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Montoro-Pérez N, Martínez-González AE, Infante-Cañete L, de Los Ángeles Martínez-González M, Hidalgo-Berutich S, Andreo-Martínez P. Development and validation of the Gastrointestinal Symptom Severity Scale in Spanish children and adolescents. Eur J Pediatr 2024; 183:2703-2715. [PMID: 38526598 PMCID: PMC11098890 DOI: 10.1007/s00431-024-05504-8] [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: 02/06/2024] [Revised: 02/29/2024] [Accepted: 03/02/2024] [Indexed: 03/26/2024]
Abstract
Functional gastrointestinal disorders (FGIDs) are characterized by chronic or recurrent gastrointestinal symptoms (GS) that are not explained by structural or biochemical abnormalities. FGIDs are related to lower quality of life, increased demands on medical resources, and greater somatization and emotional instability. Furthermore, GS appears to be an indicator of dysbiosis in gut-microbiota, affecting the gut-microbiota-brain relationship. To develop and evaluate the psychometric properties of a new instrument called the Gastrointestinal Symptom Severity Scale (GSSS) using a web-based survey in a sample of neurotypical children and adolescents from Spain. Instrument development and validation processes were applied to the GSSS following its administration as part of an online survey. The sample included 1242 neurotypical children and adolescents. The mean age of participants was 13.95 years, with a standard deviation of 1.37 years. Overall, 13.8% suffered infectious diarrhea, 12.6% suffered abdominal pain, 5% suffered dyspepsia and 2.6% suffered gastro-esophageal reflux. A single-factor model produced good fit indices. Furthermore, internal consistency and test-retest reliability outcomes were acceptable. The GSSS was found to have acceptable metric measurement invariance. Significant correlations with other instruments were produced and were of expected direction and magnitude, confirming scale validity for hypothesis testing. Conclusions: The GSSS shows promising psychometric properties for assessing GS in neurotypical Spanish adolescents and children. What is Known: • To the best of our knowledge, instruments assessing the severity of gastrointestinal symptoms in children and adolescents are still too few. What is New: • The GSSS shows promising psychometric properties for assessing GS in neurotypical adolescents and children. The GSSS may help improve understanding of GS involvement in the gut-brain microbiota axis in children and adolescents.
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Affiliation(s)
- Néstor Montoro-Pérez
- Department of Nursing, Faculty of Health Sciences, Person-Centred Care and Health Outcomes Innovation Group, University of Alicante, San Vicente del Raspeig, Spain
- GREIACC Research Group, La Fe Health Research Institute, Valencia, Spain
| | | | - Lidia Infante-Cañete
- Department of Developmental and Educational Psychology, Faculty of Psychology, University of Malaga, Malaga, Spain
| | | | - Silvia Hidalgo-Berutich
- Department of Developmental and Educational Psychology, Faculty of Psychology, University of Malaga, Malaga, Spain
| | - Pedro Andreo-Martínez
- Department of Agricultural Chemistry, Faculty of Chemistry, University of Murcia, Murcia, Spain
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Schienle A, Schlintl C, Wabnegger A. Brain mechanisms for processing caress-like touch in skin-picking disorder. Eur Arch Psychiatry Clin Neurosci 2024; 274:235-243. [PMID: 37610499 PMCID: PMC10786990 DOI: 10.1007/s00406-023-01669-9] [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: 02/27/2023] [Accepted: 07/31/2023] [Indexed: 08/24/2023]
Abstract
Skin-picking disorder (SPD) is characterized by repetitive touching and picking of one's skin. The picking is typically experienced as pleasant although this behavior leads to tissue damage. The present functional magnetic resonance imaging (fMRI) study investigated how individuals with SPD react to caress-like touch, which stimulates C-tactile afferents. A standardized touch procedure was used. Seventy females with a primary diagnosis of SPD and 62 healthy females received CT-optimal brushing of their forearms (3 cm/s) and non-optimal brushing (30 cm/s) during an fMRI session. The two types of tactile stimulation were rated according to pleasure, arousal, and urge to pick one's skin. Relative to healthy controls, patients with SPD showed greater activation in parietal regions (supramarginal/angular gyrus) during CT-optimal touch. Moreover, the deactivation of the middle/ inferior frontal cortex displayed by control participants was absent in the SPD group. Being touched was rated as less pleasant, more arousing, and elicited a greater urge to perform skin-picking in participants with SPD. The mentioned frontal and parietal brain regions are sources of attentional control. They are involved in integrating somatosensory information and switching attention between external/internal stimuli. The present study adds to the limited database on the dysfunctional processing of touch in SPD. This study was preregistered on the German Clinical Trials Register (DRKS00022123, June 8th, 2020).
