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Barber KE, Woods DW, Ely LJ, Saunders SM, Compton SN, Neal-Barnett A, Franklin ME, Capriotti MR, Conelea CA, Twohig MP. Long-term follow-up of acceptance-enhanced behavior therapy for trichotillomania. Psychiatry Res 2024; 333:115767. [PMID: 38330639 PMCID: PMC10911454 DOI: 10.1016/j.psychres.2024.115767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/26/2024] [Accepted: 01/28/2024] [Indexed: 02/10/2024]
Abstract
Acceptance-enhanced behavior therapy for trichotillomania (AEBT-TTM) is effective in reducing trichotillomania (TTM) symptoms, but the durability of treatment effects remains in question. This study analyzed 6-month follow-up data from a large randomized clinical trial comparing AEBT-TTM to an active psychoeducation and supportive therapy control (PST). Adults with TTM (N=85; 92% women) received 10 sessions of AEBT-TTM or PST across 12 weeks. Independent evaluators assessed participants at baseline, post-treatment, and 6 months follow-up. For both AEBT-TTM and PST, self-reported and evaluator-rated TTM symptom severity decreased from baseline to follow-up. TTM symptoms did not worsen from post-treatment to follow-up. At follow-up, AEBT-TTM and PST did not differ in rates of treatment response, TTM diagnosis, or symptom severity. High baseline TTM symptom severity was a stronger predictor of high follow-up severity for PST than for AEBT-TTM, suggesting AEBT-TTM may be a better option for more severe TTM. Results support the efficacy of AEBT-TTM and show that treatment gains were maintained over time. Although AEBT-TTM yielded lower symptoms at post-treatment, 6-month follow-up outcomes suggest AEBT-TTM and PST may lead to similar symptom levels in the longer term. Future research should examine mechanisms that contribute to long-term gain maintenance.
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Affiliation(s)
- Kathryn E Barber
- Department of Psychology, Marquette University, 317 Cramer Hall, 604 North 16th St., Milwaukee, WI 53233, USA
| | - Douglas W Woods
- Department of Psychology, Marquette University, 317 Cramer Hall, 604 North 16th St., Milwaukee, WI 53233, USA.
| | - Laura J Ely
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Stephen M Saunders
- Department of Psychology, Marquette University, 317 Cramer Hall, 604 North 16th St., Milwaukee, WI 53233, USA
| | - Scott N Compton
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | | | | | | | - Christine A Conelea
- Department of Psychiatry & Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA
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2
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Comprehensive Behavioral Treatment of an Older Adult Man with Trichotillomania. Clin Case Stud 2022. [DOI: 10.1177/15346501221130500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The Comprehensive Behavioral (ComB) model of treatment for trichotillomania (TTM) and other body-focused repetitive behaviors offers a framework for individualized, flexible intervention based on functional analysis. This case report focuses on the treatment of a patient who enrolled in the first randomized clinical trial of ComB for TTM (Carlson et al., 2021) as well as a long-term follow-up of participants from that trial conducted during the COVID-19 pandemic (Flannery et al., in press). Walter (pseudonym) entered the treatment trial at 69, having had TTM since age 17 but not received treatment for it. Walter showed clinically significant improvement in treatment, ultimately abstaining from hair pulling for two years. A single case from a parallel-groups trial cannot support strong conclusions about why his results were favorable, but qualitative review of Walter’s experience in therapy suggested that allowing him a good deal of collaborative input on the specific methods of implementation of ComB principles was helpful. Along with the general literature on patient age as a predictor of therapy outcome, Walter’s case serves as a reminder that older adults, even those with highly chronic clinical conditions, can benefit greatly from psychotherapy.
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Asplund M, Rück C, Lenhard F, Gunnarsson T, Bellander M, Delby H, Ivanov VZ. ACT-enhanced group behavior therapy for trichotillomania and skin-picking disorder: A feasibility study. J Clin Psychol 2021; 77:1537-1555. [PMID: 33937998 DOI: 10.1002/jclp.23147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/28/2021] [Accepted: 03/28/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To evaluate the feasibility and efficacy of ACT-enhanced Group Behavior Therapy (AEGBT) for mixed diagnosis groups including patients with trichotillomania (TTM) and skin-picking disorder (SPD) in routine psychiatric care. METHOD Adult patients (N = 40) with TTM and/or SPD received 10 weeks of AEGBT followed by five booster sessions. The primary outcome measure for TTM was the Massachusetts General Hospital Hairpulling Scale (MGH-HPS) and for SPD the Skin Picking Scale-Revised (SPS-R), assessed at posttreatment and at booster sessions. RESULTS Results showed significant reductions in hair pulling and skin-picking severity from baseline to posttreatment and large effect sizes at posttreatment. Improvements remained significant at the 12-month follow-up for patients with SPD, but not for patients with TTM. Group attendance was high and few patients dropped out from treatment. The group format enabled therapists to see 25% more patients compared with an individual format. CONCLUSION The results provide initial support for the feasibility and efficacy of an adapted treatment approach for TTM and SPD.
