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Reid M, Lin A, Farhat LC, Fernandez TV, Olfson E. The genetics of trichotillomania and excoriation disorder: A systematic review. Compr Psychiatry 2024; 133:152506. [PMID: 38833896 DOI: 10.1016/j.comppsych.2024.152506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 05/09/2024] [Accepted: 05/30/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND Trichotillomania (TTM) and excoriation disorder (ED) are impairing obsessive-compulsive related disorders that are common in the general population and for which there are no clear first-line medications, highlighting the need to better understand the underlying biology of these disorders to inform treatments. Given the importance of genetics in obsessive-compulsive disorder (OCD), evaluating genetic factors underlying TTM and ED may advance knowledge about the pathophysiology of these body-focused repetitive behaviors. AIM In this systematic review, we summarize the available evidence on the genetics of TTM and ED and highlight gaps in the field warranting further research. METHOD We systematically searched Embase, PsycInfo, PubMed, Medline, Scopus, and Web of Science for original studies in genetic epidemiology (family or twin studies) and molecular genetics (candidate gene and genome-wide) published up to June 2023. RESULTS Of the 3536 records identified, 109 studies were included in this review. These studies indicated that genetic factors play an important role in the development of TTM and ED, some of which may be shared across the OCD spectrum, but there are no known high-confidence specific genetic risk factors for either TTM or ED. CONCLUSIONS Our review underscores the need for additional genome-wide research conducted on the genetics of TTM and ED, for instance, genome-wide association and whole-genome/whole-exome DNA sequencing studies. Recent advances in genomics have led to the discovery of risk genes in several psychiatric disorders, including related conditions such as OCD, but to date, TTM and ED have remained understudied.
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Affiliation(s)
- Madison Reid
- Child Study Center, Yale University School of Medicine, New Haven, CT, USA; The University of the South, USA
| | - Ashley Lin
- Child Study Center, Yale University School of Medicine, New Haven, CT, USA
| | - Luis C Farhat
- Department of Psychiatry, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Thomas V Fernandez
- Child Study Center, Yale University School of Medicine, New Haven, CT, USA; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Emily Olfson
- Child Study Center, Yale University School of Medicine, New Haven, CT, USA; Wu Tsai Institute, Yale University, New Haven, CT, USA.
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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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Coyne AF, Carlson EJ, Malloy EJ, Haaga DAF. Predicting response to and relapse after treatment of trichotillomania with the Comprehensive Behavioral model (ComB). Bull Menninger Clin 2024; 88:81-99. [PMID: 38527102 DOI: 10.1521/bumc.2024.88.1.81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
Prior studies of behavior therapy for trichotillomania (TTM) have shown that response is variable, and relapse after treatment discontinuation is common. Little information is available concerning prognostic factors capable of predicting individual differences in response or maintenance of improvement. The present study is a secondary analysis of a randomized controlled trial (N = 36) of the Comprehensive Behavioral (ComB) model of treatment for TTM (Carlson et al., 2021). We investigated age, disorder history, pre-treatment symptom severity, longest prior period of abstinence from pulling, and Emotion and Intention hair pulling styles as predictors of initial response. We studied age, disorder history, pre-treatment symptom severity, longest prior period of abstinence from pulling, and post-treatment symptom severity or hair-pulling abstinence as predictors of relapse following treatment. Older age significantly predicted lower TTM severity following treatment. Lower pre-treatment severity significantly predicted lower severity of TTM at the 3-month follow-up.
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Affiliation(s)
- Allison F Coyne
- Doctoral candidate in clinical psychology at American University, Washington, DC
| | - Emily J Carlson
- Postdoctoral fellow at the Children's Hospital of Philadelphia
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Farhat LC, Reid M, Bloch MH, Olfson E. Prevalence and gender distribution of excoriation (skin-picking) disorder: A systematic review and meta-analysis. J Psychiatr Res 2023; 161:412-418. [PMID: 37023597 PMCID: PMC11137851 DOI: 10.1016/j.jpsychires.2023.03.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 02/21/2023] [Accepted: 03/27/2023] [Indexed: 04/08/2023]
Abstract
Epidemiological studies of excoriation disorder have reported different prevalence estimates for this condition, limiting our understanding of its public health impact. We performed a systematic review and meta-analysis to collate epidemiological studies of excoriation disorder. We aimed to estimate the pooled prevalence and the female-to-male ratio of excoriation disorder in the general population. We searched Embase, PsycInfo, and PubMed up to May 2020 and updated the PubMed search in October 2021. Studies which reported the frequency of excoriation disorder in a sample from the general population were included in our meta-analyses. We made no restrictions regarding the definition or assessment of excoriation disorder. Data were pooled through random-effects meta-analyses. Of the 677 records identified through database searches, 19 studies involving 38,038 participants met our inclusion criteria. Meta-analyses demonstrated that excoriation disorder has an overall prevalence of 3.45% (95% CI 2.55, 4.65%) and impacts women more than men (female-to-male OR = 1.45; 95% CI 1.15, 1.81, p = 0.001). These findings underscore the public health impact of excoriation disorder, which will hopefully motivate future research focused on advancing our understanding and management of this condition.
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Affiliation(s)
- Luis C Farhat
- Child Study Center, Yale University, New Haven, CT, USA; Department of Psychiatry, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, BR, Brazil
| | - Madison Reid
- Child Study Center, Yale University, New Haven, CT, USA
| | - Michael H Bloch
- Child Study Center, Yale University, New Haven, CT, USA; Department of Psychiatry, Yale University, New Haven, CT, USA
| | - Emily Olfson
- Child Study Center, Yale University, New Haven, CT, USA.
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Lin A, Farhat LC, Flores JM, Levine JLS, Fernandez TV, Bloch MH, Olfson E. Characteristics of trichotillomania and excoriation disorder across the lifespan. Psychiatry Res 2023; 322:115120. [PMID: 36842397 PMCID: PMC10023474 DOI: 10.1016/j.psychres.2023.115120] [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: 12/11/2022] [Revised: 01/31/2023] [Accepted: 02/18/2023] [Indexed: 02/23/2023]
Abstract
Trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder are body-focused repetitive behaviors, which often first present in adolescence and cause distress and impairment into adulthood. Few studies have examined the clinical characteristics of the co-occurrence of these conditions across the lifespan. We examined cross-sectional survey responses collected from April 2018-February 2020 to evaluate the relationship between trichotillomania, excoriation disorder, and their co-occurrence. Responses from individuals with trichotillomania (n = 50), excoriation disorder (n = 52), and both conditions (n = 50) ages 4-67 years old were compared for co-occurring conditions and current symptoms. Self-report measures of hair-pulling and skin-picking severity and subtypes were assessed. Gender, race, and co-occurring conditions were generally similarly distributed across the three groups with high rates of self-reported anxiety (63-82%), depression (34-50%), obsessive-compulsive disorder (16-29%), and attention-deficit/hyperactivity disorder (12-32%). Among individuals with both trichotillomania and excoriation disorder, significant positive correlations were observed between hair-pulling and skin-picking severity scores as well as hair-pulling and skin-picking subtypes. Hair-pulling and skin-picking severity peaked at the transition from adolescence to adulthood and hair-pulling/skin-picking styles appeared to shift across the lifespan. Our results support several similarities between trichotillomania and excoriation disorder, providing new insight into the clinical characteristics of these conditions.
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Affiliation(s)
- Ashley Lin
- Child Study Center, Yale University School of Medicine, 230 S. Frontage Rd., New Haven CT, United States
| | - Luis C Farhat
- Child Study Center, Yale University School of Medicine, 230 S. Frontage Rd., New Haven CT, United States; Department of Psychiatry, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - José M Flores
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Jessica L S Levine
- Child Study Center, Yale University School of Medicine, 230 S. Frontage Rd., New Haven CT, United States
| | - Thomas V Fernandez
- Child Study Center, Yale University School of Medicine, 230 S. Frontage Rd., New Haven CT, United States; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Michael H Bloch
- Child Study Center, Yale University School of Medicine, 230 S. Frontage Rd., New Haven CT, United States; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Emily Olfson
- Child Study Center, Yale University School of Medicine, 230 S. Frontage Rd., New Haven CT, United States.
