Can the Yale-Brown Obsessive Compulsive Scale be used to assess trichotillomania? A preliminary report

A Qualitative Study Exploring International Experiences of Seeking Treatment for Adults With Trichotillomania: A Story of Frustration and Unmet Need

Trichotillomania (TTM) is a poorly understood disorder with no consensus on aetiology or epidemiology; often overlooked due to high comorbidity rates. Cross-cultural qualitative research is sparse; therefore, an international qualitative study was conducted. A generic qualitative approach with thematic analysis was used to explore data from asynchronous email interviews. The aim of this article is to report participant experiences of seeking treatment. Using a sample of 20 adults (18-55 years) from 15 different countries, this article highlights lack of access and unmet healthcare needs signifying an inadequate supply of TTM expertise globally and the need for more robust clinical guidance.

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.

A Preliminary Investigation of Metacognitive Therapy and Habit Reversal as a Treatment for Trichotillomania

BACKGROUND

Not all patients suffering from trichotillomania (TTM) recover completely using CBT and of those that do, only a few maintain their recovery over time.

AIMS

The purpose of the present study was to investigate the effectiveness of metacognitive methods combined with habit reversal (MCT/HRT) in trichotillomania with a relatively long-term follow-up.

METHOD

A case series (n = 8) and a randomized wait-list controlled trial (n = 34) design were conducted in this study. In the case series, three of the eight patients dropped out of the study. Therefore, TTM-related symptoms were evaluated in five patients suffering from TTM before and after brief metacognitive plus habit reversal therapy during 1-month, 6-month, and 12-month follow-ups. The treatment consisted of detached mindfulness (DM) techniques, ritual postponement and habit reversal training (HRT) in eight sessions.

RESULTS

All patients were responders at post-treatment in case series. After the 12-month follow-up, the results were associated with higher pre-treatment levels of self-esteem and global functioning and lower pre-treatment levels of depression and anxiety with nearly complete abstinence from hair pulling immediately after treatment. A randomized wait-list controlled trial with experimental (n = 17) and waiting list group (n = 17) was then conducted to confirm the case series results. There were significant differences between the two groups regarding changes in MGH-HPS, Y-BOCS-TM, RSES, GAF, BDI, BAI and self-monitoring. Therefore, the MCT/HRT treatment was found to be more effective than the waiting list group.

CONCLUSIONS

A combined treatment including metacognitive and habit reversal techniques is remarkably effective in patients with TTM.

Defining treatment response in trichotillomania: a signal detection analysis

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.

The Role of Cognitions and Beliefs in Trichotillomania: A Qualitative Study Using Interpretative Phenomenological Analysis

Trichotillomania (TTM) is characterised by the removal of one's hair, causing hair loss. Phenomenological research on TTM has investigated its associated behavioural and affective factors. Few studies have investigated the possible role of cognitions and beliefs, despite emerging support for cognitive therapies in treating this disorder. This study aimed to explore and describe the cognitions and beliefs that contribute to the onset and maintenance of hairpulling in TTM. Eight women with TTM participated in semi-structured, in-depth interviews to explore their experience of cognitions and beliefs before, during and after typical hairpulling episodes. Interviews were analysed using the qualitative method of Interpretative Phenomenological Analysis. Six superordinate themes of beliefs were identified as important: negative self-beliefs, control beliefs, beliefs about coping, beliefs about negative emotions, permission-giving beliefs, and perfectionism. These preliminary findings suggest that cognitions may play an important role in TTM phenomenology. Future quantitative research on the role of cognitions and beliefs in TTM in larger samples has the potential to advance cognitive-behavioural models and treatments of this poorly understood disorder.

Diagnosis, evaluation, and management of trichotillomania

Trichotillomania, or chronic hairpulling, is a common condition that affects primarily women. The disorder can cause significant psychosocial impairment and is associated with elevated rates of psychiatric comorbidity. In this article, the phenomenology, etiology, assessment, and treatment of the disorder are discussed.

