Affective correlates of trichotillomania

Clinical Characteristics, Sleep, and Temperament in Infants and Young Children with Problematic Hair Pulling and Skin Picking

Background

This study examined clinical characteristics of problematic hair pulling (HP) and skin picking (SP) in infants and young children and their association with self-soothing, sleep, and temperament.

Methods

An internet survey of parents/caregivers of 0-5-year-olds (n = 384 with data analyzed, of whom 26 experienced HP, 62 experienced SP, and 302 were controls free of HP and SP) assessed demographics and medical history, HP and SP characteristics, contextual factors, self-soothing, sleep patterns, and temperament. Participants were recruited through both HP and SP advocacy and support webpages and general webpages (e.g., parenting groups). Descriptive statistics, chi-square tests of independence, independent samples t-test clinically characterized HP, SP, and control groups. Logistic regression and one-way analysis of covariance controlled for sex and age in analyses.

Results

HP and SP rates were 6.1% (n = 26) and 14.5% (n = 62), respectively. SP presented in 23.1% of children with HP, and HP presented in 9.7% of children with SP. Mean HP and SP onset occurred at 12.2 (SD = 11.2) and 24.1 (SD = 15.8) months, respectively. Contextual factors, including boredom, upset, and awake-in-bed were common in HP and SP. Common caregiver responses included distracting the child, moving the hand away, and telling the child to stop. Few caregivers sought professional help for the child. Children with HP engaged in more hair twirling than controls, and children with SP engaged in more nail biting than controls. Children with HP, but not SP, had more sleep disturbance than controls. In terms of temperament, children with HP displayed sensitivity to stimuli, children with SP exhibited low persistence, and both HP and SP groups displayed serious, observant mood relative to controls.

Conclusions

Findings expand clinical understanding of HP and SP in children aged 0-5 and provide targets (contextual factors, sleep, sensory sensitivity, persistence, and mood) for behavioral interventions. Low rates of treatment seeking highlight the need for expansion of clinical guidelines for HP and SP in this age range.

Latent class analysis of emotions experienced during compulsive hair-pulling episodes

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.

Sleep Disturbances in Pediatric Body-Focused Repetitive Behaviors: A Preliminary Investigation

Body-focused repetitive behaviors (BFRBs) are repeated actions to one's body resulting in physical damage. Limited research has examined sleep, a known factor in psychological health, within the context of pediatric BFRBs. The current study sought to explore the connection between disordered sleep and BFRBs in a community sample. Aim 1 of the study was to determine the predictive power of group membership [control group (no BFRB symptoms reported), subthreshold BFRB group (mild BFRB symptoms reported; severity score of 2 or less out of 9), and those with symptoms characteristic of BFRBs (more than mild BFRB symptoms reported; severity score of 3 or higher out of 9)] for level of sleep disturbance. A hierarchical regression revealed that there was a significant effect of group membership after controlling for anxiety (F (3, 410) = 152.976, p < .001). Aim 2 of the study was to test whether there was a relationship between sleep disturbance and BFRB severity. The hierarchical regression revealed that at Step 1, anxiety accounted for 23.1% of the variance in BFRB severity (β = 0.48, t = 8.87, p < 0.001). At Step 2, sleep disturbance total score accounted for an additional 7.2% of the variance, suggesting this variable makes a unique contribution to overall BFRB severity (SDSC: β = 0.40, t = 5.18, p < 0.001). The findings of this study suggest that sleep could be a clinical factor to consider when conceptualizing a child with BFRBs.

Negative Affectivity Moderates the Relationship between Attentional Control and Focused Skin Picking

Very little is known about the cognitive functioning of people with body-focused repetitive behaviours and the few existing studies provide mixed findings. The aim of this study was to investigate the interplay between attentional control, negative affectivity, and focused skin picking. We hypothesized that the control of attention is associated with focused style of skin picking and that this relationship is moderated by negative affectivity. The final sample consisted of 273 non-clinical subjects (79% women) aged 18 to 54 years; study variables were assessed using questionnaires. Moderation analysis was conducted, followed by a simple slope analysis, and the Johnson–Neyman technique was used to probe the interaction effect. We found that at the low level of negative affectivity, the relationship between attentional control and focused skin picking is negative, but not at the higher levels of this trait. Interestingly, when negative affectivity reaches very high intensity, the association between attentional control and skin picking becomes positive. This relationship seems to be quite complex and may depend on the way that cognitive abilities are used by the individual, as well as on the stage of cognitive processing that they are applied to. Further studies using behavioural measures of attention are needed to better understand this issue.

