Personal toll of trichotillomania: behavioral and interpersonal sequelae

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.

Short-term intervention complemented by wearable technology improves Trichotillomania - A naturalistic single-case report

There is a growing interest in using wearable technology for the treatment of body-focused repetitive behaviors (BFRBs), such as Trichotillomania. Yet, to our knowledge, few studies address the applicability and use of wearable technology as a therapeutic element in more naturalistic situations. Here we would like to introduce its potential use combined with a Habit-Reversal Training in a single-case experimental design. In practice, individuals with BFRBs frequently show complex constellations of psychiatric disorders. Accordingly, the here presented participant was diagnosed with Trichotillomania as well as comorbid ADHD and examination phobia. The participant was offered to wear an unobtrusive and user-friendly vibration device that sent an alarm when her critical hairpulling behaviors occurred. The complementing Habit-Reversal Training included an Awareness Training supported by the vibration alarm of the wearable device. It further included a Competing Response Training by learning benign behaviors that could replace the hairpulling behavior. The frequency of hairpulling episodes was assessed using daily self-reports and by using the monitoring function of the wearable device. The intervention procedure was implemented into the participant's everyday life and evaluated over the course of 214 days. The results indicated a significant reduction in the daily episodes of hair pulling. Our preliminary findings suggest that the here applied intervention has the potential to effectively treat Trichotillomania in individuals with comorbid disorders in psychotherapeutic outpatient care. Certainly, group-studies will need to further validate the approach's effectiveness.

Untroubled Pullers: An Examination of Nonclinical Hair-Pulling

Nonclinical hair-pulling is much more prevalent than hair pulling associated with a diagnosis of trichotillomania (TTM). However, little is known about nonclinical pulling. The purpose of this exploratory research was to begin characterizing a subset of nonclinical hair pullers we refer to as "untroubled pullers," people who engage in recurrent, noncosmetic hair-pulling without associated distress or impairment. In a secondary analysis of two studies conducted online, untroubled pullers reported significantly lower symptom severity than did those diagnosed with TTM. The Big Five personality dimensions did not differentiate the groups in Study 1, but untroubled pullers endorsed significantly less disability, focused and automatic pulling, social anxiety, perceived risk in intimacy, and perfectionism in Study 2. These findings remained significant after controlling for symptom severity. Age and race resulted in mixed findings between the two studies, but no differences arose in other demographics. These findings suggest that symptom severity may not sufficiently explain differences in associated distress and impairment. Future studies are needed on how other constructs related to distress and impairment interact with hair-pulling behavior to provide insight into when pulling is associated with clinically significant distress or impairment.

Comprehensive Behavioral Treatment of an Older Adult Man with Trichotillomania

The Comprehensive Behavioral (ComB) model of treatment for trichotillomania (TTM) and other body-focused repetitive behaviors offers a framework for individualized, flexible intervention based on functional analysis. This case report focuses on the treatment of a patient who enrolled in the first randomized clinical trial of ComB for TTM (Carlson et al., 2021) as well as a long-term follow-up of participants from that trial conducted during the COVID-19 pandemic (Flannery et al., in press). Walter (pseudonym) entered the treatment trial at 69, having had TTM since age 17 but not received treatment for it. Walter showed clinically significant improvement in treatment, ultimately abstaining from hair pulling for two years. A single case from a parallel-groups trial cannot support strong conclusions about why his results were favorable, but qualitative review of Walter’s experience in therapy suggested that allowing him a good deal of collaborative input on the specific methods of implementation of ComB principles was helpful. Along with the general literature on patient age as a predictor of therapy outcome, Walter’s case serves as a reminder that older adults, even those with highly chronic clinical conditions, can benefit greatly from psychotherapy.

Characterizing the content, messaging, and tone of trichotillomania on YouTube: A content analysis

BACKGROUND

Trichotillomania is associated with secrecy and reluctance to seek help due to shame and lack of knowledge. Social media can connect people with similar lived experience. However, there is no literature regarding online communities related to trichotillomania. This study is a content analysis of depictions of trichotillomania on YouTube to identify the potential role of social media in this disorder.

METHODS

We used a cross-sectional observational study to examine the 100 most-viewed YouTube videos for trichotillomania content until June 2018. Up to 96 variables were abstracted from each video including demographics, characteristics of the videos, and depictions of trichotillomania.

