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Barber KE, Woods DW, Deckersbach T, Bauer CC, Compton SN, Twohig MP, Ricketts EJ, Robinson J, Saunders SM, Franklin ME. Neurocognitive functioning in adults with trichotillomania: Predictors of treatment response and symptom severity in a randomized control trial. Behav Res Ther 2024; 179:104556. [PMID: 38761558 DOI: 10.1016/j.brat.2024.104556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/26/2024] [Accepted: 05/02/2024] [Indexed: 05/20/2024]
Abstract
Trichotillomania (TTM) is associated with impairments in response inhibition and cognitive flexibility, but it is unclear how such impairments relate to treatment outcome. The present study examined pre-treatment response inhibition and cognitive flexibility as predictors of treatment outcome, change in these domains from pre-to post-treatment, and associations with TTM severity. Participants were drawn from a randomized controlled trial comparing acceptance-enhanced behavior therapy (AEBT) to psychoeducation and supportive therapy (PST) for TTM. Adults completed assessments at pre-treatment (n = 88) and following 12 weeks of treatment (n = 68). Response inhibition and cognitive flexibility were assessed using the Stop Signal Task and Object Alternation Task, respectively. Participants completed the MGH-Hairpulling Scale. Independent evaluators administered the NIMH-Trichotillomania Severity Scale and Clinical Global Impressions-Improvement Scale. Higher pre-treatment TTM severity was associated with poorer pre-treatment cognitive flexibility, but not response inhibition. Better pre-treatment response inhibition performance predicted positive treatment response and lower post-treatment TTM symptom severity, irrespective of treatment assignment. Cognitive flexibility did not predict treatment response. After controlling for age, neither neurocognitive variable changed during treatment. Response inhibition and cognitive flexibility appear uniquely related to hair pulling severity and treatment response in adults with TTM. Implications for treatment delivery and development are discussed.
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Affiliation(s)
- Kathryn E Barber
- Department of Psychology, Marquette University, 317 604 N. 16th St. Milwaukee, WI, 53233, USA.
| | - Douglas W Woods
- Department of Psychology, Marquette University, 317 604 N. 16th St. Milwaukee, WI, 53233, USA
| | - Thilo Deckersbach
- University of Applied Sciences, DIPLOMA Hochschule, Am Hegeberg 2, 37242 Bad Sooden-Allendorf, Germany
| | - Christopher C Bauer
- Medical College of Wisconsin, Health Resource Center, 8701 Watertown Plank Rd., 5th Floor, Milwaukee, WI, 53226, USA
| | - Scott N Compton
- Department of Psychiatry and Behavioral Sciences, Duke University, Duke Child and Family Study Center, 2608 Erwin Road Durham, NC, 27705, USA
| | - Michael P Twohig
- Utah State University, Department of Psychology, 2810 Old Main Hill, Logan, UT, 84322, USA
| | - Emily J Ricketts
- Department of Neuroscience, UCLA Semel Institute, 1506 Gonda Center Los Angeles, California, 90095, USA
| | - Jordan Robinson
- JSR Neuropsychological Services, 3209 W 76th St, Edina, MN, 55435, USA
| | - Stephen M Saunders
- Department of Psychology, Marquette University, 317 604 N. 16th St. Milwaukee, WI, 53233, USA
| | - Martin E Franklin
- Rogers Behavioral Health, 1 Winding Drive, Suite 106, Philadelphia, PA, 19131, USA
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Reid M, Lin A, Farhat LC, Fernandez TV, Olfson E. The genetics of trichotillomania and excoriation disorder: A systematic review. Compr Psychiatry 2024; 133:152506. [PMID: 38833896 DOI: 10.1016/j.comppsych.2024.152506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 05/09/2024] [Accepted: 05/30/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND Trichotillomania (TTM) and excoriation disorder (ED) are impairing obsessive-compulsive related disorders that are common in the general population and for which there are no clear first-line medications, highlighting the need to better understand the underlying biology of these disorders to inform treatments. Given the importance of genetics in obsessive-compulsive disorder (OCD), evaluating genetic factors underlying TTM and ED may advance knowledge about the pathophysiology of these body-focused repetitive behaviors. AIM In this systematic review, we summarize the available evidence on the genetics of TTM and ED and highlight gaps in the field warranting further research. METHOD We systematically searched Embase, PsycInfo, PubMed, Medline, Scopus, and Web of Science for original studies in genetic epidemiology (family or twin studies) and molecular genetics (candidate gene and genome-wide) published up to June 2023. RESULTS Of the 3536 records identified, 109 studies were included in this review. These studies indicated that genetic factors play an important role in the development of TTM and ED, some of which may be shared across the OCD spectrum, but there are no known high-confidence specific genetic risk factors for either TTM or ED. CONCLUSIONS Our review underscores the need for additional genome-wide research conducted on the genetics of TTM and ED, for instance, genome-wide association and whole-genome/whole-exome DNA sequencing studies. Recent advances in genomics have led to the discovery of risk genes in several psychiatric disorders, including related conditions such as OCD, but to date, TTM and ED have remained understudied.
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Affiliation(s)
- Madison Reid
- Child Study Center, Yale University School of Medicine, New Haven, CT, USA; The University of the South, USA
| | - Ashley Lin
- Child Study Center, Yale University School of Medicine, New Haven, CT, USA
| | - Luis C Farhat
- Department of Psychiatry, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Thomas V Fernandez
- Child Study Center, Yale University School of Medicine, New Haven, CT, USA; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Emily Olfson
- Child Study Center, Yale University School of Medicine, New Haven, CT, USA; Wu Tsai Institute, Yale University, New Haven, CT, USA.
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Barber KE, Woods DW, Ely LJ, Saunders SM, Compton SN, Neal-Barnett A, Franklin ME, Capriotti MR, Conelea CA, Twohig MP. Long-term follow-up of acceptance-enhanced behavior therapy for trichotillomania. Psychiatry Res 2024; 333:115767. [PMID: 38330639 PMCID: PMC10911454 DOI: 10.1016/j.psychres.2024.115767] [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: 10/16/2023] [Revised: 01/26/2024] [Accepted: 01/28/2024] [Indexed: 02/10/2024]
Abstract
Acceptance-enhanced behavior therapy for trichotillomania (AEBT-TTM) is effective in reducing trichotillomania (TTM) symptoms, but the durability of treatment effects remains in question. This study analyzed 6-month follow-up data from a large randomized clinical trial comparing AEBT-TTM to an active psychoeducation and supportive therapy control (PST). Adults with TTM (N=85; 92% women) received 10 sessions of AEBT-TTM or PST across 12 weeks. Independent evaluators assessed participants at baseline, post-treatment, and 6 months follow-up. For both AEBT-TTM and PST, self-reported and evaluator-rated TTM symptom severity decreased from baseline to follow-up. TTM symptoms did not worsen from post-treatment to follow-up. At follow-up, AEBT-TTM and PST did not differ in rates of treatment response, TTM diagnosis, or symptom severity. High baseline TTM symptom severity was a stronger predictor of high follow-up severity for PST than for AEBT-TTM, suggesting AEBT-TTM may be a better option for more severe TTM. Results support the efficacy of AEBT-TTM and show that treatment gains were maintained over time. Although AEBT-TTM yielded lower symptoms at post-treatment, 6-month follow-up outcomes suggest AEBT-TTM and PST may lead to similar symptom levels in the longer term. Future research should examine mechanisms that contribute to long-term gain maintenance.
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Affiliation(s)
- Kathryn E Barber
- Department of Psychology, Marquette University, 317 Cramer Hall, 604 North 16th St., Milwaukee, WI 53233, USA
| | - Douglas W Woods
- Department of Psychology, Marquette University, 317 Cramer Hall, 604 North 16th St., Milwaukee, WI 53233, USA.
| | - Laura J Ely
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Stephen M Saunders
- Department of Psychology, Marquette University, 317 Cramer Hall, 604 North 16th St., Milwaukee, WI 53233, USA
| | - Scott N Compton
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | | | | | | | - Christine A Conelea
- Department of Psychiatry & Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA
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Hicks MM, Mouton-Odum S, Patyk KC, Zamora RJ, De Nadai AS. Latent class analysis of emotions experienced during compulsive hair-pulling episodes. J Behav Ther Exp Psychiatry 2023; 81:101882. [PMID: 37331096 DOI: 10.1016/j.jbtep.2023.101882] [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] [Received: 03/11/2022] [Revised: 04/11/2023] [Accepted: 05/23/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND AND OBJECTIVES Reasons for compulsive hair pulling are heterogeneous and not fully understood. Given that many people who experience compulsive hair pulling do not respond to treatment, identifying subgroups can inform potential mechanisms and treatment design. METHODS We sought to identify empirical subgroups among participants in an online treatment program for trichotillomania (N = 1728). A latent class analysis was used to identify patterns of emotions associated with compulsive hair-pulling episodes. RESULTS Six classes of participants were found which reflected three predominant themes. One theme reflected expected patterns, where emotional changes were seen following pulling. Two other themes were more surprising, where one reflected high overall emotional activation that did not show consistent change in response to pulling, and another showed low emotional activation overall. These results suggest that there are multiple types of hair-pulling and a sizeable group of people may benefit from treatment adjustments. LIMITATIONS Participants did not receive semi-structured diagnostic assessment. A majority of participants were Caucasian, and future research would benefit from increased participant diversity. Emotions associated with compulsive hair-pulling were measured across an entire treatment program, but the relationship between specific intervention components and change in specific emotions was not systematically collected. CONCLUSIONS While previous research has addressed overall phenomenology and comorbidity, the present study is the first to identify empirical subgroups of people who experience compulsive hair-pulling at the level of individual pulling episodes. Identified participant classes had distinguishing features that can aid in personalizing treatment to individual symptom presentations.
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Affiliation(s)
- Macy M Hicks
- Psychology Department, Texas State University, San Marcos, TX, USA.
| | - Suzanne Mouton-Odum
- Psychiatry and Behavioral Sciences, Baylor College of Medicine; Psychology Houston, PC, Director, Houston, TX, USA
| | | | - Ryan J Zamora
- McLean Hospital, Harvard Medical School, Belmont, MA, USA
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Rahman SM, Jafferany M, Barkauskaite R. Habit-reversal training: a psychotherapeutic approach in treating body-focused repetitive behaviour disorders. Clin Exp Dermatol 2023; 48:1310-1316. [PMID: 37470438 DOI: 10.1093/ced/llad247] [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: 06/08/2023] [Revised: 06/29/2023] [Accepted: 07/17/2023] [Indexed: 07/21/2023]
Abstract
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.