Dissociative Experiences Mediate the Relationship Between Traumatic Life Events and Types of Skin Picking. Findings From Non-clinical Sample

Aim: Skin-picking (excoriation) disorder is considered as a form of maladaptive coping methods used by individuals who have difficulties in applying more adaptive strategies. Skin-picking development has been suggested to be preceded by traumatic life events. Dissociative symptoms have been reported as experienced by skin-picking sufferers during picking episodes. The purpose of the study was to examine whether the link between trauma and automatic type of skin-picking is mediated by the frequency of dissociative experiences, and whether the COVID-19 pandemic conditions have changed this relationship in any way. Methods: The study sample consisted of 594 adults (76% women) aged from 18 to 60. Traumatic life events, dissociative experiences, and types of skin-picking (focused vs. automatic) were assessed with self-report questionnaires. Mediation analyses and multigroup path analyses were carried out. Results: Dissociative experiences partially mediated the link between traumatic events and both types of skin-picking. The model was robust considering the conditions in which survey was filled out (pre-pandemic vs. pandemic). Conclusions: Traumatic life events and dissociative experiences are associated with both automatic and focused skin-picking regardless of pandemic conditions. Further studies are needed to understand mechanisms underlying the relationship between dissociation and skin-picking styles.

Sensory symptoms in body-focused repetitive behaviors, restless legs syndrome, and Tourette syndrome: An overlap?

Tourette syndrome (TS) is a neurodevelopmental condition characterized by multiple tics. Sensory symptoms play a key role in the clinical phenomenology and pathophysiology of TS, as most patients report premonitory urges driving tic expression. Interestingly, sensory symptoms have also been reported in other conditions characterized by repeated behaviors. This review explores the nature of sensory symptoms reported by patients with body focused repetitive behaviors (BFRBs, especially trichotillomania and skin picking disorder) and restless legs syndrome (RLS) in comparison to TS. A sense of mounting inner tension and reinforcement mechanisms driven by gratification and relief on expression of the tic or repetitive behavior appear to be implicated across all conditions. Subjective urges can be temporarily suppressed by patients with TS and selected BFRBs, whereas patients with RLS tend to report dysesthesia more frequently than a suppressible urge to move. The observed similarities in the phenomenology of sensory symptoms across these conditions raise the possibility of a comparable underlying pathophysiology. Preliminary findings suggest an overlap of neural pathways encompassing the insula, basal ganglia (putamen), and posterior cingulate cortex.

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.

Hair pulling antecedents in trichotillomania: Their relationship with experiential avoidance

In this study, 285 adults who met criteria for trichotillomania (TTM) via self-report completed an online, cross-sectional survey examining antecedent phenomenological experiences pertaining to hair pulling along with measures of TTM severity and experiential avoidance (i.e., avoidance of or escape from unwanted thoughts or feelings). Results showed a heterogeneous depiction of antecedent experiences. Subsequent analyses revealed that certain antecedents were not significantly related to TTM severity but were significantly correlated with higher levels of experiential avoidance. In particular, four of five classes of antecedents (i.e., bodily sensations, physical symptoms, mental anxiety, and general uncomfortableness) were significantly related to greater experiential avoidance. The authors conclude that treatments may need to be designed to address specific private antecedents, and that this may be done through targeting experiential avoidance.

Comprehensive behavioral treatment for an adult with sensory-based trichotillomania: An illustrative case study

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.

Abnormal perceptual sensitivity in body-focused repetitive behaviors

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.

Systematic Review of Published Primary Studies of Neuropsychology and Neuroimaging in Trichotillomania

OBJECTIVES

Existing models of trichotillomania (TTM; hair pulling disorder) rely heavily on a biological predisposition or biological pathogenesis of the disorder, but fail to capture the specific neuropsychological mechanisms involved. The present systematic review aims to scope existing neuropsychological studies of TTM to explore gaps in current models.

