) Behavior recording as treatment: A brief note. Behau. Ther. 5, 107-I 11. MALONE A. J. and MASSLER M. (1952) Index of nail biting in children. J. ahnorm. sot. Psychol. 47, 193-202. MCNAMARA J. R. (1972) The use of self-monitoring techniques to treat nailbiting. Behav. Res. Ther. IO.

193-194. NUNN R. G. and AZRIN N. H. (1976) Eliminating nail-biting by the habit reversal procedure. Behac. Res.

Thu. 14. 65-67. SMITH M. (1957) Effectiveness of symptomatic treatment of nailbiting in college students. Psychology NewsI.

8. 219-231. STEPHEN L. S. and KOENIG K. P. (1970) Habit modification through threatened loss of money. Behau. Res.

Ther. 8. 21 l-212. TINLING D. C. (1972) Cognitive and behavioral aspects of aversive therapy. In Aduances in Behauior Therapy

(Edited by J. 0. Henderson. H. Fensterheim and L. P. Ullman). Academic Press, New York.

Suppression and substitution in the treatment of nailbiting

Documents

Transcript of Suppression and substitution in the treatment of nailbiting