Habit reversal training in trichotillomania: guide for the clinician

Action sequence learning, habits, and automaticity in obsessive-compulsive disorder

This study investigates the goal/habit imbalance theory of compulsion in obsessive-compulsive disorder (OCD), which postulates enhanced habit formation, increased automaticity, and impaired goal/habit arbitration. It directly tests these hypotheses using newly developed behavioral tasks. First, OCD patients and healthy participants were trained daily for a month using a smartphone app to perform chunked action sequences. Despite similar procedural learning and attainment of habitual performance (measured by an objective automaticity criterion) by both groups, OCD patients self-reported higher subjective habitual tendencies via a recently developed questionnaire. Subsequently, in a re-evaluation task assessing choices between established automatic and novel goal-directed actions, both groups were sensitive to re-evaluation based on monetary feedback. However, OCD patients, especially those with higher compulsive symptoms and habitual tendencies, showed a clear preference for trained/habitual sequences when choices were based on physical effort, possibly due to their higher attributed intrinsic value. These patients also used the habit-training app more extensively and reported symptom relief post-study. The tendency to attribute higher intrinsic value to familiar actions may be a potential mechanism leading to compulsions and an important addition to the goal/habit imbalance hypothesis in OCD. We also highlight the potential of smartphone app training as a habit reversal therapeutic tool.

Comparing the 'When' and the 'Where' of Electrocortical Activity in Patients with Tourette Syndrome, Body-Focused Repetitive Behaviors, and Obsessive Compulsive Disorder

Background/Objectives: Tourette Syndrome (TS), Obsessive Compulsive Disorder (OCD), and Body-Focused Repetitive Behaviors (BFRB) are three disorders that share many similarities in terms of phenomenology, neuroanatomy, and functionality. However, despite the literature pointing toward a plausible spectrum of these disorders, only a few studies have compared them. Studying the neurocognitive processes using Event-Related Potentials (ERPs) offers the advantage of assessing brain activity with excellent temporal resolution. The ERP components can then reflect specific processes known to be potentially affected by these disorders. Our first goal is to characterize 'when' in the processing stream group differences are the most prominent. The second goal is to identify 'where' in the brain the group discrepancies could be. Methods: Participants with TS (n = 24), OCD (n = 18), and BFRB (n = 16) were matched to a control group (n = 59) and were recorded with 58 EEG electrodes during a visual counting oddball task. Three ERP components were extracted (i.e., P200, N200, and P300), and generating sources were modelized with Standardized Low-Resolution Electromagnetic Tomography. Results: We showed no group differences for the P200 and N200 when controlling for anxiety and depressive symptoms, suggesting that the early cognitive processes reflected by these components are relatively intact in these populations. Our results also showed a decrease in the later anterior P300 oddball effect for the TS and OCD groups, whereas an intact oddball effect was observed for the BFRB group. Source localization analyses with sLORETA revealed activations in the lingual and middle occipital gyrus for the OCD group, distinguishing it from the other two clinical groups and the controls. Conclusions: It seems that both TS and OCD groups share deficits in anterior P300 activation but reflect distinct brain-generating source activations.

Management of Mental Health Challenges in Athletes: Screening, Pharmacology, and Behavioral Approaches

Athletes are incredibly motivated and perpetually pursuing dominance in skill, strength, endurance, and execution-often while balancing many additional responsibilities. Despite the appearance of living fun, luxurious, care-free lifestyles, they are vulnerable to exceptional stressors and the same mental health challenges as the general population. The use of screening tools and assessment guided by a biopsychosocial framework can assist in understanding the factors that contribute to the athlete's mental health status. This can facilitate the development of a targeted management approach to mental health challenges.

