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Ricketts EJ, Peris TS, Grant JE, Valle S, Cavic E, Lerner JE, Lochner C, Stein DJ, Dougherty DD, O'Neill J, Woods DW, Keuthen NJ, Piacentini J. Clinical Characteristics of Youth with Trichotillomania (Hair-Pulling Disorder) and Excoriation (Skin-Picking) Disorder. Child Psychiatry Hum Dev 2024; 55:975-986. [PMID: 36315372 DOI: 10.1007/s10578-022-01458-w] [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: 04/15/2022] [Revised: 10/02/2022] [Accepted: 10/08/2022] [Indexed: 11/24/2022]
Abstract
Body-focused repetitive disorders (BFRBDs) are understudied in youth and understanding of their underlying mechanisms is limited. This study evaluated BFRBD clinical characteristics, and two factors commonly implicated in their maintenance - emotion regulation and impulsivity - in 53 youth aged 11 to 17 years: 33 with BFRBDs and 20 controls. Evaluators administered psychiatric diagnostic interviews. Participants rated BFRBD severity, negative affect, quality of life, family functioning, emotion regulation, distress tolerance, and impulsivity. Youth with BFRBDs showed poorer distress tolerance and quality of life, and higher impulsivity and negative affect than controls, with no differences in family impairment. BFRBD distress/impairment, but not BFRBD severity, correlated with anxiety and depression, and poorer distress tolerance. Findings suggest youth with BFRBDs show clinical patterns aligning with prior research; highlight the role of distress tolerance in child BFRBDs; and suggest the utility of acceptance and mindfulness-based therapies for unpleasant emotions in BFRBDs. Continued research should evaluate factors underlying BFRBDs in youth.
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Affiliation(s)
- Emily J Ricketts
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA.
| | - Tara S Peris
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jon E Grant
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
| | - Stephanie Valle
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
| | - Elizabeth Cavic
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
| | - Juliette E Lerner
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
| | - Christine Lochner
- SA MRC Unit on Risk & Resilience in Mental Disorders, Department of Psychiatry, University of Stellenbosch, Stellenbosch, South Africa
| | - Dan J Stein
- SA MRC Unit on Risk & Resilience in Mental Disorders, Department of Psychiatry and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Darin D Dougherty
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph O'Neill
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
| | - Douglas W Woods
- Department of Psychology, Marquette University, Milwaukee, WI, USA
| | - Nancy J Keuthen
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - John Piacentini
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
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Taylor Browne Lūka C, Hendry K, Dutriaux L, Stevenson JL, Barsalou LW. Developing and Evaluating a Situated Assessment Instrument for Trichotillomania: The SAM 2 TAI. Assessment 2024:10731911241262140. [PMID: 39066613 DOI: 10.1177/10731911241262140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Abstract
Measuring trichotillomania is essential for understanding and treating it effectively. Using the Situated Assessment Method (SAM2), we developed a psychometric instrument to assess hair pulling in situations where it occurs. In two studies, pullers evaluated their pulling in relevant situations, along with how much they experience factors that potentially influence it (e.g., external triggers, reduction in negative emotion, negative self-thoughts). Individual measures of pulling, averaged across situations, exhibited high test reliability, construct validity, and content validity. Large differences between situations in pulling were observed, along with large individual-situation interactions (with limited evidence distinguishing focused versus automatic pulling subtypes). In linear regressions for individual participants, factors that influence pulling tended to correlate with pulling as predicted, explaining a median 74%-83% of its variance. By identifying factors that predict pulling for each individual across situations, the SAM2 Trichotillomania Assessment Instrument (TAI) offers a rich understanding of an individual's pulling experience, potentially supporting individualized pulling interventions.