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Internet-delivered acceptance-based behavior therapy for trichotillomania and skin-picking disorder in a psychiatric setting: A feasibility trial. Internet Interv 2022; 30:100573. [PMID: 36133915 PMCID: PMC9483632 DOI: 10.1016/j.invent.2022.100573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 09/06/2022] [Accepted: 09/09/2022] [Indexed: 12/21/2022] Open
Abstract
Trichotillomania (TTM) and skin-picking disorder (SPD) are two clinically related conditions that can be successfully treated with behavior therapy (BT). There is some research indicating that BT for TTM and SPD can be efficacious also when delivered online instead of face-to-face, however, previous studies have mainly used self-recruited samples in a university context and it is unclear if the effects of online BT also extend to regular psychiatric patients. The current study set out to investigate if internet-delivered BT (I-BT) is a feasible, acceptable and preliminarily efficacious treatment for patients in a routine psychiatric setting. Twenty-five adult clinician-referred patients with TTM (n = 7) and/or SPD (n = 18) received 10 weeks of therapist-guided I-BT. The I-BT program incorporated both traditional interventions (e.g. habit reversal) as well as more recent acceptance-based techniques (e.g. embracing the urges and mindfulness). Clinician- and self-rated outcomes were assessed at pretreatment, posttreatment and at the delivery of 4 additional booster modules. Results showed that the majority of the participants were satisfied with the treatment and found it credible. The average number of completed internet modules was 7.2/10; five participants ended treatment prematurely. Significant decreases in hair pulling and skin picking severity were demonstrated from pretreatment to posttreatment with within-group effect sizes ranging from d = 0.89 to 1.75. The results remained significant up to the 12-month follow-up on most outcome measures. Altogether, the results provide initial evidence suggesting that I-BT could be a feasible, acceptable and potentially effective treatment for TTM and SPD for patients in a regular psychiatric setting.
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Thomson HA, Farhat LC, Olfson E, Levine JLS, Bloch MH. Prevalence and gender distribution of trichotillomania: A systematic review and meta-analysis. J Psychiatr Res 2022; 153:73-81. [PMID: 35802953 DOI: 10.1016/j.jpsychires.2022.06.058] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 04/29/2022] [Accepted: 06/24/2022] [Indexed: 11/30/2022]
Abstract
Epidemiological studies have provided varying prevalence estimates of trichotillomania (TTM) and other hair-pulling behaviors. We performed a systematic review and meta-analysis to provide data-driven prevalence estimates of TTM and hair-pulling. PubMed, PsycInfo and Embase were searched on June 2020 (updated in November 2021). Studies reporting the frequency of TTM defined by Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria or hair-pulling behaviors were included. Prevalence data was extracted for both genders, and female-to-male odds ratios (OR) were computed for TTM and any hair-pulling behaviors. Data were pooled through random-effects meta-analyses. Of the 713 records identified through database searches, 30 studies involving 38,526 participants were included. Meta-analyses indicated TTM had a prevalence of 1.14% (95% CI 0.66%, 1.96%), while any hair-pulling behavior had a prevalence of 8.84% (95% CI 6.33%, 12.20%). Meta-analyses demonstrated females were at an increased risk of any hair-pulling when noticeable hair loss was required (OR = 2.23, 95% CI 1.60, 3.10, p < 0.0001), but not of any hair-pulling when noticeable hair loss was not required (OR = 0.90, 95% CI 0.72, 1.64, p = 0.33). Meta-analyses did not indicate female preponderance in TTM (k = 10; N = 22,775; OR = 1.29; 95% CI 0.91, 1.83; I2 = 28%, p = 0.15), although there was considerable heterogeneity across studies. This study demonstrates that TTM impacts ∼1% of the population, while general hair-pulling behaviors affects ∼8%, highlighting the significant public health impact of this understudied condition. Additional research should clarify the gender distribution of TTM in epidemiological samples.
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Affiliation(s)
| | - Luis C Farhat
- Department of Psychiatry, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Emily Olfson
- Yale Child Study Center, Yale University, New Haven, CT, USA
| | | | - Michael H Bloch
- Yale Child Study Center, Yale University, New Haven, CT, USA; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA.
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Stiede JT, Woods DW, Idnani AK, Pritchard J, Klobe K, Kumar S. Pilot trial of a technology assisted treatment for trichotillomania. J Obsessive Compuls Relat Disord 2022; 33:100726. [PMID: 37305101 PMCID: PMC10256116 DOI: 10.1016/j.jocrd.2022.100726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The present study examined the usability, acceptability, feasibility, and preliminary efficacy of a prototype wrist-worn motion detection device and accompanying mobile app, developed by HabitAware®, as a system for delivering self-administered Habit Reversal Training (HRT). As an exploratory aim, the effect of the device and HRT app combination was compared to a reminder bracelet. The pilot trial included 15 adults with trichotillomania who interacted with the device and app system (n = 10) or reminder bracelet (n = 5) for 4 weeks. Participants in the device and app condition reported high usability, acceptability, and perceived efficacy of the system. The device and HRT app combination reduced hair pulling severity. Individuals in the reminder bracelet condition also showed a significant improvement in hair pulling. A future efficacy study with a larger sample size, longer timeframe, and improved gesture detection algorithm is warranted.
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Flannery MK, Coyne AF, Carlson EJ, Haaga DAF. Extended follow-up of a comprehensive behavioral (ComB) treatment sample during the COVID-19 pandemic. J Obsessive Compuls Relat Disord 2022; 32:100706. [PMID: 34956828 PMCID: PMC8683380 DOI: 10.1016/j.jocrd.2021.100706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 01/02/2023]
Abstract
This study provides the longest follow-up yet for comprehensive behavioral (ComB) treatment of trichotillomania (TTM) (M = 24.59 months after pre-treatment and 15.92 months after the last follow-up point in a recent clinical trial (Carlson et al., 2021), which had shown ComB to be significantly more efficacious than minimal attention at post-treatment). This study also examined changes in TTM severity from before to during the COVID-19 pandemic. Participants (N = 23) completed a survey assessing current TTM symptoms, the impact of the pandemic on their coping with TTM, and their experience with ComB treatment. Self-reported symptom severity at this follow-up evaluation fell between the scores obtained at the clinical trial's pre-treatment assessment and at its last follow-up before the pandemic and did not significantly differ from either time point. Most participants (73%) reported some change in their TTM management since onset of the pandemic, with changes to their environment/routine (61%) and in anxiety (32%) being the most common. Pandemic-related changes were associated with variable outcomes, improving symptoms and management for some while worsening them for others. Use of strategies from ComB had declined since the most recent follow-up, but more than half (55%) of participants reported that strategies from ComB remained useful.