RESULTS

View counts ranged from 9,186 to 15,597,149. Uploaders had a mean age of 20.1 years, were mostly female (85%) and appearing Caucasian (63%). Nearly half of the videos were self-filmed stories (48%). Most had a neutral message (44%), provided strategies to stop hair-pulling (31%), or focused on stimulating discussion (17%). Approximately half had a factual tone (51%) and many were hopeful (44%). Videos accurately described hair-pulling and associated characteristics.

LIMITATIONS

This study was limited to an analysis of video content. Future research should examine the comments on the videos as well as other social media platforms. It may also be important to assess the socioeconomic status of video uploaders and ensure the broader accessibility of positive messages on trichotillomania.

CONCLUSIONS

People with trichotillomania may find positive messages, information, and helpful recommendations on YouTube. This may represent an under-leveraged venue to improve clinical outcomes for people with trichotillomania.

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

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

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.

Development of the social concerns in individuals with body-focused repetitive behaviors (SCIB) scale

Body-focused repetitive behaviors (BFRBs) include such disorders as compulsive hair pulling, skin picking, nail biting, and cheek biting, which can lead to significant psychosocial impairment (American Psychiatric Association, 2013). As such, social concerns (i.e., concerns about how others view their behavior or affected body sites) are common in these individuals, and may significantly associate with BFRB symptomology (Snorrason et al., 2012). Currently, there are no measures to adequately assess social concerns specific to BFRBs. To this end, we developed a new self-report measure called the Social Concerns in Individuals with BFRBs (SCIB) that aimed to assess these concerns using two independent samples of individuals reporting elevated BFRB symptoms. Results showed that the overall level of social concerns reported on the SCIB significantly explained the variance in hair pulling and skin picking symptom severity even after controlling for the influence of other general social concern and emotional distress measures. Exploratory and confirmatory factor analyses provided psychometric evidence for the two-factor structure of the SCIB: (1) Concern about Physical Unattractiveness and (2) Concern about Social Disapproval, which were found to assess distinguishable aspects of BFRB-relevant social concerns. Overall, the findings suggest that the SCIB is a useful measure that can be used to evaluate social concerns in those with BFRB disorders.

Pharmacotherapy for trichotillomania in adults

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

The Beliefs in Trichotillomania Scale (BiTS): Factor analyses and preliminary validation

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.

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.

Types of avoidance in hair-pulling disorder (trichotillomania): An exploratory and confirmatory analysis

Hair-pulling disorder (HPD) or Trichotillomania is a complex disorder with frequent relapses. Avoidance has been highlighted as an important behavioural feature in HPD. To improve our understanding of avoidance, two studies were conducted to identify the types of avoidance that may be experienced by those who pull hair. Internet questionnaires were used to collect data. Data from study one was split into two subsets. An exploratory factor analysis was conducted to identify the different types of avoidance experienced by those reporting symptoms of hair pulling (subset one, n = 278), followed by a confirmatory factor analysis (subset two, n = 295). In study two a MANOVA was conducted (n = 300) to examine whether levels of avoidance differed between controls and those with hair pulling symptoms. Participants with hair pulling symptoms had greater levels of avoidance on each of the five types: 'Avoidance of non-social goals', 'Self-concealment', 'Behavioural social avoidance', 'Avoidance of relationship problem solving' and 'Avoidance of thinking about the future'. These data expand on the current literature, which has predominantly focused on experiential avoidance. Future research will need to validate these findings in a clinical group.

Perfectionism, Shame, and Trichotillomania Symptoms in Clinical and Nonclinical Samples

This study explored the relationships between multidimensional perfectionism (adaptive and maladaptive), shame (characterological, behavioral, and bodily), and trichotillomania (TTM) symptom severity in a nonclinical sample of 284 college students and a clinical sample of 125 individuals with TTM. Results suggested that the clinical sample reported significantly higher levels of maladaptive perfectionism, all three subtypes of shame, and TTM compared to the nonclinical sample. While none of the three subtypes of shame mediated the relationship between either form of perfectionism and TTM for the nonclinical sample, behavioral shame was a significant mediator between maladaptive perfectionism and TTM for the clinical sample. Implications for mental health counselors are discussed.

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.