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3
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Gallinat C, Moessner M, Wilhelm M, Keuthen N, Bauer S. Patterns of Skin Picking in Skin Picking Disorder: Ecological Momentary Assessment Study. Interact J Med Res 2024; 13:e53831. [PMID: 39024568 PMCID: PMC11294777 DOI: 10.2196/53831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/12/2023] [Accepted: 05/03/2024] [Indexed: 07/20/2024] Open
Abstract
BACKGROUND Skin picking disorder (SPD) is an understudied mental illness that is classified as a body-focused repetitive behavior disorder. Literature suggests that pathological skin picking is strongly integrated into the daily lives of affected individuals and may involve a high degree of variability in terms of episode characteristics, frequency, and intensity. However, existing data on the phenomenology of SPD are limited and typically involve retrospective assessments, which may fail to accurately capture the behavior's variability. OBJECTIVE This study aimed to investigate skin picking in the daily lives of individuals with SPD by using ecological momentary assessment (EMA). The first aim focused on the description of skin picking patterns (eg, characteristics, intensity, and distribution of episodes and urges), and the second aim explored differences in characteristics and patterns between automatic and focused skin picking. METHODS Participants were recruited online and underwent a web-based screening, a diagnostic telephone interview, and a comprehensive online self-report questionnaire before participating in an EMA protocol. The latter included 10 consecutive days with 7 pseudorandom, time-contingent assessments per day between 8 AM and 10 PM. The EMA questionnaire assessed the current skin picking urge, the occurrence of the behavior, and a detailed assessment of the episodes' characteristics (eg, length, intensity, and consciousness) if applicable. RESULTS The final sample consisted of 57 participants, who completed at least 70% of the scheduled assessments (n=54, 94.7% female: mean age 29.3, SD 6.77 years). They completed 3758 EMAs and reported 1467 skin picking episodes. Skin picking occurred frequently (mean 2.57, SD 1.12 episodes per day and person) in relatively short episodes (10-30 min; 10 min: nepisodes=642, 43.8%; 20 min: nepisodes=312, 21.3%; 30 min: nepisodes=217, 14.8%), and it was distributed quite evenly throughout the day and across different days of the week. Focused and automatic episodes were relatively balanced across all reported episodes (focused: nepisodes=806, 54.9%) and over the course of the day. The analyses showed statistically significant differences between self-reported triggers for the different styles. Visual or tactile cues and the desire to pick the skin were more important for the focused style (visual or tactile cues: mean focused style [Mf]=4.01, SD 0.69 vs mean automatic style [Ma]=3.47, SD 0.99; P<.001; SMD=0.64; desire to pick: Mf=2.61, SD 1.06 vs Ma=1.94, SD 1.03; P<.001; SMD=0.82), while boredom and concentration problems were more prominent in automatic skin picking (boredom: Mf=1.69, SD 0.89 vs Ma=1.84, SD 0.89; P=.03; SMD=-0.31; concentration problems: Mf=2.06, SD 0.87 vs Ma=2.31, SD 1.06; P=.006; SMD=-0.41). CONCLUSIONS These results contribute to an enhanced understanding of the phenomenology of SPD using a more rigorous assessment methodology. Our findings underscore that picking can impact affected persons multiple times throughout their daily lives. TRIAL REGISTRATION German Clinical Trials Register DRKS00025168; https://tinyurl.com/mr35pdwh.
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Affiliation(s)
- Christina Gallinat
- Center for Psychotherapy Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus Moessner
- Center for Psychotherapy Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Maximilian Wilhelm
- Center for Psychotherapy Research, University Hospital Heidelberg, Heidelberg, Germany
- German Center for Mental Health (DZPG), partner site Mannheim-Heidelberg-Ulm, Heidelberg, Germany
| | - Nancy Keuthen
- Trichotillomania and Excoriation Disorder Program, Center for OCD and Related Disorders, Massachusetts General Hospital, Boston, MA, United States
| | - Stephanie Bauer
- Center for Psychotherapy Research, University Hospital Heidelberg, Heidelberg, Germany
- German Center for Mental Health (DZPG), partner site Mannheim-Heidelberg-Ulm, Heidelberg, Germany
- Heidelberg University, Heidelberg, Germany
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Ali A, Ioannidis K, Grant JE, Chamberlain SR. Cognition in trichotillomania: a meta-analysis. CNS Spectr 2024; 29:158-165. [PMID: 38477170 DOI: 10.1017/s1092852924000129] [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: 03/14/2024]
Abstract
OBJECTIVE Trichotillomania (TTM) is a mental health disorder characterized by repetitive urges to pull out one's hair. Cognitive deficits have been reported in people with TTM compared to controls; however, the current literature is sparse and inconclusive about affected domains. We aimed to synthesize research on cognitive functioning in TTM and investigate which cognitive domains are impaired. METHODS After preregistration on the International Prospective Register of Systematic Reviews (PROSPERO), we conducted a comprehensive literature search for papers examining cognition in people with TTM versus controls using validated tests. A total of 793 papers were screened using preestablished inclusion/exclusion criteria, yielding 15 eligible studies. Random-effects meta-analysis was conducted for 12 cognitive domains. RESULTS Meta-analysis demonstrated significant deficits in motor inhibition and extradimensional (ED) shifting in people with TTM versus controls as measured by the stop-signal task (SST) (Hedge's g = 0.45, [CI: 0.14, 0.75], p = .004) and ED set-shift task (g = 0.38, [CI: 0.13, 0.62], p = .003), respectively. There were no significant between-group differences in the other cognitive domains tested: verbal learning, intradimensional (ID) shifting, road map spatial ability, pattern recognition, nonverbal memory, executive planning, spatial span length, Stroop inhibition, Wisconsin card sorting, and visuospatial functioning. Findings were not significantly moderated by study quality scores. CONCLUSIONS Motor inhibition and ED set-shifting appear impaired in TTM. However, a cautious interpretation of results is necessary as samples were relatively small and frequently included comorbidities. Treatment interventions seeking to improve inhibitory control and cognitive flexibility merit exploration for TTM.