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Affiliation(s)
- Meghan K Flannery
- Department of Psychology, American University, 4400 Massachusetts Avenue NW, Washington, DC, 20016-8062, USA
| | - Allison F Coyne
- Department of Psychology, American University, 4400 Massachusetts Avenue NW, Washington, DC, 20016-8062, USA
| | - Emily J Carlson
- Department of Psychology, American University, 4400 Massachusetts Avenue NW, Washington, DC, 20016-8062, USA
| | - David A F Haaga
- Department of Psychology, American University, 4400 Massachusetts Avenue NW, Washington, DC, 20016-8062, USA
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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, Lam S, Maloney A, Nedeljkovic M. A brief, residential peer‐support retreat for trichotillomania: A mixed methods evaluation. AUSTRALIAN PSYCHOLOGIST 2020. [DOI: 10.1111/ap.12420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Reneta Slikboer
- Department of Psychology and Centre for Mental Health, Swinburne University of Technology, Melbourne, Victoria, Australia,
| | - Imogen C. Rehm
- College of Science Engineering and Health, School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia,
| | - Sandy Lam
- Department of Psychology and Centre for Mental Health, Swinburne University of Technology, Melbourne, Victoria, Australia,
| | - Alycia Maloney
- Department of Psychology and Centre for Mental Health, Swinburne University of Technology, Melbourne, Victoria, Australia,
| | - Maja Nedeljkovic
- Department of Psychology and Centre for Mental Health, Swinburne University of Technology, Melbourne, Victoria, Australia,
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Slikboer R, Nedeljkovic M, Bowe SJ, Moulding R. A systematic review and meta‐analysis of behaviourally based psychological interventions and pharmacological interventions for trichotillomania. CLIN PSYCHOL-UK 2020. [DOI: 10.1111/cp.12074] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Reneta Slikboer
- School of Psychology, Swinburne University of Technology, Hawthorn, Victoria, Australia,
| | - Maja Nedeljkovic
- Brain and Psychological Sciences Research Centre (BPsyC), Swinburne University of Technology, Hawthorn, Victoria, Australia,
| | - Steven J. Bowe
- School of Psychology, Swinburne University of Technology, Hawthorn, Victoria, Australia,
| | - Richard Moulding
- Centre for Mental Health and Wellbeing Research, School of Psychology, Deakin University, Burwood, Victoria, Australia,
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McGuire JF, Myers NS, Lewin AB, Storch EA, Rahman O. The Influence of Hair Pulling Styles in the Treatment of Trichotillomania. Behav Ther 2020; 51:895-904. [PMID: 33051032 DOI: 10.1016/j.beth.2019.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 11/19/2019] [Accepted: 12/08/2019] [Indexed: 11/15/2022]
Abstract
This report investigated the improvement in Automatic and Focused styles of hair pulling among youth with trichotillomania (TTM). Youth with TTM (N = 40) participated in a clinical trial that compared habit reversal training (HRT) to treatment-as-usual (TAU). Participants completed a baseline assessment to characterize hair pulling severity, self-reported hair pulling styles, and co-occurring psychiatric conditions. Youth were randomly assigned to receive eight weekly sessions of HRT or eight weeks of TAU. Afterward, youth completed a post-treatment assessment of hair pulling severity and hair pulling styles. Youth in the TAU condition then received eight weekly sessions of HRT and completed another post-treatment assessment. Analyses revealed that the Focused pulling style largely improved with HRT (d = 0.73) compared to TAU (d = 0.11). However, there was limited improvement for the Automatic pulling style following either HRT (d = 0.10) or TAU (d = -0.31). This same pattern of effects was also found during open-label treatment with HRT. Although behavior therapies such as HRT are the principle treatment for youth with TTM, the Automatic pulling style exhibited limited improvement to this therapeutic approach. Therefore, therapeutic strategies that enhance awareness to pulling behaviors may produce more robust outcomes to behavior therapy for youth with TTM.
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Neal-Barnett A, Woods DW, Espil FM, Davis M, Alexander JR, Compton SN, Walther MR, Twohig MP, Saunders SM, Cahill SP, Franklin ME. Acceptance-enhanced behavior therapy for trichotillomania: Randomized controlled trial rationale, method, and strategies for recruiting minority participants. Bull Menninger Clin 2019; 83:399-431. [PMID: 31380699 DOI: 10.1521/bumc_2019_83_04] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Trichotillomania (TTM) involves the chronic pulling out of hair to the point of hair loss or thinning, which continues despite repeated attempts to stop. Behavior therapy is a promising treatment for the condition, but studies have been limited by the lack of a credible control condition, small sample sizes, follow-up periods of short duration, and low participation by underrepresented populations. In the current article, the authors describe the theoretical rationale for an acceptance-enhanced form of behavior therapy for TTM in adults and describe the methodology used to test the efficacy of this intervention against a psychoeducation and supportive control condition. In addition, the authors discuss the importance of and difficulties encountered with enrolling minority participants into TTM research, as well as strategies used to enhance minority recruitment. Finally, the authors discuss the instruments, procedures, and related outcomes of the fidelity measures used in the randomized controlled trial.
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Affiliation(s)
| | - Douglas W Woods
- Texas A&M University, College Station, Texas
- Marquette University, Milwaukee, Wisconsin
| | - Flint M Espil
- Stanford University School of Medicine, Stanford, California
| | | | - Jennifer R Alexander
- Texas A&M University, College Station, Texas
- Marquette University, Milwaukee, Wisconsin
| | | | | | | | | | | | - Martin E Franklin
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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15
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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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16
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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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17
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Slikboer R, Castle DJ, Nedeljkovic M, Rossell SL. Types of avoidance in hair-pulling disorder (trichotillomania): An exploratory and confirmatory analysis. Psychiatry Res 2018; 261:154-160. [PMID: 29306818 DOI: 10.1016/j.psychres.2017.12.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 11/27/2017] [Accepted: 12/20/2017] [Indexed: 01/16/2023]
Abstract
Hair-pulling disorder (HPD) or Trichotillomania is a complex disorder with frequent relapses. Avoidance has been highlighted as an important behavioural feature in HPD. To improve our understanding of avoidance, two studies were conducted to identify the types of avoidance that may be experienced by those who pull hair. Internet questionnaires were used to collect data. Data from study one was split into two subsets. An exploratory factor analysis was conducted to identify the different types of avoidance experienced by those reporting symptoms of hair pulling (subset one, n = 278), followed by a confirmatory factor analysis (subset two, n = 295). In study two a MANOVA was conducted (n = 300) to examine whether levels of avoidance differed between controls and those with hair pulling symptoms. Participants with hair pulling symptoms had greater levels of avoidance on each of the five types: 'Avoidance of non-social goals', 'Self-concealment', 'Behavioural social avoidance', 'Avoidance of relationship problem solving' and 'Avoidance of thinking about the future'. These data expand on the current literature, which has predominantly focused on experiential avoidance. Future research will need to validate these findings in a clinical group.
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Affiliation(s)
- Reneta Slikboer
- Centre for Mental Health, Swinburne University of Technology, Melbourne, Australia.
| | - David J Castle
- Monash Alfred Psychiatry Research Centre, The Alfred Hospital and Monash University Central Clinical School, Melbourne, VIC, Australia
| | - Maja Nedeljkovic
- Centre for Mental Health, Swinburne University of Technology, Melbourne, Australia
| | - Susan L Rossell
- Centre for Mental Health, Swinburne University of Technology, Melbourne, Australia; Monash Alfred Psychiatry Research Centre, Melbourne, Australia; Monash Alfred Psychiatry Research Centre, The Alfred Hospital and Monash University Central Clinical School, Melbourne, VIC, Australia
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18
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Himle JA, Bybee D, O’Donnell LA, Weaver A, Vlnka S, DeSena DT, Rimer JM. Awareness Enhancing and Monitoring Device plus Habit Reversal in the Treatment of Trichotillomania: An Open Feasibility Trial. J Obsessive Compuls Relat Disord 2018; 16:14-20. [PMID: 29607291 PMCID: PMC5873594 DOI: 10.1016/j.jocrd.2017.10.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Habit Reversal Therapy (HRT) is helpful for many persons suffering from trichotillomania. However successful habit reversal therapy requires awareness of hair pulling behaviors. Available methods to monitor hair pulling behaviors are less than ideal, particularly when sufferers are unaware of their pulling-related behaviors. This open feasibility trial included 20 persons with trichotillomania who were treated with nine weeks of HRT with experienced clinicians following a well-established HRT protocol. HRT was augmented with an electronic Awareness Enhancing and Monitoring Device (AEMD) designed to alert users of hand to head contact and to monitor the frequency of pulling-related behaviors. The AEMD included a neck unit and two wrist units, each equipped with vibrating alert functions. The results of the open trial revealed significant improvements in trichotillomania symptoms as measured by clinician and self-report rating scales. Most participants met study criteria for HRT completion and treatment effects were large. Participants reported that the AEMD, when operational, was effective in alerting participants to TTM-related behaviors. The monitoring function of the AEMD did not operate as designed. Subjective feedback focused on the AEMD concept was positive but AEMD reliability problems and complaints about the wearability the units were common. Recommendations for AEMD design modifications were included.
