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Leibinger KW, Murray E, Aschenbrenner S, Randerath J. Short-term intervention complemented by wearable technology improves Trichotillomania - A naturalistic single-case report. Front Psychol 2023; 14:1071532. [PMID: 37731870 PMCID: PMC10507401 DOI: 10.3389/fpsyg.2023.1071532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 08/16/2023] [Indexed: 09/22/2023] Open
Abstract
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.
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Affiliation(s)
| | - Eileen Murray
- Psychotherapy Training Center Bodensee (apb), Konstanz, Germany
| | - Steffen Aschenbrenner
- Section for Clinical Psychology and Neuropsychology, Department for Psychiatry and Psychotherapy, SRH Klinikum Karlsbad-Langensteinbach, Karlsbad, Germany
| | - Jennifer Randerath
- Department of Psychology, University of Konstanz, Konstanz, Germany
- Psychotherapy Training Center Bodensee (apb), Konstanz, Germany
- Lurija Institute for Rehabilitation Science and Health Research, Kliniken Schmieder, Allensbach, Germany
- Outpatient Unit for Research, Teaching and Practice, Faculty of Psychology, University of Vienna, Vienna, Austria
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Ong CW, Woods DW, Franklin ME, Saunders SM, Neal-Barnett AM, Compton SN, Twohig MP. The role of psychological flexibility in acceptance-enhanced behavior therapy for trichotillomania: Moderation and mediation findings. Behav Res Ther 2023; 164:104302. [PMID: 37030243 PMCID: PMC10115155 DOI: 10.1016/j.brat.2023.104302] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 03/16/2023] [Accepted: 03/18/2023] [Indexed: 04/07/2023]
Abstract
Trichotillomania is characterized by recurrent pulling out of one's hair, leading to significant hair loss and accompanied by clinically significant distress and/or functional impairment. The current study used data from a randomized controlled trial comparing the effectiveness of acceptance-enhanced behavior therapy (AEBT) to psychoeducation plus supportive therapy (PST; active control) for trichotillomania in an adult sample. The objectives were to examine the moderating and mediating influence of trichotillomania-specific psychological flexibility in treatment for trichotillomania. Participants with lower baseline flexibility performed better in AEBT than PST in terms of greater symptom reduction and quality of life. Lower baseline flexibility also predicted higher likelihood of disorder recovery in AEBT relative to PST. In addition, relative to PST, symptom reduction in AEBT was mediated by psychological flexibility, controlling for anxiety and depression. These findings suggest that psychological flexibility is a relevant process of change in the treatment of trichotillomania. Clinical implications and directions for future research are discussed.
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Affiliation(s)
- Clarissa W Ong
- Department of Psychology, University of Toledo, Toledo, OH, USA.
| | - Douglas W Woods
- Department of Psychology, Marquette University, Milwaukee, WI, USA
| | | | | | | | - Scott N Compton
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
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Spitzer C, Lübke L, Müller S, Conrad R, Gallinat C. State and trait dissociation in pathological skin picking. EUROPEAN JOURNAL OF TRAUMA & DISSOCIATION 2023. [DOI: 10.1016/j.ejtd.2023.100317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Zhang J, Grant JE. Significance of family history in understanding and subtyping trichotillomania. Compr Psychiatry 2022; 119:152349. [PMID: 36215772 DOI: 10.1016/j.comppsych.2022.152349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 09/28/2022] [Accepted: 09/30/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND AIMS The existence of subtypes of trichotillomania (TTM) have long been hypothesized, and recent studies have further elucidated characteristic subtypes of TTM and possible ramifications of subtyping for treatment. In clinical applications of subtyping for treatment of TTM, family history (FH) of psychiatric disorders in patients may serve as a tool to differentiate disorder presentations and inform care. We compared prevalence of psychiatric illnesses in first-degree relatives of participants with TTM and healthy controls, respectively, in a large sample, and examined associations between those psychiatric disorders that were significantly different in the FH between groups and measures of disability, severity, and neuropsychological constructs. METHODS We compared FHs of 152 participants (mean age = 29.9) with TTM and 71 healthy controls (mean age = 29.6), utilizing chi-squared tests to determine which psychiatric illnesses were more prevalent in FHs of participants with TTM. We then used two-tailed t-tests to compare TTM participants with those more prevalent FHs to participants without those FHs on measures of disorder severity, disability, and neuropsychological constructs. FINDINGS Obsessive-compulsive disorder (OCD), TTM, skin picking disorder (SPD), and major depressive disorder (MDD) were significantly more frequent in first-degree relatives (p < 0.0033) of TTM participants than those of healthy controls. TTM participants with a FH of OCD scored significantly higher on measures of impulsivity and lower on measures of distress tolerance. Those with FH of TTM, SPD, and MDD did not differ significantly across measured variables. CONCLUSION OCD, TTM, SPD, and MDD are more prevalent in the FHs of people with TTM, as compared to healthy controls. TTM participants with a family history of OCD may be more likely to demonstrate decreased distress tolerance and increased impulsivity. In all, as understanding of TTM subtypes develops, the FH may prove a useful tool in delineating subtypes and informing care.