Habit-reversal training: a psychotherapeutic approach in treating body-focused repetitive behaviour disorders

Body-focused repetitive behaviours (BFRBs) are recurrent, compulsive, destructive behaviours directed towards the body. Although studies have demonstrated a 12-14% prevalence rate, researchers found that dermatologists and psychiatrists show a lack of knowledge regarding psychodermatology resources and information about BFRB disorders (BFRBDs) such as trichotillomania (TTM). There is limited research about treatments including ones investigating the clinical applications of various self-help training such as decoupling (DC) and DC in sensu (DC-is) as well as about habit-reversal training (HRT). HRT is a five-component behavioural intervention that aims to develop a competing response to a specific unwanted behaviour. Studies have found substantial support for HRT's efficacy in treating a variety of maladaptive repetitive behaviours including onychotillomania, TTM, skin-picking disorder and chronic cheek biting. Additionally, many psychotherapies can augmented HRT. Psychotherapies include acceptance and commitment therapy, dialectical behaviour therapy, psychodynamic psychotherapy, mindfulness mediation and the cognitive psychophysiological model. A recently investigated variant of HRT, DC-is, resulted in consistently satisfactory objective and subjective improvement for treating BFRBDs, and HRT showed good subjective but poor objective improvement compared with standard DC. HRT and HRT variants are effective therapeutic treatments for BFRBDs; however, further randomized double-blinded and placebo-controlled trials are required to examine HRT's therapeutic profile.

"Don't Touch Your Face!" The Contribution of Habit Reversal in the COVID-19 Pandemic

The Habit Reversal Training (HRT) is a behavioral procedure for treating the so-called nervous habits, such as nail biting, hair pulling and thumb sucking. In addition to being an established clinical procedure, HRT is also a strategy for behavioral change that can serve the entire community. For this reason, this review aims to explore the studies proposing the use of HRT for the reduction of hand-to-face habits in the context of COVID-19 pandemic. Touching one's nose, mouth and eyes, indeed, is one of the means of virus transmission that many awareness campaigns seek to highlight. After an overview of how HRT works and of the current epidemiological situation, studies supporting Habit Reversal Training for the reduction of risky hand-to-face habits are presented. The possible strategies are then exposed and critically discussed to identify their limitations and propose a new version according to the Relational Frame Theory.

Protocol and Outcome Evaluation of Comprehensive Outpatient Treatment of Adolescent Rumination Syndrome

OBJECTIVES

Rumination syndrome (RS) is an increasingly recognized functional gastrointestinal condition with limited treatment research. Current treatment recommendations emphasize diaphragmatic breathing (DB), despite limited outcomes, and the most robust results have originated from inpatient treatment models. This paper described the protocol for Comprehensive Behavioral Treatment for Rumination Syndrome (CBT-R) utilized in an outpatient setting and evaluation of preliminary outcomes.

METHODS

The CBT-R protocol is described in detail, grounded in behavioral theory and phased treatment approach to symptom elimination. The treatment is evaluated via a retrospective case series design of pediatric patients (aged 8-18) with a primary diagnosis of RS treated in an outpatient setting by a pediatric psychologist.

RESULTS

Twenty-eight patients met inclusion criteria and are included in intent-to-treat analysis, with 23 patients evaluated for outcomes (47.8% female, M age = 14.3; SD = 2.8). Sample included 17.4% with comorbid psychiatric diagnosis and 43.5% with comorbid medical diagnoses. Outcome results demonstrate improvement for a majority of patients (87.0%), with most demonstrating complete resolution of symptoms (73.9%). Treatment length varied significantly, ranging from 1 to 22 visits (M = 4.8, SD = 5.4) and was complicated by necessary admission or supplemental nutrition in 21.7% of patients. Psychological factors were related to poor treatment outcomes and longer treatment duration.

CONCLUSIONS

CBT-R results in positive treatment outcomes for majority of patients, with most patients demonstrating complete resolution of symptoms, providing a superior outpatient treatment option for some pediatric patients. Sample characteristics challenge previous understanding of RS as female dominated and with high levels of psychiatric comorbidity.

Tetrahydrocannabinol fails to reduce hair pulling or skin picking: results of a double-blind, placebo-controlled study of dronabinol

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.

Pharmacotherapy for trichotillomania in adults

INTRODUCTION

Currently conceptualized as an obsessive compulsive and related disorder, trichotillomania, or hair-pulling disorder, is a common illness that causes significant distress or functional impairments in various life domains. Most individuals with trichotillomania also have other comorbid diagnoses. Treating trichotillomania with pharmacotherapy is complicated since there are currently no FDA-approved drugs for its treatment.