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Affiliation(s)
- Mia Asplund
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Sweden
| | - Christian Rück
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Sweden
| | - Fabian Lenhard
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Sweden
| | - Tove Gunnarsson
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Sweden
| | - Martin Bellander
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Sweden
| | - Hanna Delby
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Sweden
| | - Volen Z Ivanov
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Sweden
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Slikboer R, Rehm IC, Smillie L, Rossell SL, Nedeljkovic M. How reward and punishment are viewed by individuals experiencing trichotillomania according to revised reinforcement sensitivity theory. CLIN PSYCHOL-UK 2020. [DOI: 10.1111/cp.12160] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Reneta Slikboer
- Department of Psychological Sciences, Faculty of Health, Arts and Design, Swinburne University of Technology, Melbourne, Victoria, Australia,
| | - Imogen C. Rehm
- Centre for Mental Health, Swinburne University of Technology, Melbourne, Victoria, Australia,
- School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia,
| | - Luke Smillie
- Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, Victoria, Australia,
| | - Susan L. Rossell
- Centre for Mental Health, Swinburne University of Technology, Melbourne, Victoria, Australia,
- Monash Alfred Psychiatry Research Centre, The Alfred Hospital and Monash University Central Clinical School, Melbourne, Victoria, Australia,
| | - Maja Nedeljkovic
- Department of Psychological Sciences, Faculty of Health, Arts and Design, Swinburne University of Technology, Melbourne, Victoria, Australia,
- Centre for Mental Health, Swinburne University of Technology, Melbourne, Victoria, Australia,
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Badenoch J, Searle T, Watson I, Cavanna AE. Sensory symptoms in body-focused repetitive behaviors, restless legs syndrome, and Tourette syndrome: An overlap? Neurosci Biobehav Rev 2020; 119:320-332. [PMID: 33086129 DOI: 10.1016/j.neubiorev.2020.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/13/2020] [Accepted: 10/15/2020] [Indexed: 12/25/2022]
Abstract
Tourette syndrome (TS) is a neurodevelopmental condition characterized by multiple tics. Sensory symptoms play a key role in the clinical phenomenology and pathophysiology of TS, as most patients report premonitory urges driving tic expression. Interestingly, sensory symptoms have also been reported in other conditions characterized by repeated behaviors. This review explores the nature of sensory symptoms reported by patients with body focused repetitive behaviors (BFRBs, especially trichotillomania and skin picking disorder) and restless legs syndrome (RLS) in comparison to TS. A sense of mounting inner tension and reinforcement mechanisms driven by gratification and relief on expression of the tic or repetitive behavior appear to be implicated across all conditions. Subjective urges can be temporarily suppressed by patients with TS and selected BFRBs, whereas patients with RLS tend to report dysesthesia more frequently than a suppressible urge to move. The observed similarities in the phenomenology of sensory symptoms across these conditions raise the possibility of a comparable underlying pathophysiology. Preliminary findings suggest an overlap of neural pathways encompassing the insula, basal ganglia (putamen), and posterior cingulate cortex.
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Affiliation(s)
- James Badenoch
- Department of Neuropsychiatry, BSMHFT and University of Birmingham, Birmingham, United Kingdom
| | - Tamara Searle
- Department of Neuropsychiatry, BSMHFT and University of Birmingham, Birmingham, United Kingdom
| | - Iona Watson
- Department of Neuropsychiatry, BSMHFT and University of Birmingham, Birmingham, United Kingdom
| | - Andrea E Cavanna
- Department of Neuropsychiatry, BSMHFT and University of Birmingham, Birmingham, United Kingdom; School of Life and Health Sciences, Aston University, Birmingham, United Kingdom; University College London and Institute of Neurology, London, United Kingdom.