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Affiliation(s)
- Joseph A. Himle
- University of Michigan, School of Social Work
- University of Michigan, Department of Psychiatry
| | | | | | | | - Sarah Vlnka
- University of Michigan, School of Social Work
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19
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A Preliminary Investigation of Metacognitive Therapy and Habit Reversal as a Treatment for Trichotillomania. Behav Cogn Psychother 2017; 46:1-20. [PMID: 28903787 DOI: 10.1017/s1352465817000546] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Not all patients suffering from trichotillomania (TTM) recover completely using CBT and of those that do, only a few maintain their recovery over time. AIMS The purpose of the present study was to investigate the effectiveness of metacognitive methods combined with habit reversal (MCT/HRT) in trichotillomania with a relatively long-term follow-up. METHOD A case series (n = 8) and a randomized wait-list controlled trial (n = 34) design were conducted in this study. In the case series, three of the eight patients dropped out of the study. Therefore, TTM-related symptoms were evaluated in five patients suffering from TTM before and after brief metacognitive plus habit reversal therapy during 1-month, 6-month, and 12-month follow-ups. The treatment consisted of detached mindfulness (DM) techniques, ritual postponement and habit reversal training (HRT) in eight sessions. RESULTS All patients were responders at post-treatment in case series. After the 12-month follow-up, the results were associated with higher pre-treatment levels of self-esteem and global functioning and lower pre-treatment levels of depression and anxiety with nearly complete abstinence from hair pulling immediately after treatment. A randomized wait-list controlled trial with experimental (n = 17) and waiting list group (n = 17) was then conducted to confirm the case series results. There were significant differences between the two groups regarding changes in MGH-HPS, Y-BOCS-TM, RSES, GAF, BDI, BAI and self-monitoring. Therefore, the MCT/HRT treatment was found to be more effective than the waiting list group. CONCLUSIONS A combined treatment including metacognitive and habit reversal techniques is remarkably effective in patients with TTM.
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20
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Maas J, Keijsers GPJ, Cangliosi CM, van der Veld W, Tanis-Jacobs J, van Minnen A. The Self-Control Cognition Questionnaire. EUROPEAN JOURNAL OF PSYCHOLOGICAL ASSESSMENT 2017. [DOI: 10.1027/1015-5759/a000290] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Abstract. Self-control cognitions arise right before or after someone gives in to an unwanted habit. This paper reports on the development of the 11-item Self-Control Cognition Questionnaire (SCCQ) in a series of three studies. In the first study (N = 308), we found that the SCCQ has a two-factor structure and is reliable. The factors were named “Giving way is rewarding” and “Resistance is impossible.” The construct validity of the SCCQ was assessed in the second study (N = 138). As expected, the SCCQ correlated positively and strongly with the preoccupation with unwanted habits and with the experience of craving, and correlations with one’s tendency to consider the long-term consequences of actions were small. The third study demonstrated that the SCCQ discriminates between patients with habit disorders (N = 63) and controls with non-pathological unwanted habits (N = 106). The SCCQ was sensitive to therapeutic change in two patient samples, one suffering from hair pulling disorder and the other from pathological skin picking. The SCCQ is applicable to unwanted habits in general, both pathological and non-pathological. It is proven to have sound psychometric properties and is suitable for use in practice.
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Affiliation(s)
- Joyce Maas
- Department of Clinical Psychology, Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands
| | - Ger P. J. Keijsers
- Department of Clinical Psychology, Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands
- Academic Centre Social Sciences, Nijmegen, The Netherlands
- Department Clinical Psychological Science, Maastricht University, The Netherlands
| | - Claudia M. Cangliosi
- Department of Clinical Psychology, Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands
| | - William van der Veld
- Department of Clinical Psychology, Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands
| | - Jorg Tanis-Jacobs
- Department of Clinical Psychology, Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands
| | - Agnes van Minnen
- Department of Clinical Psychology, Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands
- Centre for Anxiety Disorders Overwaal, Nijmegen, The Netherlands
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21
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O'Connor K, Lavoie M, Desaulniers B, Audet JS. Cognitive psychophysiological treatment of bodily-focused repetitive behaviors in adults: An open trial. J Clin Psychol 2017; 74:273-285. [PMID: 28815684 DOI: 10.1002/jclp.22501] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 04/04/2017] [Accepted: 04/16/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND Body-focused repetitive behaviors (BFRBs), such as hair pulling, skin picking, and nail biting, are repetitive, destructive, and nonfunctional habits that cause significant distress. Separate BFRBs form a cohesive group and could be assessed as part of the Tourette/tic spectrum or obsessive-compulsive spectrum of disorders. The treatment of choice is either antidepressant or behavioral treatment, both of which have shown effectiveness. The cognitive psychophysiological (CoPs) model focuses on the tension and emotional build up that triggers habits by addressing cognitive-behavioral, emotional and psychophysiological processes preceding onset rather than the habit itself. The CoPs approach has already shown efficacy in treatment of tic and Tourette disorder. OBJECTIVE The aim of the current open trial was to view whether BFRBs can be validly assessed on a standard tic scale (Tourette Symptom Global Scale; TSGS) and evaluate the efficacy of the CoPs intervention on 64 participants (54 completers) with 1 of 3 subtypes of BFRBs (hair pulling, nail biting, and skin picking) compared to a waitlist control. METHOD Participants were assessed at baseline on an adapted TSGS and after receving 14 weeks of CoPs therapy with six months follow up. RESULTS The TSGS was reliably and validly adapted to measure BFRBs. The CoPs intervention was effective for all BRFB subtypes with a large effect size (intention-to-treat g = 1.54; completers g = 2.04), with 74% of patients showing clinically significant improvement. Mood and self-esteem also improved posttreatment. The decrease in symptoms was maintained at the 6-month follow-up, with a further decrease in perfectionism. CONCLUSION BFRBs can be reliably assessed as a tic spectrum disorder rather than as part of the obsessive-compulsive spectrum. The CoPs model may offer a complementary treatment for BFRBs.
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Affiliation(s)
- Kieron O'Connor
- University of Montreal.,Research Center of the Montreal Institute of Mental Health.,University of Quebec in Outaouais
| | - Marc Lavoie
- University of Montreal.,Research Center of the Montreal Institute of Mental Health
| | | | - Jean-Sébastien Audet
- University of Montreal.,Research Center of the Montreal Institute of Mental Health
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22
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Houghton DC, Maas J, Twohig MP, Saunders S, Compton SN, Neal-Barnett A, Franklin ME, Woods DW. Comorbidity and quality of life in adults with hair pulling disorder. Psychiatry Res 2016; 239:12-9. [PMID: 27137957 PMCID: PMC4855296 DOI: 10.1016/j.psychres.2016.02.063] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 10/09/2015] [Accepted: 02/27/2016] [Indexed: 01/12/2023]
Abstract
Hair pulling disorder (HPD; trichotillomania) is thought to be associated with significant psychiatric comorbidity and functional impairment. However, few methodologically rigorous studies of HPD have been conducted, rendering such conclusions tenuous. The following study examined comorbidity and psychosocial functioning in a well-characterized sample of adults with HPD (N=85) who met DSM-IV criteria, had at least moderate hair pulling severity, and participated in a clinical trial. Results revealed that 38.8% of individuals with HPD had another current psychiatric diagnosis and 78.8% had another lifetime (present and/or past) psychiatric diagnosis. Specifically, HPD showed substantial overlap with depressive, anxiety, addictive, and other body-focused repetitive behavior disorders. The relationships between certain comorbidity patterns, hair pulling severity, current mood and anxiety symptoms, and quality of life were also examined. Results showed that current depressive symptoms were the only predictor of quality of life deficits. Implications of these findings for the conceptualization and treatment of HPD are discussed.