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Affiliation(s)
- James Zhang
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Jon E Grant
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA.
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Grant JE, Chamberlain SR. Automatic and focused hair pulling in trichotillomania: Valid and useful subtypes? Psychiatry Res 2021; 306:114269. [PMID: 34758405 PMCID: PMC7612152 DOI: 10.1016/j.psychres.2021.114269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 10/25/2021] [Accepted: 10/31/2021] [Indexed: 11/25/2022]
Abstract
Prior work suggested that trichotillomania may have four subtypes based on the extent to which pulling is automatic or focused in nature. 238 adults with trichotillomania undertook clinical and cognitive assessments and were assigned into four subtypes based on k-means clustering of Milwaukee Inventory for Subtypes of Trichotillomania-Adult Version (MIST-A) scores. We examined whether a cluster solution was apparent using conventional metrics. Based on prior literature, we then force-fitted a four subtype model (low-low, low-high, high-low, high-high). Subtypes were compared and validity of the MIST-A subtyping approach was evaluated. A cluster solution did not converge based on conventional metrics. Following force-fitting, subtypes did not differ on demographic variables, age at symptom onset, nor duration of illness. The high-focused high-automatic subtype had worse symptom severity than other subtypes. Co-morbid depression was more common in the low-focused low-automatic and high-focused low-automatic subtypes. This study suggests that MIST-A subtypes may not be valid or clinically useful based on several issues. First, k-means models indicated that the MIST-A data did not generate any cluster solutions. Second, when a forced cluster solution was fitted, the subtypes did not differ on the vast majority of measures. Third, force-fitting four subtypes yielded findings that were logically inconsistent (e.g. worse quality of life in one group, but higher rates of comorbid anxiety/depression in others). Overall, we suggest that both focused and automatic pulling may characterize the same pulling episode, or certainly the same person across episodes. Thus they may be clinically relevant variables, but not forming coherent subtypes.
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Affiliation(s)
- Jon E. Grant
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL USA,Correspondence: Jon E. Grant, JD, MD, MPH, Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Pritzker School of Medicine, 5841 S. Maryland Avenue, MC-3077, Chicago, IL 60637 USA,
| | - Samuel R. Chamberlain
- Department of Psychiatry, Faculty of Medicine, University of Southampton, Southampton, UK; and Southern Health NHS Foundation Trust, Southampton, UK
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Hoffman J, Williams T, Rothbart R, Ipser JC, Fineberg N, Chamberlain SR, Stein DJ. Pharmacotherapy for trichotillomania. Cochrane Database Syst Rev 2021; 9:CD007662. [PMID: 34582562 PMCID: PMC8478440 DOI: 10.1002/14651858.cd007662.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Trichotillomania (TTM; hair-pulling disorder) is a prevalent and disabling disorder characterised by recurrent hair-pulling. Here we update a previous Cochrane Review on the effects of medication for TTM. OBJECTIVES To assess the effects of medication for trichotillomania (TTM) in adults, children and adolescents compared with placebo or other medication. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, PsycINFO, eleven other bibliographic databases, trial registries and grey literature sources (to 26 November 2020). We checked reference lists and contacted subject experts. SELECTION CRITERIA We selected randomised controlled trials of medication versus placebo or other medication for TTM in adults, children and adolescents. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS Twelve studies were included. We identified 10 studies in adults (286 participants) with a mean sample size of 29 participants per trial; one study in children and adolescents (39 participants); and, one study in adults and adolescents (22 participants: 18 adults and 4 adolescents). All studies were single-centre, outpatient trials. Eleven studies compared medication and placebo (334 participants); one study compared two medications (13 participants). Studies were 5 to 13 weeks duration. We undertook meta-analysis only for opioid antagonists as other comparisons contained a single study, or reported insufficient data. Antioxidants versus placebo in adults There was little to no difference in treatment response between antioxidant (35.7%) and placebo groups (28.6%) after six weeks, based on a single trial of silymarin (risk ratio (RR) 2.25, 95% confidence interval (CI) 0.84 to 5.99; 36 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (18 participants; low-certainty evidence). Antioxidants versus placebo in adolescents There was little to no difference in treatment response between antioxidant (50%) and placebo groups (25%) after six weeks, based on a single trial of silymarin (RR 2.00, 95% CI 0.28 to 14.20; 8 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (8 participants; low-certainty evidence). Antipsychotics versus placebo in adults There may be greater treatment response in the antipsychotic group (85%) compared to the placebo group (17%) after 12 weeks, based on a single trial of olanzapine (RR 5.08, 95% CI 1.4 to 18.37; 25 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (25 participants; low-certainty evidence). Cell signal transducers versus placebo in adults There was little to no difference in treatment response between cell signal transducer (42.1%) and placebo groups (31.6%) after 10 weeks, based on a single trial of inositol (RR 1.33, 95% CI 0.57 to 3.11; 38 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (38 participants; low-certainty evidence). Glutamate modulators versus placebo in adults There is probably greater treatment response in the glutamate modulator group (56%) compared to the placebo group (16%) after 12 weeks, based on a single trial of N-acetylcysteine (RR 3.5, 95% CI 1.34 to 9.17; 50 