METHODS

A systematic literature search was conducted to detect all published primary studies using neuropsychological and neuroimaging measures in a cohort of individuals experiencing TTM. Studies addressing neuropsychological function were divided into domains. Findings from imaging studies were considered within brain regions and across methodology.

RESULTS

Thirty studies with a combined 591 participants with TTM, 372 healthy controls and 225 participants in other types of control group were included. Sixteen studies investigated neuropsychological parameters, and 14 studies pursued neuroimaging technologies. Available studies that used neuropsychological assessments and reported a statistically significant difference between those with TTM and controls ranged in effect size from 0.25 to 1.58. All domains except verbal ability and visual ability reported a deficit. In neuroimaging studies, several structural and functional brain changes were reported that might be of significance to TTM. Only tentative conclusions can be made due to the use of multiple methodologies across studies, a major limitation to meaningful interpretations.

CONCLUSIONS

Positive neuropsychological and neuroimaging results require replication, preferably with multi-site studies using standardized methodology. Increased standardized testing and analyses across the literature, as a whole, would improve the utility and interpretability of knowledge in this field. (JINS, 2018, 24, 188-205).

Emotion regulation deficits in persons with body-focused repetitive behavior disorders

BACKGROUND

Conceptualizations of emotion dysregulation (ED) and body-focused repetitive behavior disorders (BFRBDs) imply that ED may be a central component of BFRBDs as well as a factor that distinguishes BFRBDs from non-impairing, subclinical body-focused repetitive behaviors (BFRBs). The current study empirically tested these observations.

METHODS

One hundred thirty-eight undergraduates (of 1900 who completed a screening survey) completed self-report measures assessing four emotion regulation (ER) deficits hypothesized to underlie ED (alexithymia, maladaptive emotional reactivity, experiential avoidance, and response inhibition when distressed); 34 of these participants had BFRBDs, 64 had subclinical BFRBs, and 42 were unaffected by BFRBs.

RESULTS

Results indicated that participants with BFRBDs reported higher levels of maladaptive emotional reactivity, experiential avoidance, and response inhibition when distressed than participants with subclinical BFRBs and participants unaffected by BFRBs. These results held even when controlling for comorbidity and total number of reported BFRBs. Participants did not differ on alexithymia.

LIMITATIONS

Limitations of the current study include the BFRB groups' different distributions of BFRB types (e.g., hair pulling versus skin picking), the sample's demographic uniformity, and the fact that negative affectivity was not controlled when exploring BFRB group differences on ER deficits. Future research should improve on these limitations.

CONCLUSIONS

The current results suggest that ED is a factor that differentiates BFRBDs from subclinical BFRBs. Such results may be useful for generating hypotheses regarding mechanisms responsible for BFRBs' development into BFRBDs. Furthermore, these results may provide insight into factors that explain the efficacy of more contemporary behavioral treatments for BFRBDs.

Awareness Enhancing and Monitoring Device plus Habit Reversal in the Treatment of Trichotillomania: An Open Feasibility Trial

Habit Reversal Therapy (HRT) is helpful for many persons suffering from trichotillomania. However successful habit reversal therapy requires awareness of hair pulling behaviors. Available methods to monitor hair pulling behaviors are less than ideal, particularly when sufferers are unaware of their pulling-related behaviors. This open feasibility trial included 20 persons with trichotillomania who were treated with nine weeks of HRT with experienced clinicians following a well-established HRT protocol. HRT was augmented with an electronic Awareness Enhancing and Monitoring Device (AEMD) designed to alert users of hand to head contact and to monitor the frequency of pulling-related behaviors. The AEMD included a neck unit and two wrist units, each equipped with vibrating alert functions. The results of the open trial revealed significant improvements in trichotillomania symptoms as measured by clinician and self-report rating scales. Most participants met study criteria for HRT completion and treatment effects were large. Participants reported that the AEMD, when operational, was effective in alerting participants to TTM-related behaviors. The monitoring function of the AEMD did not operate as designed. Subjective feedback focused on the AEMD concept was positive but AEMD reliability problems and complaints about the wearability the units were common. Recommendations for AEMD design modifications were included.