Evidence-based assessment of compulsive skin picking, chronic tic disorders and trichotillomania in children

Body-focused repetitive behavior (BFRB) is an umbrella term for debilitating, repetitive behaviors that target one or more body regions. Despite regularly occurring in youth, there has been limited investigation of BFRBs in pediatric populations. One reason for this may be that there are few reliable and valid assessments available to evaluate the presence, severity and impairment of BFRBs in youth. Given the shift toward evidence-based assessment in mental health, the development and utilization of evidence-based measures of BFRBs warrants increasing attention. This paper examines the available evidence-base for assessments in youth across three BFRB-related disorders: compulsive skin picking, chronic tic disorders and trichotillomania. Based upon present empirical support in samples of youth, recommendations are made for an evidence-based assessment of each condition.

Prototype awareness enhancing and monitoring device for trichotillomania

Trichotillomania is an impairing condition that involves repetitive hair pulling. Habit reversal therapy is helpful for many persons with this disorder. Unfortunately, habit reversal therapy is not helpful for everyone and maintenance of gains is often problematic. Successful habit reversal therapy requires the individual to be aware of hair pulling and handling. Unfortunately, most people with trichotillomania report that much of their plucking occurs outside of awareness. Monitoring of trichotillomania behaviors is also problematic. The present project involved a pilot study of a prototype awareness enhancing and monitoring device aimed at increasing the effectiveness of habit reversal therapy. The device included a watch, bracelet, magnetic necklace, and a pager that was hard-wired for remote activation of a vibrating alert when hair pulling behaviors occurred. Following structured diagnostic assessment, three female participants were randomly assigned to be initially observed for varied lengths of time without the device followed by observation with the device in place. The results indicated a marked reduction in trichotillomania behaviors when the device was in place. Semi-structured interviews revealed that the device was very effective in enhancing awareness and monitoring of trichotillomania related behaviors and enthusiastic acceptance of the device was provided by all participants.

Motor inhibition in trichotillomania and obsessive-compulsive disorder

We investigated motor inhibition abilities in trichotillomania (TTM) and obsessive-compulsive disorder (OCD), two disorders characterized by repetitive, intentionally performed behaviors. Performance in a GoNogo experiment of 25 TTM and 21 OCD participants was compared to the performance of 26 HC participants. In contrast to OCD and HC participants, TTM participants tended to perform either 'fast and inaccurate' (indicating poor motor inhibition) or 'slow and accurate'. TTM participants with poor motor inhibition reported a significantly earlier age of TTM onset than those TTM participants who performed well. There was no evidence for motor inhibition deficits in OCD. Based on our data, a subgroup of TTM sufferers seems to be characterized by motor inhibition deficits.

Factor analysis of the Massachusetts General Hospital Hairpulling Scale

OBJECTIVE

We explored the factor structure of the Massachusetts General Hospital Hairpulling Scale (MGH-HPS), a self-report measure for trichotillomania (TTM).

METHODS

Self-reported hairpullers who responded to an Internet-based survey (N=990) completed the MGH-HPS, demographic items, and other survey instruments. Principal axis exploratory factor analysis with Promax rotation of scores was conducted.

RESULTS

A two-factor solution was revealed, with "Severity" and "Resistance and Control" as separate factors.

CONCLUSION

The MGH-HPS consists of two separate factors. Factor scores can be utilized to track naturalistic TTM symptom changes, improve patient characterization and treatment matching, and clarify the timing and mechanism of action for different treatment modalities.

Trichotillomania +/- trichobezoar: revisited

Trichotillomania is an intriguing psychosomatic entity in which there is an irresistible desire to pull out the hair from the scalp, eyelashes, eyebrows and other parts of the body. The process results in an instant release of tension, a sense of relief and security. However, non-scaring alopecia is its clinical presentation. The development of trichobezoar following ingestion of the pulled hair is its salient complication in a few cases. Subsequently, it may cause symptoms pertaining to the gastrointestinal tract culminating in intestinal obstruction, perforation, pancreatitis and obstructive jaundice. The Rapunzel syndrome (trichobezoar) may occur when gastrointestinal obstruction is produced by a rare manifestation of a trichobezoar with a long tail that extends to or beyond the ileocecal valve. In most cases in children, trichotillomania +/- trichobezoar is a habit disorder and thus has a better prognosis. However, in adults the psychopathology is usually deeper and thus entails a poor prognosis. The diagnosis is made after taking a thorough history, noting the clinical features and evaluating a hair-root examination, where telogen hair is (almost) completely lacking, which distinguish trichotillomania from other hair disorders. Treatment modalities vary in childhood and adult varieties. Apart from psychotherapy, the drug treatment involves several agents including selective serotonin reuptake inhibitors (SSRIs) and domipramine. Trichobezoar/Rapunzel syndrome requires surgical intervention.