participants; moderate-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (50 participants; low-certainty evidence). Glutamate modulators versus placebo in children and adolescents There was little to no difference in treatment response between the glutamate modulator (25%) and placebo groups (21.1%) in children and adolescents, based on a single trial of N-acetylcysteine (RR 1.19, 95% CI 0.37 to 3.77; 39 participants; low-certainty evidence). There was little to no difference in dropouts due to adverse events between glutamate modulator (5%) and placebo (0%) groups, based on a single trial (RR 2.86, 95% CI 0.12 to 66.11; 39 participants; low-certainty evidence). Opioid antagonists versus placebo in adults There may be little to no difference in treatment response between opioid antagonist (37.5%) and placebo groups (25%) after six to eight weeks, based on two studies of naltrexone, but the evidence is very uncertain (RR 2.14, 95% CI 0.25 to 18.17; 2 studies, 68 participants; very low-certainty evidence). No data were available regarding dropouts due to adverse events. Selective serotonin reuptake inhibitors (SSRIs) versus placebo in adults There were no data available for treatment response to SSRIs. There was little to no difference in dropouts due to adverse events in the SSRI group (5.1%) compared to the placebo group (0%) after 6 to 12 weeks, based on two trials of fluoxetine (RR 3.00, 95% CI 0.33 to 27.62; 2 studies, 78 participants; low-certainty evidence). Tricyclic antidepressants (TCAs) with predominantly serotonin reuptake inhibitor (SRI) actions versus placebo in adults There may be greater treatment response in the TCAs with predominantly SRI actions group (40%) compared to the placebo group (0%) after nine weeks, but the evidence is very uncertain, based on a single trial of clomipramine (RR 5.73, 95% CI 0.36 to 90.83; 16 participants; very low-certainty evidence). There may be increased dropouts due to adverse events in the TCAs with predominantly SRI actions group (30%) compared to the placebo group (0%), but the evidence is very uncertain (RR 4.45, 95% CI 0.27 to 73.81; 16 participants; very low-certainty evidence). TCAs with predominantly SRI actions versus other TCAs in adults There may be greater treatment response in the TCAs with predominantly SRI actions group compared to the other TCAs group after five weeks, based on a single trial comparing clomipramine to desipramine (mean difference (MD) -4.00, 95% CI -6.13 to -1.87; 26 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (26 participants; low-certainty evidence). AUTHORS' CONCLUSIONS There was insufficient evidence from meta-analysis to confirm or refute the efficacy of any agent or class of medication for the treatment of TTM in adults, children or adolescents. Preliminary evidence suggests there may be beneficial treatment effects for N-acetylcysteine, clomipramine and olanzapine in adults based on four trials, albeit with relatively small sample sizes.
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Affiliation(s)
- Jacob Hoffman
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Taryn Williams
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Rachel Rothbart
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | - Jonathan C Ipser
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Naomi Fineberg
- National Obsessive Compulsive Disorders Treatment Service, Queen Elizabeth II Hospital, Welwyn Garden City, UK
| | | | - Dan J Stein
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
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Kłosowska J, Antosz-Rekucka R, Kałużna-Wielobób A, Prochwicz K. Dissociative Experiences Mediate the Relationship Between Traumatic Life Events and Types of Skin Picking. Findings From Non-clinical Sample. Front Psychiatry 2021; 12:698543. [PMID: 34349684 PMCID: PMC8326802 DOI: 10.3389/fpsyt.2021.698543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/18/2021] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Joanna Kłosowska
- Institute of Psychology, Jagiellonian University, Krakow, Poland
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8
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Mathew AS, Davine TP, Snorrason I, Houghton DC, Woods DW, Lee HJ. Body-focused repetitive behaviors and non-suicidal self-injury: A comparison of clinical characteristics and symptom features. J Psychiatr Res 2020; 124:115-122. [PMID: 32135390 DOI: 10.1016/j.jpsychires.2020.02.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 02/20/2020] [Accepted: 02/22/2020] [Indexed: 10/24/2022]
Abstract
Body-focused repetitive behaviors (BFRBs) and non-suicidal self-injury (NSSI) are recognized as distinct categories in the DSM-5. However, definitions and assessment of NSSI sometimes encompasses behaviors similar to BFRBs, and little data exist about their clinical differences. The current study examined clinical characteristics and symptom features associated with NSSI vs. BFRBs. The current sample included 1523 individuals who endorsed moderate to severe NSSI (n = 165) or BFRBs: hair pulling group (n = 102), skin picking group (n = 216), nail picking group (n = 253), nail biting group (n = 487), and cheek biting group (n = 300). Responders were asked to complete questionnaires on clinical features relevant for BFRBs and NSSI. NSSI and BFRBs had significant differences on several clinical features. Individuals in the NSSI group were more likely than individuals with BFRBs to report engaging in the behavior for social-affective reasons (i.e., to get out of doing something, or receive attention from others). Individuals in the NSSI group were also more likely to engage in the behavior to regulate tension and feelings of emptiness, and to experience relief during the act. In contrast, individuals in the BFRB groups were more likely to engage in the behavior automatically without reflective awareness, to reduce boredom, or to fix appearance. The NSSI group obtained significantly higher scores on questionnaires assessing stress, anxiety, depression, and harm avoidance. Overall, the results showed several notable differences between NSSI and BFRBs that are consistent with clinical literature and definitions of these problems in the DSM-5.