Presidential Address: Are the Obsessive-Compulsive Related Disorders Related to Obsessive-Compulsive Disorder? A Critical Look at DSM-5's New Category

The 5^th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) includes a new class of obsessive-compulsive and related disorders (OCRDs) that includes obsessive-compulsive disorder (OCD) and a handful of other putatively related conditions. Although this new category promises to raise awareness of underrecognized and understudied problems, the empirical validity and practical utility of this new DSM category is questionable. This article critically examines the arguments underlying the new OCRD class, illuminates a number of problems with this class, and then discusses implications for clinicians and researchers.

Clarifying the Relationship between Trichotillomania and Anxiety

Although research has consistently linked unidimensional anxiety with Trichotillomania (TTM) severity, the relationships between TTM severity and anxiety dimensions (i.e., cognitive and somatic anxiety) are unknown. This knowledge gap limits current TTM conceptualization and treatment. The current study examined these relationships with data collected from ninety-one adults who participated in a randomized clinical trial for TTM treatment. To examine whether the Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988) could be used to measure multidimensional anxiety in TTM samples, we conducted a factor analysis. Results showed four emergent factors, including a cognitive factor and three somatic factors (neurophysiological, autonomic, and panic). Based on prior research, it was hypothesized that TTM severity would be related to the cognitive anxiety dimension and that psychological inflexibility would mediate the association. Hypotheses were not made regarding the relationship between TTM severity and somatic anxiety. Regression analyses indicated that only cognitive dimensions of anxiety predicted TTM severity and that psychological inflexibility mediated this relationship. Implications for the conceptualization and treatment of TTM are discussed.

An examination of the role of intolerance of distress and uncertainty in hoarding symptoms

BACKGROUND

Hoarding disorder (HD) is a common and debilitating disorder characterized by an accumulation of and failure to discard one's possessions. The identification and examination of underlying factors that may contribute to hoarding symptoms are needed to elucidate the nature of the disorder and refine existing treatments. Two transdiagnostic vulnerability factors that have been associated with hoarding symptoms are distress intolerance (DI) and intolerance of uncertainty (IU).

OBJECTIVES

This study examined the relationships between DI, IU, and symptoms of hoarding in two samples consisting of outpatients and individuals recruited from Amazon's Mechanical Turk. We hypothesized that DI and IU would show unique and interactive associations with hoarding symptoms.

RESULTS

Across both samples, DI and IU were significantly associated with hoarding symptoms. However, DI and IU did not interact in their prediction of symptoms, and only IU remained a significant predictor, when accounting for relevant covariates.

CONCLUSIONS

Results suggest that IU is a robust predictor of hoarding symptoms and may be a promising and novel treatment target for HD.

Affective correlates of trichotillomania across the pulling cycle: Findings from an Italian sample of self-identified hair pullers

Etiological models of trichotillomania (TTM) conceptualize hair pulling as a dysfunctional emotion regulation strategy; accordingly, some research has found that affective states change differentially across the hair pulling cycle. We explored emotional changes in a sample of Italian individuals reporting TTM. Eighty-nine participants reporting TTM completed a 12-item section of the Italian Hair Pulling Questionnaire online and rated the extent to which they had experienced 12 affective states before, during, and after hair pulling. Overall, participants reported increased levels of shame, sadness, and frustration from pre- to post-pulling, and decreased levels of calmness after hair pulling episodes. Moreover, participants reported increased pleasure and relief across the pulling cycle, and variations in the direction of change for anger and anxiety depending on the hair pulling phase. Lastly, reported boredom decreased across the hair pulling cycle. These findings highlight the importance of considering emotional changes experienced across the pulling cycle in Italian hair pullers.

Factor analysis of the Milwaukee Inventory for Subtypes of Trichotillomania-Adult Version

The Milwaukee Inventory for Subtypes of Trichotillomania-Adult Version (MIST-A; Flessner et al., 2008) measures the degree to which hair pulling in Trichotillomania (TTM) can be described as "automatic" (i.e., done without awareness and unrelated to affective states) and/or "focused" (i.e., done with awareness and to regulate affective states). Despite preliminary evidence in support of the psychometric properties of the MIST-A, emerging research suggests the original factor structure may not optimally capture TTM phenomenology. Using data from a treatment-seeking TTM sample, the current study examined the factor structure of the MIST-A via exploratory factor analysis. The resulting two factor solution suggested the MIST-A consists of a 5-item "awareness of pulling" factor that measures the degree to which pulling is done with awareness and an 8-item "internal-regulated pulling" factor that measures the degree to which pulling is done to regulate internal stimuli (e.g., emotions, cognitions, and urges). Correlational analyses provided preliminary evidence for the validity of these derived factors. Findings from this study challenge the notions of "automatic" and "focused" pulling styles and suggest that researchers should continue to explore TTM subtypes.