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Affiliation(s)
- David C. Houghton
- Texas A&M University, Department of Psychology, 4235 TAMU, College Station, TX 77843-4235
| | - Joyce Maas
- Radboud University-Nijmegen, Department of Clinical Psychology, P.O. Box 9104, NL-6500 HE Nijmegen, The Netherlands.
| | - Michael P. Twohig
- Utah State University, Department of Psychology, 2810 Old Main Hill, Logan, UT 84322-2810
| | - Stephen Saunders
- Marquette University, Department of Psychology, 328E Cramer Hall, Milwaukee, WI 53233
| | - Scott N. Compton
- Duke University School of Medicine, Department of Psychiatry and Behavioral Sciences, DUMC 3527, Durham, NC 27710
| | - Angela Neal-Barnett
- Kent State University, Department of Psychology, 203 Kent Hall Addition, Kent, OH 44242
| | - Martin E. Franklin
- University of Pennsylvania School of Medicine, Department of Psychiatry, 3535 Market Street, 6th Floor, Philadelphia, PA 19104
| | - Douglas W. Woods
- Texas A&M University, Department of Psychology, 4235 TAMU, College Station, TX 77843-4235,Corresponding author. Tel.: (979)845 2540
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Keijsers GPJ, Maas J, van Opdorp A, van Minnen A. Addressing Self-Control Cognitions in the Treatment of Trichotillomania: A Randomized Controlled Trial Comparing Cognitive Therapy to Behaviour Therapy. COGNITIVE THERAPY AND RESEARCH 2016; 40:522-531. [PMID: 27471331 PMCID: PMC4947120 DOI: 10.1007/s10608-016-9754-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
People with trichotillomania often have persistent negative beliefs about giving into one's habit. Central in the present study was the hypothesis that the follow-up effects of cognitive therapy (CT), in which these negative beliefs are directly addressed, are better compared to the follow-up effects of behaviour therapy (BT). Fifty-six trichotillomania patients were randomly assigned to either six sessions CT or BT. Forty-eight completed their treatment. Follow-up measurements took place after a 3 months treatment-free period, and at 12 and 24 months. CT and BT both resulted in clear reductions of trichotillomania symptoms (severity, urge, inability to resist, and negative beliefs) immediately after treatment. There were no differences between the groups. Following the treatment-free period, there was a reoccurrence of symptoms. In contrast to our expectation, we failed to show that CT compared to BT resulted in lower relapse rates after the treatment-free period.
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Affiliation(s)
- Ger P J Keijsers
- Behavioural Science Institute, Radboud University Nijmegen, P.O. Box 9104, 6500 HE Nijmegen, The Netherlands ; Department of Clinical Psychological Science, University Maastricht, Maastricht, The Netherlands
| | - Joyce Maas
- Behavioural Science Institute, Radboud University Nijmegen, P.O. Box 9104, 6500 HE Nijmegen, The Netherlands
| | - Amras van Opdorp
- Behavioural Science Institute, Radboud University Nijmegen, P.O. Box 9104, 6500 HE Nijmegen, The Netherlands
| | - Agnes van Minnen
- Behavioural Science Institute, Radboud University Nijmegen, P.O. Box 9104, 6500 HE Nijmegen, The Netherlands ; Centre of Anxiety Disorders Overwaal, Nijmegen, The Netherlands
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24
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Schumer MC, Panza KE, Mulqueen JM, Jakubovski E, Bloch MH. LONG-TERM OUTCOME IN PEDIATRIC TRICHOTILLOMANIA. Depress Anxiety 2015; 32:737-43. [PMID: 26139231 PMCID: PMC4591183 DOI: 10.1002/da.22390] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 05/27/2015] [Accepted: 05/30/2015] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To examine long-term outcome in children with trichotillomania. METHOD We conducted follow-up clinical assessments an average of 2.8 ± 0.8 years after baseline evaluation in 30 of 39 children who previously participated in a randomized, double-blind, placebo-controlled trial of N-acetylcysteine (NAC) for pediatric trichotillomania. Our primary outcome was change in hairpulling severity on the Massachusetts General Hospital Hairpulling Hospital Hairpulling Scale (MGH-HPS) between the end of the acute phase and follow-up evaluation. We also obtained secondary measures examining styles of hairpulling, comorbid anxiety and depressive symptoms, as well as continued treatment utilization. We examined both correlates and predictors of outcome (change in MGH-HPS score) using linear regression. RESULTS None of the participants continued to take NAC at the time of follow-up assessment. No significant changes in hairpulling severity were reported over the follow-up period. Subjects reported significantly increased anxiety and depressive symptoms but improvement in automatic pulling symptoms. Increased hairpulling symptoms during the follow-up period were associated with increased depression and anxiety symptoms and increased focused pulling. Older age and greater focused pulling at baseline assessment were associated with poor long-term prognosis. CONCLUSIONS Our findings suggest that few children with trichotillomania experience a significant improvement in trichotillomania symptoms if behavioral treatments are inaccessible or have failed to produce adequate symptom relief. Our findings also confirm results of previous cross-sectional studies that suggest an increased risk of depression and anxiety symptoms with age in pediatric trichotillomania. Increased focused pulling and older age among children with trichotillomania symptoms may be associated with poorer long-term prognosis.
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Affiliation(s)
| | | | | | | | - Michael H. Bloch
- Yale Child Study Center; New Haven Connecticut
- Department of Psychiatry; Yale University; New Haven Connecticut
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25
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The Role of Cognitions and Beliefs in Trichotillomania: A Qualitative Study Using Interpretative Phenomenological Analysis. BEHAVIOUR CHANGE 2015. [DOI: 10.1017/bec.2015.11] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Trichotillomania (TTM) is characterised by the removal of one's hair, causing hair loss. Phenomenological research on TTM has investigated its associated behavioural and affective factors. Few studies have investigated the possible role of cognitions and beliefs, despite emerging support for cognitive therapies in treating this disorder. This study aimed to explore and describe the cognitions and beliefs that contribute to the onset and maintenance of hairpulling in TTM. Eight women with TTM participated in semi-structured, in-depth interviews to explore their experience of cognitions and beliefs before, during and after typical hairpulling episodes. Interviews were analysed using the qualitative method of Interpretative Phenomenological Analysis. Six superordinate themes of beliefs were identified as important: negative self-beliefs, control beliefs, beliefs about coping, beliefs about negative emotions, permission-giving beliefs, and perfectionism. These preliminary findings suggest that cognitions may play an important role in TTM phenomenology. Future quantitative research on the role of cognitions and beliefs in TTM in larger samples has the potential to advance cognitive-behavioural models and treatments of this poorly understood disorder.
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26
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Rehm I, Moulding R, Nedeljkovic M. Psychological treatments for trichotillomania: update and future directions. Australas Psychiatry 2015; 23:365-8. [PMID: 26104780 DOI: 10.1177/1039856215590029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This paper aims to provide an overview of evidence-based psychological treatments for trichotillomania. CONCLUSIONS Advances in the understanding of the phenomenology of trichotillomania has led to the augmentation of behavioural treatments with dialectical behaviour therapy and acceptance and commitment therapy. Further studies of treatment component efficacy and cognitive behavioural models are required.