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Affiliation(s)
- Syed Minhaj Rahman
- Department of Dermatology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Mohammad Jafferany
- Department of Psychiatry, Central Michigan University/CMU Medical Education Partners, Saginaw, MI, USA
| | - Ruta Barkauskaite
- Institute of Psychology, Mykoles Romeris University, Vilnius, Lithuania
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Miller ML, McGuire JF. Targeting intolerance of uncertainty in treatment: A meta-analysis of therapeutic effects, treatment moderators, and underlying mechanisms. J Affect Disord 2023; 341:283-295. [PMID: 37657623 DOI: 10.1016/j.jad.2023.08.132] [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] [Received: 06/22/2023] [Revised: 08/21/2023] [Accepted: 08/29/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVE Anxiety-related disorders are among the most prevalent psychiatric conditions and cause significant impairment. Intolerance of uncertainty (IU) contributes to the emergence, maintenance, and symptom severity of anxiety-related disorders, yet information regarding treatment-related changes in IU is limited. This systematic review and meta-analysis examined the efficacy of evidence-based treatments for anxiety-related disorders on IU, explored factors moderating treatment effects of IU, and examined whether therapeutic improvement in IU corresponded with improvements in anxiety symptom severity. METHODS PubMED and PsycINFO were searched for randomized controlled trials (RCTs) using the terms "intolerance of uncertainty" AND "treatment" OR "therapy." Data for pre and post-treatment measures and patient, intervention, and trial-level characteristics were extracted from 28 RCTs. Separate random effects models examined the treatment efficacy of interventions on IU and symptom severity. Moderators of therapeutic effects were analyzed via method-of-moments meta-regression or an analog to the analysis of variance. RESULTS Across RCTs, interventions exhibited a large therapeutic effect on IU compared to control conditions (g = 0.89). Treatment effects on IU positively corresponded with improved symptom severity and accounted for 36 % of the variance. Interestingly, comorbid depression and certain treatment approaches were associated with larger improvements in IU. CONCLUSION Evidence-based treatments are effective in improving IU, highlighting the importance of IU in the treatment of anxiety-related disorders. Moderator analyses identified patient and intervention-level factors to inform approaches to improve therapeutic effects on IU. Future research is needed to optimize interventions targeting IU and evaluate long-term efficacy of interventions on IU for anxiety-related disorders.
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Affiliation(s)
- Michelle L Miller
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Joseph F McGuire
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America.
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Bhat RR, Vellekkat F, Goutama IL, Gill PS, Kakar G, Jabeen H, Gireesh K, Sanker V, Gupta U. A case of trichotillomania and bulimia nervosa in a patient with adult-onset attention-deficit/hyperactivity disorder (ADHD). Clin Case Rep 2023; 11:e7800. [PMID: 37601423 PMCID: PMC10432585 DOI: 10.1002/ccr3.7800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/08/2023] [Accepted: 07/27/2023] [Indexed: 08/22/2023] Open
Abstract
Key Clinical Message Identifying any potential comorbidity such as bulimia nervosa (BN) and ADHD in trichotillomania patients is essential for a thorough treatment plan. Combining a multidisciplinary approach was found to be feasible and effective in the treatment. Abstract Trichotillomania is frequently considered an isolated disorder; nevertheless, emerging evidence suggests that other psychiatric conditions, including obsessive-compulsive disorder (OCD), eating disorders, and attention-deficit/hyperactivity disorder (ADHD), are often found to coexist. Several studies showed that eating disorders, such as bulimia nervosa, were found in chronic hair-pullers, while OCD was considered a factor in predicting the prevalence of eating disorders, as well as the severity of trichotillomania in the populations. While the relationship between trichotillomania and OCD has been quite well-documented, the evidence of its association with bulimia nervosa and ADHD remains limited. Here, we report a case of trichotillomania with comorbid bulimia nervosa, major depressive disorder, and ADHD.
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Affiliation(s)
- Rakshita Ramesh Bhat
- Bangalore Medical College and Research InstituteBangaloreIndia
- Team ErevnitesTrivandrumIndia
| | - Faheem Vellekkat
- Team ErevnitesTrivandrumIndia
- Indira Gandhi Medical College and Research InstitutePuducherryIndia
| | - Ivany Lestari Goutama
- Team ErevnitesTrivandrumIndia
- Faculty of MedicineTarumanagara UniversityJakartaIndonesia
| | | | - Gauri Kakar
- Team ErevnitesTrivandrumIndia
- Jawaharlal Nehru Medical CollegeWardhaIndia
| | - Hafsa Jabeen
- Team ErevnitesTrivandrumIndia
- Dow Medical CollegeKarachiPakistan
| | - Krishnan Gireesh
- Team ErevnitesTrivandrumIndia
- School of Behavioural SciencesTamil NaduIndia
| | - Vivek Sanker
- Team ErevnitesTrivandrumIndia
- Noorul Islam Institute of Medical SciencesTrivandrumIndia
| | - Umang Gupta
- Team ErevnitesTrivandrumIndia
- Nepalgunj Medical CollegeNepalgunjNepal
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Ong CW, Woods DW, Franklin ME, Saunders SM, Neal-Barnett AM, Compton SN, Twohig MP. The role of psychological flexibility in acceptance-enhanced behavior therapy for trichotillomania: Moderation and mediation findings. Behav Res Ther 2023; 164:104302. [PMID: 37030243 PMCID: PMC10115155 DOI: 10.1016/j.brat.2023.104302] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 03/16/2023] [Accepted: 03/18/2023] [Indexed: 04/07/2023]
Abstract
Trichotillomania is characterized by recurrent pulling out of one's hair, leading to significant hair loss and accompanied by clinically significant distress and/or functional impairment. The current study used data from a randomized controlled trial comparing the effectiveness of acceptance-enhanced behavior therapy (AEBT) to psychoeducation plus supportive therapy (PST; active control) for trichotillomania in an adult sample. The objectives were to examine the moderating and mediating influence of trichotillomania-specific psychological flexibility in treatment for trichotillomania. Participants with lower baseline flexibility performed better in AEBT than PST in terms of greater symptom reduction and quality of life. Lower baseline flexibility also predicted higher likelihood of disorder recovery in AEBT relative to PST. In addition, relative to PST, symptom reduction in AEBT was mediated by psychological flexibility, controlling for anxiety and depression. These findings suggest that psychological flexibility is a relevant process of change in the treatment of trichotillomania. Clinical implications and directions for future research are discussed.
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Affiliation(s)
- Clarissa W Ong
- Department of Psychology, University of Toledo, Toledo, OH, USA.
| | - Douglas W Woods
- Department of Psychology, Marquette University, Milwaukee, WI, USA
| | | | | | | | - Scott N Compton
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
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Comertoglu Arslan S, Uzun Cicek A, Ucuz I, Dogru H. Sociodemographic variables, clinical characteristics, and treatments in children with trichotillomania in terms of age and gender: a multicenter study. Nord J Psychiatry 2023; 77:36-45. [PMID: 35352628 DOI: 10.1080/08039488.2022.2052179] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Although trichotillomania (TTM) is a common, typically pediatric-onset disorder, data on the phenomenology of TTM in children, accompanying comorbid psychiatric disorders, and treatment options are extremely limited. In our study, it was aimed to investigate these variables and related factors in patients undergoing psychiatric evaluation and follow-up. METHOD The study included 79 children and adolescents between the ages of 4 and 17 who were diagnosed with TTM and followed up in four different Child and Adolescent Psychiatry outpatient clinics between 2015 and 2020. The sociodemographic characteristics of these patients, clinical features of the disease, comorbid psychiatric disorders, and treatment approaches have been studied. RESULTS Our results showed that TTM was more common in girls, hair and eyebrow plucking was the most common, and symptoms and features accompanying TTM changed with age, but not with gender. Again, 79.7% of these children had at least one psychiatric comorbid disorder (most common being anxiety disorders and Attention Deficit/Hyperactivity Disorder), comorbidity was closely related to TTM severity, 93.7% used at least one pharmacotherapeutic agent, and positive response rates to treatment were found to be low. Moreover, TTM severity was found to increase with age and disease duration. CONCLUSION Study findings support that clinical presentation, disease severity and comorbidity rates may change with age in children and adolescents with TTM, and early intervention is important to prevent clinical progression/worsening and mental health sequela.
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Affiliation(s)
- Semiha Comertoglu Arslan
- Department of Child and Adolescent Psychiatry, Kahramanmaras Sutcuımam University, Kahramanmaras, Turkey
| | - Ayla Uzun Cicek
- Department of Child and Adolescent Psychiatry, Cumhuriyet University, Sivas, Turkey
| | - Ilknur Ucuz
- Department of Child and Adolescent Psychiatry, Inonu University, Malatya, Turkey
| | - Hicran Dogru
- Department of Child and Adolescent Psychiatry, Ataturk University, Erzurum, Turkey
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Woods DW, Ely LJ, Bauer CC, Twohig MP, Saunders SM, Compton SN, Espil FM, Neal-Barnett A, Alexander JR, Walther MR, Cahill SP, Deckersbach T, Franklin ME. Acceptance-enhanced behavior therapy for trichotillomania in adults: A randomized clinical trial. Behav Res Ther 2022; 158:104187. [PMID: 36099688 PMCID: PMC9561035 DOI: 10.1016/j.brat.2022.104187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/12/2022] [Accepted: 09/01/2022] [Indexed: 11/21/2022]
Abstract
Given the limited treatment options for trichotillomania (TTM), or Hair Pulling Disorder, this large randomized clinical trial evaluated the efficacy of acceptance-enhanced behavior therapy for TTM (AEBT-TTM) in reducing TTM severity relative to psychoeducation and supportive therapy (PST). Eighty-five adults (78 women) with TTM received 10 sessions (over 12 weeks) of either AEBT-TTM or PST. Independent evaluators masked to treatment assignment assessed participants at baseline (week 0), midpoint (week 6), and endpoint (week 12). Consistent with a priori hypotheses, 64% of the adults treated with AEBT-TTM were classified as clinical responders at post-treatment relative to 38% treated with PST. Clinical responders were identified by a score of 1 or 2 on the Clinical Global Impressions-Improvement (CGI-I) scale. Relative to the PST group, the AEBT-TTM group demonstrated significantly greater pre-to post-treatment reductions on the self-report Massachusetts General Hospital-Hairpulling Scale (MGH-HS) and the evaluator-rated National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS). There were no significant post-treatment group differences on the Clinical Global Impressions-Severity (CGI-S) scale, or rate of TTM diagnoses. Results suggest AEBT-TTM provides greater treatment benefit than PST. Future research should continue to investigate AEBT-TTM along with mediators and moderators of its efficacy.
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Affiliation(s)
- Douglas W Woods
- Marquette University, Department of Psychology, Cramer Hall, Room 317, 604 N. 16th St., Milwaukee, WI, 53233, USA; University of Wisconsin-Milwaukee, Department of Psychology, Garland Hall, Room 224, 2441 E. Hartford Ave., Milwaukee, WI, 53211, USA.
| | - Laura J Ely
- University of Wisconsin-Milwaukee, Department of Psychology, Garland Hall, Room 224, 2441 E. Hartford Ave., Milwaukee, WI, 53211, USA.
| | - Christopher C Bauer
- Marquette University, Department of Psychology, Cramer Hall, Room 317, 604 N. 16th St., Milwaukee, WI, 53233, USA; University of Wisconsin-Milwaukee, Department of Psychology, Garland Hall, Room 224, 2441 E. Hartford Ave., Milwaukee, WI, 53211, USA.
| | - Michael P Twohig
- State University, Department of Psychology, 2810 Old Main Hill, Logan, UT, 84322, USA.
| | - Stephen M Saunders
- Marquette University, Department of Psychology, Cramer Hall, Room 317, 604 N. 16th St., Milwaukee, WI, 53233, USA.
| | - Scott N Compton
- Duke University School of Medicine, Department of Psychiatry & Behavioral Sciences, 2608 Erwin Rd, Suite 300, Durham, NC, 27705, USA.
| | - Flint M Espil
- University of Wisconsin-Milwaukee, Department of Psychology, Garland Hall, Room 224, 2441 E. Hartford Ave., Milwaukee, WI, 53211, USA.
| | - Angela Neal-Barnett
- Kent State University, Department of Psychology, 144 Kent Hall, Kent State University, Kent, OH, 44242-0001, USA.
| | - Jennifer R Alexander
- Marquette University, Department of Psychology, Cramer Hall, Room 317, 604 N. 16th St., Milwaukee, WI, 53233, USA.
| | - Michael R Walther
- University of Wisconsin-Milwaukee, Department of Psychology, Garland Hall, Room 224, 2441 E. Hartford Ave., Milwaukee, WI, 53211, USA.
| | - Shawn P Cahill
- University of Wisconsin-Milwaukee, Department of Psychology, Garland Hall, Room 224, 2441 E. Hartford Ave., Milwaukee, WI, 53211, USA.
| | | | - Martin E Franklin
- Rogers Behavioral Health, 1 Winding Drive, Suite 106, Philadelphia, PA, 19131, USA.
