Computerized response inhibition training for children with trichotillomania

Neurocognitive functioning in adults with trichotillomania: Predictors of treatment response and symptom severity in a randomized control trial

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.

Impulsivity in adolescent girls diagnosed with trichotillomania: an evaluation of clinical and neuropsychological characteristics

The aim of this study is to compare the clinical and neuropsychological features of impulsivity in adolescent girls with trichotillomania (TTM) and healthy controls, and to assess the relationships between the severity of TTM and the impulsivity/concomitant symptoms of anxiety and depression. The study sample consisted of 43 adolescent girls who were 12 to 18 years old. The Kiddie-Schedule for Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime Version DSM-5 (K-SADS-PL) was administered to the adolescents and their parents. All of the participants completed a sociodemographic data form, the Revised Children's Anxiety and Depression Scale-Child Version (RCADS-CV), the Barratt Impulsiveness Scale-Brief (BIS-Brief), and the Massachusetts General Hospital Hairpulling Scale (MGH-HPS). The Eriksen Flanker task, the Stop Signal Reaction Time (SSRT) task, the Go/No-Go task, and the Balloon Analog Risk Task (BART) were used to assess behavioral impulsivity. The adolescents with TTM reported higher levels of impulsivity and anxiety/depression symptoms than the healthy controls, and they also performed worse on the behavioral tasks. While there were no relationships between clinical and behavioral impulsivity and TTM severity, social anxiety symptoms were the most important predictor of the severity of TTM. It seems important to better understand the role of impulsivity in the onset and persistence of TTM symptoms in adolescents.

Sociodemographic variables, clinical characteristics, and treatments in children with trichotillomania in terms of age and gender: a multicenter study

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.

Artificial Cognitive Systems Applied in Executive Function Stimulation and Rehabilitation Programs: A Systematic Review

This article presents a systematic review of studies on cognitive training programs based on artificial cognitive systems and digital technologies and their effect on executive functions. The aim has been to identify which populations have been studied, the characteristics of the implemented programs, the types of implemented cognitive systems and digital technologies, the evaluated executive functions, and the key findings of these studies. The review has been carried out following the PRISMA protocol; five databases have been selected from which 1889 records were extracted. The articles were filtered following established criteria, to give a final selection of 264 articles that have been used for the purposes of this study in the analysis phase. The findings showed that the most studied populations were school-age children and the elderly. The most studied executive functions were working memory and attentional processes, followed by inhibitory control and processing speed. Many programs were commercial, customizable, gamified, and based on classic tasks. Some more recent initiatives have begun to incorporate user-machine interfaces, robotics, and virtual reality, although studies on their effects remain scarce. The studies recognize multiple benefits of computerized neuropsychological stimulation and rehabilitation programs for executive functions in different age groups, but there is a lack of studies in specific population sectors and with more rigorous research designs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13369-022-07292-5.

Trichotillomania and Skin-Picking Disorder: An Update

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.

Cognitive-behavioral and related therapies for obsessive-compulsive and related disorders

PURPOSE OF REVIEW

Cognitive behavioral therapy (CBT) with exposure and response prevention is the first-line treatment for obsessive-compulsive disorder (OCD) and related disorders such as body dysmorphic disorder (BDD). We review here recent developments in CBT and related therapies in treating OCD and related disorders.

RECENT FINDINGS

Superiority of CBT over medications in treating OCD is being questioned by some recent meta-analyses, nonetheless CBT continues to be the mainstay of treatment. Web-based therapies have been shown to be beneficial in treating at least mild-to-moderately ill patients. Mindfulness-based CBT, intensive residential treatment and Bergen 4-day concentrated exposure are also proving to be useful in treating OCD. Large well designed studies have demonstrated the efficacy CBT over supportive therapy in treating BDD. Research on the efficacy of CBT in treating hoarding disorder is accumulating.

SUMMARY

Efficacy of web-based CBT has a potential public health importance in that CBT may now become accessible to all and benefit at least mild-to-moderately ill patients who form most of the clinically ill sample. Similarly, efficacy of Bergen 4-day concentrated exposure will have a huge public health implication if the findings can be replicated in other centers across the world.

ACT-enhanced group behavior therapy for trichotillomania and skin-picking disorder: A feasibility study

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.

Feasibility and acceptability of an online response inhibition cognitive training program for youth with Williams syndrome

Williams syndrome (WS) is a genetic neurodevelopmental disorder often accompanied by inhibitory difficulties. Online cognitive training programs show promise for improving cognitive functions. No such interventions have been developed for individuals with WS, but to explore the practicality of large-scale online cognitive training for this population, we must first investigate whether families of those with WS find these programs feasible and acceptable. Twenty individuals aged 10-17 years with WS, along with parents, participated in a pilot online cognitive training program supervised in real time using videoconference software. We evaluated the feasibility and acceptability of this response inhibition training using three parent questionnaires. Descriptive data are reported for the measures of feasibility and acceptability. Overall, the online procedures received a positive reaction from families. Parents were likely to recommend the study to others. They indicated training was ethical and acceptable despite feeling neutral about effectiveness. The frequency and duration of sessions were acceptable to families (two 20-to-30-min sessions per week; 10 sessions total). Families provided feedback and offered suggestions for improvement, such as more flexibility in scheduling and decreasing time spent in review of procedures.

Pharmacological and behavioral treatment for trichotillomania: An updated systematic review with meta-analysis

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.

Measuring Treatment Response in Pediatric Trichotillomania: A Meta-Analysis of Clinical Trials

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.

Pediatric trichotillomania: Review of management

Trichotillomania can present in childhood, with many families seeking initial evaluation by a dermatologist for hair loss. Prompt and accurate diagnosis by dermatologists is crucial, as children can suffer from academic or social impairments as well as mental health sequelae. Children are especially vulnerable to lasting psychological distress from appearance-related bullying. This article reviews the psychosocial impacts of pediatric trichotillomania and the current interventions studied in this population. Included are studies evaluating behavioral therapies as well as pharmacologic options. This review highlights the importance of early and appropriate identification, intervention, and the need for more treatment studies in the pediatric population.