Impulsivity and compulsivity in patients with trichotillomania or skin picking compared with patients with obsessive-compulsive disorder

To compare impulsivity and compulsivity, we performed a case control study comparing a group of 20 patients with obsessive-compulsive disorder with a group of 20 patients with skin picking and/or trichotillomania (SP/T). The instruments used were Structured Clinical Interview for DSM-IV Axis I Diagnosis, Yale-Brown Obsessive-Compulsive Scale, Schalling Impulsivity Scale, and Hamilton Anxiety and Depression Inventories. A Multidimensional Impulsive-Compulsive Spectrum Assessment Instrument was designed for this particular study. The Yale-Brown Obsessive-Compulsive Scale scores were significantly higher in patients with obsessive-compulsive disorder, compared with patients with SP/T (F = 90.29; P < .001). The Hamilton Inventories and Schalling Impulsivity Scale revealed no significant intergroup differences. The Multidimensional Impulsive-Compulsive Spectrum Assessment Instrument allowed us to find 6 statistically significant differences between groups: the ability or inability to delay an impulse, quick response or action planning, feelings of pleasure or guilt during or after an act, ritualization, and whether the patient believes he/she has losses or benefits if prevented from acting. In conclusion, SP/T should deserve further attention about their classification in future versions of diagnostic manuals because, as in International Classification of Diseases, Tenth Revision, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition includes these disorders in the same chapter as pathological gambling, kleptomania, pyromania and others. Despite their resemblance to compulsions, their classification under the Obsessive-Compulsive Spectrum needs particular phenomenological and neurobiologic investigation.

Understanding and treating trichotillomania: what we know and what we don't know

This article reviews current issues in the understanding and clinical management of trichotillomania (TTM). After diagnostic considerations and epidemiology are discussed, a brief update on biologic and environmental precipitants is provided, and emerging research on possible TTM subtypes is discussed. Current strategies for assessing TTM and t heir applicability to clinical practice are reviewed, as is the current state of pharmacologic and nonpharmacologic treatments for the disorder. The article concludes with suggestions for future research and descriptions of the authors'research agenda.

Trichotillomania: impact on psychosocial functioning and quality of life

This study explored the impact of hair pulling on psychosocial functioning for patients diagnosed with trichotillomania (TTM; n = 28). TTM patients were compared to age and gender-matched groups of psychiatric patients without TTM (n = 28) and nonpsychiatric control volunteers (NC, n = 28) on measures of psychological distress, functioning/quality of life, and self-esteem. Results indicated that TTM patients reported more severe psychosocial impairments than did NC volunteers; however, these differences were mediated by differences in level of depression. Regression analyses indicated significant relationships between some measures of psychosocial functioning and severity of hair pulling, independent of level of depression. Finally, an interview of the impact of hair pulling on 6 domains of daily functioning (negative affect/negative self-evaluations, grooming, recreational activities, social interaction, work/housework productivity, and physical health) indicated common and wide-ranging impairments for both lifetime and current (i.e., past week) ratings. These results highlight the importance of promoting and improving resources for the clinical care of TTM patients, and provide some directions for clinicians to enhance assessment of interference caused by TTM.