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Affiliation(s)
- Anne Schienle
- Clinical Psychology, University of Graz, BioTechMed, Universitätsplatz 2/III, 8010, Graz, Austria.
| | - Carina Schlintl
- Clinical Psychology, University of Graz, BioTechMed, Universitätsplatz 2/III, 8010, Graz, Austria
| | - Albert Wabnegger
- Clinical Psychology, University of Graz, BioTechMed, Universitätsplatz 2/III, 8010, Graz, Austria
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Roos A, Fouche JP, Stein DJ, Lochner C. Structural brain network connectivity in trichotillomania (hair-pulling disorder). Brain Imaging Behav 2023; 17:395-402. [PMID: 37059898 PMCID: PMC10435646 DOI: 10.1007/s11682-023-00767-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 04/16/2023]
Abstract
Neuroimaging studies suggest involvement of frontal, striatal, limbic and cerebellar regions in trichotillomania, an obsessive-compulsive related disorder. However, findings regarding the underlying neural circuitry remains limited and inconsistent. Graph theoretical analysis offers a way to identify structural brain networks in trichotillomania. T1-weighted MRI scans were acquired in adult females with trichotillomania (n = 23) and healthy controls (n = 16). Graph theoretical analysis was used to investigate structural networks as derived from cortical thickness and volumetric FreeSurfer output. Hubs, brain regions with highest connectivity in the global network, were identified, and group differences were determined. Regions with highest connectivity on a regional level were also determined. There were no differences in small-worldness or other network measures between groups. Hubs in the global network of trichotillomania patients included temporal, parietal, and occipital regions (at 2SD above mean network connectivity), as well as frontal and striatal regions (at 1SD above mean network connectivity). In contrast, in healthy controls hubs at 2SD represented different frontal, parietal and temporal regions, while at 1SD hubs were widespread. The inferior temporal gyrus, involved in object recognition as part of the ventral visual pathway, had significantly higher connectivity on a global and regional level in trichotillomania. The study included women only and sample size was limited. This study adds to the trichotillomania literature on structural brain network connectivity. Our study findings are consistent with previous studies that have implicated somatosensory, sensorimotor and frontal-striatal circuitry in trichotillomania, and partially overlap with structural connectivity findings in obsessive-compulsive disorder.
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Affiliation(s)
- Annerine Roos
- Department of Psychiatry and Neuroscience Institute, University of Cape Town, Cape Town, South Africa.
- SAMRC Unit on Risk and Resilience in Mental Disorders, Department of Psychiatry, Stellenbosch University, Cape Town, South Africa.
| | - Jean-Paul Fouche
- Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
| | - Dan J Stein
- Department of Psychiatry and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
- SAMRC Unit on Risk and Resilience in Mental Disorders, Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
| | - Christine Lochner
- SAMRC Unit on Risk and Resilience in Mental Disorders, Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
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Flannery MK, Falkenstein MJ, Boyd M, Haaga DAF. Untroubled Pullers: An Examination of Nonclinical Hair-Pulling. J Obsessive Compuls Relat Disord 2023; 38:100821. [PMID: 37485310 PMCID: PMC10358351 DOI: 10.1016/j.jocrd.2023.100821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
Nonclinical hair-pulling is much more prevalent than hair pulling associated with a diagnosis of trichotillomania (TTM). However, little is known about nonclinical pulling. The purpose of this exploratory research was to begin characterizing a subset of nonclinical hair pullers we refer to as "untroubled pullers," people who engage in recurrent, noncosmetic hair-pulling without associated distress or impairment. In a secondary analysis of two studies conducted online, untroubled pullers reported significantly lower symptom severity than did those diagnosed with TTM. The Big Five personality dimensions did not differentiate the groups in Study 1, but untroubled pullers endorsed significantly less disability, focused and automatic pulling, social anxiety, perceived risk in intimacy, and perfectionism in Study 2. These findings remained significant after controlling for symptom severity. Age and race resulted in mixed findings between the two studies, but no differences arose in other demographics. These findings suggest that symptom severity may not sufficiently explain differences in associated distress and impairment. Future studies are needed on how other constructs related to distress and impairment interact with hair-pulling behavior to provide insight into when pulling is associated with clinically significant distress or impairment.