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Affiliation(s)
- Aliza Ali
- University of Southampton Faculty of Medicine, Southampton, UK
| | - Konstantinos Ioannidis
- Department of Psychiatry, University of Southampton, Southampton, UK
- Southern Health NHS Foundation Trust, Southampton, UK
| | - Jon E Grant
- Department of Psychiatry, University of Chicago, USA
| | - Samuel R Chamberlain
- Department of Psychiatry, University of Southampton, Southampton, UK
- Southern Health NHS Foundation Trust, Southampton, UK
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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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Grant JE, Valle S, Aslan I, Chesivoir EK, Chamberlain SR. Temperament in trichotillomania and skin picking disorder. Ann Clin Psychiatry 2023; 35:87-92. [PMID: 37074974 PMCID: PMC7614459 DOI: 10.12788/acp.0096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
BACKGROUND Trichotillomania (TTM) and skin picking disorder (SPD) result in significant psychosocial burden. Despite this burden, however, risk factors related to the development of these disorders remain unclear. The present study assessed temperament in a well-characterized sample of adults with TTM or SPD. METHODS A total of 202 adults age 18 to 65 were enrolled; 44 had TTM, 30 had SPD, and 128 served as controls. Participants completed the self-report Tridimensional Personality Questionnaire (TPQ) to examine the severity of TTM and SPD symptoms, quality of life, and temperament. Group differences were characterized and correlations with other measures were examined. RESULTS Compared to controls, those with TTM or SPD scored significantly higher on harm avoidance and its subscales, with TTM associated with higher scores than SPD. Those with TTM or SPD scored significantly higher on only 1 measure of novelty seeking (extravagance). Higher TPQ harm avoidance correlated with worse hair pulling severity and worse quality of life. CONCLUSIONS The temperament traits of participants with TTM or SPD differed in significant ways from controls; those with TTM or SPD generally demonstrated similar trait profiles. A dimensional approach to the personalities of those with TTM or SPD may offer insight and provide clues to treatment strategies.
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Affiliation(s)
- Jon E Grant
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Stephanie Valle
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Ibrahim Aslan
- Department of Psychiatry, Southampton University, Southampton, UK
| | - Eve K Chesivoir
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
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7
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Öğüt Ç, Öğüt ND. Impulsivity in patients with acne excoriee. J Cosmet Dermatol 2023; 22:1099-1104. [PMID: 36409553 DOI: 10.1111/jocd.15535] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/22/2022] [Accepted: 11/13/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Impulsivity is the tendency to make decisions and act quickly without adequate planning and anticipating risks. Impulsivity is among the core symptoms of many psychiatric disorders. In addition, impulsivity can affect the course of various diseases shaped by behaviors. AIMS This study aimed to evaluate the relationship between the presence of acne excoriee and different impulsivity dimensions. STUDY DESIGN A case-control study. METHODS Thirty patients with acne excoriee (AE+) and 30 acne vulgaris patients without excoriated lesions (AE-) enrolled in this study. Impulsivity was evaluated by The Barratt Impulsivity Scale (BIS). In addition, The Beck Anxiety Inventory, The Beck Depression Inventory, and The Skin Picking Scale were applied to assess the clinical characteristics of the participants. RESULTS AE+ patients had higher non-planning subscale scores of BIS than AE- patients in this study. In addition, the acne-picking severity score determined by The Skin Picking Scale was positively correlated with non-planning subscale scores of BIS. There was no significant difference between the groups regarding the Beck Depression Inventory and Beck Anxiety Inventory. CONCLUSIONS These results indicate that AE patients have a lack of forethought. In other words, it has been shown that impulsive personality traits, which indicate a lack of planning for the future, may be associated with the acne-picking behavior of the patients.
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Affiliation(s)
- Çağrı Öğüt
- Department of Psychiatry, Uşak University Faculty of Medicine, Uşak, Turkey
| | - Neslihan Demirel Öğüt
- Department of Dermatology and Venereology, Uşak University Faculty of Medicine, Uşak, Turkey
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8
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Neurobiology of subtypes of trichotillomania and skin picking disorder. CNS Spectr 2023; 28:98-103. [PMID: 34730081 PMCID: PMC7614223 DOI: 10.1017/s109285292100095x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Trichotillomania (TTM) and skin picking disorder (SPD) are common and often debilitating mental health conditions, grouped under the umbrella term of body-focused repetitive behaviors (BFRBs). Recent clinical subtyping found that there were three distinct subtypes of TTM and two of SPD. Whether these clinical subtypes map on to any unique neurobiological underpinnings, however, remains unknown. METHODS Two hundred and fifty one adults [193 with a BFRB (85.5% [n = 165] female) and 58 healthy controls (77.6% [n = 45] female)] were recruited from the community for a multicenter between-group comparison using structural neuroimaging. Differences in whole brain structure were compared across the subtypes of BFRBs, controlling for age, sex, scanning site, and intracranial volume. RESULTS When the subtypes of TTM were compared, low awareness hair pullers demonstrated increased cortical volume in the lateral occipital lobe relative to controls and sensory sensitive pullers. In addition, impulsive/perfectionist hair pullers showed relative decreased volume near the lingual gyrus of the inferior occipital-parietal lobe compared with controls. CONCLUSIONS These data indicate that the anatomical substrates of particular forms of BFRBs are dissociable, which may have implications for understanding clinical presentations and treatment response.