Experiential Avoidance as a Mediator of Relationships Between Cognitions and Hair-Pulling Severity

Cognitive-behavioral models suggest that certain cognitions and beliefs are functionally related to hair pulling in persons with trichotillomania (TTM), but little empirical data have been collected to test such claims. This study assessed dysfunctional beliefs about appearance, shameful cognitions, and fear of negative evaluation and their relation to hair-pulling severity in a sample of individuals self-reporting a diagnosis of TTM. Results showed significant correlations between these cognitions and hair-pulling severity; however, relations diminished or disappeared when controlling for experiential avoidance, a tendency to avoid or escape from unwanted private events. These findings suggest that treatments targeting cognitions may benefit from focusing on experiential avoidance more broadly.

The Milwaukee Inventory for Styles of Trichotillomania-Child Version (MIST-C)

This article describes the development and initial psychometric properties of the Milwaukee Inventory for Styles of Trichotillomania-Child Version (MIST-C), a self-report scale designed to assess styles of hair pulling in children and adolescents diagnosed with trichotillomania (TTM). Using Internet sampling procedures, the authors recruited 164 parent–child dyads, the children of whom met modified diagnostic criteria for TTM. The MIST-C was administered in the context of a larger survey examining functional impairment experienced by children with TTM. Results of an exploratory factor analysis on MIST-C items revealed a two-factor solution. Factors 1 (“focused” pulling scale) and 2 (“automatic” pulling scale) consisted of 21 and 4 items, respectively, with both scales demonstrating acceptable internal consistency and good construct and discriminant validity. The development of the MIST-C provides researchers with a reliable and valid assessment of “automatic” and “focused” pulling, and provides a means by which to examine the developmental trajectory and treatment implications of these pulling styles.

Treating Trichotillomania

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

Comorbidity and quality of life in adults with hair pulling disorder

Hair pulling disorder (HPD; trichotillomania) is thought to be associated with significant psychiatric comorbidity and functional impairment. However, few methodologically rigorous studies of HPD have been conducted, rendering such conclusions tenuous. The following study examined comorbidity and psychosocial functioning in a well-characterized sample of adults with HPD (N=85) who met DSM-IV criteria, had at least moderate hair pulling severity, and participated in a clinical trial. Results revealed that 38.8% of individuals with HPD had another current psychiatric diagnosis and 78.8% had another lifetime (present and/or past) psychiatric diagnosis. Specifically, HPD showed substantial overlap with depressive, anxiety, addictive, and other body-focused repetitive behavior disorders. The relationships between certain comorbidity patterns, hair pulling severity, current mood and anxiety symptoms, and quality of life were also examined. Results showed that current depressive symptoms were the only predictor of quality of life deficits. Implications of these findings for the conceptualization and treatment of HPD are discussed.

Behavioural addiction-A rising tide?

The term 'addiction' was traditionally used in relation to centrally active substances, such as cocaine, alcohol, or nicotine. Addiction is not a unitary construct but rather incorporates a number of features, such as repetitive engagement in behaviours that are rewarding (at least initially), loss of control (spiralling engagement over time), persistence despite untoward functional consequences, and physical dependence (evidenced by withdrawal symptoms when intake of the substance diminishes). It has been suggested that certain psychiatric disorders characterized by maladaptive, repetitive behaviours share parallels with substance addiction and therefore represent 'behavioural addictions'. This perspective has influenced the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which now has a category 'Substance Related and Addictive Disorders', including gambling disorder. Could other disorders characterised by repetitive behaviours, besides gambling disorder, also be considered 'addictions'? Potential examples include kleptomania, compulsive sexual behaviour, 'Internet addiction', trichotillomania (hair pulling disorder), and skin-picking disorder. This paper seeks to define what is meant by 'behavioural addiction', and critically considers the evidence for and against this conceptualisation in respect of the above conditions, from perspectives of aetiology, phenomenology, co-morbidity, neurobiology, and treatment. Research in this area has important implications for future diagnostic classification systems, neurobiological models, and novel treatment directions.