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Affiliation(s)
- Meghan K. Flannery
- Department of Psychology, American University, 4400 Massachusetts Avenue NW, Washington, DC 20016-8062
| | - Martha J. Falkenstein
- McLean Hospital OCD Institute/Harvard Medical School, 115 Mill Street, Mail Stop #207, Belmont, MA 02478
| | - Megan Boyd
- Department of Psychology, American University, 4400 Massachusetts Avenue NW, Washington, DC 20016-8062
| | - David A. F. Haaga
- Department of Psychology, American University, 4400 Massachusetts Avenue NW, Washington, DC 20016-8062
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Schienle A, Schlintl C, Wabnegger A. A neurobiological evaluation of soft touch training for patients with skin-picking disorder. Neuroimage Clin 2022; 36:103254. [PMID: 36451359 PMCID: PMC9668654 DOI: 10.1016/j.nicl.2022.103254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/13/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Individuals with skin-picking disorder (SPD) display reduced neural sensitivity to slow/soft touch. This functional magnetic resonance imaging (fMRI) study investigated the effects of Soft Touch Training (STT) on neural correlates of touch processing and SPD symptoms. METHOD Females with a primary diagnosis of SPD (n = 57) were randomly assigned to receive either four weeks of STT (guided soft brushing of selected skin regions) or Progressive Muscle Relaxation (PMR) training (guided tensing and relaxing of selected muscle regions). The app-assisted intervention consisted of 15-minute daily training sessions at home. Before and after the four-week intervention, the two groups participated in a standardized tactile stimulation procedure during fMRI (affective vs nonaffective touch of the forearm). Intervention-based changes in subjective and neural responses to the tactile stimulation as well as SPD severity were compared between the groups. RESULTS STT increased the pleasantness ratings for (affective) touch administered during fMRI, which was accompanied by decreased activation in the parietal operculum (PO) and supramarginal gyrus (SMG), as well as increased PO-SMG connectivity. These findings possibly reflect normalized affective touch processing due to STT. Both interventions (STT and PMR) reduced SPD severity. CONCLUSIONS This study demonstrated that a brief app-assisted touch training can change the experience of receiving touch from others and the associated brain activity and connectivity. Adaptations of the training relating to duration/ frequency of sessions might enhance its effectiveness.
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Affiliation(s)
- Anne Schienle
- Clinical Psychology, University of Graz, BioTechMed Graz, Austria.
| | - Carina Schlintl
- Clinical Psychology, University of Graz, BioTechMed Graz, Austria
| | - Albert Wabnegger
- Clinical Psychology, University of Graz, BioTechMed Graz, Austria
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Schienle A, Wabnegger A. Discriminative and Affective Processing of Touch: Associations with Severity of Skin-picking. JOURNAL OF NONVERBAL BEHAVIOR 2022; 46:537-545. [PMID: 36312223 PMCID: PMC9596513 DOI: 10.1007/s10919-022-00415-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2022] [Indexed: 11/03/2022]
Abstract
AbstractSkin-picking is a common behavior in the general population that generally serves emotion regulation (e.g., reduction of tension). However, recent research suggests it may also be associated with changes in tactile processing sensitivity. Along these lines, the present study examined whether the severity of skin-picking (SOSP) is related to discriminative and affective touch processing. A total of 160 participants (59 males, 101 females, mean age = 31 years) completed two tactile discrimination tests (two-point discrimination, surface texture discrimination), as well as a well-validated affective touch paradigm (delivery of soft/slow touch, which is found to be generally pleasant). A hierarchical regression analysis was carried out to investigate the association between SOSP, age, sex, and indicators of tactile sensitivity. Replicating previous findings, females reported higher SOSP. While the performance in the discrimination tests did not predict SOSP, affective touch processing was associated with SOSP. Participants with high SOSP reported an urge to pick their skin after being softly touched. This seems paradoxical since previous findings have suggested skin-picking may be carried out to manage negative affective states. Our findings add to the literature describing altered sensitivity and responsivity to specific tactile stimuli in individuals with excessive skin-picking.