Parent Coping With Adolescent Trichotillomania

Adolescents who struggle with trichotillomania (TTM; hairpulling disorder) are not alone, their parents also struggle. The focus of this qualitative study was to identify what parents (N = 30) perceive as stressful about parenting an adolescent with TTM and how they cope with these stressors. Parents described uncertainty about the course of the disorder and powerlessness in the ability to protect their adolescent from the reactions of others or assist them in curtailing the hairpulling as very distressing. Data analysis revealed eight coping strategies used to manage these stressors and the accompanying grief: (a) information gathering, (b) anticipatory guidance, (c) crying, (d) hypervigilance, (e) gaining emotional support from others, (f) acceptance, (g) goal revision, and (h) guiding rather than protecting their adolescent. The study findings can be used by school nurses to gain a deeper understanding of this disorder and to provide family-centered care in the school setting.

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.

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.

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.

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.

Symptom accommodation, trichotillomania-by-proxy, and interpersonal functioning in trichotillomania (hair-pulling disorder)

OBJECTIVE

This study investigated relationship functioning in trichotillomania (TTM) as well as specific interpersonal behaviors that have received little attention in TTM research, including by-proxy pulling, symptom accommodation, and self-disclosure. The objective was to contribute data for future development of components of treatment that focus on interpersonal functioning.

METHODS

Data were collected through survey about relationships and related difficulties among adults who endorsed criteria consistent with DSM-5 criteria for TTM (n=670).

RESULTS

Consistent with our hypotheses, TTM symptom severity was correlated negatively with relationship satisfaction and perceived social support, positively with perceived criticism, perceived risk in intimacy, and social interaction anxiety, though these correlations were small (absolute values r=.08 to .17). Approximately one-quarter of survey respondents had not told their closest friend about their trichotillomania, and one-fifth had not told their spouse or long-term romantic partner. TTM-by-proxy urges were reported by 54% of participants, and 37% of participants reported having actually pulled hair from other people, with the most common proxies specified as significant others (51%), parents (13%), friends (8%), siblings (8%), children (7%) and pets (5%). Higher levels of TTM-by-proxy urges were associated with "focused" pulling (d=.37) and perfectionistic thinking (d=.16 to .20), yet current by-proxy urges were not associated with, functional impairment. A small minority of individuals (7%) reported having asked other people to pull hair for them (78% of these requests were granted); there was increased endorsement of "focused" pulling among these individuals. The people who participants asked to pull hairs for them included significant others (66%), mothers (20%), siblings (11%), friends (9%) and one's children (9%).

CONCLUSION

More than one-third of respondents had pulled hair from others, 7% had asked others to pull their hair, and sizable minorities kept TTM secret from their closest friends or even spouse/partners. Clinical levels of social interaction anxiety were endorsed by 51% of the sample. Understanding these interpersonal experiences more fully could improve our understanding of relationship functioning in TTM and guide efforts to individualize treatment for adults with TTM.

DSM-5 Trichotillomania: Perception of Adults with Trichotillomania After Psychosocial Treatment

OBJECTIVE

Trichotillomania (TTM) is associated with significant embarrassment and is viewed negatively by others. A potentially important outcome variable that is often overlooked in treatment for TTM is appearance and social perception.

METHOD

The present study tested whether participants in a randomized controlled trial (RCT) of psychotherapy for TTM are viewed more positively by others. All participants in the trial were photographed at baseline and posttreatment. Three treatment responders and three treatment nonresponders were selected randomly for the present study. Several healthy controls were also photographed in a similar manner. Undergraduate college students (N = 245) assessed whether they would reject the person socially, whether the individual has a psychological or medical problem, and attractiveness.

RESULTS

Individuals with TTM were viewed more negatively than healthy controls at baseline, but treatment responders showed positive improvements on all perceptions relative to nonresponders. While treatment responders were still perceived more poorly than controls on social rejection and perceptions of problems at posttreatment, responders where rated no differently than controls on attractiveness at posttreatment.

CONCLUSIONS

The results suggest that persons with TTM who respond to treatment are rated by others as significantly improved in appearance, but they might be still stigmatized or socially rejected.

Shame in the obsessive compulsive related disorders: a conceptual review

BACKGROUND

Theoretical and anecdotal support for the role of shame in obsessive compulsive related disorders (OCRDs) is prominent. Developing our understanding of shame׳s role in OCRDs is important to building knowledge about this new diagnostic category. This review aims to consolidate our understanding of shame in each OCRD, through summarizing existing clinical, conceptual, and empirical work.