Affective correlates of trichotillomania

Affective correlates of hair pulling were investigated in a sample of 44 participants diagnosed with trichotillomania (TM). Participants completed the Hair Pulling Survey on which they rated the intensity of ten different affective states across three different phases of hair pulling (before, during and after). Repeated measures analysis of variance was used to examine the change of emotional experience across the hair pulling cycle. Results indicated significant decreases in boredom, anxiety and tension, and significant increases in guilt relief, sadness and anger across time (p<0.005). The role of co-existent anxiety and mood disorders also was examined using repeated measures analysis of variance. Results of these analyses indicated that patients with and without co-existent disorders differed only on patterns of anger across time, and therefore do not support affective subtypes of TM patients based on co-existent diagnosis. Implications of these findings for conceptualization and treatment of TM are discussed.

A cognitive-behavioral/psychophysiological model of tic disorders

This article discusses current cognitive behavioral, as well as neurophysiological, accounts of the development and maintenance of tic behavior in chronic (simple or complex) tic disorders. A cognitive psychophysiological model is further elaborated, highlighting the reciprocal interplay of background cognitive and physiological factors preceding tic onset. According to the model, cognitive factors such as perfectionist concerns and heightened sensory awareness and self-attention, as well as physiological factors such as a high level of motor activation and accompanying elevated muscle tension, play a role in tic habits. Negative appraisals of tics and counter-productive coping strategies developed by clients as a means to suppress or to disguise the tic behavior may also locally reinforce tic onset. Neurochemical factors are viewed largely as concomitants of behavioral adaptations or compensations to the tic problem rather than as independent markers or precursors of tic onset. Clinically, the model emphasizes the role of cognitive-behavioral factors in tic onset, and suggests that tic management is best accomplished through cognitive behavioral interventions designed to prevent build up of both tension and pre-monitory urge in tic-affected muscles, rather than reverse the tic at the onset of the premonitory urge. The clinical validity of parts of the model is supported by recent experimental, psychometric and clinical studies. Other parts of the model remain speculative but at least yield testable predictions. A strength of the model is its ability to account for findings over diverse psychological and biological domains.

Evaluation of a cognitive-behavioural program for the management of chronic tic and habit disorders

The aim was to evaluate the efficacy of a manualized cognitive-behavioural program based on habit reversal for the management of chronic tic disorder (CTD) and habit disorder (HD). Forty-seven CTD and 43 HD received a 4-month treatment program. Thirty-eight (22 CTD, 16 HD) were placed on a waitlist control group, which subsequently received treatment. The treatment approach combined awareness training, relaxation (including modification of a tension-producing style of action), and habit-reversal training, with more general cognitive restructuring of anticipations linked to ticcing. Sixty-five percent of completers reported between 75 and 100% control over the tic. At 2-year follow-up, 52% rated 75-100% control. There were also significant changes post-treatment in measures of self-esteem, anxiety, depression and style of planning action. Successful tic/habit modification was associated in CTD and HD groups with successful change in style of planning action. There were no consistent differences in any outcome measures between CTD and HD groups.

Trichotillomania: a challenge to research and practice

This review explores several aspects of trichotillomania relevant to clinical theory and practice. It is concluded that research outlining the phenomenology and patterns of comorbidity of trichotillomania have been advanced significantly in recent years. However, no current diagnostic category appropriately classifies trichotillomania. Research with nonclinical populations suggests that trichotillomania is more common than previously believed and that additional epidemiological research is warranted. Continued elaboration of existing etiological models incorporating varying theoretical perspectives is also encouraged. Assessment of trichotillomania could also be improved by the continued development of reliable and valid standardized measures. This article reviews both pharmacological and psychological treatments for trichotillomania, with an emphasis on habit-reversal training. Though some interventions appear effective in the short-term, reported relapse rates are high and future research on treatment for trichotillomania should focus on improving long-term outcomes. It is clear that despite a recent flux of research centering on trichotillomania, significant challenges for understanding and treating this psychological disorder still exist for researchers and clinicians. Based on this review of the literature, and on our clinical experience with trichotillomania, we propose directions for future research with this underserved psychiatric group.