Affective regulation in trichotillomania before and after self-help interventions

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The role of emotion regulation in body-focused repetitive behaviours

Body-focused repetitive behaviours (BFRBs) including trichotillomania, skin picking, and nail biting, are non-functional self-destructive habits, which have a severe negative impact on everyday functioning. Although BFRBs cause distress, they are maintained by both negative (relief) and positive (stimulation) reinforcement. The emotional regulation (ER) model proposes that people with BFRBs have a general deficit in ER and, as a consequence, engage in BFRBs to alleviate affect and reinforce the behaviour. The current study was designed to explore differences in ER between people with BFRBs and controls to identify specific emotions triggering BFRBs. Forty-eight participants (24 BFRB, 24 controls) completed questionnaires measuring Difficulties in Emotional Regulation (DERS), a Triggers Scale and an Affective Regulation Scale (ARS). Significant differences in people with BFRBs and controls were reported principally on the DERS subscales of lack of emotional clarity, difficulties in impulse control, and access to ER strategies. On the ARS, the BFRB group reported overall difficulty ‘snapping out’ of emotions. The majority of BFRBs were reported to be triggered by anxiety (78%), tension (70%), or boredom (52%). The clinical implication is that ER could be beneficially targeted in therapy for BFRBs.

The Phenomenology of Hair Pulling Urges in Trichotillomania: A Comparative Approach

Trichotillomania is a disorder characterized by recurrent urges to pull out one's hair, but the experiential characteristics of hair pulling urges are poorly understood. This study used a comparative approach to understand the subjective phenomenology of hair pulling: participants with trichotillomania symptoms were asked about their hair pulling urges as well as their urges to eat unhealthy foods. Participants who reported experiencing problematic unhealthy food urges were identified and asked to compare the phenomenological characteristics of their hair pulling and unhealthy food urges across a variety of dimensions. Results revealed significant differences for only some urge properties measured, and differences that existed were small to moderate in magnitude. Qualitative comparisons of the two urges revealed situational characteristics of hair pulling that could explain these small to moderate differences between the two urges. We conclude that hair pulling urges may be more comparable to ordinary urges such as unhealthy food urges than one might expect, but that hair pulling urges may nevertheless be rated as slightly more severe due to situational characteristics of these urges. This conception may improve clinician and lay understanding of the condition, assist with destigmatization efforts, and facilitate the development of treatment strategies.

Investigation of the Phenomenological and Psychopathological Features of Trichotillomania in an Italian Sample

Trichotillomania (TTM) is still a scarcely known and often inadequately treated disorder in Italian clinical settings, despite growing evidence about its severe and disabling consequences. The current study investigated the phenomenology of TTM in Italian individuals; in addition, we sought to examine patterns of self-esteem, anxiety, depression, and OCD-related symptoms in individuals with TTM compared to healthy participants. The current study represents the first attempt to investigate the phenomenological and psychopathological features of TTM in Italian hair pullers. One hundred and twenty-two individuals with TTM were enrolled: 24 were assessed face-to-face (face-to-face group) and 98 were recruited online (online group). An additional group of 22 face-to-face assessed healthy controls (HC group) was included in the study. The overall female to male ratio was 14:1, which is slightly higher favoring female than findings reported in literature. Main results revealed that a higher percentage of individuals in the online group reported pulling from the pubic region than did face-to-face participants; furthermore, the former engaged in examining the bulb and running the hair across the lips and reported pulling while lying in bed at higher frequencies than the latter. Interestingly, the online TTM group showed greater functional and psychological impairment, as well as more severe psychopathological characteristics (self-esteem, physiological and social anxiety, perfectionism, overestimation of threat, and control of thoughts), than the face-to-face one. Differences between the two TTM groups may be explained by the anonymity nature of the online group, which may have led to successful recruitment of more serious TTM cases, or fostered more open answers to questions. Overall, results revealed that many of the phenomenological features of Italian TTM participants matched those found in U.S. clinical settings, even though some notable differences were observed; therefore, cross-cultural invariance might represent a characteristic of OCD-related disorders.