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Popova L, Mancuso J. Dramatic Improvement of Trichotillomania with 6 Months of Treatment With N-Acetylcysteine. Glob Pediatr Health 2022; 9:2333794X221086576. [PMID: 35647220 PMCID: PMC9133858 DOI: 10.1177/2333794x221086576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/17/2022] [Indexed: 11/24/2022] Open
Abstract
We present a case of a 17-year-old male with recurrent hair twirling resulting in patchy alopecia, who improved dramatically on N-acetylcysteine (NAC). Trichotillomania is characterized by repetitive hair pulling, twisting, or twirling and can vary from a mild habit to an impulse-control disorder. Standard treatment for pediatric trichotillomania includes cognitive behavioral therapy or medical therapy with selective serotonin reuptake inhibitors. NAC is a more recently utilized, safe, and well-tolerated over-the-counter supplement with some evidence of benefit for habitual skin and hair disorders. For this patient, we recommended 600 mg twice daily, increasing to 1200 mg twice daily as tolerated. After 6 months, our patient reported decreased desire to twirl his hair and his hair had almost completely regrown. Pediatricians who see patients with trichotillomania or other habitual disorders can consider treating these patients with NAC given its potential benefits and favorable side effect profile.
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Affiliation(s)
- Lilia Popova
- University of Michigan Medical School, Ann
Arbor, MI, USA
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Abstract
ABSTRACT Body-focused repetitive behavior (BFRB) is a significantly underrecognized phenomenon that can cause physical complications and marked mental distress. Understanding the condition and offering patients pharmacologic as well as psychotherapeutic support may effectively reduce adverse health outcomes. This article reviews BFRBs, which can present clinically in multiple settings.
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Affiliation(s)
- Deanna Bridge Najera
- Deanna Bridge Najera practices in the ED at MedStar Montgomery Medical Center in Olney, Md.; in the Reproductive Health Clinic at the Carroll County Health Department in Westminster, Md.; and in psychiatric medical management at True North Wellness Services in Hanover, Pa. The author has disclosed no potential conflicts of interest, financial or otherwise
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Mosca M, Martin K, Hadeler E, Hong J, Brownstone N, Koo J. Review of the diagnosis and management of pediatric psychodermatologic conditions: Part I. Pediatr Dermatol 2022; 39:17-21. [PMID: 34929757 DOI: 10.1111/pde.14888] [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: 06/17/2021] [Revised: 10/29/2021] [Accepted: 11/21/2021] [Indexed: 12/01/2022]
Abstract
Pediatric psychodermatologic conditions encompass both primary dermatologic conditions with psychiatric comorbidities and primary psychiatric conditions with self-induced dermatologic manifestations. Detection, diagnosis, and management of primary psychiatric conditions with dermatologic manifestations are challenging due to patient-perceived stigma and lack of educational opportunities for dermatology providers. This two-part series highlights the most up-to-date evidence-based data and management techniques of some of the more common dermatoses of primary psychiatric conditions in children. Part I includes trichotillomania, skin-picking disorder, and onychophagia, and part II covers dermatitis artefacta, body dysmorphic disorder, and delusions of parasitosis by proxy, with special considerations for family dynamics.
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Affiliation(s)
- Megan Mosca
- Department of Dermatology, Psoriasis and Skin Treatment Center, University of California San Francisco, San Francisco, California, USA
| | - Kari Martin
- Department of Dermatology, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Edward Hadeler
- Department of Dermatology, Psoriasis and Skin Treatment Center, University of California San Francisco, San Francisco, California, USA
| | - Julie Hong
- Department of Dermatology, Psoriasis and Skin Treatment Center, University of California San Francisco, San Francisco, California, USA
| | - Nicholas Brownstone
- Department of Dermatology, Psoriasis and Skin Treatment Center, University of California San Francisco, San Francisco, California, USA
| | - John Koo
- Department of Dermatology, Psoriasis and Skin Treatment Center, University of California San Francisco, San Francisco, California, USA
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14
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Grant JE, Chamberlain SR. Trichotillomania and Skin-Picking Disorder: An Update. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2021; 19:405-412. [PMID: 35747295 DOI: 10.1176/appi.focus.20210013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Trichotillomania (hair pulling disorder) and skin-picking (excoriation) disorder are common neuropsychiatric disorders (each with a point prevalence of around 2%) but are underrecognized by professionals. Affected individuals repeatedly pull out their own hair or pick at their skin, and these symptoms not only have a negative impact on these individuals because of the time they occupy but can also lead to considerable physical disfigurement, with concomitant loss of self-esteem and avoidance of social activities and intimate relationships. The behaviors may also have serious physical consequences. Trichotillomania and skin picking frequently co-occur, and both disorders commonly present with co-occurring depression, anxiety, impulsive, and obsessive-compulsive disorders. Behavioral therapy currently appears to be the most effective treatment for both. Pharmacotherapy, in the form of N-acetylcysteine or olanzapine, may also play a role in treatment.
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Affiliation(s)
- Jon E Grant
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (Grant); Department of Psychiatry, Faculty of Medicine, University of Southampton, and Southern Health NHS Foundation Trust, both in Southampton, United Kingdom (Chamberlain)
| | - Samuel R Chamberlain
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (Grant); Department of Psychiatry, Faculty of Medicine, University of Southampton, and Southern Health NHS Foundation Trust, both in Southampton, United Kingdom (Chamberlain)
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15
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Hoffman J, Williams T, Rothbart R, Ipser JC, Fineberg N, Chamberlain SR, Stein DJ. Pharmacotherapy for trichotillomania. Cochrane Database Syst Rev 2021; 9:CD007662. [PMID: 34582562 PMCID: PMC8478440 DOI: 10.1002/14651858.cd007662.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Trichotillomania (TTM; hair-pulling disorder) is a prevalent and disabling disorder characterised by recurrent hair-pulling. Here we update a previous Cochrane Review on the effects of medication for TTM. OBJECTIVES To assess the effects of medication for trichotillomania (TTM) in adults, children and adolescents compared with placebo or other medication. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, PsycINFO, eleven other bibliographic databases, trial registries and grey literature sources (to 26 November 2020). We checked reference lists and contacted subject experts. SELECTION CRITERIA We selected randomised controlled trials of medication versus placebo or other medication for TTM in adults, children and adolescents. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS Twelve studies were included. We identified 10 studies in adults (286 participants) with a mean sample size of 29 participants per trial; one study in children and adolescents (39 participants); and, one study in adults and adolescents (22 participants: 18 adults and 4 adolescents). All studies were single-centre, outpatient trials. Eleven studies compared medication and placebo (334 participants); one study compared two medications (13 participants). Studies were 5 to 13 weeks duration. We undertook meta-analysis only for opioid antagonists as other comparisons contained a single study, or reported insufficient data. Antioxidants versus placebo in adults There was little to no difference in treatment response between antioxidant (35.7%) and placebo groups (28.6%) after six weeks, based on a single trial of silymarin (risk ratio (RR) 2.25, 95% confidence interval (CI) 0.84 to 5.99; 36 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (18 participants; low-certainty evidence). Antioxidants versus placebo in adolescents There was little to no difference in treatment response between antioxidant (50%) and placebo groups (25%) after six weeks, based on a single trial of silymarin (RR 2.00, 95% CI 0.28 to 14.20; 8 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (8 participants; low-certainty evidence). Antipsychotics versus placebo in adults There may be greater treatment response in the antipsychotic group (85%) compared to the placebo group (17%) after 12 weeks, based on a single trial of olanzapine (RR 5.08, 95% CI 1.4 to 18.37; 25 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (25 participants; low-certainty evidence). Cell signal transducers versus placebo in adults There was little to no difference in treatment response between cell signal transducer (42.1%) and placebo groups (31.6%) after 10 weeks, based on a single trial of inositol (RR 1.33, 95% CI 0.57 to 3.11; 38 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (38 participants; low-certainty evidence). Glutamate modulators versus placebo in adults There is probably greater treatment response in the glutamate modulator group (56%) compared to the placebo group (16%) after 12 weeks, based on a single trial of N-acetylcysteine (RR 3.5, 95% CI 1.34 to 9.17; 50 participants; moderate-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (50 participants; low-certainty evidence). Glutamate modulators versus placebo in children and adolescents There was little to no difference in treatment response between the glutamate modulator (25%) and placebo groups (21.1%) in children and adolescents, based on a single trial of N-acetylcysteine (RR 1.19, 95% CI 0.37 to 3.77; 39 participants; low-certainty evidence). There was little to no difference in dropouts due to adverse events between glutamate modulator (5%) and placebo (0%) groups, based on a single trial (RR 2.86, 95% CI 0.12 to 66.11; 39 participants; low-certainty evidence). Opioid antagonists versus placebo in adults There may be little to no difference in treatment response between opioid antagonist (37.5%) and placebo groups (25%) after six to eight weeks, based on two studies of naltrexone, but the evidence is very uncertain (RR 2.14, 95% CI 0.25 to 18.17; 2 studies, 68 participants; very low-certainty evidence). No data were available regarding dropouts due to adverse events. Selective serotonin reuptake inhibitors (SSRIs) versus placebo in adults There were no data available for treatment response to SSRIs. There was little to no difference in dropouts due to adverse events in the SSRI group (5.1%) compared to the placebo group (0%) after 6 to 12 weeks, based on two trials of fluoxetine (RR 3.00, 95% CI 0.33 to 27.62; 2 studies, 78 participants; low-certainty evidence). Tricyclic antidepressants (TCAs) with predominantly serotonin reuptake inhibitor (SRI) actions versus placebo in adults There may be greater treatment response in the TCAs with predominantly SRI actions group (40%) compared to the placebo group (0%) after nine weeks, but the evidence is very uncertain, based on a single trial of clomipramine (RR 5.73, 95% CI 0.36 to 90.83; 16 participants; very low-certainty evidence). There may be increased dropouts due to adverse events in the TCAs with predominantly SRI actions group (30%) compared to the placebo group (0%), but the evidence is very uncertain (RR 4.45, 95% CI 0.27 to 73.81; 16 participants; very low-certainty evidence). TCAs with predominantly SRI actions versus other TCAs in adults There may be greater treatment response in the TCAs with predominantly SRI actions group compared to the other TCAs group after five weeks, based on a single trial comparing clomipramine to desipramine (mean difference (MD) -4.00, 95% CI -6.13 to -1.87; 26 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (26 participants; low-certainty evidence). AUTHORS' CONCLUSIONS There was insufficient evidence from meta-analysis to confirm or refute the efficacy of any agent or class of medication for the treatment of TTM in adults, children or adolescents. Preliminary evidence suggests there may be beneficial treatment effects for N-acetylcysteine, clomipramine and olanzapine in adults based on four trials, albeit with relatively small sample sizes.