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Affiliation(s)
- Imogen Rehm
- Faculty of Health, Arts and Design, Swinburne University of Technology, Melbourne, VIC, Australia
| | - Richard Moulding
- Senior Lecturer, Centre for Mental Health and Wellbeing Research, Deakin University, Melbourne, VIC, Australia
| | - Maja Nedeljkovic
- Senior Lecturer, Brain and Psychological Sciences Research Centre, Swinburne University of Technology, Melbourne, VIC, Australia
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27
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Falkenstein MJ, Rogers K, Malloy EJ, Haaga DAF. Race/Ethnicity and Treatment Outcome in a Randomized Controlled Trial for Trichotillomania (Hair-Pulling Disorder). J Clin Psychol 2015; 71:641-52. [PMID: 25846982 DOI: 10.1002/jclp.22171] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Treatment outcome was compared among non-Hispanic White and racial/ethnic minority participants with trichotillomania (TTM), or hair-pulling disorder. METHOD Symptom severity, quality of life, and TTM-related disability were compared in a behavior therapy trial with a stepped care approach: web-based self-help and then individual behavior therapy. The sample comprised 72% (n = 38) non-Hispanic White participants and 28% (n = 15) minority participants. RESULTS The ethnic groups responded differently to treatment, with fewer minority participants showing improvement during web-based self-help. Response rates were equivalent between ethnic groups during the in-person behavior therapy. These results should be interpreted with caution because of the small sample size of minorities in the study and consequent inability to analyze results for each racial/ethnic group individually. CONCLUSIONS Future studies should focus on the investigation of factors that may enable or hinder racial and ethnic minority participants to benefit from online and/or self-help behavior therapy for TTM.
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28
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Snorrason I, Berlin GS, Lee HJ. Optimizing psychological interventions for trichotillomania (hair-pulling disorder): an update on current empirical status. Psychol Res Behav Manag 2015; 8:105-13. [PMID: 25897268 PMCID: PMC4396507 DOI: 10.2147/prbm.s53977] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Trichotillomania (hair-pulling disorder) is a psychiatric condition characterized by a persistent habit of pulling out one's hair. In treatment-seeking populations, hair-pulling disorder can be severe, chronic, and difficult to treat. In the early 1970s, behavioral interventions (eg, habit reversal training) were developed and proved effective in treating chronic hair-pulling for many individuals. In order to further increase treatment efficacy and improve long-term outcome, several authors have developed augmented treatment protocols that combine traditional behavioral strategies with other cognitive-behavioral interventions, including cognitive therapy, dialectical behavioral therapy, and acceptance and commitment therapy. In the present review, we give an overview of the clinical and diagnostic features of hair-pulling disorder, describe different cognitive-behavioral interventions, and evaluate research on their efficacy.
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Affiliation(s)
- Ivar Snorrason
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Gregory S Berlin
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Han-Joo Lee
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
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29
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Chandran NS, Novak J, Iorizzo M, Grimalt R, Oranje AP. Trichotillomania in Children. Skin Appendage Disord 2015; 1:18-24. [PMID: 27172263 DOI: 10.1159/000371809] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 12/29/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Trichotillomania is an often underdiagnosed condition. Little is known about trichotillomania in childhood. We aimed to analyze the characteristics of children with trichotillomania to increase information on this condition. METHODS A retrospective study of an electronic database was performed in a tertiary children's hospital. Information from patients with trichotillomania was systematically classified under the categories 'who', 'what', 'when', 'where', 'why', and 'how'. RESULTS A total of 33 patients had a diagnosis of trichotillomania (28 females, 5 males; peak age between 3 and 4 years). Scalp involvement was most common and nail biting was observed in 5 patients. Only 51.5% of patients had parents who noticed their child's hairpulling. Hair on or under the bed was the most common clue suggesting that hairpulling occurred. Triggering factors identified in 16 children included physical appearance, family-related issues, school-related issues, and concurrent illness. The noninvasive hair pull test was negative in all children. There was a high non-follow-up rate, and treatment outcomes varied. CONCLUSION A set of 6 specific questions, based on the '5Ws and 1H' principle, facilitates the gathering of important information on children with unexplained nonscarring hair loss and helps clinicians be cognizant of possible outcomes of trichotillomania. This will be especially useful to clinicians who are not familiar with this elusive condition.
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Affiliation(s)
- Nisha Suyien Chandran
- Division of Dermatology, University Medicine Cluster, National University Hospital, Singapore, Singapore
| | - Jeroen Novak
- PsyQ Psycho-Medical Programs, Programs Psychotrauma, Personality Disorders and Anxiety Disorders, Breda, The Netherlands
| | | | - Ramon Grimalt
- Facultat de Medicina i Ciències de la Salut, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Arnold P Oranje
- Department of Dermatology, Maasstad Hospital Rotterdam and Dermicis Alkmaar, Rotterdam, The Netherlands
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Falkenstein MJ, Rogers K, Malloy EJ, Haaga DAF. Predictors of Relapse Following Treatment of Trichotillomania. J Obsessive Compuls Relat Disord 2014; 3:345-353. [PMID: 25405081 PMCID: PMC4231486 DOI: 10.1016/j.jocrd.2014.09.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study sought to identify predictors of relapse in a behavior therapy trial for trichotillomania (TTM), or hair-pulling disorder. Relapse is common after treatment for TTM, and only a few studies have examined what might predict relapse. METHOD Data was examined from a TTM treatment study with a stepped-care approach (step 1. web-based self-help; step 2. individual behavior therapy) (N = 60). Implications of significant predictive relations were illustrated by constructing Probability of Treatment Benefit (PTB) charts (Lindhiem, Kolko, & Cheng, 2012), which quantify the probability of maintaining gains according to predictors of maintenance. RESULTS Abstinence at the conclusion of treatment and lower TTM severity during initial response significantly predicted maintenance. Abstinence periods prior to treatment, residual urges after achieving abstinence, pre-treatment TTM severity, intrinsic motivation, and treatment compliance did not predict maintenance. CONCLUSIONS Post-treatment abstinence and lower TTM severity during initial response predicted maintenance. Replications of this research are needed to determine the usefulness of these possible predictors in identifying relapse-prone patients, with the aim of improving clinical decision-making and developing strategies to help these patients better maintain gains. This is the first TTM study to use PTB charts, which can help clarify the meaning of prognostic analyses.
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Nelson SO, Rogers K, Rusch N, McDonough L, Malloy EJ, Falkenstein MJ, Banis M, Haaga DAF. Validating indicators of treatment response: application to trichotillomania. Psychol Assess 2014; 26:857-64. [PMID: 24708079 DOI: 10.1037/a0036333] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Different studies of the treatment of trichotillomania (TTM) have used varying standards to determine the proportion of patients who obtain clinically meaningful benefits, but there is little information on the similarity of results yielded by these methods or on their comparative validity. Data from a stepped-care (Step 1: Web-based self-help; Step 2: Individual behavior therapy; N = 60) treatment study of TTM were used to evaluate 7 potential standards: complete abstinence, ≥ 25% symptom reduction, recovery of normal functioning, and clinical significance (recovery + statistically reliable change), each of the last 3 being measured by self-report (Massachusetts General Hospital Hairpulling Scale; MGH-HPS) or interview (Psychiatric Institute Trichotillomania Scale). Depending on the metric, response rates ranged from 25 to 68%. All standards were significantly associated with one another, though less strongly for the 25% symptom reduction metrics. Concurrent (with deciding to enter Step 2 treatment) and predictive (with 3-month follow-up treatment satisfaction, TTM-related impairment, quality of life, and diagnosis) validity results were variable but generally strongest for clinical significance as measured via self-report. Routine reporting of the proportion of patients who make clinically significant improvement on the MGH-HPS, supplemented by data on complete abstinence, would bolster the interpretability of TTM treatment outcome findings.