METHODS

We provide an overview of shame, its measurement considerations, and a full review of 110 articles addressing shame in OCRDs.

RESULTS

General shame and shame about having a mental illness are the broadest types of shame relevant to OCRDs; symptom-based shame and body shame may be more specific to OCRDs. In OCD, violent, sexual, or blasphemous obsessions may trigger symptom-based shame. In trichotillomania (TTM) and skin picking (SP), symptom-based shame may be related to pulling, picking, and post-pulling/picking behaviors. In hoarding disorder, symptom-based shame may accompany beliefs about being defective due to living with clutter. Body shame appears inherent to body dysmorphic disorder, while in TTM and SP it may arise as a secondary response to damage resulting from body focused repetitive behaviors.

LIMITATIONS

Much of the current knowledge on shame in OCRDs comes from anecdotal, case, and conceptual work. Empirical studies do not always assess specific types of shame, instead assessing shame as a general construct.

CONCLUSIONS

Shame is closely related to OCRDs. Clinical and research recommendations drawing from the literature are provided.

Treating trichotillomania: a meta-analysis of treatment effects and moderators for behavior therapy and serotonin reuptake inhibitors

Few randomized controlled trials (RCTs) exist examining the efficacy of behavior therapy (BT) or serotonin reuptake inhibitors (SRIs) for the treatment of trichotillomania (TTM), with no examination of treatment moderators. The present meta-analysis synthesized the treatment effect sizes (ES) of BT and SRI relative to comparison conditions, and examined moderators of treatment. A comprehensive literature search identified 11 RCTs that met inclusion criteria. Clinical characteristics (e.g., age, comorbidity, therapeutic contact hours), outcome measures, treatment subtypes (e.g., SRI subtype, BT subtype), and ES data were extracted. The standardized mean difference of change in hair pulling severity was the outcome measure. A random effects meta-analysis found a large pooled ES for BT (ES = 1.41, p < 0.001). BT trials with greater therapeutic contact hours exhibited larger ES (p = 0.009). Additionally, BT trials that used mood enhanced therapeutic techniques exhibited greater ES relative to trials including only traditional BT components (p = 0.004). For SRI trials, a random effects meta-analysis identified a moderate pooled ES (ES = 0.41, p = 0.02). Although clomipramine exhibited larger ES relative to selective serotonin reuptake inhibitors, the difference was not statistically significant. Publication bias was not identified for either treatment. BT yields large treatment effects for TTM, with further examination needed to disentangle confounded treatment moderators. SRI trials exhibited a moderate pooled ES, with no treatment moderators identified. Sensitivity analyses highlighted the need for further RCTs of SRIs, especially among youth with TTM.

Body esteem in adolescent hair pullers

BACKGROUND AND AIMS

Trichotillomania (TTM) often first presents in adolescence, a developmental period marked by vulnerability in body image. To date, no one has studied the relationship between this disorder and body esteem.

METHODS

49 adolescents with DSM-IV TTM or chronic hair pulling (HP) and 23 control adolescents were administered diagnostic assessments and self-report measures of hair pulling and body esteem.

RESULTS

HP youth vs. controls reported lower levels of body esteem on all Body-Esteem Scale for Adolescents and Adults (BESAA) subscales (appearance, attribution and weight satisfaction). HP contributed to lowered body esteem, independent of comorbid anxiety or depression. As expected, HP youth with vs. without comorbid anxiety or depression reported lowered levels of body esteem. Further, greater HP severity and distress were significantly associated with lower levels of body esteem. HP severity alone but not distress/impairment predicted lower levels of body esteem, independent of comorbid anxiety and depression.

CONCLUSIONS

Both hair pulling and comorbid anxiety and depression can independently impact body esteem in adolescent hair pullers.

Pediatric trichotillomania

Trichotillomania (TTM) is an impulse control disorder characterized by chronic hair-pulling, distress, and impairment. Although the negative effects of TTM are documented and often readily evident, there remains a paucity of psychopathology and treatment research on this disorder, particularly in pediatric populations. In an effort to improve assessment of pediatric TTM, several TTM-specific instruments for youth have now been developed to reliably identify symptoms and examine related phenomenology. Instrument development has now yielded instruments to evaluate TTM and related symptoms in the context of clinical trials of youth, and the first randomized controlled trial of any treatment for pediatric TTM was recently published. Using the initial pediatric TTM studies as building blocks, future research is now needed to create a stronger body of knowledge about the relative and combined efficacy of potential interventions for TTM in youth, as well as to examine the effects of TTM phenomenology and comorbidity on treatment outcome. Dissemination efforts must also be heightened for this knowledge to best reach these vulnerable populations.

