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BehaviourmodificationinthemanagementofchronichabitsofabnormaleyerubbingCharlesW.McMonnies,a,aSchoolofOptometryandVisionScience,UniversityofNewSouthWales,Kensington2052,AustraliaAvailableonline1February2009.AbstractObjectivesTodescribehowandwhymanykeratoconuspatientsdonotcomplywithstrongadvicetocontrolchronichabitsofabnormalrubbing.Tooutlineabehaviourmodificationapproachforcontrollingchronichabitsofabnormalrubbing.MethodsCommonreasonsforchronichabitsofabnormalrubbinghavebeenreviewedasabasisforspecifyingabehaviouralmodificationapproachtohabitreversal.ResultsThemethodsdescribedareorganizedintotheclassicbehaviouralmodificationstructureof:(1)habitawareness,(2)competingresponses,(3)developmentofmotivation,and(4)socialsupport.Thisstructureissupportedbytheapplicationofsocialinfluenceprinciplestoachieveoptimumcompliance.ConclusionsTheuseoftake-homewritteninformationintheformofanAbnormalRubbingGuideisthebasisforthedevelopmentofmotivation.Familysocialsupportisbaseduponawideningoftheresponsibilityforavoidingeyerubbingtoallfamilymembers.Somepatientswillneedminimalapplicationoftheseprincipleswithpatienteducationbeingsufficientinterventiontoachievehabitreversal.Forpatientswithstrongprovocationtorubbingand/orbyhavingawellestablishedrubbinghabit,agreaterexposuretothehabitreversalprogramdescribedisindicated.Successfulhabitreversalmayslowtherateofectasiaprogression.Prophylacticapplicationofthemethodsdescribedforpatientswhoareatriskfordevelopingkeratoconus,orpost-laserassistedinsitukeratomileusiskeratectasia,mayshowthatsomeformsofkeratectasiaarepreventable.Keywords:Eyerubbing;Behaviourmodification;Compliance;KeratectasiaArticleOutline1.Introduction2.Whyaresomerubbinghabitssodifficulttobreak?2.1.PartA:itch2.2.PartB:psychogenicfactors2.3.Managementofabnormalrubbing2.4.Behaviourmodification3.Abehaviourmodificationapproachtohabitreversalforpatientswhorubtheireyesabnormally3.1.Stage1:rubbinghabitawareness3.1.1.Aim:toobtainareliableassessmentofrubbingactivityandincreaseawarenessofthisactivity3.2.Stage2:competingresponses3.2.1.Aim:tofindactivitiesthatcouldsubstituteforrubbingand/ordistractfromtheurgetorub3.3.Stage3:developinghighmotivation3.3.1.Aim:toraiseawarenessoftheassociationbetweenKCandchronichabitsofabnormalrubbing3.4.Stage4:socialsupport3.4.1.Aim:tocreateanunderstandingandsympatheticfamilyapproachtotheneedforrubbinghabitreversal3.5.Compliance4.ConclusionsConflictofinterestReferences1.IntroductionChronichabitsofabnormalrubbing(AR)appeartobeatleastacontributorycausalfactorinthedevelopmentand/orprogressionofsomeformsofkeratoconus(KC)[1]and[2].ChronichabitsofARmaybeasufficientcauseinsomecases[3],butadefinitecausallinkhasnotyetbeenestablished[4].AdvicetopatientswithkeratoconusthattheyshouldcontrolARhabitshasbeenacommonrecommendation[5],[6],[7],[8],[9]and[10].Thisadvicemayalsobeindicatedforpatientswith,oratriskfordevelopingpost-laserassistedinsitukeratectasia[1].Thelevelofrubbingpracticedbyanunselected(consecutive)sequenceofover30-year-oldKCsubjects,wasmeasuredusingvisualanaloguescales,andfoundtobesignificantlygreaterthanthatreportedbynormalover30-year-oldcontrolsubjects.Thecontrolsubjectsalsoroutinelyworerigidgaspermeablecontactlensesalldayeverydayandareassumedtohavehadthesamelimitedopportunitiestorubtheireyes[11].AlloftheKCsubjectshadbeengivenanoralexplanationofhowARmightbeacontributingcausalfactorinthedevelopmentandprogressionoftheirKC,andhadbeenadvisedtoabstainfromrubbing.Clearly,manyhadnotbeenabletocomplywiththatadvice.Compliancewithtreatmentrecommendationsisoftenpoorinotherareasofeyecare.Areviewof100patientsrevealedthat74%ofthemwerenon-compliantwithatleastoneaspectoftheinstructionsprovidedregardingthemaintenanceoftheircontactlenses[12].Patientswithglaucomaarefrequentlynon-compliantwiththeirmedication[13].Inaddition,patientswhoaremonitoredforadherencetoprescribeddosageshavebeenfoundtooverestimatetheircompliancewithglaucomatherapy[13].Similarly,inthetreatmentofamblyopiainchildren,patchingtimesnotedbyparentswereusuallyfoundtooverestimatethetimesrecordedbydosemonitors[14].Giventheirexposuretoadvicetoabstainfromrubbing,theremayalsohavebeensomeunder-reportingofrubbinglevelsbytheKCsamplethatwasstudied[11].Thetruelevelofnon-compliancemayhavebeenhigherthanwasfound[11].Clearlyoraladvicetoabstainfromrubbingthatincludeddiscussionofapossiblecausalrolewasshowntobeineffectiveforasignificantnumberofpatients.OneofthereasonsforthelackofsuccessmaybethattheadvicewasbasedonthepossibilitythatARmaybeacontributorycausalfactorinsomeformsofKC.InAustralia,“Smokingmaybeinjurioustoyourhealth”asawarningoncigarettepacketshasbeenreplacedbystatementssuchas“Smokingcauseslungcancer”.Credibilityofsmokingrelatedwarningsisenhancedbyusingmessagesthataredirectandunambiguous[15].Thechangetoaclearcausalstatement,leavingnoroomfordoubt,appearstobecontributingtoareductioninsmokingprevalence[15].Smokershavebeenfoundtorecallcausalsmokingmessagesinmoredetail[15].Similarly,advicetocontrolARmaybemoreeffectiveifARwasknowntobeacauseofKC.Theimpactofthisadvicecouldbegreaterifrub