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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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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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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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Health-related quality of life in hoarding: A comparison to chronic conditions with high disease burden. J Psychiatr Res 2022; 149:68-75. [PMID: 35255385 DOI: 10.1016/j.jpsychires.2022.02.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/28/2022] [Accepted: 02/28/2022] [Indexed: 12/21/2022]
Abstract
Hoarding disorder often results in debilitating functional impairment and may also compromise health-related quality of life (QoL). This study investigated the association between hoarding behavior and QoL relative to six highly impairing medical and psychiatric disorders in a sample of 20,722 participants enrolled in the internet-based Brain Health Registry. Nearly 1 in 8 participants (12.2%) endorsed clinically relevant hoarding symptoms (CHS). In separate multivariable linear regression models, hoarding was more strongly associated with mental QoL than diabetes (Standardizedβ = -0.21, 95% CI: [-0.22, -0.20] vs. -0.01 [-0.02, 0.0]), heart disease (-0.22 [-0.23, -0.20] vs. 0.00 [-0.02, 0.01]), chronic pain (-0.18 [-0.19, -0.16] vs. -0.12 [-0.13, -0.10]), post-traumatic stress disorder (PTSD; -0.20 [-0.22, -0.19] vs. -0.07 [-0.09, -0.06]), and substance use disorder (SUD; -0.21 [-0.23, -0.20] vs. -0.04 [-0.05, -0.03]). Similarly, CHS was more strongly negatively associated with physical QoL than diabetes (-0.11 [-0.10, -0.12] vs. -0.08 [-0.06, -0.09]), major depressive disorder (-0.09 [-0.10, -0.08] vs. -0.05 [-0.06, 0.03]), PTSD (-0.11 [-0.12, -0.10] vs. -0.08 [-0.09, -0.07]), and SUD (-0.12 [-0.13, -0.09] vs. -0.01 [-0.02, 0.00]). Higher hoarding severity was associated with reductions in both mental (Standardizedβ = -0.28, ΔR2 = 0.08, p < 0.0001) and physical (β = -0.12, ΔR2 = 0.02, p < 0.0001) QoL, though the strength of the relationship between hoarding symptoms and QoL varied with depression severity. Efforts to improve the overall QoL and well-being of those with CHS are needed.
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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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Carlson EJ, Malloy EJ, Brauer L, Golomb RG, Grant JE, Mansueto CS, Haaga DAF. Comprehensive Behavioral (ComB) Treatment of Trichotillomania: A Randomized Clinical Trial. Behav Ther 2021; 52:1543-1557. [PMID: 34656205 DOI: 10.1016/j.beth.2021.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study is the first controlled trial of comprehensive behavioral (ComB) treatment of trichotillomania (TTM). ComB provides individualized treatment based on factors triggering and maintaining hair pulling. METHOD Participants (N = 36) were adults (M = 34.08 years old, SD = 12.26) meeting DSM5 criteria for TTM. A majority were female (80%) and Caucasian (75%), whereas 17% were African American and 19% Hispanic/Latinx. In a parallel-group design, participants were randomly assigned to (a) Immediate ComB (12 sessions) or (b) Minimal Attention Control (MAC), followed by delayed ComB after week 12. Follow-up continued through week 38. Primary outcomes were self-report (Massachusetts General Hospital Hair pulling Scale; MGH-HPS) and interviewer-rated (NIMH-Trichotillomania Impact Scale and Trichotillomania Severity Scale; TIS/TSS) TTM symptom severity, as well as diagnosis (Trichotillomania Diagnostic Interview). RESULTS Immediate efficacy of ComB (vs. MAC) was statistically significant (p = .03) for self-reported symptoms, with an effect size d = -.78, but not significant for interviewer-rated symptoms or diagnostic status. Immediate ComB was significantly more likely than MAC (27% vs. 0%) to lead to complete abstinence from hair pulling at week 12. Follow-ups showed good maintenance of effects. CONCLUSIONS Efficacy of ComB was established for self-reported symptoms. Future research is needed to establish whether the lack of more widespread effects stems from limitations of the model or to a need for more extensive therapist training, as secondary analyses suggested stronger results among therapists with more TTM experience.
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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, 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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Wetterneck C, Singh RS, Woods DW. Hair pulling antecedents in trichotillomania: Their relationship with experiential avoidance. Bull Menninger Clin 2020; 84:35-52. [DOI: 10.1521/bumc_2020_84_01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In this study, 285 adults who met criteria for trichotillomania (TTM) via self-report completed an online, cross-sectional survey examining antecedent phenomenological experiences pertaining to hair pulling along with measures of TTM severity and experiential avoidance (i.e., avoidance of or escape from unwanted thoughts or feelings). Results showed a heterogeneous depiction of antecedent experiences. Subsequent analyses revealed that certain antecedents were not significantly related to TTM severity but were significantly correlated with higher levels of experiential avoidance. In particular, four of five classes of antecedents (i.e., bodily sensations, physical symptoms, mental anxiety, and general uncomfortableness) were significantly related to greater experiential avoidance. The authors conclude that treatments may need to be designed to address specific private antecedents, and that this may be done through targeting experiential avoidance.