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Affiliation(s)
- Abel S Mathew
- Department of Psychology, University of Wisconsin-Milwaukee, USA
| | - Taylor P Davine
- Department of Psychology, University of Wisconsin-Milwaukee, USA
| | | | - David C Houghton
- Department of Psychiatry & Behavioral Sciences, University of Texas Medical Branch, USA
| | | | - Han-Joo Lee
- Department of Psychology, University of Wisconsin-Milwaukee, USA.
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9
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França K, Kumar A, Castillo D, Jafferany M, Hyczy da Costa Neto M, Damevska K, Wollina U, Lotti T. Trichotillomania (hair pulling disorder): Clinical characteristics, psychosocial aspects, treatment approaches, and ethical considerations. Dermatol Ther 2018; 32:e12622. [DOI: 10.1111/dth.12622] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 05/16/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Katlein França
- Institute for Bioethics & Health Policy, Department of Dermatology & Cutaneous Surgery and Department of Psychiatry & Behavioral Sciences; University of Miami Miller School of Medicine; Miami Florida
- Università G Marconi; Rome Italy
| | - Anagha Kumar
- Department of Medical Oncology; Mayo Clinic; Rochester Minnesota
| | - David Castillo
- Department of Dermatology & Cutaneous Surgery; University of Miami Miller School of Medicine; Miami Florida
| | - Mohammad Jafferany
- Department of Psychiatry and Behavioral Sciences, College of Medicine; Central Michigan University; Saginaw Michigan
| | | | - Katerina Damevska
- Clinic of Dermatology, Medical Faculty; University “Ss. Cyril and Methodius,”; Skopje Macedonia
| | - Uwe Wollina
- Department of Dermatology and Allergology; Dresden Germany
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Lee EB, Homan KJ, Morrison KL, Ong CW, Levin ME, Twohig MP. Acceptance and Commitment Therapy for Trichotillomania: A Randomized Controlled Trial of Adults and Adolescents. Behav Modif 2018; 44:70-91. [DOI: 10.1177/0145445518794366] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this study was to examine acceptance and commitment therapy (ACT) as a standalone treatment for trichotillomania in a randomized controlled trial of adults and adolescents. Participants consisted of a community sample of treatment seeking adults and adolescents with trichotillomania. Of the eligible 39 participants randomized into treatment and waitlist groups, 25 completed treatment and were included in the final analysis. Treatment consisted of a 10-session ACT protocol. Multiple mixed models repeated measures analyses were utilized to evaluate changes in trichotillomania symptom severity, daily number of hairs pulled and urges experienced, and experiential avoidance from pretreatment to posttreatment. Findings indicated significant changes in symptom severity and daily hairs pulled, but not daily urges experienced or psychological flexibility. However, psychological flexibility saw a 24.5% decrease in the treatment group and reduced from clinical to subclinical levels on average. This study suggests that ACT alone is an effective treatment for adults and adolescents with trichotillomania. Outcomes appear to be similar to trials that combined ACT and habit reversal training (HRT).
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Krooks JA, Weatherall AG, Holland PJ. Review of epidemiology, clinical presentation, diagnosis, and treatment of common primary psychiatric causes of cutaneous disease. J DERMATOL TREAT 2017; 29:418-427. [DOI: 10.1080/09546634.2017.1395389] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- J. A. Krooks
- Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
| | - A. G. Weatherall
- Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
- ClearlyDerm Center for Dermatology, Boca Raton, FL, USA
| | - P. J. Holland
- Psychiatry and Neurology Department, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
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12
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Noble CM, Gnilka PB, Ashby JS, McLaulin SE. Perfectionism, Shame, and Trichotillomania Symptoms in Clinical and Nonclinical Samples. ACTA ACUST UNITED AC 2017. [DOI: 10.17744/mehc.39.4.05] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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13
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Affective correlates of trichotillomania across the pulling cycle: Findings from an Italian sample of self-identified hair pullers. Psychiatry Res 2016; 246:606-611. [PMID: 27836242 DOI: 10.1016/j.psychres.2016.10.080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 07/20/2016] [Accepted: 10/31/2016] [Indexed: 11/22/2022]
Abstract
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.