AREAS COVERED

The databases PubMed, PsychINFO, CINAHL, Evidence-based Medicine Reviews, and Cochrane Database of Systematic Reviews were searched, yielding a total of 10 open trials and 10 controlled trials selected. This review aims to examine pharmacotherapeutic options for the treatment of trichotillomania in adults and makes recommendations for the assessment and management of the disorder.

EXPERT OPINION

There is preliminary evidence that clomipramine, olanzapine, and N-acetylcysteine may be effective in cases of trichotillomania, however, given the paucity of controlled studies with large sample sizes, decisions regarding the use of drugs should be made on a case-by-case basis taking into account the severity of trichotillomania and the nature of psychiatric comorbidity.

Habit reversal therapy in the management of body focused repetitive behavior disorders

Body-focused repetitive behavior disorders are a group of disorders characterized by repetitive actions that include skin picking, hair pulling, nail biting, and other compulsions. These disorders can range from a common habit to a pathological disorder, that negatively impacts the psychiatric health and social well-being of an individual. Diagnosis can be made clinically, and monitored using different scales and assessments. Various treatments have been tried with differing successes. There are currently no first line curative medications for these disorders, but cognitive behavioral therapy has seen the most success in treatment. Specifically habit reversal therapy has shown the most promise in reducing the repetitive behaviors and symptoms seen in these disorders. Habit reversal therapy has also seen success through augmentation with additional therapies such as mindfulness, or treatment with a selective serotonin reuptake inhibitor in a patient with comorbid obsessive compulsive disorder. This paper aims to explore the efficacy of different treatment modalities specifically the effectiveness and approach of habit reversal therapy.

Trichotillomania is more related to Tourette disorder than to obsessive-compulsive disorder

OBJECTIVE

Trichotillomania (TTM) is characterized by the pulling out of one's hair. TTM was classified as an impulse control disorder in DSM-IV, but is now classified in the obsessive-compulsive related disorders section of DSM-5. Classification for TTM remains an open question, especially considering its impact on treatment of the disorder. In this review, we questioned the relation of TTM to tic disorder and obsessive-compulsive disorder (OCD).

METHOD

We reviewed relevant MEDLINE-indexed articles on clinical, neuropsychological, neurobiological, and therapeutic aspects of trichotillomania, OCD, and tic disorders.

RESULTS

Our review found a closer relationship between TTM and tic disorder from neurobiological (especially imaging) and therapeutic standpoints.

CONCLUSION

We sought to challenge the DSM-5 classification of TTM and to compare TTM with both OCD and tic disorder. Some discrepancies between TTM and tic disorders notwithstanding, several arguments are in favor of a closer relationship between these two disorders than between TTM and OCD, especially when considering implications for therapy. This consideration is essential for patients.

Mapping Compulsivity in the DSM-5 Obsessive Compulsive and Related Disorders: Cognitive Domains, Neural Circuitry, and Treatment

Compulsions are repetitive, stereotyped thoughts and behaviors designed to reduce harm. Growing evidence suggests that the neurocognitive mechanisms mediating behavioral inhibition (motor inhibition, cognitive inflexibility) reversal learning and habit formation (shift from goal-directed to habitual responding) contribute toward compulsive activity in a broad range of disorders. In obsessive compulsive disorder, distributed network perturbation appears focused around the prefrontal cortex, caudate, putamen, and associated neuro-circuitry. Obsessive compulsive disorder-related attentional set-shifting deficits correlated with reduced resting state functional connectivity between the dorsal caudate and the ventrolateral prefrontal cortex on neuroimaging. In contrast, experimental provocation of obsessive compulsive disorder symptoms reduced neural activation in brain regions implicated in goal-directed behavioral control (ventromedial prefrontal cortex, caudate) with concordant increased activation in regions implicated in habit learning (presupplementary motor area, putamen). The ventromedial prefrontal cortex plays a multifaceted role, integrating affective evaluative processes, flexible behavior, and fear learning. Findings from a neuroimaging study of Pavlovian fear reversal, in which obsessive compulsive disorder patients failed to flexibly update fear responses despite normal initial fear conditioning, suggest there is an absence of ventromedial prefrontal cortex safety signaling in obsessive compulsive disorder, which potentially undermines explicit contingency knowledge and may help to explain the link between cognitive inflexibility, fear, and anxiety processing in compulsive disorders such as obsessive compulsive disorder.