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Affiliation(s)
| | - Kate Rogers
- Department of Psychology, American University
| | | | | | | | | | - Maria Banis
- Department of Psychology, American University
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Changing automatic behavior through self-monitoring: does overt change also imply implicit change? J Behav Ther Exp Psychiatry 2013; 44:279-84. [PMID: 23388468 DOI: 10.1016/j.jbtep.2012.12.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Revised: 11/08/2012] [Accepted: 12/17/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Self-monitoring of unwanted behavior is a common component of effective cognitive-behavioral therapy. Self-monitoring has often shown to lead to decreases in undesirable behavior. To investigate the underlying mechanisms of these 'reactive effects', we investigated whether behavioral changes as a result of self-monitoring were accompanied by changes in explicit and implicit evaluation. For this purpose, monitoring of snack-eating was compared to monitoring of alcohol-drinking, since reactive effects are found absent in alcohol-drinking. METHODS Implicit evaluations (Affective Priming Task), estimated frequency and satisfaction of consumption (Snacks and Drinks Questionnaire) were assessed before and after a 15-day self-monitoring period. Consumption was measured using self-monitoring forms. Participants were randomly assigned to a group that either monitored snack-eating behavior (experimental group) or to a group that monitored alcohol-drinking behavior (control group). RESULTS After self-monitoring, consumption only decreased in the experimental group, although both groups estimated their snack-eating frequency to be higher after self-monitoring. Explicit satisfaction of the habit remained the same but self-monitoring did result in a slightly more implicit negative evaluation of the monitored substance in both groups. In both groups, participants were less satisfied with their snack-eating behavior than with their alcohol-drinking behavior. CONCLUSIONS Self-monitoring reduced snack-eating but not alcohol-drinking. In both groups, self-monitoring appeared to be accompanied by small implicit, but not explicit changes in evaluation. Changes in evaluation apparently do not lead to actual behavioral change on their own. Other factors are expected to be involved as well, such as dissatisfaction at the start of monitoring.
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Roberts S, O'Connor K, Bélanger C. Emotion regulation and other psychological models for body-focused repetitive behaviors. Clin Psychol Rev 2013; 33:745-62. [DOI: 10.1016/j.cpr.2013.05.004] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 05/08/2013] [Accepted: 05/08/2013] [Indexed: 11/26/2022]
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Welch SS, Kim J. DBT-Enhanced Cognitive Behavioral Therapy for Adolescent Trichotillomania: An Adolescent Case Study. COGNITIVE AND BEHAVIORAL PRACTICE 2012. [DOI: 10.1016/j.cbpra.2011.11.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Keuthen NJ, Sprich SE. Utilizing DBT Skills to Augment Traditional CBT for Trichotillomania: An Adult Case Study. COGNITIVE AND BEHAVIORAL PRACTICE 2012. [DOI: 10.1016/j.cbpra.2011.02.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Franklin ME, Edson AL, Ledley DA, Cahill SP. Behavior therapy for pediatric trichotillomania: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry 2011; 50:763-71. [PMID: 21784296 PMCID: PMC3143367 DOI: 10.1016/j.jaac.2011.05.009] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Revised: 05/19/2011] [Accepted: 05/20/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine the efficacy and durability of a behavioral therapy (BT) protocol for pediatric TTM compared with a minimal attention control (MAC) condition. It was hypothesized that the BT condition would be superior to MAC at the end of acute treatment, and would also demonstrate durability of gains through the maintenance treatment phase. METHOD A randomized controlled trial in which 24 youths were assigned to either a pilot-tested BT protocol, consisting of eight weekly sessions, or to MAC, consisting of three sessions and five telephone calls over 8 weeks. Independent evaluators assessed outcome at pretreatment (week 0) and post-treatment (week 8) for BT and MAC, and again at week 16 for BT patients only. The primary outcome measure was the National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS). RESULTS For the BT condition, the week 8 mean NIMH-TSS score was significantly lower than that of the MAC condition. The BT condition's mean week 8 score was also significantly lower than their own mean week 0 score, whereas no such reductions were observed for the MAC condition. Upon completion of acute treatment at week 8, the BT group's gains were maintained through an 8-week maintenance treatment phase. CONCLUSIONS BT produced a superior outcome compared with a condition that controlled for participation in a pediatric TTM research study, nonspecific therapist contact effects, repeated assessments, and the passage of time. Maintenance of gains after acute BT provides preliminary support for the durability of treatment gains. CLINICAL TRIAL REGISTRATION INFORMATION Cognitive Behavioral Treatment of Pediatric Trichotillomania; http://www.clinicaltrials.gov; R21 MH 61457.
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Affiliation(s)
- Martin E Franklin
- Child/Adolescent OCD, Tics, Trichotillomania and Anxiety Group (COTTAGe), Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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Keuthen NJ, Rothbaum BO, Falkenstein MJ, Meunier S, Timpano KR, Jenike MA, Welch SS. DBT-enhanced habit reversal treatment for trichotillomania: 3-and 6-month follow-up results. Depress Anxiety 2011; 28:310-3. [PMID: 21456040 DOI: 10.1002/da.20778] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2010] [Revised: 11/10/2010] [Accepted: 11/11/2010] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Maintenance of gains with cognitive-behavioral treatment for trichotillomania (TTM) has historically been problematic. METHODS We conducted follow-up assessments 3 and 6 months after completion of a 3-month maintenance phase on 10 individuals with DSM-IV-TR TTM who participated in an open trial of a dialectical behavior therapy (DBT)-enhanced habit reversal treatment (HRT). RESULTS Significant improvement from baseline was reported at 3-and 6-month follow-up on all measures of hair pulling severity and emotion regulation, although some worsening was reported on some measures from earlier study time points. At 6-month follow-up, five and four participants were full and partial responders, respectively. Significant correlations were reported at both follow-up time points between changes in hair pulling severity and emotion regulation capacity. CONCLUSIONS DBT-enhanced HRT offers promise for improved long-term treatment results in TTM. Changes in TTM severity from baseline to 3-and 6-month follow-up is correlated with changes in emotion regulation capacity.
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Affiliation(s)
- Nancy J Keuthen
- Trichotillomania Clinic and Research Unit, Massachusetts General Hospital/Harvard Medical School, 185 Cambridge Street, Boston, MA 02114, USA.
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Schuck K, Keijsers GP, Rinck M. The effects of brief cognitive-behaviour therapy for pathological skin picking: A randomized comparison to wait-list control. Behav Res Ther 2011; 49:11-7. [DOI: 10.1016/j.brat.2010.09.005] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Revised: 09/02/2010] [Accepted: 09/13/2010] [Indexed: 11/16/2022]
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Keuthen NJ, Rothbaum BO, Welch SS, Taylor C, Falkenstein M, Heekin M, Jordan CA, Timpano K, Meunier S, Fama J, Jenike MA. Pilot trial of dialectical behavior therapy-enhanced habit reversal for trichotillomania. Depress Anxiety 2010; 27:953-9. [PMID: 20721929 DOI: 10.1002/da.20732] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Not all hair pullers improve acutely with cognitive-behavioral treatment (CBT) and few maintain their gains over time. METHODS We conducted an open clinical trial of a new treatment that addresses affectively triggered pulling and emphasizes relapse prevention in addition to standard CBT approaches. Ten female participants satisfying DSM-IV criteria for trichotillomania (TTM) at two study sites received Dialectical Behavior Therapy (DBT)-enhanced CBT consisting of 11 weekly sessions and 4 maintenance sessions over the following 3 months. Independent assessors rated hair pulling impairment and global improvement at several study time points. Participants completed self-report measures of hair pulling severity and emotion regulation. RESULTS Significant improvement in hair pulling severity and emotion regulation, as well as hair pulling impairment and anxiety and depressive symptoms, occurred during acute treatment and were maintained during the subsequent 3 months. Significant correlations were reported between changes in emotion regulation and hair pulling severity during both the acute treatment and maintenance phases. CONCLUSIONS This study offers preliminary evidence for the efficacy of DBT-enhanced CBT for TTM and suggests the importance of addressing emotion regulation during TTM treatment.
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Affiliation(s)
- Nancy J Keuthen
- Massachusetts General Hospital/Harvard Medical School, Boston, USA.