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Affiliation(s)
- Jacob Hoffman
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Taryn Williams
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Rachel Rothbart
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | - Jonathan C Ipser
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Naomi Fineberg
- National Obsessive Compulsive Disorders Treatment Service, Queen Elizabeth II Hospital, Welwyn Garden City, UK
| | | | - Dan J Stein
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
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16
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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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17
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Bellia F, Vismara M, Annunzi E, Cifani C, Benatti B, Dell'Osso B, D'Addario C. Genetic and epigenetic architecture of Obsessive-Compulsive Disorder: In search of possible diagnostic and prognostic biomarkers. J Psychiatr Res 2021; 137:554-571. [PMID: 33213890 DOI: 10.1016/j.jpsychires.2020.10.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/25/2020] [Accepted: 10/28/2020] [Indexed: 02/07/2023]
Abstract
Obsessive-Compulsive Disorder (OCD) is a prevalent and severe clinical condition whose hallmarks are excessive, unwanted thoughts (obsessions) and repetitive behaviors (compulsions). The onset of symptoms generally occurs during pre-adult life and typically affects subjects in different aspects of their life's, compromising social and professional relationships. Although robust evidence suggests a genetic component in the etiopathogenesis of OCD, the causes of the disorder are still not completely understood. It is thus of relevance to take into account how genes interact with environmental risk factors, thought to be mediated by epigenetic mechanisms. We here provide an overview of genetic and epigenetic mechanisms of OCD, focusing on the modulation of key central nervous system genes, in the attempt to suggest possible disease biomarkers.
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Affiliation(s)
- Fabio Bellia
- Faculty of Bioscience, University of Teramo, Teramo, Italy
| | - Matteo Vismara
- Department of Biomedical and Clinical Sciences Luigi Sacco, University of Milan, Milano, Italy
| | - Eugenia Annunzi
- Faculty of Bioscience, University of Teramo, Teramo, Italy; Department of Neuroscience, Imaging and Clinical Sciences, Gabriele D'Annunzio University, Chieti, Italy
| | - Carlo Cifani
- School of Pharmacy, University of Camerino, Camerino, Italy
| | - Beatrice Benatti
- Department of Biomedical and Clinical Sciences Luigi Sacco, University of Milan, Milano, Italy; CRC "Aldo Ravelli", University of Milan, Milano, Italy
| | - Bernardo Dell'Osso
- Department of Biomedical and Clinical Sciences Luigi Sacco, University of Milan, Milano, Italy; CRC "Aldo Ravelli", University of Milan, Milano, Italy; Department of Psychiatry and Behavioral Sciences, Stanford University, CA, USA.
| | - Claudio D'Addario
- Faculty of Bioscience, University of Teramo, Teramo, Italy; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
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18
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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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19
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McGuire JF, Myers NS, Lewin AB, Storch EA, Rahman O. The Influence of Hair Pulling Styles in the Treatment of Trichotillomania. Behav Ther 2020; 51:895-904. [PMID: 33051032 DOI: 10.1016/j.beth.2019.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 11/19/2019] [Accepted: 12/08/2019] [Indexed: 11/15/2022]
Abstract
This report investigated the improvement in Automatic and Focused styles of hair pulling among youth with trichotillomania (TTM). Youth with TTM (N = 40) participated in a clinical trial that compared habit reversal training (HRT) to treatment-as-usual (TAU). Participants completed a baseline assessment to characterize hair pulling severity, self-reported hair pulling styles, and co-occurring psychiatric conditions. Youth were randomly assigned to receive eight weekly sessions of HRT or eight weeks of TAU. Afterward, youth completed a post-treatment assessment of hair pulling severity and hair pulling styles. Youth in the TAU condition then received eight weekly sessions of HRT and completed another post-treatment assessment. Analyses revealed that the Focused pulling style largely improved with HRT (d = 0.73) compared to TAU (d = 0.11). However, there was limited improvement for the Automatic pulling style following either HRT (d = 0.10) or TAU (d = -0.31). This same pattern of effects was also found during open-label treatment with HRT. Although behavior therapies such as HRT are the principle treatment for youth with TTM, the Automatic pulling style exhibited limited improvement to this therapeutic approach. Therefore, therapeutic strategies that enhance awareness to pulling behaviors may produce more robust outcomes to behavior therapy for youth with TTM.
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20
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Farhat LC, Olfson E, Nasir M, Levine JLS, Li F, Miguel EC, Bloch MH. Pharmacological and behavioral treatment for trichotillomania: An updated systematic review with meta-analysis. Depress Anxiety 2020; 37:715-727. [PMID: 32390221 DOI: 10.1002/da.23028] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 04/01/2020] [Accepted: 04/19/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Trichotillomania (TTM) is a difficult-to-treat psychiatric condition with no first-line medications approved by the Food and Drug Administration. Individuals with TTM often feel that clinicians know little about this disorder. Here, we present an updated meta-analysis of randomized controlled trials (RCTs) examining treatments for TTM. METHODS Pubmed, PsychINFO, Embase, and CENTRAL were searched with the terms "Trichotillomania OR Hair Pulling Disorder" to identify randomized controlled clinical trials evaluating treatments for TTM. RESULTS Twenty-four trials involving 26 comparisons and 857 participants were included in this meta-analysis. Behavioral therapy with habit-reversal training components (BT-HRT) demonstrated a large benefit compared to control conditions (standardized mean difference [SMD] [95% CI] = -1.22 [-1.71, -0.73], p < .0001) for improving TTM symptoms. Clomipramine (SMD [95% CI] = -0.71 [-1.38, -0.05], p = .036), N-acetylcysteine (SMD [95% CI] = -0.75 [-1.36, -0.13], p = .017) and olanzapine (SMD [95% CI] = -0.94 [-1.77, -0.12], p = .025) demonstrated significant benefits compared to placebo in RCTs. CONCLUSIONS BT-HRT has demonstrated the largest treatment effects and has the strongest evidence base for reducing TTM symptoms. In contrast, several pharmacological agents have demonstrated efficacy in single randomized clinical trials that would benefit from replication. Additional trials are needed to identify other effective medications for TTM and determine the relative efficacy of available agents.
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Affiliation(s)
- Luis C Farhat
- Departamento de Psiquiatria da Faculdade de Medicina FMUSP, Universidade de São Paulo São Paulo, São Paulo, Brazil
| | - Emily Olfson
- Yale Child Study Center, Yale University School of Medicine, New Haven, Connecticut.,Department of Psychiatry, Yale University, New Haven, Connecticut
| | - Madeeha Nasir
- Yale Child Study Center, Yale University School of Medicine, New Haven, Connecticut
| | - Jessica L S Levine
- Yale Child Study Center, Yale University School of Medicine, New Haven, Connecticut
| | - Fenghua Li
- Yale Child Study Center, Yale University School of Medicine, New Haven, Connecticut
| | - Euripedes C Miguel
- Departamento de Psiquiatria da Faculdade de Medicina FMUSP, Universidade de São Paulo São Paulo, São Paulo, Brazil
| | - Michael H Bloch
- Yale Child Study Center, Yale University School of Medicine, New Haven, Connecticut.,Department of Psychiatry, Yale University, New Haven, Connecticut
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21
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Baczynski C, Sharma V. Pharmacotherapy for trichotillomania in adults. Expert Opin Pharmacother 2020; 21:1455-1466. [PMID: 32633577 DOI: 10.1080/14656566.2020.1761324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
| | - Verinder Sharma
- Parkwood Institute , London, Canada.,Department of Psychiatry and Department of Obstetrics & Gynecology, Western University , London, Canada
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22
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Everett GJ, Jafferany M, Skurya J. Recent advances in the treatment of trichotillomania (hair-pulling disorder). Dermatol Ther 2020; 33:e13818. [PMID: 32531098 DOI: 10.1111/dth.13818] [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: 06/05/2020] [Revised: 06/09/2020] [Accepted: 06/10/2020] [Indexed: 12/16/2022]
Abstract
Trichotillomania (TTM) is a condition in which affected individuals pull out their hair resulting in hair loss. This disorder affects roughly 0.5% to 2.0% of the population and can have significant psychological morbidity. Behavioral therapy has been used with success in the treatment of TTM, but not all patients are willing or able to comply with this treatment strategy. There is a need for effective pharmacological treatment options. Historically, pharmacotherapy for TTM has been inadequate in most cases, but recent advances have been made in this regard. Fluoxetine, clomipramine, olanzapine, and naltrexone have all been used in the treatment of TTM, but evidence of benefit has varied, and side effect profiles can limit practical utility. Recent advances in the understanding of the pathophysiology of TTM, as well as evidence of benefit seen with some glutamate-modulating agents such as N-acetylcysteine and dronabinol, have provided newer potential pharmacotherapy options.
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Affiliation(s)
- Gregory J Everett
- Division of Psychodermatology, Central Michigan University, Saginaw, Michigan, USA
| | - Mohammad Jafferany
- Division of Psychodermatology, Central Michigan University, Saginaw, Michigan, USA
| | - Jonathon Skurya
- Division of Psychodermatology, Central Michigan University, Saginaw, Michigan, USA
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23
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Farhat LC, Olfson E, Levine JL, Li F, Franklin ME, Lee HJ, Lewin AB, McGuire JF, Rahman O, Storch EA, Tolin DF, Zickgraf HF, Bloch MH. Measuring Treatment Response in Pediatric Trichotillomania: A Meta-Analysis of Clinical Trials. J Child Adolesc Psychopharmacol 2020; 30:306-315. [PMID: 31794677 PMCID: PMC7476376 DOI: 10.1089/cap.2019.0103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objectives: In clinical trials of pediatric trichotillomania (TTM), three instruments are typically employed to rate TTM severity: (1) the Massachusetts General Hospital Hair Pulling Scale (MGH-HPS), (2) the National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS), and (3) the Trichotillomania Scale for Children (TSC). These instruments lack standardized definitions of treatment response, which lead researchers to determine their own definitions of response post hoc and potentially inflate results. We performed a meta-analysis to provide empirically determined accuracy measures for percentage reduction cut points in these three instruments. Methods: MEDLINE was searched for TTM clinical trials. A total of 67 studies were initially identified, but only 5 were clinical trials focused on TTM in pediatric populations and therefore were included in this meta-analysis (n = 180). A Clinical Global Impressions Improvement score ≤2 was used to define clinical response. Receiver operating characteristic principles were employed to determine accuracy measures for percentage reduction cut points on each one of the instruments. Meta-DiSc software was employed to provide pooled accuracy measures for each cut point for each instrument. The Youden Index and the distance to corner methods were used to determine the optimal cut point. Results: The optimal cut points to determine treatment response were a 45% reduction on the MGH-HPS (Youden Index 0.40, distance to corner 0.20), a 35% reduction on the NIMH-TSS (Youden Index 0.42, distance to corner 0.17), a 25% reduction on the TSC child version (TSC-C; Youden Index 0.40, distance to corner 0.18), and a 45% (distance to corner 0.30) or 50% reduction (Youden Index 0.33) on the TSC parent version (TSC-P). The TSC-C had less discriminative ability at determining response in younger children in comparison to older children; no age-related differences were observed on the TSC-P. Conclusions: This study provides empirically determined cut points of treatment response on three instruments that rate TTM severity. These data-driven cut points will benefit future research on pediatric TTM.