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Abstract
Trichotillomania is an underreported and underdiagnosed condition associated with significant impairments in social and functional relationships. The connection between celiac disease and trichotillomania is not yet established clearly. Only a few cases of trichotillomania have been reported to date. Here, we report the case of a 22-year-old Saudi female, who presented with celiac disease and trichotillomania to the psychiatry clinic. This is the first report of its kind in Saudi Arabia. By reporting this case, I highlight the importance of psychiatric and comprehensive approaches in patients with celiac disease.
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15
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Alexander JR, Houghton DC, Twohig MP, Franklin ME, Saunders SM, Neal-Barnett AM, Compton SN, Woods DW. Factor analysis of the Milwaukee Inventory for Subtypes of Trichotillomania-Adult Version. J Obsessive Compuls Relat Disord 2016; 11:31-38. [PMID: 27668153 PMCID: PMC5033380 DOI: 10.1016/j.jocrd.2016.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
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.
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Affiliation(s)
- Jennifer R. Alexander
- Department of Psychology, Texas A&M University, 4235 TAMU, College Station, TX 77840, USA
| | - David C. Houghton
- Department of Psychology, Texas A&M University, 4235 TAMU, College Station, TX 77840, USA
| | - Michael P. Twohig
- Department of Psychology, Utah State University, 2810 Old Main Hill, Logan, UT 84322, USA
| | - Martin E. Franklin
- Department of Psychiatry, University of Pennsylvania School of Medicine, 3535 Market St., Philadelphia, PA 19104, USA
| | - Stephen M. Saunders
- Department of Psychology, Marquette University, 604 N. 16th St., Milwaukee, WI 53233, USA
| | | | - Scott N. Compton
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, 2213 Elba St., Durham, NC 27705, USA
| | - Douglas W. Woods
- Department of Psychology, Texas A&M University, 4235 TAMU, College Station, TX 77840, USA
- Department of Psychology, Marquette University, 604 N. 16th St., Milwaukee, WI 53233, USA
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16
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Abstract
Trichotillomania, characterized by the repetitive pulling out of one’s own hair leading to hair loss and functional impairment, has been documented in the medical literature since the 19th century, but has received scant research attention. Community prevalence studies suggest that trichotillomania is a common disorder with point prevalence estimate of 0.5% to 2.0%. Although recently grouped with OCD in the DSM-5, clinicians need to be aware that trichotillomania and OCD may have less in common than originally thought. In fact, approaches to treating trichotillomania, which include habit reversal therapy and medication (n-acetyl cysteine or olanzapine), are quite different from those used to treat OCD; and some first-line treatments used for OCD appear ineffective for trichotillomania. Based on our clinical experience and research findings, the article recommends several management approaches to trichotillomania.
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Affiliation(s)
- Jon E. Grant
- Department of Psychiatry & Behavioral Neuroscience, University of Chicago
| | - Samuel R. Chamberlain
- Department of Psychiatry, University of Cambridge, and Cambridge and Peterborough NHS Foundation Trust, UK
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Flessner CA, Woods DW, Franklin ME, Keuthen NJ, Piacentini J, Cashin SE, Moore PS. The Milwaukee Inventory for Styles of Trichotillomania-Child Version (MIST-C). Behav Modif 2016; 31:896-918. [DOI: 10.1177/0145445507302521] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Redden SA, Leppink EW, Grant JE. Body focused repetitive behavior disorders: Significance of family history. Compr Psychiatry 2016; 66:187-92. [PMID: 26995252 DOI: 10.1016/j.comppsych.2016.02.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 01/07/2016] [Accepted: 02/01/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The significance of family history in body-focused repetitive behavior disorders (BFRBs) (i.e. trichotillomania and skin picking) has received scant research attention. We sought to understand the clinical and cognitive impact of having a first-degree relative with a BFRB or a substance use disorder (SUD). METHODS 265 participants with BFRBs undertook clinical and neurocognitive evaluations. Those with a first-degree relative with a BFRB or an SUD were compared to those without on a number of clinical and cognitive measures. RESULTS 77 (29.1%) participants had a first-degree family member with a BFRB and 59 (22.2%) had a first-degree family member with an SUD. In terms of clinical severity, the amount of time spent picking or pulling per day in the past week was higher among those with a first-degree relative with an SUD. There were a higher rate of ADHD and higher HAM-D scores among those with a positive family history of an SUD. There were no significant cognitive differences based on family history. CONCLUSIONS These results indicate that among those with BFRBs, having a first-degree family member with an SUD may be associated with a unique clinical and cognitive presentation. Whether family history also is associated with differential response to treatments awaits further research.