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Affiliation(s)
| | - R. Sonia Singh
- Postdoctoral Psychology Fellow at the South Central Mental Illness Research, Education and Clinical Center (MIRECC), Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock
| | - Douglas W. Woods
- Department of Psychology at Marquette University, Milwaukee, Wisconsin
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Falkenstein MJ, Mouton-Odum S, Mansueto CS, Golomb RG, Haaga DAF. Comprehensive Behavioral Treatment of Trichotillomania. Behav Modif 2015; 40:414-38. [DOI: 10.1177/0145445515616369] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This study aimed to concretize and pilot test comprehensive behavioral (ComB) treatment of trichotillomania (TTM), to facilitate rigorous testing of its efficacy. ComB provides a conceptualization to develop individualized treatment and choose interventions for managing distinct factors that maintain the individual’s hair pulling. It has been used by clinicians for almost three decades, yet was not previously manualized or studied empirically. A manual was drafted and revised based on patient ( N = 16) and therapist feedback, an intervention choice study demonstrated therapists reliably selected model-consistent interventions, and a therapist adherence measure was developed and tested. Uncontrolled preliminary data showed ComB to be highly acceptable, and it led to reduced TTM symptom severity and impairment, with large effects. Quality of life and disability also improved, with effects maintained at follow-up. This study resulted in the development of a manual and measures to be used in a randomized controlled trial (RCT) of ComB for TTM.
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Houghton DC, Capriotti MR, De Nadai AS, Compton SN, Twohig MP, Neal-Barnett AM, Saunders SM, Franklin ME, Woods DW. Defining treatment response in trichotillomania: a signal detection analysis. J Anxiety Disord 2015; 36:44-51. [PMID: 26422605 PMCID: PMC4658278 DOI: 10.1016/j.janxdis.2015.09.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 09/07/2015] [Accepted: 09/14/2015] [Indexed: 12/25/2022]
Abstract
The Massachusetts General Hospital Hairpulling Scale (MGH-HPS) and the NIMH Trichotillomania Severity Scale (NIMH-TSS) are two widely used measures of trichotillomania severity. Despite their popular use, currently no empirically-supported guidelines exist to determine the degrees of change on these scales that best indicate treatment response. Determination of such criteria could aid in clinical decision-making by defining clinically significant treatment response/recovery and producing accurate power analyses for use in clinical trials research. Adults with trichotillomania (N=69) participated in a randomized controlled trial of psychotherapy and were assessed before and after treatment. Response status was measured via the Clinical Global Impressions-Improvement Scale, and remission status was measured via the Clinical Global Impressions-Severity Scale. For treatment response, a 45% reduction or 7-point raw score change on the MGH-HPS was the best indicator of clinically significant treatment response, and on the NIMH-TSS, a 30-40% reduction or 6-point raw score difference was most effective cutoff. For disorder remission, a 55-60% reduction or 7-point raw score change on the MGH-HPS was the best predictor, and on the NIMH-TSS, a 65% reduction or 6-point raw score change was the best indicator of disorder remission. Implications of these findings are discussed.
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Affiliation(s)
- David C. Houghton
- Texas A&M University – Department of Psychology, 4235 TAMU, College Station, TX, 77843, USA, D.C.H.
| | - Matthew R. Capriotti
- University of California San Francisco – Department of Psychiatry, 401 Parnassus Ave., Box 0984, San Francisco, CA, 94143, USA,
| | - Alessandro S. De Nadai
- University of South Florida – Department of Psychology, 4202 East Fowler Ave., PCD4118G, Tampa, FL, 33620, USA,
| | - Scott N. Compton
- Duke University School of Medicine – Department of Psychiatry and Behavioral Sciences, 2213 Elba St., Durham, NC, 27705, USA,
| | - Michael P. Twohig
- Utah State University – Department of Psychology, 2810 Old Main Hill, Logan, UT, 84322, USA,
| | - Angela M. Neal-Barnett
- Kent State University – Department of Psychological Sciences, 600 Hilltop Drive, Kent, OH, 44242, USA,
| | - Stephen M. Saunders
- Marquette University – Department of Psychology, 317 Cramer Hall, Milwaukee, WI, 53233, USA,
| | - Martin E. Franklin
- University of Pennsylvania School of Medicine – Department of Psychiatry, 3535 Market St., Philadelphia, PA, 19104, USA,
| | - Douglas W. Woods
- Texas A&M University – Department of Psychology, 4235 TAMU, College Station, TX, 77843, USA, D.C.H. ,D.W.W. , D.W.W. phone: 1-(979)845-2540, D.W.W. fax: 1-(979)-845-4727
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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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