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Affiliation(s)
- Luis C. Farhat
- Departamento de Psiquiatria da Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, Brazil.,Funding: No funding was received for this article
| | - Emily Olfson
- Department of Psychiatry, Yale University, New Haven, Connecticut, USA.,Yale Child Study Center, New Haven, Connecticut, USA.,Funding: No funding was received for this article
| | - Jessica L.S. Levine
- Yale Child Study Center, New Haven, Connecticut, USA.,Funding: No funding was received for this article
| | - Fenghua Li
- Yale Child Study Center, New Haven, Connecticut, USA.,Funding: No funding was received for this article
| | - Martin E. Franklin
- Child and Adolescent OCD, Tic, Trich and Anxiety Group (COTTAGe), Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Funding: No funding was received for this article
| | - Han-Joo Lee
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, Illinois, USA.,Funding: No funding was received for this article
| | - Adam B. Lewin
- Department of Pediatrics, University of South Florida, Tampa, Florida, USA.,Funding: No funding was received for this article
| | - Joseph F. McGuire
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Funding: No funding was received for this article
| | - Omar Rahman
- Department of Pediatrics, University of South Florida, Tampa, Florida, USA.,Funding: No funding was received for this article
| | - Eric A. Storch
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA.,Funding: No funding was received for this article
| | - David F. Tolin
- Institute of Living, Hartford, Connecticut, USA.,Yale University School of Medicine, New Haven, Connecticut, USA.,Funding: No funding was received for this article
| | - Hana F. Zickgraf
- Child and Adolescent OCD, Tic, Trich and Anxiety Group (COTTAGe), Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, Illinois, USA.,Funding: No funding was received for this article
| | - Michael H. Bloch
- Department of Psychiatry, Yale University, New Haven, Connecticut, USA.,Yale Child Study Center, New Haven, Connecticut, USA.,Funding: No funding was received for this article.,Address correspondence to: Michael H. Bloch, MD, MS, Yale Child Study Center, PO Box 207900, New Haven, CT 06520, USA
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Kar SK, Dixit S, Agarwal V, Tripathi A. Successful treatment of trichotillomania with repetitive transcranial magnetic stimulation: A report of two cases with review of literature. Asian J Psychiatr 2020; 49:101987. [PMID: 32135483 DOI: 10.1016/j.ajp.2020.101987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 02/24/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Sujita Kumar Kar
- Department of Psychiatry, King George's Medical University, Lucknow, U.P., India.
| | - Sankalp Dixit
- Department of Psychiatry, King George's Medical University, Lucknow, U.P., India.
| | - Vivek Agarwal
- Department of Psychiatry, King George's Medical University, Lucknow, U.P., India.
| | - Adarsh Tripathi
- Department of Psychiatry, King George's Medical University, Lucknow, U.P., India.
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25
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Mariusso LM, Costa ACB, Canassa TC, Tanouye ATDA, Porcu M. Trichotillomania: Case report of pharmacological treatment outcome with clomipramine. Psychiatry Res 2020; 284:112663. [PMID: 31740214 DOI: 10.1016/j.psychres.2019.112663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 10/26/2019] [Accepted: 10/26/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Laís Medina Mariusso
- Department of Medicine, Psychiatry Residency Program, State University of Maringá, Maringá, Paraná, Brazil
| | | | - Thaisa Carla Canassa
- Department of Medicine, Psychiatry Residency Program, State University of Maringá, Maringá, Paraná, Brazil
| | | | - Mauro Porcu
- Department of Medicine, Psychiatry Residency Program, State University of Maringá, Maringá, Paraná, Brazil.
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26
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Lamothe H, Baleyte JM, Mallet L, Pelissolo A. Trichotillomania is more related to Tourette disorder than to obsessive-compulsive disorder. REVISTA BRASILEIRA DE PSIQUIATRIA (SAO PAULO, BRAZIL : 1999) 2020; 42:87-104. [PMID: 31576938 PMCID: PMC6986481 DOI: 10.1590/1516-4446-2019-0471] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 06/08/2019] [Indexed: 01/18/2023]
Abstract
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.
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Affiliation(s)
- Hugues Lamothe
- Centre Hospitalier Intercommunal de Créteil, Université Paris Est Créteil, Créteil, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), U955, Créteil, France
- Fondation FondaMental, Créteil, France
| | - Jean-Marc Baleyte
- Centre Hospitalier Intercommunal de Créteil, Université Paris Est Créteil, Créteil, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), U955, Créteil, France
- Fondation FondaMental, Créteil, France
- Université de Caen Normandie (UNICAEN), INSERM, U1077, Caen, France
| | - Luc Mallet
- Fondation FondaMental, Créteil, France
- Assistance Publique Hôspitaux de Paris (APHP), Hôpitaux Universitaires Henri Mondor Albert Chenevier, Université Paris Est Créteil, Créteil, France
- Department of Mental Health and Psychiatry, Geneva University Hospital, University of Geneva, Geneva, Switzerland
- Unité Mixte de Recherche (UMR) S1127, Centre National de la Recherche Scientifique (CNRS), UMR 7225, Institut du Cerveau et de la Moelle Epinière, Paris, France
| | - Antoine Pelissolo
- Institut National de la Santé et de la Recherche Médicale (INSERM), U955, Créteil, France
- Fondation FondaMental, Créteil, France
- Assistance Publique Hôspitaux de Paris (APHP), Hôpitaux Universitaires Henri Mondor Albert Chenevier, Université Paris Est Créteil, Créteil, France
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27
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Gallinat C, Moessner M, Haenssle HA, Winkler JK, Backenstrass M, Bauer S. An Internet-Based Self-Help Intervention for Skin Picking (SaveMySkin): Pilot Randomized Controlled Trial. J Med Internet Res 2019; 21:e15011. [PMID: 31586368 PMCID: PMC6779027 DOI: 10.2196/15011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/19/2019] [Accepted: 07/19/2019] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND In spite of the psychosocial burden and medical risks associated with skin picking disorder, the health care system does not provide sufficient treatment for affected individuals to date. Therefore, an internet-based self-help program for skin picking was developed to offer easily accessible support for this population. OBJECTIVE This pilot study evaluated the internet-based self-help program SaveMySkin. The 12-week program is based on cognitive-behavioral therapy and contains comprehensive information and exercises, a daily supportive monitoring system, and dermatological and psychological counseling via internet chat. Primary objectives were the investigation of attitudes and expectations toward the program, intervention effects on skin picking severity, user satisfaction, adherence, and willingness to participate. Secondary outcomes included the feasibility of study procedures, adequacy of assessment instruments, effects on skin picking-related impairment, dimensions of skin picking, and general psychological impairment. METHODS A two-arm randomized controlled trial was conducted in a sample of 133 participants (female: 124/133, 93.2%; mean age 26.67 [SD 6.42]) recruited via the internet. Inclusion required a minimum age of 17 years and at least mild skin picking severity. Participants were randomly allocated to the intervention (64/133, 48.1%) or waitlist control group (69/133, 51.9%). All assessments were conducted online and based on self-report. RESULTS The willingness to participate was very high in the study, so the initially planned sample size of 100 was exceeded after only 18 days. Participant expectations indicate that they believed the program to be beneficial for them (131/133, 98.5%) and provide a feeling of support (119/133, 89.5%). Reasons for study participation were insufficient outpatient health care (83/133, 62.4%) and flexibility regarding time (106/133, 79.7%) and location (109/133, 82.0%). The post-assessment was completed by 65.4% (87/133) of the sample. The majority of the intervention group who completed the entire post-assessment were satisfied with SaveMySkin (28/38, 74%) and agreed that the program is an appropriate support service (35/38, 92%). On average, participants viewed 29.31 (SD 42.02) pages in the program, and 47% (30/64) of the intervention group used the monitoring at least once a week. In comparison with the control group, the intervention group displayed substantial improvements in the skin picking severity total score (Cohen d=0.67) and especially on the subscale Symptom Severity (Cohen d=0.79). No effects on secondary outcomes were found. CONCLUSIONS This study confirms the need for easily accessible interventions for skin picking disorder and the high interest in internet-based self-help within the target population. It provides important insights into the attitudes toward online support and actual user experiences. Participant feedback will be used to further enhance the intervention. Our results point to the preliminary efficacy of SaveMySkin and may lay the foundation for future research into the efficacy and cost-effectiveness of the program in a multicenter clinical trial. TRIAL REGISTRATION German Clinical Trial Register DRKS00015236; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00015236. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1016/j.conctc.2018.100315.
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Affiliation(s)
- Christina Gallinat
- Center for Psychotherapy Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus Moessner
- Center for Psychotherapy Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Holger A Haenssle
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Julia K Winkler
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Backenstrass
- Institute of Clinical Psychology, Hospital Stuttgart, Stuttgart, Germany.,Institute of Psychology, Department of Clinical Psychology and Psychotherapy, Heidelberg University, Heidelberg, Germany
| | - Stephanie Bauer
- Center for Psychotherapy Research, University Hospital Heidelberg, Heidelberg, Germany
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28
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Neal-Barnett A, Woods DW, Espil FM, Davis M, Alexander JR, Compton SN, Walther MR, Twohig MP, Saunders SM, Cahill SP, Franklin ME. Acceptance-enhanced behavior therapy for trichotillomania: Randomized controlled trial rationale, method, and strategies for recruiting minority participants. Bull Menninger Clin 2019; 83:399-431. [PMID: 31380699 DOI: 10.1521/bumc_2019_83_04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Trichotillomania (TTM) involves the chronic pulling out of hair to the point of hair loss or thinning, which continues despite repeated attempts to stop. Behavior therapy is a promising treatment for the condition, but studies have been limited by the lack of a credible control condition, small sample sizes, follow-up periods of short duration, and low participation by underrepresented populations. In the current article, the authors describe the theoretical rationale for an acceptance-enhanced form of behavior therapy for TTM in adults and describe the methodology used to test the efficacy of this intervention against a psychoeducation and supportive control condition. In addition, the authors discuss the importance of and difficulties encountered with enrolling minority participants into TTM research, as well as strategies used to enhance minority recruitment. Finally, the authors discuss the instruments, procedures, and related outcomes of the fidelity measures used in the randomized controlled trial.