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Affiliation(s)
- Sarah A Redden
- Department of Psychiatry & Behavioral Neuroscience, University of Chicago, Pritzker School of Medicine, Chicago, IL, USA
| | - Eric W Leppink
- Department of Psychiatry & Behavioral Neuroscience, University of Chicago, Pritzker School of Medicine, Chicago, IL, USA
| | - Jon E Grant
- Department of Psychiatry & Behavioral Neuroscience, University of Chicago, Pritzker School of Medicine, Chicago, IL, USA.
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19
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Abstract
AbstractBody-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.
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20
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Madjar S, Sripada CS. The Phenomenology of Hair Pulling Urges in Trichotillomania: A Comparative Approach. Front Psychol 2016; 7:199. [PMID: 26925017 PMCID: PMC4759292 DOI: 10.3389/fpsyg.2016.00199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 02/02/2016] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Shai Madjar
- University of Michigan Medical SchoolAnn Arbor, MI, USA; Department of Philosophy, University of MichiganAnn Arbor, MI, USA
| | - Chandra S Sripada
- Department of Philosophy, University of MichiganAnn Arbor, MI, USA; Department of Psychiatry, University of MichiganAnn Arbor, MI, USA
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21
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Johnson J, El-Alfy AT. Review of available studies of the neurobiology and pharmacotherapeutic management of trichotillomania. J Adv Res 2016; 7:169-84. [PMID: 26966559 PMCID: PMC4767796 DOI: 10.1016/j.jare.2015.05.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 05/05/2015] [Accepted: 05/20/2015] [Indexed: 12/16/2022] Open
Abstract
Trichotillomania (TTM) is a psychiatric disorder characterized by an irresistible urge to pull out one's hair. Currently there are no FDA approved treatments for TTM, which makes it difficult for clinicians to select an appropriate therapeutic plan. The clinical studies that have been performed do not provide sufficient or consistent evidence regarding which drug classes should be administered. Unfortunately, most of the available data consist of case reports and clinical trials with limited sample size. This review provides an overview of currently available clinical literature that targets TTM. A summary of clinical trials as well as case reports is provided. The most common rating scales used for clinical assessment are also reviewed. The etiology of TTM remains unclear. Studies that examine various neuroanatomical, neurobiologic, as well as genetic factors associated with TTM are thoroughly discussed in this review. It is evident that clear understanding of TTM is crucial to provide better recognition, assessment, and treatment to patients of this disorder. Finally, despite research efforts for establishing pharmacological options for treatment, it is clear that new targets are warranted in order to ensure a clinically supported effective pharmacological approach to treat TTM.
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Affiliation(s)
| | - Abir T. El-Alfy
- Department of Pharmaceutical Sciences, Chicago State University, Chicago, IL 60628, USA
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22
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Bottesi G, Cerea S, Razzetti E, Sica C, Frost RO, Ghisi M. Investigation of the Phenomenological and Psychopathological Features of Trichotillomania in an Italian Sample. Front Psychol 2016; 7:256. [PMID: 26941700 PMCID: PMC4766287 DOI: 10.3389/fpsyg.2016.00256] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 02/09/2016] [Indexed: 02/02/2023] Open
Abstract
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.
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Affiliation(s)
- Gioia Bottesi
- Department of General Psychology, University of Padova Padova, Italy
| | - Silvia Cerea
- Department of General Psychology, University of Padova Padova, Italy
| | - Enrico Razzetti
- Department of General Psychology, University of Padova Padova, Italy
| | - Claudio Sica
- Department of Health Sciences, University of Firenze Firenze, Italy
| | | | - Marta Ghisi
- Department of General Psychology, University of Padova Padova, Italy
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23
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Rozenman M, Peris TS, Gonzalez A, Piacentini J. Clinical Characteristics of Pediatric Trichotillomania: Comparisons with Obsessive-Compulsive and Tic Disorders. Child Psychiatry Hum Dev 2016; 47:124-32. [PMID: 25894516 DOI: 10.1007/s10578-015-0550-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Michelle Rozenman
- Division of Child and Adolescent Psychiatry, UCLA Semel Institute for Neuroscience and Human Behavior, 760 Westwood Plaza, 67-455, Los Angeles, CA, 90095, USA.
| | - Tara S Peris
- Division of Child and Adolescent Psychiatry, UCLA Semel Institute for Neuroscience and Human Behavior, 760 Westwood Plaza, 67-455, Los Angeles, CA, 90095, USA
| | - Araceli Gonzalez
- Department of Psychology, California State University Long Beach, Long Beach, CA, USA
| | - John Piacentini
- Division of Child and Adolescent Psychiatry, UCLA Semel Institute for Neuroscience and Human Behavior, 760 Westwood Plaza, 67-455, Los Angeles, CA, 90095, USA
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24
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The Role of Cognitions and Beliefs in Trichotillomania: A Qualitative Study Using Interpretative Phenomenological Analysis. BEHAVIOUR CHANGE 2015. [DOI: 10.1017/bec.2015.11] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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25
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Rehm I, Moulding R, Nedeljkovic M. Psychological treatments for trichotillomania: update and future directions. Australas Psychiatry 2015; 23:365-8. [PMID: 26104780 DOI: 10.1177/1039856215590029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This paper aims to provide an overview of evidence-based psychological treatments for trichotillomania. CONCLUSIONS Advances in the understanding of the phenomenology of trichotillomania has led to the augmentation of behavioural treatments with dialectical behaviour therapy and acceptance and commitment therapy. Further studies of treatment component efficacy and cognitive behavioural models are required.