Pediatric trichotillomania: clinical presentation, treatment, and implications for nursing professionals

Trichotillomania (TTM), or compulsive hair pulling, is a disorder that typically onsets in childhood. It is mistaken to believe that children will "age out" of this behavior, as pediatric TTM often has a chronic, debilitating course that does not remit without treatment, resulting in considerable psychological and physical impairment. Because most children with TTM will be seen initially by nursing professionals in the practices of dermatologists, pediatricians, gastroenterologists, and other disciplines, raising nurses' awareness of this disorder is of the utmost importance for accurate nursing diagnosis and assessment. As the health care providers who spend the greatest amount of time with patients, nurses' detection and diagnosis of TTM can make a critical difference in the initiation of early intervention. Therefore, the purpose of this article is to provide an overview of pediatric TTM, including its epidemiology, clinical presentation, and treatment options, from the perspective of nurses who may interact with such patients in their workplace.

Early childhood trichotillomania: Initial considerations on phenomenology, treatment, and future directions

Historically, trichotillomania (TTM) in young children (0-3 years old) generally has been considered to be a benign habit that is clinically distinct from the TTM seen in older children and adults. However, early childhood TTM can be an impairing pathological disorder that merits formal intervention. The present article reviews the extant literature on TTM in young children, highlighting the limited available phenomenological data. We discuss a behavioral approach to conceptualization and treatment, highlighting core intervention strategies in three early childhood TTM cases seen in our clinic. We conclude by discussing areas in need of further empirical attention.

Trichotillomania and its treatment: a review and recommendations

Trichotillomania (TTM) is characterized as an impulse control disorder in which individuals fail to resist urges to pull out their own hair, and is associated with significant functional impairment and psychiatric comorbidity across the developmental spectrum. Onset in childhood or adolescence appears to be the norm, yet the research literature involving pediatric samples is particularly sparse. Efficacious treatments have been developed, in particular cognitive-behavioral interventions involving procedures collectively known as habit reversal training, yet relapse in adults appears to be common. Recent developments in pharmacotherapies for TTM and in combining cognitive-behavioral therapy approaches with medication hold promise, and efforts to examine their relative and combined efficacy are needed. Dissemination of information about TTM and its treatment is a critical next step in the field, since many affected individuals and families cannot find local treatment providers with sufficient knowledge to deliver interventions known to reduce hair pulling behavior.

Behavior therapy for pediatric trichotillomania: a randomized controlled trial

OBJECTIVE

To examine the efficacy and durability of a behavioral therapy (BT) protocol for pediatric TTM compared with a minimal attention control (MAC) condition. It was hypothesized that the BT condition would be superior to MAC at the end of acute treatment, and would also demonstrate durability of gains through the maintenance treatment phase.

METHOD

A randomized controlled trial in which 24 youths were assigned to either a pilot-tested BT protocol, consisting of eight weekly sessions, or to MAC, consisting of three sessions and five telephone calls over 8 weeks. Independent evaluators assessed outcome at pretreatment (week 0) and post-treatment (week 8) for BT and MAC, and again at week 16 for BT patients only. The primary outcome measure was the National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS).

RESULTS

For the BT condition, the week 8 mean NIMH-TSS score was significantly lower than that of the MAC condition. The BT condition's mean week 8 score was also significantly lower than their own mean week 0 score, whereas no such reductions were observed for the MAC condition. Upon completion of acute treatment at week 8, the BT group's gains were maintained through an 8-week maintenance treatment phase.

CONCLUSIONS

BT produced a superior outcome compared with a condition that controlled for participation in a pediatric TTM research study, nonspecific therapist contact effects, repeated assessments, and the passage of time. Maintenance of gains after acute BT provides preliminary support for the durability of treatment gains.

CLINICAL TRIAL REGISTRATION INFORMATION

Cognitive Behavioral Treatment of Pediatric Trichotillomania; http://www.clinicaltrials.gov; R21 MH 61457.

Obsessive-compulsive spectrum disorder symptoms in college students

OBJECTIVE

This study investigated the occurrence of obsessive-compulsive spectrum disorders (OCSDs) and associated symptomology in college students.