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Affiliation(s)
| | - Douglas W Woods
- Texas A&M University, College Station, Texas
- Marquette University, Milwaukee, Wisconsin
| | - Flint M Espil
- Stanford University School of Medicine, Stanford, California
| | | | - Jennifer R Alexander
- Texas A&M University, College Station, Texas
- Marquette University, Milwaukee, Wisconsin
| | | | | | | | | | | | - Martin E Franklin
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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29
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Lee MT, Mpavaenda DN, Fineberg NA. Habit Reversal Therapy in Obsessive Compulsive Related Disorders: A Systematic Review of the Evidence and CONSORT Evaluation of Randomized Controlled Trials. Front Behav Neurosci 2019; 13:79. [PMID: 31105537 PMCID: PMC6491945 DOI: 10.3389/fnbeh.2019.00079] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 04/01/2019] [Indexed: 12/17/2022] Open
Abstract
Background: Habit Reversal Therapy (HRT) has long been used in the treatment of Tourette Syndrome and Tic Disorders. It has more recently been used to treat Trichotillomania and skin picking behaviors, both considered as Obsessive Compulsive Related Disorders (OCRD). Objectives: This literature review sought to establish and quality assess the existing randomized controlled trial evidence supporting the use of HRT in the DSM-5 family of OCRDs. Search Methods: EMBASE, PsycINFO, PubMed, and Cochrane databases were searched for key terms relating to each OCRD (as classified in the DSM-5), and HRT. Selection Criteria: Titles and abstracts were screened, and any literature matching pre-specified criteria were then selected to be reviewed further. Of these, 8 Randomized Controlled Trials (RCT) relating to Trichotillomania, and 2 RCTs relating to Excoriation Disorder, were extracted and reviewed against the 2010 Consolidating Standards of Reporting Trials (CONSORT) statement. Results: The review identified 10 RCTs of HRT, but these were limited to patients with a primary diagnosis of Trichotillomania or "excoriation behavior," only. There were some reports of the use of HRT in Tourette Syndrome or Tic Disorder with secondary OCD, but the OCD symptoms were not reliably reported on. Conclusion: There is a gap in the current literature regarding the use of HRT in the DSM-5 OCRDs. In those RCTs that have been reported, the quality of study methodology was questionable as evaluated by CONSORT criteria. The implications of these findings are discussed, and suggestions are made for future research.
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Affiliation(s)
- Melissa T. Lee
- Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, United Kingdom
| | - Davis N. Mpavaenda
- Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, United Kingdom
- University of Hertfordshire, Hatfield, United Kingdom
| | - Naomi A. Fineberg
- Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, United Kingdom
- University of Hertfordshire, Hatfield, United Kingdom
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30
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Rehm IC, Nedeljkovic M, Moulding R, Thomas A. The Beliefs in Trichotillomania Scale (BiTS): Factor analyses and preliminary validation. BRITISH JOURNAL OF CLINICAL PSYCHOLOGY 2019; 58:384-405. [PMID: 30968971 DOI: 10.1111/bjc.12219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 03/14/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The role of cognitions and beliefs in trichotillomania (TTM; hair pulling disorder) has been the subject of only limited investigation. This study aimed to develop and validate the Beliefs in TTM Scale (BiTS). METHODS A pool of 50 items based upon themes identified in previous research was administered online to 841 participants with and without self-reported problematic, non-cosmetic hair pulling behaviours. RESULTS Exploratory and confirmatory factor analyses conducted in randomly split-halves of the sample supported retention of 14 items comprising three factors: negative self-beliefs, low coping efficacy, and perfectionism. CONCLUSIONS The BiTS demonstrated satisfactory psychometric properties and all three subscales significantly correlated with greater hair pulling severity. Negative self-beliefs predicted hair pulling severity over and above mood symptoms, suggesting the importance of addressing self-construals in psychological treatments for TTM. Validation in a clinician diagnosed sample is required. PRACTITIONER POINTS Research supports cognitive therapies for treating trichotillomania (hair pulling disorder), although studies investigating the nature and role of cognitions and beliefs in this disorder have been lacking. This study developed and validated a self-report measure of three styles of beliefs most relevant to trichotillomania: negative self-beliefs, low coping efficacy, and perfectionism. Negative self-beliefs predicted the severity of trichotillomania symptoms over and above depression and anxiety, suggesting such cognitions may not necessarily be due to comorbidities. Future research should validate the new measure in a clinician diagnosed sample, and therapies for trichotillomania may be enhanced by targeting shame specifically.
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Affiliation(s)
- Imogen C Rehm
- Department of Psychological Sciences, Swinburne University of Technology, Melbourne, Victoria, Australia.,School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
| | - Maja Nedeljkovic
- Centre for Mental Health, Swinburne University of Technology, Melbourne, Victoria, Australia
| | - Richard Moulding
- School of Psychology, Deakin University, Melbourne, Victoria, Australia
| | - Anna Thomas
- Department of Psychological Sciences, Swinburne University of Technology, Melbourne, Victoria, Australia.,Research and Innovation Portfolio, RMIT University, Melbourne, Victoria, Australia
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31
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Fontenelle LF, Dos Santos-Ribeiro S, Kalaf J, Yücel M. Electroconvulsive therapy for trichotillomania in a bipolar patient. Bull Menninger Clin 2019; 83:97-104. [PMID: 30888852 DOI: 10.1521/bumc.2019.83.1.97] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
A recent review on the use of electroconvulsive therapy (ECT) in obsessive-compulsive-related disorders (OCRDs) identified reports of trichotillomania (TTM) in only three patients, but it did not describe the specific effect of ECT on hair-pulling behaviors. The authors present a case report of Mrs. A, a 77-year-old widowed housewife with a lifelong history of episodic TTM and bipolar disorder who was effectively treated with ECT. However, on each attempt to withdraw ECT, her condition deteriorated. Eventually, a decision was made to maintain ECT (one session every week), which resulted in no further relapse over the followup period. ECT shows some potential promise for reducing hair-pulling behaviors in the context of severe depression.
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Affiliation(s)
- Leonardo F Fontenelle
- Obsessive, Compulsive, and Anxiety Spectrum Research Program, Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,D'Or Institute for Research and Education, Rio de Janeiro, Brazil.,Brain and Mental Health Research Hub, Monash Institute of Cognitive and Clinical Neurosciences (MICCN) and School of Psychological Sciences, Monash University, Clayton, Victoria, Australia
| | - Samara Dos Santos-Ribeiro
- Obsessive, Compulsive, and Anxiety Spectrum Research Program, Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Juliana Kalaf
- ECT Service, Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Murat Yücel
- Brain and Mental Health Research Hub, Monash Institute of Cognitive and Clinical Neurosciences (MICCN) and School of Psychological Sciences, Monash University, Clayton, Victoria, Australia
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32
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Farhat LC, Olfson E, Li F, Telang S, Bloch MH. Identifying standardized definitions of treatment response in trichotillomania: A meta-analysis. Prog Neuropsychopharmacol Biol Psychiatry 2019; 89:446-455. [PMID: 30336171 DOI: 10.1016/j.pnpbp.2018.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 09/25/2018] [Accepted: 10/14/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND Symptom severity in trichotillomania clinical trials is typically rated using the Massachusetts General Hospital Hair Pulling Scale (MGH-HPS) and the National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS). There are no universal definitions of treatment response on these scales. The absence of empirically supported definitions of treatment response hampers advances in trichotillomania treatment. METHODS PubMed and CENTRAL databases were searched for trichotillomania clinical trials. A total of 14 studies were identified and 7 provided adequate data to be included in the meta-analysis (n = 270). Meta-DiSc software was employed. The Youden index and distance to corner were used to determine the optimal cut-point. Response was defined by the Clinical Global Impressions Improvement scale score ≤ 2. RESULTS The optimal cut-points for identifying response on the MGH-HPS was a 35% percent reduction [Youden Index 0.48; distance to corner 0.37] or a seven-point reduction [Youden Index 0.43; distance to corner 0.40]. The optimal cut-points for the NIMH-TSS was a 50% reduction [Youden Index 0.57; distance to corner 0.34] or a six-point reduction [Youden Index 0.53; distance to corner 0.36]. The optimal cut-points were similar when the analysis was confined to only trichotillomania trials involving adult subjects, but the scales appeared to have improved ability to define treatment response when pediatric subjects were excluded. CONCLUSION This study provides empirically determined cut-points of treatment response on the MGH-HPS and NIMH-TSS. These data-driven cut-points will benefit future research in trichotillomania by providing definitions of treatment response that can be defined a priori in clinical trials.
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Affiliation(s)
- Luis C Farhat
- Yale Child Study Center, New Haven, CT, United States
| | - Emily Olfson
- Yale Child Study Center, New Haven, CT, United States; Department of Psychiatry, Yale University, New Haven, CT, United States
| | - Fenghua Li
- Yale Child Study Center, New Haven, CT, United States
| | - Shilpa Telang
- Yale Child Study Center, New Haven, CT, United States
| | - Michael H Bloch
- Yale Child Study Center, New Haven, CT, United States; Department of Psychiatry, Yale University, New Haven, CT, United States.
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33
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Satodiya R, Nemiary D, Peckham A, Boggs D. Trichotillomania: Improved Clinical Outcomes with a Novel Psychotropic Combination-Treatment Regimen. Psychiatr Ann 2019. [DOI: 10.3928/00485713-20190131-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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34
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Braun TL, Patel V, DeBord LC, Rosen T. A review of N-acetylcysteine in the treatment of grooming disorders. Int J Dermatol 2019; 58:502-510. [PMID: 30667049 DOI: 10.1111/ijd.14371] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 11/24/2018] [Accepted: 12/05/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pathologic grooming disorders can lead to clinically significant distress and functional impairment. Studies on treatment of these disorders with selective serotonin reuptake inhibitors (SSRIs) and anticonvulsants have led to inconsistent findings. N-acetylcysteine (NAC) has shown promise in treatment of obsessive-compulsive and related disorders. The objective of this article is to perform an updated review of NAC in the treatment of grooming disorders. METHODS PubMed was searched from inception to October 2017 to identify literature on the use of NAC in the management of trichotillomania, onychophagia, and pathological skin picking. Case reports, case series, and randomized controlled trials were included. Data on study design, dosing regimens, comorbidities, concurrent treatment, and side effects were extracted from the included articles. RESULTS Fifteen articles were included in this review, which consisted of 10 case reports, one case series, and four randomized controlled trials. Dosing of oral NAC ranged from 450 to 2,400 mg per day, and treatment periods lasted from 1 to 8 months. Side effects were uncommon, mild, and usually gastrointestinal in nature, with severe aggression reported in one child. CONCLUSIONS While there are multiple reports of the safety and efficacy of NAC in the treatment of grooming disorders, there are currently few randomized controlled trials on this topic, and more research is needed to develop a formal treatment algorithm. While current data should be considered very preliminary, case reports have demonstrated mostly positive results and a lack of significant side effects. A trial of NAC may be a viable option for pathologic grooming disorders, especially in patients who have failed prior psychologic or pharmacologic treatment.