Behavioral Changes Associated with a Disruptive New Student in the Classroom

Marcus is a 10-year-old boy who was followed by his pediatrician for several years. She knows him as a socially engaged, active athlete, playing soccer and baseball, out-going, and a good student. He has been in good health without a significant medical history.At the beginning of this academic year, a new student was placed in Marcus's fourth grade class. This student is disruptive, impulsive, and abusive. He has frequent violent outbursts, yelling, kicking, and throwing objects, including recently throwing a desk across the room. The school has made efforts to manage this student. The teacher sets up behavior contracts, and the school has temporarily suspended the child; however, the school is unable to remove the child from the classroom. Many students, including Marcus, have been significantly affected by this disruption.Marcus describes the classroom environment as "tense." He reports he is never sure what is going to make the student "so mad." Over the last 3-4 months, Marcus developed nightmares, enuresis, and trichotillomania. The hair pulling is the most distressing feature for both Marcus and his parents. Marcus acknowledges that he is usually unaware of the behavior at first but then finds the sensation is relaxing. Afterward, he is typically embarrassed by the behavior. There is a family history of anxiety in both parents.He has been seeing a psychologist with some mild improvement in his enuresis. However, the hair pulling has not improved and has worsened. They were seeking additional advice regarding the next steps.

Endoscopic shaving of hair in a gastric bypass patient with a large bezoar

Trichotillomania can be associated with the formation of trichobezoars (hair ball) usually located in the stomach. Trichobezoars may lead to complications including bowel obstruction, and perforation. Patients with a history of diabetes, certain psychiatric disorders, prior gastric surgery and poor mastication ability are at an increased risk of developing bezoars. We are presenting a case of patient who suffered from a large, recurrent trichobezoar, who had a history of gastric bypass surgery as well as trichotillophagia. The endoscopic method used to remove the large bezoar will also be discussed. We have reviewed the cases published, in which patients developed bezoars after undergoing gastric bypass surgery. The purpose of this study is to raise awareness among clinicians that patients with certain psychiatric issues who had prior gastric surgeries, are at eminent risk of bezoar formation. A multidisciplinary approach including cognitive behavioural therapy, dietary education and pharmacotherapy should be taken to prevent complications.

Diagnosis and management of hair loss in children

PURPOSE OF REVIEW

Hair loss is common in infants and children and the ability to distinguish why a child is losing hair enables providers to distinguish hair loss that is related to infection, autoimmune conditions, nutrition, medications, trauma/traction, or underlying genetic disorders such as ectodermal dysplasias. Making these distinctions leads to best management and guidance for patients and their families.

RECENT FINDINGS

Careful physical examination of the hair, scalp, skin, and nails coupled with dermoscopy or trichoscopy, or both, can yield more accurate and faster diagnosis. Biopsy is rarely needed in children for hair loss conditions.

SUMMARY

Hair loss, particularly on the scalp, can affect all ages and can impact patients socially and emotionally. The majority of hair loss in children is nonscarring. Diagnosis begins with a good history, including personal and family history, medication use, a thorough physical examination, and use of dermoscopy or trichoscopy, or both. With these, providers can begin to divide hair loss into congenital vs. acquired, and then further subdivide into focal vs. diffuse and scarring vs. nonscarring. Secondary change, including scale and erythema, can further help with diagnosis.

Treating Trichotillomania

Trichotillomania (TTM) involves the compulsive pulling of one’s bodily hair and is often associated with significant distress or impairment. The present case study concerns a college-aged woman, whose history of TTM extended over 5 years and had been unsuccessfully treated by psychotherapy and medication management. Although TTM can be a challenging disorder to treat, the literature indicates that cognitive-behavioral therapy (CBT) has been successful in this regard. Therefore, we implemented CBT based on the manual developed by Keuthen, Stein, and Christenson; specific elements of therapy used included relaxation, self-monitoring, habit reversal training (HRT), reinforcement/punishment contingencies, thought monitoring, and cognitive restructuring. This approach was successful, as the client evidenced a 72% decrease in hair-pulling after using HRT alone, and complete elimination of hair-pulling after introducing the cognitive-restructuring element. Impressively, the gains lasted not only in the short term, but also had been reportedly maintained at a 5-year follow-up.