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9
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Prevalence and Correlates of Hair Pulling Disorder and Skin Picking Disorder in an Acute Psychiatric Sample. J Nerv Ment Dis 2023; 211:163-167. [PMID: 36716064 DOI: 10.1097/nmd.0000000000001593] [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: 01/31/2023]
Abstract
Hair pulling disorder (HPD; trichotillomania) and skin picking disorder (SPD; excoriation disorder) are understudied psychiatric disorders. The aim of this study was to examine the prevalence and correlates of HPD and SPD in an acute psychiatric sample. Semistructured interviews and self-report measures were administered to patients in a psychiatric partial hospital (N = 599). The past-month prevalence of HPD and SPD was 2.3% and 9%, respectively. HPD and SPD had highly similar clinical characteristics and a strong co-occurrence. Patients with HPD/SPD were significantly younger than other patients and more likely to be female. Logistic regression controlling for age and sex showed that diagnosis of HPD/SPD was not significantly associated with suicidal ideation, suicidal behaviors, nonsuicidal self-injury, or emotional disorder diagnoses (e.g., borderline personality disorder, major depressive disorder). HPD/SPD status was significantly associated with an increased risk of generalized anxiety disorder. However, patients with HPD/SPD did not differ from other patients on self-report measures of generalized anxiety, depression, and distress intolerance. HPD and SPD are common and frequently co-occurring disorders in psychiatric settings.
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10
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Spitzer C, Lübke L, Müller S, Conrad R, Gallinat C. State and trait dissociation in pathological skin picking. EUROPEAN JOURNAL OF TRAUMA & DISSOCIATION 2023. [DOI: 10.1016/j.ejtd.2023.100317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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11
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Öğüt Ç, Öğüt ND. Trichotillomania, Skin Picking Disorder, and Different Aspects of Impulsivity: A Systematic Review. Psychiatr Ann 2022. [DOI: 10.3928/00485713-20221220-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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12
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Zhang J, Grant JE. Significance of family history in understanding and subtyping trichotillomania. Compr Psychiatry 2022; 119:152349. [PMID: 36215772 DOI: 10.1016/j.comppsych.2022.152349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 09/28/2022] [Accepted: 09/30/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND AIMS The existence of subtypes of trichotillomania (TTM) have long been hypothesized, and recent studies have further elucidated characteristic subtypes of TTM and possible ramifications of subtyping for treatment. In clinical applications of subtyping for treatment of TTM, family history (FH) of psychiatric disorders in patients may serve as a tool to differentiate disorder presentations and inform care. We compared prevalence of psychiatric illnesses in first-degree relatives of participants with TTM and healthy controls, respectively, in a large sample, and examined associations between those psychiatric disorders that were significantly different in the FH between groups and measures of disability, severity, and neuropsychological constructs. METHODS We compared FHs of 152 participants (mean age = 29.9) with TTM and 71 healthy controls (mean age = 29.6), utilizing chi-squared tests to determine which psychiatric illnesses were more prevalent in FHs of participants with TTM. We then used two-tailed t-tests to compare TTM participants with those more prevalent FHs to participants without those FHs on measures of disorder severity, disability, and neuropsychological constructs. FINDINGS Obsessive-compulsive disorder (OCD), TTM, skin picking disorder (SPD), and major depressive disorder (MDD) were significantly more frequent in first-degree relatives (p < 0.0033) of TTM participants than those of healthy controls. TTM participants with a FH of OCD scored significantly higher on measures of impulsivity and lower on measures of distress tolerance. Those with FH of TTM, SPD, and MDD did not differ significantly across measured variables. CONCLUSION OCD, TTM, SPD, and MDD are more prevalent in the FHs of people with TTM, as compared to healthy controls. TTM participants with a family history of OCD may be more likely to demonstrate decreased distress tolerance and increased impulsivity. In all, as understanding of TTM subtypes develops, the FH may prove a useful tool in delineating subtypes and informing care.
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Affiliation(s)
- James Zhang
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Jon E Grant
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA.