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Affiliation(s)
- Imogen Rehm
- Faculty of Health, Arts and Design, Swinburne University of Technology, Melbourne, VIC, Australia
| | - Richard Moulding
- Senior Lecturer, Centre for Mental Health and Wellbeing Research, Deakin University, Melbourne, VIC, Australia
| | - Maja Nedeljkovic
- Senior Lecturer, Brain and Psychological Sciences Research Centre, Swinburne University of Technology, Melbourne, VIC, Australia
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Houghton DC, Balsis S, Stein DJ, Compton SN, Twohig MP, Saunders SM, Franklin ME, Neal-Barnett AM, Woods DW. Examining DSM criteria for trichotillomania in a dimensional framework: implications for DSM-5 and diagnostic practice. Compr Psychiatry 2015; 60:9-16. [PMID: 25972228 PMCID: PMC4459902 DOI: 10.1016/j.comppsych.2015.04.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 04/06/2015] [Accepted: 04/18/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Diagnosis of trichotillomania (TTM) requires meeting several criteria that aim to embody the core pathology of the disorder. These criteria are traditionally interpreted monothetically, in that they are all equally necessary for diagnosis. Alternatively, a dimensional conceptualization of psychopathology allows for examination of the relatedness of each criterion to the TTM latent continuum. OBJECTIVES First, to examine the ability of recently removed criteria (B and C) to identify the latent dimensions of TTM psychopathology, such that they discriminate between individuals with low and high degrees of hair pulling severity. Second, to determine the impact of removing criteria B and C on the information content of remaining diagnostic criteria. Third, to determine the psychometric properties of remaining TTM diagnostic criteria that remain largely unchanged in DSM-5; that is, whether they measure distinct or overlapping levels of TTM psychopathology. Fourth, to determine whether information content derived from diagnostic criteria aid in the prediction of disease trajectory (i.e., can relapse propensity be predicted from criteria endorsement patterns). METHOD Statistics derived from item response theory were used to examine diagnostic criteria endorsement in 91 adults with TTM who underwent psychotherapy. RESULTS The removal of two criteria in DSM-5 and psychometric validity of remaining criteria was supported. Additionally, individual trait parameters were used to predict treatment progress, uncovering predictive power where none previously existed. CONCLUSIONS Diagnostic criteria for TTM should be examined in dimensional models, which allow for nuanced and sensitive measurement of core symptomology in treatment contexts.
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Affiliation(s)
- David C Houghton
- Department of Psychology, Texas A&M University, 4235 TAMU, College Station, TX, 77834, USA.
| | - Steve Balsis
- Department of Psychology, Texas A&M University, 4235 TAMU, College Station, TX, 77834, USA.
| | - Dan J Stein
- MRC Unit on Anxiety & Stress Disorders, Department of Psychiatry and Mental Health, University of Cape Town, Rondebasch, Cape Town, 7700, South Africa.
| | - Scott N Compton
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, 2213 Elba St., Durham, NC, 27705, USA.
| | - Michael P Twohig
- Department of Psychology, Utah State University, 2810 Old Main Hill, Logan, UT, 84322, USA.
| | - Stephen M Saunders
- Department of Psychology, Marquette University, Cramer Hall, 317, Milwaukee, WI, 53233, USA.
| | - Martin E Franklin
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market St., Philadelphia, PA, 19104, USA.
| | - Angela M Neal-Barnett
- Department of Psychology, Kent State University, 600 Hilltop Drive, Kent, OH, 44242, USA.
| | - Douglas W Woods
- Department of Psychology, Texas A&M University, 4235 TAMU, College Station, TX, 77834, USA.
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Keuthen NJ, Tung ES, Woods DW, Franklin ME, Altenburger EM, Pauls DL, Flessner CA. Replication study of the milwaukee inventory for subtypes of trichotillomania-adult version in a clinically characterized sample. Behav Modif 2015; 39:580-99. [PMID: 25868534 DOI: 10.1177/0145445515580533] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In the present study, we evaluated the Milwaukee Inventory for Subtypes of Trichotillomania-Adult Version (MIST-A) in a replication sample of clinically characterized hair pullers using exploratory factor analysis (EFA; N = 193). EFA eigenvalues and visual inspection of our scree plot revealed a two-factor solution. Factor structure coefficients and internal consistencies suggested a 13-item scale with an 8-item "Intention" scale and a 5-item "Emotion" scale. Both scales displayed good construct and discriminant validity. These findings indicate the need for a revised scale that provides a more refined assessment of pulling phenomenology that can facilitate future treatment advances.