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Walther MR, Ricketts EJ, Conelea CA, Woods DW. Recent Advances in the Understanding and Treatment of Trichotillomania. J Cogn Psychother 2010; 24:46-64. [PMID: 26658787 PMCID: PMC4674792 DOI: 10.1891/0889-8391.24.1.46] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Trichotillomania (TTM), or chronic hair pulling, is associated with significant levels of distress and impairment. While research is in its infancy, more data are accumulating regarding the impact, phenomenology, maintaining variables, etiology, and treatment of TTM. Behavior therapy and clomipramine have been moderately effective in reducing TTM symptoms in clinical trials. Enhancing behavior therapy with techniques designed to address TTM patients' emotional control tendencies (e.g., acceptance-based procedures) represents a promising direction in treating TTM.
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van Zeeland YR, Spruit BM, Rodenburg TB, Riedstra B, van Hierden YM, Buitenhuis B, Korte SM, Lumeij JT. Feather damaging behaviour in parrots: A review with consideration of comparative aspects. Appl Anim Behav Sci 2009. [DOI: 10.1016/j.applanim.2009.09.006] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ravindran AV, da Silva TL, Ravindran LN, Richter MA, Rector NA. Obsessive-compulsive spectrum disorders: a review of the evidence-based treatments. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2009; 54:331-43. [PMID: 19497165 DOI: 10.1177/070674370905400507] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To provide a review of the evidence-based treatments for obsessive-compulsive spectrum disorders (OCSD), a group of conditions related to obsessive-compulsive disorder (OCD) by phenomenological and etiological similarities, the morbidity of which is increasingly recognized. METHOD Literature relating to the following disorders: body dysmorphic disorder, hypochondriasis, trichotillomania, onychophagia, psychogenic excoriation, compulsive buying, kleptomania, and pathological gambling, and published between January 1965 and October 2007, was found using PubMed. Included in this review were 107 treatment reports. RESULTS Serotonin reuptake inhibitors (SRIs) have shown benefits as first-line, short-term treatments for body dysmorphic disorder, hypochondriasis, onychophagia, and psychogenic excoriation, with some benefits in trichotillomania, pathological gambling, and compulsive buying. There are also suggested benefits for several atypical antipsychotics in disorders with a high degree of impulsivity, including trichotillomania and pathological gambling, and to a lesser extent, kleptomania and psychogenic excoriation. Cognitive-behavioural interventions have generally shown evidence for use as first-line treatment across the spectrum, with some variability in degree of benefit. CONCLUSIONS As in OCD, several conditions in the proposed OCSD benefit from SRIs and (or) cognitive-behavioural interventions. However, the treatment literature is generally limited, and more randomized controlled trials (RCTs) are needed to evaluate individual and combination treatments, for short-term use and as maintenance.
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Trichotillomania: neurobiology and treatment. Neurosci Biobehav Rev 2009; 33:831-42. [PMID: 19428495 DOI: 10.1016/j.neubiorev.2009.02.002] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2008] [Revised: 02/10/2009] [Accepted: 02/10/2009] [Indexed: 12/13/2022]
Abstract
Trichotillomania is a disorder characterized by repetitive hair pulling, leading to noticeable hair loss and functional impairment. This paper provides an overview of what is known of trichotillomania from several perspectives. We begin by considering historical descriptions of hair pulling that ultimately contributed to the inclusion of trichotillomania as a formal diagnostic entity in the Diagnostic and Statistical Manual. Psychological factors involved in the mediation of symptoms are examined, including positive and negative reinforcement. The relationships between trichotillomania, other body-focused repetitive behaviours, and disorders of the putative obsessive-compulsive (OC) spectrum are surveyed. The review then explores findings from the available controlled treatment trials that utilized psychotherapy, pharmacotherapy, or both. Neural circuitry involved in the manifestation of hair pulling is then identified by considering data from animal models of the condition, along with neurocognitive and neuroimaging results from patients. Finally, we highlight important areas for future neurobiological and treatment research.
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Adewuya EC, Zinser W, Thomas C. Trichotillomania: a case of response to valproic acid. J Child Adolesc Psychopharmacol 2008; 18:533-6. [PMID: 18928419 DOI: 10.1089/cap.2008.076] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Trichotillomania (TTM) is a commonly undiagnosed psychiatric illness with known medical complications whose symptoms interfere markedly with daily functioning. Studies regarding the pharmacological treatment of TTM in the adult or pediatric population are sparse, and there is a lack of consensus on drug treatment for TTM. The current trend is to use selective serotonin reuptake inhibitors (SSRIs) on the basis of the current hypothesis that TTM may be a part of the obsessive compulsive spectrum of disorders. However, attempts to substantiate the efficacy of SSRI use in TTM has produced conflicting results. There is increasing evidence that mood stabilizers decrease symptoms of TTM. We present the case of a 10-year-old girl whose lifelong hair-plucking symptoms showed remarkable sustained improvement in response to increased levels of valproic acid. This report, the first with valproic acid, indicates that this drug is potentially effective in significantly reducing symptoms of TTM in a sustained manner. This single case report calls for further investigation regarding the utility of valproic acid in the treatment of TTM.
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Affiliation(s)
- Edore C. Adewuya
- Division of Child & Adolescent Psychiatry, Department of Psychiatry & Behavioral Sciences, University of Texas Medical Branch at Galveston, Galveston Texas
| | - William Zinser
- Department of Pediatric Neurology, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
| | - Christopher Thomas
- Division of Child & Adolescent Psychiatry, Department of Psychiatry & Behavioral Sciences, University of Texas Medical Branch at Galveston, Galveston Texas
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Abstract
Trichotillomania (TTM) is a common psychiatric illness with marked chronicity and comorbidity that significantly impacts on psychosocial functioning and physical features of the sufferer. Treatment studies, to date, using behavioral and pharmacological interventions alone or simultaneously, are equivocal with few showing a sustained cessation of hair-plucking. In this report of a single patient with treatment resistant TTM, the sole use of the atypical neuroleptic Aripiprazole resulted in a cessation of hair-plucking maintained, at the time of reporting, for a period of 24 months. This finding, a first with Aripiprazole, warrants further investigation of this drug in the treatment of TTM.
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Affiliation(s)
- Don Jefferys
- School of Psychology, Deakin University, Burwood, Victoria, Australia.
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Mouton-Odum S, Keuthen NJ, Wagener PD, Stanley MA. StopPulling.com: An Interactive, Self-Help Program for Trichotillomania. COGNITIVE AND BEHAVIORAL PRACTICE 2006. [DOI: 10.1016/j.cbpra.2005.05.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
PURPOSE OF REVIEW Factitial skin diseases are characterized by unusual patterns of skin lesions that do not conform to any known dermatologic condition and that are consciously or subconsciously fabricated by the patient. This review summarizes the current literature regarding the diagnosis and management of factitial dermatoses in children. RECENT FINDINGS Neurotic excoriations, acne excoriee and trichotillomania are the most common factitial skin diseases seen in children. Dermatitis artefacta is also seen in children, but is less common. In many cases, the development of factitial skin disease is associated with a comorbid psychiatric condition or identifiable psychosocial stressor. With regard to the management of factitial dermatoses in children, it is of paramount importance for the clinician to establish an appropriate physician-patient-family relationship. Although controlled studies in children are lacking, pharmacologic and/or nonpharmacologic adjunctive therapy can be helpful in the treatment of these difficult conditions. SUMMARY The diagnosis and management of factitial skin diseases in children is a challenge. Clinicians caring for children should be able to recognize the common factitial dermatoses that are seen in the pediatric population. The conveyance of support and acceptance by the physician is essential to the treatment process. Both psychotherapy and psychopharmacology can be important adjunctive treatments.
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Affiliation(s)
- Kara N Shah
- Section of Pediatric Dermatology, Children's Hospital of Philadelphia, PA 19104, USA.
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