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Moreno-Amador B, Cervin M, Martínez-González AE, Piqueras JA. Sensory over-responsivity and symptoms across the obsessive-compulsive spectrum: a web-based study (Preprint). J Med Internet Res 2022; 25:e37847. [PMID: 37052983 PMCID: PMC10141273 DOI: 10.2196/37847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 07/19/2022] [Accepted: 02/27/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Sensory overresponsivity (SOR) has emerged as a potential endophenotype in obsessive-compulsive disorder (OCD), but few studies have examined SOR in relation to the major symptom dimensions of OCD and to symptoms across the full obsessive-compulsive (OC) symptom spectrum. OBJECTIVE This study had 2 main objectives. First, we examined the psychometric properties of the SOR Scales in a community-based sample of Spanish adolescents and adults. Second, we identified how SOR difficulties are related to symptoms across the full OC spectrum (eg, OC, body dysmorphic, hoarding, skin-picking, and hair-pulling symptoms), including the heterogeneity of OC symptoms. METHODS We translated the SOR Scales into Spanish-a measure that assesses SOR across the 5 sensory modalities-and created a web-based version of the measure. A sample of 1454 adolescents and adults (mean age 23.84, SD 8.46 years) participated in the study, and 388 (26.69%) participants completed the survey twice (approximately 8 months apart). The survey also contained a web-based measure that assesses symptoms across the full OC spectrum: harm and checking, taboo obsessions, contamination or cleaning, symmetry and ordering, body dysmorphic, hoarding, hair-pulling, and skin-picking symptoms. RESULTS The psychometric properties of the SOR Scales were excellent, and the test-retest reliability was adequate. All types of SOR were related to all major symptom dimensions of OCD and to all OC spectrum symptoms. CONCLUSIONS SOR across the sensory modalities can be validly assessed using a web-based measure. SOR emerged as a pure transdiagnostic phenomenon in relation to symptoms across the OC spectrum, with no specific sensory modality being more strongly related to OC symptoms. SOR can shed much needed light on basic mechanisms that are important for the onset and maintenance of OC spectrum symptoms, and this study shows that large-scale web-based studies can aid in this endeavor. Future studies should examine whether SOR precedes or emerges alongside OC symptoms.
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Affiliation(s)
- Beatriz Moreno-Amador
- Area of Personality, Assessment and Psychological Treatment, Department of Health Psychology, Universidad Miguel Hernández de Elche, Elche, Spain
| | - Matti Cervin
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Child and Adolescent Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden
| | | | - Jose A Piqueras
- Area of Personality, Assessment and Psychological Treatment, Department of Health Psychology, Universidad Miguel Hernández de Elche, Elche, Spain
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Badenoch J, Searle T, Watson I, Cavanna AE. Sensory symptoms in body-focused repetitive behaviors, restless legs syndrome, and Tourette syndrome: An overlap? Neurosci Biobehav Rev 2020; 119:320-332. [PMID: 33086129 DOI: 10.1016/j.neubiorev.2020.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/13/2020] [Accepted: 10/15/2020] [Indexed: 12/25/2022]
Abstract
Tourette syndrome (TS) is a neurodevelopmental condition characterized by multiple tics. Sensory symptoms play a key role in the clinical phenomenology and pathophysiology of TS, as most patients report premonitory urges driving tic expression. Interestingly, sensory symptoms have also been reported in other conditions characterized by repeated behaviors. This review explores the nature of sensory symptoms reported by patients with body focused repetitive behaviors (BFRBs, especially trichotillomania and skin picking disorder) and restless legs syndrome (RLS) in comparison to TS. A sense of mounting inner tension and reinforcement mechanisms driven by gratification and relief on expression of the tic or repetitive behavior appear to be implicated across all conditions. Subjective urges can be temporarily suppressed by patients with TS and selected BFRBs, whereas patients with RLS tend to report dysesthesia more frequently than a suppressible urge to move. The observed similarities in the phenomenology of sensory symptoms across these conditions raise the possibility of a comparable underlying pathophysiology. Preliminary findings suggest an overlap of neural pathways encompassing the insula, basal ganglia (putamen), and posterior cingulate cortex.