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Bottesi G, Ouimet AJ, Cerea S, Granziol U, Carraro E, Sica C, Ghisi M. Comprehensive Behavioral Therapy of Trichotillomania: A Multiple-Baseline Single-Case Experimental Design. Front Psychol 2020; 11:1210. [PMID: 32587552 PMCID: PMC7298435 DOI: 10.3389/fpsyg.2020.01210] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 05/11/2020] [Indexed: 12/03/2022] Open
Abstract
Despite rapidly increasing knowledge about Trichotillomania (TTM), no gold-standard evidence-based psychological intervention has been identified. In the current study, we evaluated the potential efficacy of an eight-session psychological intervention for TTM, namely the Comprehensive Behavioral Model (ComB) treatment, using a multiple-baseline single-case experimental design with three Italian women with TTM. The study included three phases: baseline, intervention, and 3-month follow-up. We assessed the intervention using daily self-monitoring of number of hair-pulling episodes, number of pulled hairs per episode, degree of resistance to pulling urges, and degree of associated distress. We also assessed for reliable improvement in general distress from baseline to post-intervention. All participants completed treatment and showed improvements on those symptom measures that were most relevant to their individualized case conceptualization. However, no participants recovered completely or demonstrated reliable improvement in general distress. Our results provide initial evidence for the utility of the ComB treatment for TTM in an Italian clinical setting. Furthermore, they support the delivery of individualized and flexible psychological treatments when treating TTM.
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Affiliation(s)
- Gioia Bottesi
- Department of General Psychology, University of Padova, Padova, Italy.,Centro di Ateneodei Servizi Clinici Universitari Psicologici (SCUP), University of Padova, Padova, Italy
| | | | - Silvia Cerea
- Department of General Psychology, University of Padova, Padova, Italy.,Centro di Ateneodei Servizi Clinici Universitari Psicologici (SCUP), University of Padova, Padova, Italy
| | - Umberto Granziol
- Department of General Psychology, University of Padova, Padova, Italy
| | - Eleonora Carraro
- Department of General Psychology, University of Padova, Padova, Italy.,Centro di Ateneodei Servizi Clinici Universitari Psicologici (SCUP), University of Padova, Padova, Italy
| | - Claudio Sica
- Department of Health Sciences, University of Firenze, Firenze, Italy
| | - Marta Ghisi
- Department of General Psychology, University of Padova, Padova, Italy.,Centro di Ateneodei Servizi Clinici Universitari Psicologici (SCUP), University of Padova, Padova, Italy
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Rehm IC, Nedeljkovic M, Moulding R, Thomas A. The Beliefs in Trichotillomania Scale (BiTS): Factor analyses and preliminary validation. BRITISH JOURNAL OF CLINICAL PSYCHOLOGY 2019; 58:384-405. [PMID: 30968971 DOI: 10.1111/bjc.12219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 03/14/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The role of cognitions and beliefs in trichotillomania (TTM; hair pulling disorder) has been the subject of only limited investigation. This study aimed to develop and validate the Beliefs in TTM Scale (BiTS). METHODS A pool of 50 items based upon themes identified in previous research was administered online to 841 participants with and without self-reported problematic, non-cosmetic hair pulling behaviours. RESULTS Exploratory and confirmatory factor analyses conducted in randomly split-halves of the sample supported retention of 14 items comprising three factors: negative self-beliefs, low coping efficacy, and perfectionism. CONCLUSIONS The BiTS demonstrated satisfactory psychometric properties and all three subscales significantly correlated with greater hair pulling severity. Negative self-beliefs predicted hair pulling severity over and above mood symptoms, suggesting the importance of addressing self-construals in psychological treatments for TTM. Validation in a clinician diagnosed sample is required. PRACTITIONER POINTS Research supports cognitive therapies for treating trichotillomania (hair pulling disorder), although studies investigating the nature and role of cognitions and beliefs in this disorder have been lacking. This study developed and validated a self-report measure of three styles of beliefs most relevant to trichotillomania: negative self-beliefs, low coping efficacy, and perfectionism. Negative self-beliefs predicted the severity of trichotillomania symptoms over and above depression and anxiety, suggesting such cognitions may not necessarily be due to comorbidities. Future research should validate the new measure in a clinician diagnosed sample, and therapies for trichotillomania may be enhanced by targeting shame specifically.