Trichotillomania: current issues in conceptualization and treatment

Trichotillomania is a little-known disorder with wider prevalence and more significant consequences than previously believed. While sharing similarities with obsessive-compulsive disorder, compelling differences from it have also been noted. This fact, coupled with recognized overlap with other obsessive-compulsive spectrum disorders, has resulted in the ongoing evolution of our conceptualization of this illness. While empirical evidence supports the use of behavioral treatment and pharmacotherapy, considerable research is still needed before we can promise highly effective interventions tailored to the individual hairpuller. This review will summarize the evidence supporting, as well as challenging, a hypothesized link with obsessive-compulsive disorder. Current treatment approaches will be reviewed, as well as evidence for their efficacy. Suggestions will be made for future directions in this field.

Fluvoxamine treatment of trichotillomania

The present study examined the efficacy of fluvoxamine in the treatment of trichotillomania (TM) and coexistent clinical features. Twenty-one participants with a principal diagnosis of TM were given fluvoxamine in a 12-week open trial. For 13 patients who completed treatment, significant improvement was noted on only a few measures of hair pulling. End-state analyses for the entire group of participants, however, demonstrated significant improvement in measures of distress, duration, control, and resistance. Significant decreases over treatment were also found on measures of coexistent anxiety for both the completer and the entire participant groups; depressive symptoms improved for completers. Conclusions about the effectiveness of fluvoxamine for treatment of TM cannot be drawn, given the uncontrolled nature of the study; however, end-state analyses suggest the potential utility of fluvoxamine in a subset of patients with TM.

Use of the selective serotonin reuptake inhibitor citalopram in treatment of trichotillomania

Previous trials of selective serotonin reuptake inhibitors (SSRIs) in the treatment of trichotillomania have provided conflicting data. Furthermore, the efficacy of citalopram, the most selective of the SSRIs, in trichotillomania has not previously been documented. Citalopram was used on an open-label naturalistic basis in 14 (1 male and 13 females) patients who presented with chronic hair-pulling and met DSM-IV criteria for trichotillomania. Ratings were completed every 2 weeks for 12 weeks, during which time dosage was increased to a maximum of 60 mg daily (mean dose 36.2 +/- 13.9 mg). One patient was unable to tolerate citalopram. In completers, ratings on each of the scales employed were significantly improved after treatment. Of completers 38.5% were responders (Clinical Global Impressions score of 2 or less) at week 12. Citalopram appears to be safe in trichotillomania, and it may be effective in a subset of patients. Given the relatively low response rate, however, a controlled trial is needed before this agent can be said to be more effective than placebo. The pharmacotherapy of trichotillomania deserves further study.

Nonclinical hair-pulling: affective correlates and comparison with clinical samples

The purposes of the current study were to examine the affective states associated with hair-pulling in a nonclinical sample and to compare levels of general psychopathology in nonclinical hair-pullers and clinic patients with trichotillomania (TM) or obsessive-compulsive disorder (OCD). Subjects included 66 college undergraduates who engaged in hair-pulling unrelated to grooming, 18 patients with TM and 29 patients with OCD. Dimensional (but not categorical) ratings of affective experiences in the nonclinical sample indicated that hair-pulling was associated with decreases in tension, boredom, anger and sadness. Further, the relationship between emotional experiences before and after hair-pulling was more salient than the pre-during relationship conceptualized as central in current diagnostic criteria for TM. Comparisons of psychopathology in nonclinical and clinical samples failed to support a continuum notion of increasing symptomatology in nonclinical pullers, TM patients and individuals with OCD. Some evidence of increased pathology in nonclinical pullers relative to TM patients was obtained, as was further support for a distinction between TM and OCD. Implications of this investigation for conceptualization of TM are discussed.

The assessment of trichotillomania

Trichotillomania is a disorder characterized by hair-pulling and resulting hair loss. Hair is usually pulled from the scalp, eyelashes, eyebrows, beard, and pubic area. Sufferers often resort to wearing wigs or elaborate hair styles and make-up to camouflage bald patches. It occurs more frequently in women and is associated with considerable distress. The two treatments of choice currently are pharmacotherapy and cognitive-behavioral therapy. The choice of assessment procedures includes self-monitoring, saving hairs, interview, observational rating, digital photograph and computer scoring, significant others' report, and standardized measures. Goals of assessment in trichotillomania and advantages and disadvantages of assessment procedures are discussed. The Trichotillomania Diagnostic Interview is presented as a standardized diagnostic interview.