Clinical Characteristics of Pediatric Trichotillomania: Comparisons with Obsessive-Compulsive and Tic Disorders

This study compared youth ages 5-17 years with a primary diagnosis of trichotillomania (TTM, n = 30) to those with primary OCD (n = 30) and tic disorder (n = 29) on demographic characteristics, internalizing, and externalizing symptoms. Findings suggest that youth with primary TTM score more comparably to youth with tics than those with OCD on internalizing and externalizing symptom measures. Compared to the OCD group, youth in the TTM group reported lower levels of anxiety and depression. Parents of youth in the TTM group also reported fewer internalizing, externalizing, attention, and thought problems than those in the OCD group. Youth with TTM did not significantly differ from those with primary Tic disorders on any measure. Findings suggest that pediatric TTM may be more similar to pediatric tic disorders than pediatric OCD on anxiety, depression, and global internalizing and externalizing problems.

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

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

Trichotillomania by proxy

Trichotillomania is a disorder of an impulsive hair pulling that occurs in both adults and children alike. Trichotillomania is seen in children and often has other psychiatric comorbidity. Here, we present an interesting case of a mother who had trichotillomania and recovered with treatment following which she resorted to pulling hair of her child and brought her child for treatment saying that the child too had trichotillomania and that we should help the child recover like her. After interviewing the child, it was revealed that it was, in fact, the mother who used to pull the child's hair as a release for her hair-pulling urges.

The impact of emotions on body-Focused repetitive behaviors: evidence from a non-treatment-seeking sample

Body-focused repetitive behaviors (BFRBs) are repetitive, injurious, and non-functional habits that cause significant distress or impairment, including hair-pulling, skin-picking, and nail-biting. The emotion regulation (ER) model suggests that BFRBs are triggered by negative emotions and reinforced by alleviation of unpleasant affect. The frustrated action (FA) model suggests that BFRBs are triggered by and alleviate impatience, boredom, frustration, and dissatisfaction. Individuals with BFRBs are hypothesized to be particularly susceptible to these emotions because they demonstrate maladaptive planning styles characterized by high standards and unwillingness to relax.

OBJECTIVES

The objective of this study was to test these two models.

METHODS

This study compared urge to engage in BFRBs in a BFRB group (n = 24) and a control group (n = 23) in experimental conditions designed to elicit boredom/frustration, stress, and relaxation, respectively.

RESULTS

The BFRB group reported a significantly greater urge to engage in BFRBs than did the control group across conditions. Participants in the BFRB group reported a stronger urge to engage in BFRBs in the boredom/frustration condition than in the relaxation condition but not in the stress condition. Finally, the BFRB group presented significantly higher scores on maladaptive planning style, and maladaptive planning style was significantly correlated with difficulties with ER.

LIMITATIONS

Future studies may wish to exclusively use validated mood induction techniques and more stringent inclusion criteria.

CONCLUSIONS

The results highlight the role of boredom, frustration, and impatience in triggering BFRBs, and support the FA model.

Trichotillomania in Children

BACKGROUND

Trichotillomania is an often underdiagnosed condition. Little is known about trichotillomania in childhood. We aimed to analyze the characteristics of children with trichotillomania to increase information on this condition.

METHODS

A retrospective study of an electronic database was performed in a tertiary children's hospital. Information from patients with trichotillomania was systematically classified under the categories 'who', 'what', 'when', 'where', 'why', and 'how'.

RESULTS

A total of 33 patients had a diagnosis of trichotillomania (28 females, 5 males; peak age between 3 and 4 years). Scalp involvement was most common and nail biting was observed in 5 patients. Only 51.5% of patients had parents who noticed their child's hairpulling. Hair on or under the bed was the most common clue suggesting that hairpulling occurred. Triggering factors identified in 16 children included physical appearance, family-related issues, school-related issues, and concurrent illness. The noninvasive hair pull test was negative in all children. There was a high non-follow-up rate, and treatment outcomes varied.

CONCLUSION

A set of 6 specific questions, based on the '5Ws and 1H' principle, facilitates the gathering of important information on children with unexplained nonscarring hair loss and helps clinicians be cognizant of possible outcomes of trichotillomania. This will be especially useful to clinicians who are not familiar with this elusive condition.