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Affiliation(s)
- Tara L Braun
- Department of Dermatology, Baylor College of Medicine, Houston, TX, USA
| | - Viraat Patel
- Department of Dermatology, Baylor College of Medicine, Houston, TX, USA
| | - Logan C DeBord
- Department of Dermatology, Baylor College of Medicine, Houston, TX, USA
| | - Theodore Rosen
- Department of Dermatology, Baylor College of Medicine, Houston, TX, USA
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Abstract
Trichotillomania is characterized by the repetitive pulling out of one's own hair leading to hair loss and possibly functional impairment. Trichotillomania has been documented in the medical literature since the 19th century. Prevalence studies suggest that trichotillomania is a common disorder (point prevalence estimates of 0.5%-2.0%). Although grouped with the obsessive-compulsive disorder (OCD) in the diagnostic and statistical manual of mental disorders-5, trichotillomania is distinct from OCD in many respects. For example, the treatment of trichotillomania generally employs habit reversal therapy and medication (n-acetylcysteine or olanzapine), both of which are quite different from those used to treat OCD. Conversely, some first-line treatments used for OCD (e.g., selective serotonin reuptake inhibitors) appear ineffective for trichotillomania. This article presents what is known about trichotillomania and the evidence for a variety of treatment interventions.
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Affiliation(s)
- Jon E Grant
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
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36
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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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de Haas EN, van der Eijk JA. Where in the serotonergic system does it go wrong? Unravelling the route by which the serotonergic system affects feather pecking in chickens. Neurosci Biobehav Rev 2018; 95:170-188. [DOI: 10.1016/j.neubiorev.2018.07.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 07/09/2018] [Accepted: 07/10/2018] [Indexed: 12/16/2022]
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38
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Assessment and treatment of trichotillomania (hair pulling disorder) and excoriation (skin picking) disorder. Clin Dermatol 2018; 36:728-736. [DOI: 10.1016/j.clindermatol.2018.08.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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39
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França K, Kumar A, Castillo D, Jafferany M, Hyczy da Costa Neto M, Damevska K, Wollina U, Lotti T. Trichotillomania (hair pulling disorder): Clinical characteristics, psychosocial aspects, treatment approaches, and ethical considerations. Dermatol Ther 2018; 32:e12622. [DOI: 10.1111/dth.12622] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 05/16/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Katlein França
- Institute for Bioethics & Health Policy, Department of Dermatology & Cutaneous Surgery and Department of Psychiatry & Behavioral Sciences; University of Miami Miller School of Medicine; Miami Florida
- Università G Marconi; Rome Italy
| | - Anagha Kumar
- Department of Medical Oncology; Mayo Clinic; Rochester Minnesota
| | - David Castillo
- Department of Dermatology & Cutaneous Surgery; University of Miami Miller School of Medicine; Miami Florida
| | - Mohammad Jafferany
- Department of Psychiatry and Behavioral Sciences, College of Medicine; Central Michigan University; Saginaw Michigan
| | | | - Katerina Damevska
- Clinic of Dermatology, Medical Faculty; University “Ss. Cyril and Methodius,”; Skopje Macedonia
| | - Uwe Wollina
- Department of Dermatology and Allergology; Dresden Germany
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40
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Maas J, Keijsers GP, Rinck M, Becker ES. Does Cognitive Bias Modification Prior to Standard Brief Cognitive Behavior Therapy Reduce Relapse Rates in Hair Pulling Disorder? A Double-Blind Randomized Controlled Trial. JOURNAL OF SOCIAL AND CLINICAL PSYCHOLOGY 2018. [DOI: 10.1521/jscp.2018.37.6.453] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background: In line with previous research in alcohol addiction, we tested whether an Approach-Avoidance Training (AAT) prior to standard six-session Cognitive Behavior Therapy (CBT) for Hair Pulling Disorder (HPD) reduced problematic relapse, commonly found in this population. Method: Prior to CBT, 54 outpatients with a primary diagnosis of HPD were randomly assigned (double-blind) to either a training condition (n = 27), learning to avoid hair-pulling-related stimuli, or to a control condition (n = 27). Symptom severity was assessed with the Massachussetts General Hospital Hairpulling Scale, Severity Urge Resistance Frequency Scale, Self-Control Cognition Questionnaire, and Alopecia Scale. Results: In line with existing research, CBT showed to be an effective treatment for HPD in the short-term. There was no significant symptom increase after one and three months, but effect sizes were reduced approximately by half at the twelve-month measurement. The AAT training prior to CBT did not result in enhanced symptom reduction or reduced relapse after CBT. Conclusions: AAT training could not resolve the substantial relapse after successful CBT. Future research should take into account the complexity of stimuli that elicit hair pulling (e.g., tactile stimuli) and consider investigating other types of biases.
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Affiliation(s)
- Joyce Maas
- Behavioural Science Institute, Radboud University Nijmegen
| | - Ger P.J. Keijsers
- Behavioural Science Institute, Radboud University Nijmegen
- Clinical Psychological Sciences, Maastricht University, Maastricht, The Netherlands
| | - Mike Rinck
- Behavioural Science Institute, Radboud University Nijmegen
| | - Eni S. Becker
- Behavioural Science Institute, Radboud University Nijmegen
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41
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Casarotto PC, Biojone C, Montezuma K, Cunha FQ, Joca SRL, Castren E, Guimaraes FS. Inducible nitric oxide synthase (NOS2) knockout mice as a model of trichotillomania. PeerJ 2018; 6:e4635. [PMID: 29682419 PMCID: PMC5909682 DOI: 10.7717/peerj.4635] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 03/27/2018] [Indexed: 01/17/2023] Open
Abstract
Background Trichotillomania (TTM) is an impulse control disorder characterized by repetitive hair pulling/trimming. Barbering behavior (BB) observed in laboratory animals is proposed as a model of TTM. The neurobiological basis of TTM is unclear, but involves striatal hyperactivity and hypoactivation of the prefrontal cortex. Methods In this study, we evaluated the BB in knockout mice for the inducible isoform of nitric oxide synthase (NOS2KO) and the consequences of silencing this enzyme in PC12 cell differentiation. Results NOS2KO exhibit exacerbated BB, starting four weeks of age, and increased repetitive movements compared to wild-type mice (WT). The expression of BB was attenuated by repeated treatment with clomipramine, a clinically approved drug to treat TTM in humans, or memantine, an antagonist of NMDA receptors, as well as partial rescue of NOS2 expression in haploinsufficient animals. The silencing of NOS2 expression reduced the MAP2 (microtubule-associated protein 2) levels in activity-induced differentiated PC12 cells. Discussion Our data led us to propose that NOS2 is putatively involved in the neuronal maturation of the inhibitory afferent pathways during neurodevelopment, and such inadequate inhibition of motor programs might be associated to the observed phenotype.
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Affiliation(s)
- Plinio C Casarotto
- Neuroscience Center, University of Helsinki, Helsinki, Finland.,Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Caroline Biojone
- Neuroscience Center, University of Helsinki, Helsinki, Finland.,Department of Physics and Chemistry, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Karina Montezuma
- Department of Physics and Chemistry, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Fernando Q Cunha
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Samia R L Joca
- Department of Physics and Chemistry, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Eero Castren
- Neuroscience Center, University of Helsinki, Helsinki, Finland
| | - Francisco S Guimaraes
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,NAPNA: Center for Interdisciplinary Research on Applied Neurosciences, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
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42
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Houghton DC, Alexander JR, Bauer CC, Woods DW. Abnormal perceptual sensitivity in body-focused repetitive behaviors. Compr Psychiatry 2018; 82:45-52. [PMID: 29407358 DOI: 10.1016/j.comppsych.2017.12.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 12/19/2017] [Accepted: 12/20/2017] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE Several compulsive grooming habits such as hair pulling, skin picking, and nail biting are collectively known as body-focused repetitive behaviors (BFRBs). Although subclinical BFRBs are common and benign, more severe and damaging manifestations exist that are difficult to manage. Researchers have suggested that BFRBs are maintained by various cognitive, affective, and sensory contingencies. Although the involvement of cognitive and affective processes in BFRBs has been studied, there is a paucity of research on sensory processes. METHODS The current study tested whether adults with subclinical or clinical BFRBs would report abnormal patterns of sensory processing as compared to a healthy control sample. RESULTS Adults with clinical BFRBs (n = 26) reported increased sensory sensitivity as compared to persons with subclinical BFRBs (n = 48) and healthy individuals (n = 33). Elevations in sensation avoidance differentiated persons with clinical versus subclinical BFRBs. Sensation seeking patterns were not different between groups. Unexpectedly, BFRB severity was associated with lower registration of sensory stimuli, but this finding may be due to high psychiatric comorbidity rates in the BFRB groups. CONCLUSIONS These findings suggest that several sensory abnormalities may underlie BFRBs. Implications for the etiology and treatment of BFRBs are discussed.
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Affiliation(s)
- David C Houghton
- Department of Psychology, Texas A&M University, 4235 TAMU, College Station, TX 77843-4235, United States.
| | - Jennifer R Alexander
- Department of Psychology, Texas A&M University, 4235 TAMU, College Station, TX 77843-4235, United States; Department of Psychology, Marquette University, P.O. Box 1881, Milwaukee, WI 53201-0327, United States.
| | - Christopher C Bauer
- Department of Psychology, Texas A&M University, 4235 TAMU, College Station, TX 77843-4235, United States; Department of Psychology, Marquette University, P.O. Box 1881, Milwaukee, WI 53201-0327, United States.
| | - Douglas W Woods
- Department of Psychology, Texas A&M University, 4235 TAMU, College Station, TX 77843-4235, United States; Department of Psychology, Marquette University, P.O. Box 1881, Milwaukee, WI 53201-0327, United States.
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43
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Lee HJ, Espil FM, Bauer CC, Siwiec SG, Woods DW. Computerized response inhibition training for children with trichotillomania. Psychiatry Res 2018; 262:20-27. [PMID: 29407564 DOI: 10.1016/j.psychres.2017.12.070] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 09/29/2017] [Accepted: 12/30/2017] [Indexed: 12/14/2022]
Abstract
Evidence suggests that trichotillomania is characterized by impairment in response inhibition, which is the ability to suppress pre-potent/dominant but inappropriate responses. This study sought to test the feasibility of computerized response inhibition training for children with trichotillomania. Twenty-two children were randomized to the 8-session response inhibition training (RIT; n = 12) or a waitlisted control (WLT; n = 10). Primary outcomes were assessed by an independent evaluator, using the Clinical Global Impression-Improvement (CGI-I), and the NIMH Trichotillomania Severity (NIMH-TSS) and Impairment scales (NIMH-TIS) at pre, post-training/waiting, and 1-month follow-up. Relative to the WLT group, the RIT group showed a higher response rate (55% vs. 11%) on the CGI-I and a lower level of impairment on the NIMH-TIS, at post-training. Overall symptom reductions rates on the NIMH-TSS were 34% (RIT) vs. 21% (WLT) at post-training. The RIT's therapeutic gains were maintained at 1-month follow-up, as indicated by the CGI-I responder status (= 66%), and a continuing reduction in symptom on the NIMH-TSS. This pattern of findings was also replicated by the 6 waitlisted children who received the same RIT intervention after post-waiting assessment. Results suggest that computerized RIT may be a potentially useful intervention for trichotillomania.