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13
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Woods DW, Ely LJ, Bauer CC, Twohig MP, Saunders SM, Compton SN, Espil FM, Neal-Barnett A, Alexander JR, Walther MR, Cahill SP, Deckersbach T, Franklin ME. Acceptance-enhanced behavior therapy for trichotillomania in adults: A randomized clinical trial. Behav Res Ther 2022; 158:104187. [PMID: 36099688 PMCID: PMC9561035 DOI: 10.1016/j.brat.2022.104187] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/12/2022] [Accepted: 09/01/2022] [Indexed: 11/21/2022]
Abstract
Given the limited treatment options for trichotillomania (TTM), or Hair Pulling Disorder, this large randomized clinical trial evaluated the efficacy of acceptance-enhanced behavior therapy for TTM (AEBT-TTM) in reducing TTM severity relative to psychoeducation and supportive therapy (PST). Eighty-five adults (78 women) with TTM received 10 sessions (over 12 weeks) of either AEBT-TTM or PST. Independent evaluators masked to treatment assignment assessed participants at baseline (week 0), midpoint (week 6), and endpoint (week 12). Consistent with a priori hypotheses, 64% of the adults treated with AEBT-TTM were classified as clinical responders at post-treatment relative to 38% treated with PST. Clinical responders were identified by a score of 1 or 2 on the Clinical Global Impressions-Improvement (CGI-I) scale. Relative to the PST group, the AEBT-TTM group demonstrated significantly greater pre-to post-treatment reductions on the self-report Massachusetts General Hospital-Hairpulling Scale (MGH-HS) and the evaluator-rated National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS). There were no significant post-treatment group differences on the Clinical Global Impressions-Severity (CGI-S) scale, or rate of TTM diagnoses. Results suggest AEBT-TTM provides greater treatment benefit than PST. Future research should continue to investigate AEBT-TTM along with mediators and moderators of its efficacy.
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Affiliation(s)
- Douglas W Woods
- Marquette University, Department of Psychology, Cramer Hall, Room 317, 604 N. 16th St., Milwaukee, WI, 53233, USA; University of Wisconsin-Milwaukee, Department of Psychology, Garland Hall, Room 224, 2441 E. Hartford Ave., Milwaukee, WI, 53211, USA.
| | - Laura J Ely
- University of Wisconsin-Milwaukee, Department of Psychology, Garland Hall, Room 224, 2441 E. Hartford Ave., Milwaukee, WI, 53211, USA.
| | - Christopher C Bauer
- Marquette University, Department of Psychology, Cramer Hall, Room 317, 604 N. 16th St., Milwaukee, WI, 53233, USA; University of Wisconsin-Milwaukee, Department of Psychology, Garland Hall, Room 224, 2441 E. Hartford Ave., Milwaukee, WI, 53211, USA.
| | - Michael P Twohig
- State University, Department of Psychology, 2810 Old Main Hill, Logan, UT, 84322, USA.
| | - Stephen M Saunders
- Marquette University, Department of Psychology, Cramer Hall, Room 317, 604 N. 16th St., Milwaukee, WI, 53233, USA.
| | - Scott N Compton
- Duke University School of Medicine, Department of Psychiatry & Behavioral Sciences, 2608 Erwin Rd, Suite 300, Durham, NC, 27705, USA.
| | - Flint M Espil
- University of Wisconsin-Milwaukee, Department of Psychology, Garland Hall, Room 224, 2441 E. Hartford Ave., Milwaukee, WI, 53211, USA.
| | - Angela Neal-Barnett
- Kent State University, Department of Psychology, 144 Kent Hall, Kent State University, Kent, OH, 44242-0001, USA.
| | - Jennifer R Alexander
- Marquette University, Department of Psychology, Cramer Hall, Room 317, 604 N. 16th St., Milwaukee, WI, 53233, USA.
| | - Michael R Walther
- University of Wisconsin-Milwaukee, Department of Psychology, Garland Hall, Room 224, 2441 E. Hartford Ave., Milwaukee, WI, 53211, USA.
| | - Shawn P Cahill
- University of Wisconsin-Milwaukee, Department of Psychology, Garland Hall, Room 224, 2441 E. Hartford Ave., Milwaukee, WI, 53211, USA.
| | | | - Martin E Franklin
- Rogers Behavioral Health, 1 Winding Drive, Suite 106, Philadelphia, PA, 19131, USA.