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Affiliation(s)
- James Badenoch
- Department of Neuropsychiatry, BSMHFT and University of Birmingham, Birmingham, United Kingdom
| | - Tamara Searle
- Department of Neuropsychiatry, BSMHFT and University of Birmingham, Birmingham, United Kingdom
| | - Iona Watson
- Department of Neuropsychiatry, BSMHFT and University of Birmingham, Birmingham, United Kingdom
| | - Andrea E Cavanna
- Department of Neuropsychiatry, BSMHFT and University of Birmingham, Birmingham, United Kingdom; School of Life and Health Sciences, Aston University, Birmingham, United Kingdom; University College London and Institute of Neurology, London, United Kingdom.
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Houghton DC, Tommerdahl M, Woods DW. Increased tactile sensitivity and deficient feed-forward inhibition in pathological hair pulling and skin picking. Behav Res Ther 2019; 120:103433. [DOI: 10.1016/j.brat.2019.103433] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 03/14/2019] [Accepted: 06/21/2019] [Indexed: 12/12/2022]
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Houghton DC, Uhde TW, Borckardt JJ, Cortese BM. Exploratory Investigation of a Brief Cognitive Behavioral Intervention and Transcranial Direct Current Stimulation on Odor Sensitivity. Psychosom Med 2019; 81:389-395. [PMID: 30762663 PMCID: PMC6961818 DOI: 10.1097/psy.0000000000000679] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Enhanced odor sensitivity is a phenomenon that potentially underlies conditions such as multiple chemical sensitivity (MCS). Currently, there are no treatments that have been shown to effectively decrease odor sensitivity. Given similarities of odor hypersensitivity/MCS to pain sensitization disorders such as fibromyalgia, there may be a potential for interventions that improve pain tolerance to modulate odor sensitivity. METHODS This exploratory study randomized 72 healthy community adult volunteers to receive one of six treatments in between two assessments of thermal pain tolerance and odor threshold. Participants were randomized to receive either cathodal, anodal, or sham transcranial direct current stimulation (tDCS) aimed at dorsolateral prefrontal cortex. In addition, participants were provided a brief cognitive behavioral intervention (CBI) for pain consisting of task framing, cognitive restructuring, and distraction technique training, or a control intervention consisting of information about pain. RESULTS Persons who received a brief CBI showed significantly increased odor thresholds (reduced sensitivity) during intervention (F (1,62) = 7.29, p = .009, ηp = .11), whereas the control intervention was not associated with altered odor thresholds. Moreover, in those who received brief CBI, more severe anxiety associated with larger reductions in odor sensitivity (ρ = .364, p = .035). There was no effect of tDCS (F (2,62) = .11, p = .90) nor interaction between tDCS and CBI (F (2,62) = .32, p = .73). CONCLUSIONS Given the connection between anxiety and MCS, results suggest that CBT techniques for somatic processes may show promise in treating conditions characterized by increased sensitivity to odors (e.g., MCS).
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Affiliation(s)
- David C. Houghton
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
- Psychological and Brain Sciences Department, Texas A&M University, College Station, TX, USA
| | - Thomas W. Uhde
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Jeffrey J. Borckardt
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Bernadette M. Cortese
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
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Khosravani V, Ganji Z, Sharifi Bastan F, Samimi Ardestani SM, Amirinezhad A. Psychometric properties of the highly sensitive person scale and its relation to symptom dimensions in patients with obsessive-compulsive disorder. CURRENT PSYCHOLOGY 2019. [DOI: 10.1007/s12144-019-00212-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Mouton-Odum S, Houghton DC. Comprehensive behavioral treatment for an adult with sensory-based trichotillomania: An illustrative case study. Bull Menninger Clin 2018; 82:288-307. [PMID: 30589578 DOI: 10.1521/bumc.2018.82.4.288] [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] [Indexed: 11/20/2022]
Abstract
Trichotillomania (TTM) is a poorly understood condition that causes significant impairment, but effective behavioral management strategies exist. The phenomenology of TTM is complex and requires an individualized treatment approach, and there are some important facets of TTM that have only recently been recognized. Specifically, contemporary research indicates that hair pulling is often performed to regulate aversive sensations and provide somatosensory reward. In this article, we describe the complex phenomenology of TTM, evidence-based treatment options, and illustrate a case of sensory-based TTM treated effectively with a comprehensive behavioral intervention.
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Affiliation(s)
- Suzanne Mouton-Odum
- Clinical assistant professor and director of Psychology Houston, PC: The Center for Cognitive Behavioral Treatment, Houston, Texas
| | - David C Houghton
- Post-doctoral fellow, Medical University of South Carolina, Charleston
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