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Affiliation(s)
- Han-Joo Lee
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, WI, USA.
| | - Flint M Espil
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Stephan G Siwiec
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Douglas W Woods
- Department of Psychology, Marquette University, Milwaukee, WI, USA
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44
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Fineberg NA, Apergis-Schoute AM, Vaghi MM, Banca P, Gillan CM, Voon V, Chamberlain SR, Cinosi E, Reid J, Shahper S, Bullmore ET, Sahakian BJ, Robbins TW. Mapping Compulsivity in the DSM-5 Obsessive Compulsive and Related Disorders: Cognitive Domains, Neural Circuitry, and Treatment. Int J Neuropsychopharmacol 2018; 21:42-58. [PMID: 29036632 PMCID: PMC5795357 DOI: 10.1093/ijnp/pyx088] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Naomi A Fineberg
- Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, Hertfordshire, United Kingdom
- University of Hertfordshire, Department of Postgraduate Medicine, College Lane Hatfield, United Kingdom
- Department of Psychiatry, School of Clinical Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Annemieke M Apergis-Schoute
- Department of Psychiatry, School of Clinical Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom
- Behavioral and Clinical Neurosciences Institute, University of Cambridge, Cambridge, United Kingdom
- Department of Psychology, University of Cambridge, Cambridge, United Kingdom
| | - Matilde M Vaghi
- Behavioral and Clinical Neurosciences Institute, University of Cambridge, Cambridge, United Kingdom
- Department of Psychology, University of Cambridge, Cambridge, United Kingdom
| | - Paula Banca
- Behavioral and Clinical Neurosciences Institute, University of Cambridge, Cambridge, United Kingdom
- Department of Psychology, University of Cambridge, Cambridge, United Kingdom
| | - Claire M Gillan
- School of Psychology, Trinity College Dublin, Dublin, Ireland
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
| | - Valerie Voon
- Department of Psychiatry, School of Clinical Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Samuel R Chamberlain
- Department of Psychiatry, School of Clinical Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom
- Cambridge and Peterborough NHS Foundation Trust, Cambridge, United Kingdom
| | - Eduardo Cinosi
- Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, Hertfordshire, United Kingdom
- University of Hertfordshire, Department of Postgraduate Medicine, College Lane Hatfield, United Kingdom
| | - Jemma Reid
- Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, Hertfordshire, United Kingdom
- University of Hertfordshire, Department of Postgraduate Medicine, College Lane Hatfield, United Kingdom
| | - Sonia Shahper
- Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, Hertfordshire, United Kingdom
| | - Edward T Bullmore
- Department of Psychiatry, School of Clinical Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Barbara J Sahakian
- Department of Psychiatry, School of Clinical Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Trevor W Robbins
- Behavioral and Clinical Neurosciences Institute, University of Cambridge, Cambridge, United Kingdom
- Department of Psychology, University of Cambridge, Cambridge, United Kingdom
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45
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Krooks JA, Weatherall AG, Holland PJ. Review of epidemiology, clinical presentation, diagnosis, and treatment of common primary psychiatric causes of cutaneous disease. J DERMATOL TREAT 2017; 29:418-427. [DOI: 10.1080/09546634.2017.1395389] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- J. A. Krooks
- Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
| | - A. G. Weatherall
- Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
- ClearlyDerm Center for Dermatology, Boca Raton, FL, USA
| | - P. J. Holland
- Psychiatry and Neurology Department, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
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46
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O'Connor K, Lavoie M, Desaulniers B, Audet JS. Cognitive psychophysiological treatment of bodily-focused repetitive behaviors in adults: An open trial. J Clin Psychol 2017; 74:273-285. [PMID: 28815684 DOI: 10.1002/jclp.22501] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 04/04/2017] [Accepted: 04/16/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND Body-focused repetitive behaviors (BFRBs), such as hair pulling, skin picking, and nail biting, are repetitive, destructive, and nonfunctional habits that cause significant distress. Separate BFRBs form a cohesive group and could be assessed as part of the Tourette/tic spectrum or obsessive-compulsive spectrum of disorders. The treatment of choice is either antidepressant or behavioral treatment, both of which have shown effectiveness. The cognitive psychophysiological (CoPs) model focuses on the tension and emotional build up that triggers habits by addressing cognitive-behavioral, emotional and psychophysiological processes preceding onset rather than the habit itself. The CoPs approach has already shown efficacy in treatment of tic and Tourette disorder. OBJECTIVE The aim of the current open trial was to view whether BFRBs can be validly assessed on a standard tic scale (Tourette Symptom Global Scale; TSGS) and evaluate the efficacy of the CoPs intervention on 64 participants (54 completers) with 1 of 3 subtypes of BFRBs (hair pulling, nail biting, and skin picking) compared to a waitlist control. METHOD Participants were assessed at baseline on an adapted TSGS and after receving 14 weeks of CoPs therapy with six months follow up. RESULTS The TSGS was reliably and validly adapted to measure BFRBs. The CoPs intervention was effective for all BRFB subtypes with a large effect size (intention-to-treat g = 1.54; completers g = 2.04), with 74% of patients showing clinically significant improvement. Mood and self-esteem also improved posttreatment. The decrease in symptoms was maintained at the 6-month follow-up, with a further decrease in perfectionism. CONCLUSION BFRBs can be reliably assessed as a tic spectrum disorder rather than as part of the obsessive-compulsive spectrum. The CoPs model may offer a complementary treatment for BFRBs.
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Affiliation(s)
- Kieron O'Connor
- University of Montreal.,Research Center of the Montreal Institute of Mental Health.,University of Quebec in Outaouais
| | - Marc Lavoie
- University of Montreal.,Research Center of the Montreal Institute of Mental Health
| | | | - Jean-Sébastien Audet
- University of Montreal.,Research Center of the Montreal Institute of Mental Health
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47
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Abstract
Nail biting, a common behavior seen in children, is typically short-lived and does not cause significant problems. However, when nail biting remains unresolved, physical and emotional consequences may occur. Exploring the etiological factors and underlying function of nail biting may help providers recommend appropriate interventions. [Journal of Psychosocial Nursing and Mental Health Services, 55(2), 23-26.].
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48
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Selles RR, McBride NM, Dammann J, Whiteside SP, Small BJ, Phares V, Storch EA. The Treatment Worries Questionnaire: Conjoined measures for evaluating worries about psychosocial treatment in youth and their parents. Psychiatry Res 2017; 250:159-168. [PMID: 28161612 DOI: 10.1016/j.psychres.2017.01.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/04/2017] [Accepted: 01/16/2017] [Indexed: 01/24/2023]
Abstract
Treatment worries, which surround requirements and results of obtaining treatment, may represent an important construct; however, previous measures were limited by their specificity, format, and lack of parent report. Therefore the present study examined the initial outcomes and psychometrics of corresponding measures of treatment worries in youth (Treatment Worries Questionnaire - Child; TWQ-C) and their parents (Treatment Worries Questionnaire - Parent; TWQ-P). Participants were 94 youth (7-17-years old) and parent dyads presenting for treatment of an anxiety disorder. Dyads completed the TWQ-C and TWQ-P along with additional measures prior to initiating treatment. Treatment worries were endorsed in the mild-moderate range by youth and the TWQ-C demonstrated good-excellent internal consistency, a three-factor structure, and consistent convergent and divergent relationships. Treatment worries were endorsed in the low-mild range by parents and the TWQ-P demonstrated fair-good internal consistency, a four-factor structure, and consistent divergent relationships, but variable (by factor) convergent relationships. The results provide information on treatment worries and support the use of the TWQ-C and TWQ-P as broad assessments of the concept. Low endorsement of worries among parents likely relates to the treatment-seeking nature of the sample. Future investigations using the TWQ-C and TWQ-P in a variety of samples is warranted.
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Affiliation(s)
- Robert R Selles
- BC Children's Hospital Research Institute, 938 West 28th Avenue, Vancouver, BC, Canada V5Z 4H4; University of British Columbia, Vancouver, BC, Canada.
| | | | | | | | | | | | - Eric A Storch
- University of South Florida, Tampa, FL, USA; Rogers Behavioral Health - Tampa Bay, Tampa, FL, USA; All Children's Hospital - Johns Hopkins Medicine, St. Petersburg, FL, USA
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49
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Abstract
Trichotillomania is a relatively understudied psychiatric disorder. Even less is known about this disorder in the elderly. We describe an unusual case of an elderly woman presenting for the first time with trichotillomania at age 70 and highlight the treatment complexities we encountered.
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50
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Rahman O, McGuire J, Storch EA, Lewin AB. Preliminary Randomized Controlled Trial of Habit Reversal Training for Treatment of Hair Pulling in Youth. J Child Adolesc Psychopharmacol 2017; 27:132-139. [PMID: 28005403 DOI: 10.1089/cap.2016.0085] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVES This study evaluated the treatment efficacy of habit reversal training (HRT) relative to treatment as usual (TAU) for children and adolescents aged 7-17 years with a primary diagnosis of trichotillomania (TTM). METHOD An initial assessment consisting of semistructured interviews and rating scales was conducted. Participants (N = 40, 85% female) meeting diagnostic criteria for TTM were randomized to either 8 weekly sessions of HRT by trained therapists or 8 weeks of TAU. One week after the final HRT session or final TAU week, patients completed a posttreatment assessment, followed by 1- and 3-month follow-up assessments. All assessments were conducted by a trained rater who was blinded to treatment condition. RESULTS The group by time analysis of variance yielded a significant interaction on the National Institute of Mental Health-Trichotillomania Severity Scale Total Score (F1,38 = 16.47, p < 0.001, η2p = 0.30). The mean score decreased from 12.67 ± 4.60 at baseline to 5.62 ± 4.38 at posttreatment in the HRT group (t20 = 5.99, p < 0.001, d = 1.31), whereas the TAU group changed from 10.42 ± 4.35 to 9.32 ± 4.11 (t18 = 1.34, p = 0.20, d = 0.31). The Massachusetts General Hospital-Hair Pulling Scale Total Score decreased from 15.14 ± 3.86 at baseline to 7.14 ± 5.54 at posttreatment in the HRT group (t20 = 6.16, p < 0.001, d = 1.34); the TAU group changed from 14.16 ± 4.51 to 12.26 ± 4.34 (t18 = 1.50, p = 0.15, d = 0.34). On the Clinical Global Impressions-Improvement, 16/21 participants (76%) were rated as treatment responders in the HRT group versus 4/19 (21%) in the TAU group (χ2 = 12.13, p < 0.001, V = 0.55). At 1-month follow-up, 10-12 treatment responders who completed the assessment maintained improvement. At 3-month follow-up, six of eight maintained improvement. CONCLUSIONS HRT can be an effective treatment for TTM in youth.
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Affiliation(s)
- Omar Rahman
- 1 Department of Pediatrics, University of South Florida , Tampa, Florida
- 2 Department of Psychiatry and Behavioral Neurosciences, University of South Florida , Tampa, Florida
| | - Joseph McGuire
- 3 Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles , Los Angeles, California
| | - Eric A Storch
- 1 Department of Pediatrics, University of South Florida , Tampa, Florida
- 2 Department of Psychiatry and Behavioral Neurosciences, University of South Florida , Tampa, Florida
- 4 Department of Health Policy and Management, University of South Florida , Tampa, Florida
- 5 Rogers Behavioral Health-Tampa Bay , Tampa, Florida
- 6 All Children's Hospital-Johns Hopkins Medicine , St. Petersburg, Florida
| | - Adam B Lewin
- 1 Department of Pediatrics, University of South Florida , Tampa, Florida
- 2 Department of Psychiatry and Behavioral Neurosciences, University of South Florida , Tampa, Florida
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