PARTICIPANTS

Participants included 358 undergraduate students.

RESULTS

Results suggest that clinically significant levels of OCSD symptoms are relatively common. Additionally, OCSD symptoms co-occurred with each other and anxiety symptoms in general, yet not significantly with impulsivity symptoms.

CONCLUSIONS

Given their prevalence in college students and potentially debilitating nature, it is important to increase awareness of OCSDs so that health professionals can better identify and treat symptoms of these disorders.

Recent Advances in the Understanding and Treatment of Trichotillomania

Trichotillomania (TTM), or chronic hair pulling, is associated with significant levels of distress and impairment. While research is in its infancy, more data are accumulating regarding the impact, phenomenology, maintaining variables, etiology, and treatment of TTM. Behavior therapy and clomipramine have been moderately effective in reducing TTM symptoms in clinical trials. Enhancing behavior therapy with techniques designed to address TTM patients' emotional control tendencies (e.g., acceptance-based procedures) represents a promising direction in treating TTM.

Trichotillomania: A current review

This review provides a broad and thorough synthesis of the Trichotillomania (TTM) literature as a resource for health professionals seeking the most current and complete information available. For the treatment provider, up to date information can help inform assessment, treatment, or referral decisions. For the student, this review provides a general overview and broad background information necessary to better understand hair-pulling and associated problems. For the researcher, information can help inform study planning. Prevalence, gender distributions, comorbidities, subtypes, and phenomenological characteristics are presented. Etiological theories are reviewed, and assessment and treatment options are offered. The validity of current DSM requirements is discussed and psychological and psychiatric treatment options are presented and evaluated for their strength of recommendation. Challenges to research and treatment are presented and directions for future research are suggested.

Depression, anxiety, and functional impairment in children with trichotillomania

BACKGROUND

Trichotillomania (TTM) remains understudied in children. Adult research suggests that TTM is accompanied by significant depression, anxiety, and functional impairment. The purpose of this study is to examine the occurrence of depression and anxiety in a relatively large sample of youth with TTM and the extent to which these symptoms mediate the relationship between TTM severity and associated impairment.

METHODS

The study utilized data from the Child and Adolescent Trichotillomania Impact Project (CA-TIP), an internet-based sample of 133 youth aged 10-17 (inclusive) with TTM.

RESULTS

Over 45% of children with TTM endorsed depressive symptoms and 40% endorsed anxiety symptoms in excess of one standard deviation (SD) above published community norms. More remarkably, 25% of our sample reported depressive and 20% reported anxiety symptoms in excess of 2 SD above these norms. Older participants reported more symptoms of depression and anxiety than younger ones; age of onset (children with later onset), but not duration of illness, was predictive of higher reports of both depressive and anxiety symptoms. Neither depressive nor anxiety symptoms were related to pulling site. Depressive symptoms partially mediated the relationship between TTM severity and functional impairment.

CONCLUSIONS

Based on an internet sample recruited from the homepage of the Trichotillomania Learning Center, data from this study suggests that symptoms of depression and anxiety may be pervasive among youth with TTM and likely impact functional impairment. Longitudinal studies using directly assessed samples are needed to replicate and extend these findings.

Skin picking behaviors: An examination of the prevalence and severity in a community sample

Body-focused repetitive behaviors such as skin picking have gained recent attention in the psychiatric literature. Prevalence of skin picking has not been well researched and is difficult to estimate; however, consequences of such behaviors can include severe medical complications and impaired social and occupational functioning. Given this, this study examined: (1) the prevalence and severity of skin picking in a nonclinical community sample, and (2) associations between skin picking and other measures of psychological functioning. Three hundred and fifty-four participants completed measures of psychological functioning and skin picking frequency and severity. A total of 62.7% endorsed some form of skin picking and 5.4% reported clinical levels of skin picking and associated distress/impact. Direct associations were found between skin picking and depressive, anxiety, and obsessive-compulsive symptoms, which may support the emotional regulation model of pathological skin picking. To establish proper diagnostic classification of pathological skin picking and optimize treatment planning and outcome, further investigation of functional relationships between skin picking and affective distress is needed.