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14
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Abstract
BACKGROUND Skin picking disorder and trichotillomania, also characterized as body-focused repetitive behaviors (BFRBs), often lead to functional impairment. Some people with BFRBs, however, report little if any psychosocial dysfunction. There has been limited research as to which clinical aspects of BFRBs are associated with varying degrees of functional impairment. METHODS Adults (n = 98), ages 18 to 65 with a current diagnosis of trichotillomania (n = 37), skin picking disorder (n = 32), trichotillomania plus skin picking disorder (n = 10), and controls (n = 19) were enrolled. Partial least squares regression (PLS) was used to identify variables associated with impairment on the Sheehan Disability Scale. RESULTS PLS identified an optimal model accounting for 45.8% of variation in disability. Disability was significantly related to (in order of descending coefficient size): severity of picking, perceived stress, comorbid disorders (specifically, anxiety disorders / obsessive-compulsive disorder), trait impulsivity, family history of alcohol use disorder, atypical pulling/picking sites, and older age. CONCLUSIONS At present mental disorders are viewed as unitary entities; however, the extent of impairment varies markedly across patients with BFRBs. These data suggest that whereas symptom nature/severity is important in determining impairment, so too are other variables commonly unmeasured in clinical practice. Outcomes for patients may thus be maximized by rigorously addressing comorbid disorders; as well as integrating components designed to enhance top-down control and stress management. Interestingly, focused picking and emotional pulling were linked to worse disability, hinting at some differences between the two types of BFRBs, in terms of determinants of impairment.
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15
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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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Xavier ACM, Prati C, Brandão MG, Ebert AB, Macedo MJDA, Fernandes MJB, Manfro GG, Dreher CB. Comorbidity of psychiatric and dermatologic disorders with skin picking disorder and validation of the Skin Picking Scale Revised for Brazilian Portuguese. REVISTA BRASILEIRA DE PSIQUIATRIA (SAO PAULO, BRAZIL : 1999) 2022; 44:621-627. [PMID: 36683012 PMCID: PMC9851763 DOI: 10.47626/1516-4446-2021-2400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 03/28/2022] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Skin picking disorder (SPD) affects up to 5.4% of the population. Less than half of patients are correctly diagnosed and treated. Developing tools to recognize SPD can help professionals and patients alike. This trial aimed to validate the Skin Picking Scale-Revised (SPS-R) for the Brazilian population and assess the psychiatric and dermatological comorbidities of patients with SPD. METHODS Brazilians with a primary diagnosis of SPD, 18 years or older, were recruited from a community sample by media advertising and evaluated by a dermatologist and a psychiatrist. Self-report instruments were used: SPS-R, Dermatology Life Quality Index (DLQI), General Anxiety Disorder-7 (GAD-7), and Patient Health Questionnaire-9 (PHQ-9). Confirmatory factor analysis (CFA) was performed to evaluate the SPS-R, and Pearson correlation (r) was used to assess the relationship between instruments. RESULTS Overall, 124 patients were included. The SPS-R demonstrated good internal consistency (Cronbach's coefficient = 0.84). CFA found a good fit to the model according to all indices (?2 = 29.67; degrees of freedom [df] = 19; p = 0.056; root mean square error of approximation [RMSEA] = 0.067; comparative fit index [CFI] = 0.969; non-normed fit index [NNFI] = 0.954). SPS-R correlated with DLQI (r = 0.73), GAD-7 (r = 0.51), and PHQ-9 (r = 0.43). The sample had a high prevalence of psychiatric disorders, mainly generalized anxiety disorder (62.1%) and current (32.3%) and past (37.1%) depressive episodes. CONCLUSION The Brazilian version of the SPS-R presents good psychometric properties. The severity of SPD is related to severity of depression, anxiety, and impairment in quality of life.
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Affiliation(s)
- Alice Castro Menezes Xavier
- Programa de Pós-Graduação em Psiquiatria e Ciências do Comportamento, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil,Correspondence: Alice Castro Menezes Xavier, Programa de Pós-Graduação em Psiquiatria e Ciências do Comportamento, Universidade Federal do Rio Grande do Sul (UFRGS), Rua Antônio Carlos Berta, 574/603, CEP 91340-020 Porto Alegre, RS, Brazil. E-mail:
| | - Clarissa Prati
- Programa de Pós-Graduação em Psiquiatria e Ciências do Comportamento, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | | | - Alice Barbieri Ebert
- Faculdade de Medicina, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil
| | - Malu Joyce de Amorim Macedo
- Programa de Pós-Graduação em Psiquiatria e Ciências do Comportamento, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | | | - Gisele Gus Manfro
- Programa de Pós-Graduação em Psiquiatria e Ciências do Comportamento, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil,Hospital de Clínicas de Porto Alegre (HCPA), Departamento de Psiquiatria e Medicina Legal, Faculdade de Medicina, UFRGS, Porto Alegre, RS, Brazil
| | - Carolina Blaya Dreher
- Programa de Pós-Graduação em Psiquiatria e Ciências do Comportamento, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil,Hospital de Clínicas de Porto Alegre (HCPA), Departamento de Psiquiatria e Medicina Legal, Faculdade de Medicina, UFRGS, Porto Alegre, RS, Brazil,Departamento de Clínica Médica, Psiquiatria, Faculdade de Medicina, UFCSPA, Porto Alegre, RS, Brazil
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Tetrahydrocannabinol fails to reduce hair pulling or skin picking: results of a double-blind, placebo-controlled study of dronabinol. Int Clin Psychopharmacol 2022; 37:14-20. [PMID: 34825898 DOI: 10.1097/yic.0000000000000382] [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: 11/25/2022]
Abstract
Body-focused repetitive behaviors (BFRBs) such as trichotillomania and skin picking disorder are associated with decreased self-esteem and poor quality of life. The objective of this study was to evaluate dronabinol, a cannabinoid agonist, for the reduction of BFRB symptoms. Fifty adults with either trichotillomania (n = 34) or skin picking disorder (n = 16) were recruited for a randomized, double-blind, placebo-controlled study. Participants received 10-week treatment with dronabinol (5-15 mg/day) or placebo. The primary efficacy outcome measure was the change on the clinician-rated National Institute of Mental Health scale for hair pulling or skin picking. Both dronabinol and placebo treatment were associated with significant reductions in BFRB symptoms. Dronabinol did not significantly separate from placebo on any efficacy measure. At week 10, 67% of the treatment group were classified as responders (Clinical Global Impressions-Improvement Score of very much or much improved) compared to 50% in the placebo group (P value = 0.459). This study assessed the efficacy of dronabinol, a synthetic form of tetrahydrocannabinol, in the treatment of BFRBs, and found no differences in symptom reductions between dronabinol and placebo.