Measuring the role of psychological inflexibility in Trichotillomania

Psychological Inflexibility (PI) is a construct that has gained recent attention as a critical theoretical component of Acceptance and Commitment Therapy (ACT). PI is typically measured by the Acceptance and Action Questionnaire-II (AAQ-II). However, the AAQ-II has shown questionable reliability in clinical populations with specific diagnoses, leading to the creation of content-specific versions of the AAQ-II that show stronger psychometric properties in their target populations. A growing body of the literature suggests that PI processes may contribute to hair pulling, and the current study sought to examine the psychometric properties and utility of a Trichotillomania-specific version of the AAQ-II, the AAQ-TTM. A referred sample of 90 individuals completed a battery of assessments as part of a randomized clinical trial of Acceptance-Enhanced Behavior Therapy for Trichotillomania. Results showed that the AAQ-TTM has two intercorrelated factors, adequate reliability, concurrent validity, and incremental validity over the AAQ-II. Furthermore, mediational analysis between emotional variables and hair pulling outcomes provides support for using the AAQ-TTM to measure the therapeutic process. Implications for the use of this measure will be discussed, including the need to further investigate the role of PI processes in Trichotillomania.

Predictors of Relapse Following Treatment of Trichotillomania

OBJECTIVE

This study sought to identify predictors of relapse in a behavior therapy trial for trichotillomania (TTM), or hair-pulling disorder. Relapse is common after treatment for TTM, and only a few studies have examined what might predict relapse.

METHOD

Data was examined from a TTM treatment study with a stepped-care approach (step 1. web-based self-help; step 2. individual behavior therapy) (N = 60). Implications of significant predictive relations were illustrated by constructing Probability of Treatment Benefit (PTB) charts (Lindhiem, Kolko, & Cheng, 2012), which quantify the probability of maintaining gains according to predictors of maintenance.

RESULTS

Abstinence at the conclusion of treatment and lower TTM severity during initial response significantly predicted maintenance. Abstinence periods prior to treatment, residual urges after achieving abstinence, pre-treatment TTM severity, intrinsic motivation, and treatment compliance did not predict maintenance.

CONCLUSIONS

Post-treatment abstinence and lower TTM severity during initial response predicted maintenance. Replications of this research are needed to determine the usefulness of these possible predictors in identifying relapse-prone patients, with the aim of improving clinical decision-making and developing strategies to help these patients better maintain gains. This is the first TTM study to use PTB charts, which can help clarify the meaning of prognostic analyses.

Diagnosis, evaluation, and management of trichotillomania

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

Cognitive behavior therapy for obsessive-compulsive and related disorders

Cognitive behavior therapy (CBT) is considered a first-line intervention for obsessive-compulsive disorder (OCD) across the lifespan. Efficacy studies of CBT with exposure and response prevention suggest robust symptom reduction, often with sustained remission. Acceptability of CBT is high, and the treatment is devoid of adverse side effects. The primary mechanism of CBT is based on operant principles, specifically extinction learning. The efficacy of extinction-based treatments such as CBT is being shown for other obsessive-compulsive spectrum disorders. This article reviews the theoretic basis, clinical application, and relevant treatment outcome research for CBT and related therapies for several obsessive-compulsive spectrum disorders.

Age and gender correlates of pulling in pediatric trichotillomania

OBJECTIVE

Our goals were to examine clinical characteristics and age and gender correlates in pediatric trichotillomania.

METHOD

A total of 62 children (8-17 years of age) were recruited for a pediatric trichotillomania treatment trial and characterized using structured rating scales of symptoms of hairpulling and common comorbid conditions. We analyzed the association between qualitative and quantitative characteristics of pulling, comorbidities, and age and gender. We also examined the type of treatments these children previously received in the community.

RESULTS

We found lower rates of comorbid depression and anxiety disorders than have been reported in adult trichotillomania samples. Focused hairpulling significantly increased with age, whereas automatic pulling remained constant. Older children with hairpulling experienced more frequent urges and a decreased ability to refrain from pulling. Female participants reported greater distress and impairment associated with hairpulling, even though the severity of pulling did not differ from that of male participants.

CONCLUSION

These results confirm several findings from the Children and Adolescent Trichotillomania Impact Project (CA-TIP). Our cross-sectional findings suggest there may be a developmental progress of symptoms in trichotillomania. Children appeared to develop more focused pulling, to become more aware of their urges, and to experience more frequent urges to pull, as they get older. Although these are important findings, they need to be confirmed in prospective longitudinal studies.

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

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