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Affiliation(s)
- Imogen C Rehm
- Department of Psychological Sciences, Swinburne University of Technology, Melbourne, Victoria, Australia.,School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
| | - Maja Nedeljkovic
- Centre for Mental Health, Swinburne University of Technology, Melbourne, Victoria, Australia
| | - Richard Moulding
- School of Psychology, Deakin University, Melbourne, Victoria, Australia
| | - Anna Thomas
- Department of Psychological Sciences, Swinburne University of Technology, Melbourne, Victoria, Australia.,Research and Innovation Portfolio, RMIT University, Melbourne, Victoria, Australia
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Maas J, Keijsers GP, Rinck M, Becker ES. Approach-avoidance, attentional and evaluation biases in hair pulling disorder and their relationship with symptom severity. JOURNAL OF COGNITIVE PSYCHOLOGY 2018. [DOI: 10.1080/20445911.2018.1503278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Joyce Maas
- Behavioural Science Institute, Radboud University Nijmegen, Nijmegen, The Netherlands
| | - Ger P.J. Keijsers
- Behavioural Science Institute, Radboud University Nijmegen, Nijmegen, The Netherlands
- Clinical Psychological Sciences, Maastricht University, Maastricht, The Netherlands
| | - Mike Rinck
- Behavioural Science Institute, Radboud University Nijmegen, Nijmegen, The Netherlands
| | - Eni S. Becker
- Behavioural Science Institute, Radboud University Nijmegen, Nijmegen, The Netherlands
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Trichotillomania and Trichophagia: Modern Diagnostic and Therapeutic Methods. Dermatol Ther (Heidelb) 2018; 8:389-398. [PMID: 30099694 PMCID: PMC6109030 DOI: 10.1007/s13555-018-0256-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Indexed: 01/25/2023] Open
Abstract
Trichotillomania is a chronic, mental disease of impulse control, characterized by repetitive, compulsive, and self-induced hair pulling. It can occur at any age but is observed more often in adolescents, with a strong predominance in females. Diagnosis of trichotillomania may be difficult, and its effective treatment challenging. The aim of this study is to critically review current literature regarding diagnostic procedures and treatment of trichotillomania, including psychotherapy, N-acetylcysteine, naltrexone, topiramate, atypical neuroleptics, and selective serotonin-reuptake inhibitors. The importance of cooperation between dermatologists and psychiatrists is emphasized to shorten the time to diagnose the disease and begin appropriate treatment. Finally, trichotillomania is also often connected with trichophagia, which may lead to formation of trichobezoars and cause a direct danger to the patient’s health and even life due to the risk of intestinal obstruction and the need for surgical intervention. Based on thorough literature review, we conclude that diagnosis of trichotillomania can be challenging. Trichoscopy could help to distinguish trichotillomania from other types of hair loss. Most clinical trials using various treatment options have been conducted on small groups of patients, and the potential benefits determined using various scales. Therefore, it is difficult to compare the effectiveness of different treatment methods. There is also a lack of studies assessing treatment efficacy over longer periods of time. Thus, there is a need to perform better-designed studies in the near future to optimize current treatment modalities for trichotillomania.
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Maas J, Keijsers GP, Rinck M, Becker ES. Does Cognitive Bias Modification Prior to Standard Brief Cognitive Behavior Therapy Reduce Relapse Rates in Hair Pulling Disorder? A Double-Blind Randomized Controlled Trial. JOURNAL OF SOCIAL AND CLINICAL PSYCHOLOGY 2018. [DOI: 10.1521/jscp.2018.37.6.453] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background: In line with previous research in alcohol addiction, we tested whether an Approach-Avoidance Training (AAT) prior to standard six-session Cognitive Behavior Therapy (CBT) for Hair Pulling Disorder (HPD) reduced problematic relapse, commonly found in this population. Method: Prior to CBT, 54 outpatients with a primary diagnosis of HPD were randomly assigned (double-blind) to either a training condition (n = 27), learning to avoid hair-pulling-related stimuli, or to a control condition (n = 27). Symptom severity was assessed with the Massachussetts General Hospital Hairpulling Scale, Severity Urge Resistance Frequency Scale, Self-Control Cognition Questionnaire, and Alopecia Scale. Results: In line with existing research, CBT showed to be an effective treatment for HPD in the short-term. There was no significant symptom increase after one and three months, but effect sizes were reduced approximately by half at the twelve-month measurement. The AAT training prior to CBT did not result in enhanced symptom reduction or reduced relapse after CBT. Conclusions: AAT training could not resolve the substantial relapse after successful CBT. Future research should take into account the complexity of stimuli that elicit hair pulling (e.g., tactile stimuli) and consider investigating other types of biases.
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Affiliation(s)
- Joyce Maas
- Behavioural Science Institute, Radboud University Nijmegen
| | - Ger P.J. Keijsers
- Behavioural Science Institute, Radboud University Nijmegen
- Clinical Psychological Sciences, Maastricht University, Maastricht, The Netherlands
| | - Mike Rinck
- Behavioural Science Institute, Radboud University Nijmegen
| | - Eni S. Becker
- Behavioural Science Institute, Radboud University Nijmegen
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