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Grant JE, Chamberlain SR. Automatic and focused hair pulling in trichotillomania: Valid and useful subtypes? Psychiatry Res 2021; 306:114269. [PMID: 34758405 PMCID: PMC7612152 DOI: 10.1016/j.psychres.2021.114269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 10/25/2021] [Accepted: 10/31/2021] [Indexed: 11/25/2022]
Abstract
Prior work suggested that trichotillomania may have four subtypes based on the extent to which pulling is automatic or focused in nature. 238 adults with trichotillomania undertook clinical and cognitive assessments and were assigned into four subtypes based on k-means clustering of Milwaukee Inventory for Subtypes of Trichotillomania-Adult Version (MIST-A) scores. We examined whether a cluster solution was apparent using conventional metrics. Based on prior literature, we then force-fitted a four subtype model (low-low, low-high, high-low, high-high). Subtypes were compared and validity of the MIST-A subtyping approach was evaluated. A cluster solution did not converge based on conventional metrics. Following force-fitting, subtypes did not differ on demographic variables, age at symptom onset, nor duration of illness. The high-focused high-automatic subtype had worse symptom severity than other subtypes. Co-morbid depression was more common in the low-focused low-automatic and high-focused low-automatic subtypes. This study suggests that MIST-A subtypes may not be valid or clinically useful based on several issues. First, k-means models indicated that the MIST-A data did not generate any cluster solutions. Second, when a forced cluster solution was fitted, the subtypes did not differ on the vast majority of measures. Third, force-fitting four subtypes yielded findings that were logically inconsistent (e.g. worse quality of life in one group, but higher rates of comorbid anxiety/depression in others). Overall, we suggest that both focused and automatic pulling may characterize the same pulling episode, or certainly the same person across episodes. Thus they may be clinically relevant variables, but not forming coherent subtypes.
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Affiliation(s)
- Jon E. Grant
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL USA,Correspondence: Jon E. Grant, JD, MD, MPH, Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Pritzker School of Medicine, 5841 S. Maryland Avenue, MC-3077, Chicago, IL 60637 USA,
| | - Samuel R. Chamberlain
- Department of Psychiatry, Faculty of Medicine, University of Southampton, Southampton, UK; and Southern Health NHS Foundation Trust, Southampton, UK
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Grant JE, Valle S, Aslan IH, Chamberlain SR. Clinical presentation of body-focused repetitive behaviors in minority ethnic groups. Compr Psychiatry 2021; 111:152272. [PMID: 34560370 PMCID: PMC7611816 DOI: 10.1016/j.comppsych.2021.152272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 08/28/2021] [Accepted: 09/10/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Body-focused repetitive behaviors (BFRBs), such as trichotillomania and skin picking disorder, are psychiatric disorders characterized by repetitive grooming that result in hair loss or excoriations. Questions remain as to whether there are racial/ethnic differences in the clinical presentation of BFRBs. METHODS We recruited 539 adults with DSM-5 trichotillomania or skin picking disorder. Of these, 76 (14.1%) self-identified as Black, Asian, or Minority Ethnic (BAME), while 463 (85.9%) self-identified as white Caucasian (hereafter referred to as non-BAME). BAME and non-BAME participants were compared on demographics, symptom severity, comorbid conditions and psychosocial impairment. RESULTS Groups did not differ in terms of age, sex, or education levels. BAME individuals reported significantly more time spent picking or hair pulling per day compared to non-BAME individuals, and were less likely to have received treatment for their BFRB symptoms. Some differences were also found with respect to where on the body people pull and pick from. DISCUSSION In general, the clinical profiles of BFRBs appeared similar between those from BAME versus non-BAME backgrounds. However, differences were found in terms of treatments received and an aspect of symptom severity. The findings highlight the need to better understand the heterogeneity of BFRBs including potential health inequalities.