Affective regulation in trichotillomania before and after self-help interventions

OBJECTIVE

Trichotillomania (TTM) is characterized by recurrent hair-pulling behaviours that cause significant distress. Deficits in affective regulation have been reported in individuals with TTM. We aimed to investigate temporal stability of affective regulation in TTM individuals.

METHODS

Eighty-one TTM individuals underwent an online intervention. Affective Regulation Scale (ARS), Massachusetts General Hospital Hair-Pulling Scale (MGH-HPS), and Beck Depression Inventory (BDI) scores were obtained at baseline, post-treatment (4 weeks), and follow-up (6 months). We examined the effect of phenotypes including hair-pulling severity and depressive symptoms on absolute and relative stability of affective regulation over time, using multiple linear and hierarchical regression analyses.

RESULTS

The ARS total-score from the present TTM sample was significantly lower than the score from non-hair pullers (p < 0.001). ARS total-scores inversely correlated with the MGH-HPS total-scores at baseline (p = 0.001) and post-treatment (p = 0.02), and with BDI total-scores at all time-points (p < 0.001). Although ARS total-scores significantly increased, all ARS sub-scores, except guilt sub-scores, did not change over time, indicating absolute stability. Baseline ARS total-, and sub-scores (except tension) were found to predict their ARS follow-up scores (all p < 0.01), confirming relative stability (i.e., the extent to which the inter-individual differences remained the same over time). The relative stability of ARS total-scores and all but two sub-scores (irritability and guilt) were independent from BDI baseline scores.

CONCLUSIONS

Individuals with TTM reported deficits in affective regulation that demonstrated mostly high relative stability and partly absolute stability. Therefore, targeting to improve affective regulation in individuals with TTM during therapy is warranted.

Impaired response inhibition and excess cortical thickness as candidate endophenotypes for trichotillomania

Trichotillomania is characterized by repetitive pulling out of one's own hair. Impaired response inhibition has been identified in patients with trichotillomania, along with gray matter density changes in distributed neural regions including frontal cortex. The objective of this study was to evaluate impaired response inhibition and abnormal cortical morphology as candidate endophenotypes for the disorder. Subjects with trichotillomania (N = 12), unaffected first-degree relatives of these patients (N = 10), and healthy controls (N = 14), completed the Stop Signal Task (SST), a measure of response inhibition, and structural magnetic resonance imaging scans. Group differences in SST performance and cortical thickness were explored using permutation testing. Groups differed significantly in response inhibition, with patients demonstrating impaired performance versus controls, and relatives occupying an intermediate position. Permutation cluster analysis revealed significant excesses of cortical thickness in patients and their relatives compared to controls, in right inferior/middle frontal gyri (Brodmann Area, BA 47 & 11), right lingual gyrus (BA 18), left superior temporal cortex (BA 21), and left precuneus (BA 7). No significant differences emerged between groups for striatum or cerebellar volumes. Impaired response inhibition and an excess of cortical thickness in neural regions germane to inhibitory control, and action monitoring, represent vulnerability markers for trichotillomania. Future work should explore genetic and environmental associations with these biological markers.

Diagnosis and management of alopecia in children

Alopecia in childhood is a source of high concern, frustration, and anxiety. Delineating types of alopecia and those that are chronic or potentially related to underlying medical problems is important. There are 5 common types of hair loss in children: alopecia related to tinea capitis, alopecia areata spectrum/autoimmune alopecia, traction alopecia, telogen effluvium, and trichotillomania/trichotillosis. Hair-cycle anomalies including loose anagen syndrome can lead to sparse-appearing hair. Rarer reasons for alopecia in children include pressure-induced alopecia, alopecia related to nutritional deficiency or toxic ingestion, and androgenetic alopecia. Congenital lesions should be considered for areas of localized alopecia occurring at birth.