Affective and Sensory Correlates of Hair Pulling in Pediatric Trichotillomania

Hair pulling in pediatric populations has not received adequate empirical study. Investigations of the affective and sensory states contributing to the etiology and maintenance of hair pulling may help to elucidate the classification of trichotillomania (TTM) as an impulse control disorder or obsessive-compulsive spectrum disorder. The current study aimed to examine children's self-reported affective and sensory states associated with hair pulling. Fifteen participants completed a questionnaire assessing children's experiences during first and recent hair pulling episodes. Results revealed that pulling hair for the first time was associated with pleasure and pain whereas recent hair pulling was associated with pleasure only, suggesting that the punishing quality of hair pulling may diminish over time. The findings also support the notion that hair pulling may be maintained primarily through positive reinforcement, which is consistent with its classification as an impulse control disorder.

Reversal of trichotillomania with aripiprazole

Trichotillomania (TTM) is a common psychiatric illness with marked chronicity and comorbidity that significantly impacts on psychosocial functioning and physical features of the sufferer. Treatment studies, to date, using behavioral and pharmacological interventions alone or simultaneously, are equivocal with few showing a sustained cessation of hair-plucking. In this report of a single patient with treatment resistant TTM, the sole use of the atypical neuroleptic Aripiprazole resulted in a cessation of hair-plucking maintained, at the time of reporting, for a period of 24 months. This finding, a first with Aripiprazole, warrants further investigation of this drug in the treatment of TTM.

Hair pulling and its affective correlates in an African-American university sample

Like other clinical phenomena, repetitive hair pulling in African-Americans has attracted little systematic investigation. Slightly over 200 participants were recruited from a historically black university. Participants completed the Hair Pulling Scale [Stanley, M. A., Borden, J. W., Bell, G. E., & Wagner, A. L. (1994). Nonclinical hair pulling: phenomenology and related psychopathology. Journal of Anxiety Disorders, 8, 119-130], the Beck Depression Inventory, and the Beck Anxiety Inventory (BAI). Ten percent of the African-American sample thought about pulling out hair and 6.3% actually pulled out hair. A variety of types of affect was reported before, during, and after pulling or picking. Several statistically significant relationships were found: status as a person who thinks about pulling out hair is significantly correlated with anxiety as measured by the BAI (r=.265, p=.000), status as a person who pulls hair is significantly correlated with anxiety as measured by the BAI (p=.192, r=.007). Implications are discussed.

Group treatment for trichotillomania: behavior therapy versus supportive therapy

In this randomized controlled trial, group behavior therapy (BT; n=12) was compared to group supportive therapy (ST; n=12) in the treatment of trichotillomania (TTM). Both treatments were also compared to a naturally occurring waiting period, the time period that participants waited for groups to form. Participants completing group BT experienced significantly greater decreases in self-reported hair-pulling symptoms and clinician-rated hair loss severity than did those in group ST. Decreases were significantly greater after treatment than after the naturalistic waiting period. In addition, a significantly higher percentage of those in the BT than ST condition were rated as much improved or very much improved on the Clinical Global Impression scale at posttreatment. However, despite substantial symptom improvement, TTM severity remained problematic at posttreatment. Specifically, few participants in either treatment met criteria for clinically significant change at posttreatment. In addition, relapse of symptoms occurred over the 6-month follow-up period. Results provided partial support for the short-term efficacy of group BT. However, the group format may not maximize the efficacy of BT for TTM. Thus, it is recommended that future BT research test either individual therapy or a combination of group and individual formats for TTM.

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

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

A survey of participants in two internet support groups for people with hair-pulling

BACKGROUND

A substantial number of patients suffering from psychological problems or psychiatric disorders have turned to internet support groups for help. This paper reports on the perceived effectiveness of trichotillomania (TTM) internet support groups for people suffering from hair-pulling.

METHODS

A questionnaire was sent via e-mail to all subscribers of two mailing lists devoted to TTM, each of which takes a somewhat different approach to the condition. The questionnaire addressed the possible benefits and problems associated with belonging to a TTM virtual support group.

RESULTS

Subscribers had similar demographic features as clinical samples of trichotillomania patients. Subscribers to both internet lists found them helpful in terms of feeling supported and in obtaining information. The different approaches to TTM on the two lists were associated with differences in treatments attempted by participants.

CONCLUSION

Internet support groups can potentially contribute to increasing awareness about and knowledge of psychiatric disorders such as TTM, as well as to their management. Nevertheless, additional effort is required to ensure that subscribers are able to make informed, evidence-based decisions.