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Affiliation(s)
- Jon E. Grant
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA,Corresponding author at: Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Pritzker School of Medicine, 5841 S. Maryland Avenue, MC-3077, Chicago, IL 60637, USA.
| | - Stephanie Valle
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
| | - Ibrahim H. Aslan
- Department of Psychiatry, Faculty of Medicine, University of Southampton, Southampton, UK,Southern Health NHS Foundation Trust, Southampton, UK
| | - Samuel R. Chamberlain
- Department of Psychiatry, Faculty of Medicine, University of Southampton, Southampton, UK,Southern Health NHS Foundation Trust, Southampton, UK
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Grant JE, Chamberlain SR. Trichotillomania and Skin-Picking Disorder: An Update. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2021; 19:405-412. [PMID: 35747295 DOI: 10.1176/appi.focus.20210013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Trichotillomania (hair pulling disorder) and skin-picking (excoriation) disorder are common neuropsychiatric disorders (each with a point prevalence of around 2%) but are underrecognized by professionals. Affected individuals repeatedly pull out their own hair or pick at their skin, and these symptoms not only have a negative impact on these individuals because of the time they occupy but can also lead to considerable physical disfigurement, with concomitant loss of self-esteem and avoidance of social activities and intimate relationships. The behaviors may also have serious physical consequences. Trichotillomania and skin picking frequently co-occur, and both disorders commonly present with co-occurring depression, anxiety, impulsive, and obsessive-compulsive disorders. Behavioral therapy currently appears to be the most effective treatment for both. Pharmacotherapy, in the form of N-acetylcysteine or olanzapine, may also play a role in treatment.
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Affiliation(s)
- Jon E Grant
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (Grant); Department of Psychiatry, Faculty of Medicine, University of Southampton, and Southern Health NHS Foundation Trust, both in Southampton, United Kingdom (Chamberlain)
| | - Samuel R Chamberlain
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (Grant); Department of Psychiatry, Faculty of Medicine, University of Southampton, and Southern Health NHS Foundation Trust, both in Southampton, United Kingdom (Chamberlain)
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Grant JE, Chamberlain SR. Personality traits and their clinical associations in trichotillomania and skin picking disorder. BMC Psychiatry 2021; 21:203. [PMID: 33882867 PMCID: PMC8059235 DOI: 10.1186/s12888-021-03209-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 04/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite being discussed in the psychiatric literature for decades, very little is known about personality features associated with trichotillomania and skin picking disorder (known as body focused repetitive behavior disorders, BFRBs); and the contribution of personality traits to their clinical presentations. AIM The present study assessed personality traits in a large and well-characterized sample of adults with either trichotillomania or skin picking disorder or both. METHODS Adults (n = 98, aged 18-65 years), with trichotillomania (n = 37), skin picking disorder (n = 32), both trichotillomania and skin picking disorder (n = 10), and controls (n = 19) were enrolled. Participants completed self-report questionnaires to quantify personality (NEO Personality Inventory), as well as extent/severity of picking/pulling symptoms, mood and anxiety, impulsive and perfectionistic tendencies, and neurocognitive functioning. Group differences were characterized and correlations with other measures were examined. RESULTS In comparison to controls, BFRBs had elevated neuroticism scores (p < 0.001), lower extraversion scores (p = 0.023), and lower conscientiousness scores (p = 0.007). Neuroticism was significantly related to both hair pulling (r = 0.24, p < 0.001) and skin picking severity (r = 0.48, p < 0.001), as well as elevated perceived stress, worse anxiety and depressive symptoms, and poorer quality of life. Introversion (i.e. lower extraversion) was significantly associated with worse picking severity, higher perceived stress, and higher depression. Lack of conscientiousness was significantly associated with more depression, impulsivity, and perceived stress. DISCUSSION Personality traits of neuroticism, introversion, and lack of conscientiousness are heightened in individuals with BFRBs and show strong associations with a number of clinically relevant features of illness. The holistic understanding and treatment of these disorders is likely to require consideration of dimensional traits such as these.
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Affiliation(s)
- Jon E. Grant
- grid.170205.10000 0004 1936 7822Department of Psychiatry & Behavioral Neuroscience, University of Chicago, 5841 S. Maryland Avenue, MC 3077, Chicago, IL 60637 USA
| | - Samuel R. Chamberlain
- grid.5491.90000 0004 1936 9297Department of Psychiatry, Faculty of Medicine, University of Southampton, Southampton, UK ,grid.467048.90000 0004 0465 4159Southern Health NHS Foundation Trust, Southampton, UK
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