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Shame in the obsessive compulsive related disorders: a conceptual review. J Affect Disord 2015; 171:74-84. [PMID: 25299438 PMCID: PMC4252512 DOI: 10.1016/j.jad.2014.09.010] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 09/05/2014] [Accepted: 09/11/2014] [Indexed: 11/24/2022]
Abstract
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.
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Özten E, Sayar GH, Eryılmaz G, Kağan G, Işık S, Karamustafalıoğlu O. The relationship of psychological trauma with trichotillomania and skin picking. Neuropsychiatr Dis Treat 2015; 11:1203-10. [PMID: 26028973 PMCID: PMC4440428 DOI: 10.2147/ndt.s79554] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Interactions between psychological, biological and environmental factors are important in development of trichotillomania and skin picking. The aim of this study is to determine the relationship of traumatic life events, symptoms of post-traumatic stress disorder and dissociation in patients with diagnoses of trichotillomania and skin picking disorder. METHODS The study included patients who was diagnosed with trichotillomania (n=23) or skin picking disorder (n=44), and healthy controls (n=37). Beck Depression Inventory, Traumatic Stress Symptoms Scale and Dissociative Experiences Scale were administered. All groups checked a list of traumatic life events to determine the exposed traumatic events. RESULTS There was no statistical significance between three groups in terms of Dissociative Experiences Scale scores (P=0.07). But Beck Depression Inventory and Traumatic Stress Symptoms Scale scores of trichotillomania and skin picking groups were significantly higher than the control group. Subjects with a diagnosis of trichotillomania and skin picking reported statistically significantly higher numbers of traumatic and negative events in childhood compared to healthy subjects. CONCLUSION We can conclude that trauma may play a role in development of both trichotillomania and skin picking. Increased duration of trichotillomania or skin picking was correlated with decreased presence of post-traumatic stress symptoms. The reason for the negatively correlation of severity of post-traumatic stress symptoms and self-harming behavior may be speculated as developing trichotillomania or skin picking symptoms helps the patient to cope with intrusive thoughts related to trauma. Future longitudinal research must focus on whether trauma and post-traumatic stress or trichotillomania and skin picking precede the development of mental disorder.
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Affiliation(s)
- Eylem Özten
- Neuropsychiatry Health, Practice, and Research Center, Üsküdar University, Istanbul, Turkey
| | - Gökben Hızlı Sayar
- Neuropsychiatry Health, Practice, and Research Center, Üsküdar University, Istanbul, Turkey
| | - Gül Eryılmaz
- Neuropsychiatry Health, Practice, and Research Center, Üsküdar University, Istanbul, Turkey
| | - Gaye Kağan
- Istanbul Neuropsychiatry Hospital, Üsküdar University, Istanbul, Turkey
| | - Sibel Işık
- Turkish Red Crescent Altıntepe Medical Center, Üsküdar University, Istanbul, Turkey
| | - Oğuz Karamustafalıoğlu
- Department of Psychology, Faculty of Human and Social Sciences, Üsküdar University, Istanbul, Turkey
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Rothbart R, Amos T, Siegfried N, Ipser JC, Fineberg N, Chamberlain SR, Stein DJ. Pharmacotherapy for trichotillomania. Cochrane Database Syst Rev 2013:CD007662. [PMID: 24214100 DOI: 10.1002/14651858.cd007662.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Trichotillomania (TTM) (hair-pulling disorder) is a prevalent and disabling disorder characterised by recurrent hair-pulling. The effect of medication on trichotillomania has not been systematically evaluated. OBJECTIVES To assess the effects of medication for trichotillomania in adults compared with placebo or other active agents. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials and the Cochrane Depression, Anxiety and Neurosis Group Register (to 31 July 2013), which includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years); EMBASE (1974 to date); MEDLINE (1950 to date) and PsycINFO (1967 to date). Two review authors identified relevant trials by assessing the abstracts of all possible studies. SELECTION CRITERIA We selected randomised controlled trials (RCTs) of a medication versus placebo or active agent for TTM in adults. DATA COLLECTION AND ANALYSIS Two review authors independently performed the data extraction and 'Risk of bias' assessments, and disagreements were resolved through discussion with a third review author. Primary outcomes included the mean difference (MD) in reduction of trichotillomania symptoms on a continuous measure of trichotillomania symptom severity, and the risk ratio (RR) of the clinical response based on a dichotomous measure, with 95% confidence intervals (CIs). MAIN RESULTS We identified eight studies with a total of 204 participants and a mean sample size of 25. All trials were single-centre trials, and participants seen on an outpatient basis. Seven studies compared medication and placebo (n = 184); one study compared medication and another active agent (n = 13). Duration of the studies was six to twelve weeks. Meta-analysis was not undertaken because of the methodological heterogeneity of the trials. The studies did not employ intention-to-treat analyses and were at a high risk of attrition bias. Adverse events were not well-documented in the studies.None of the three studies of selective serotonin reuptake inhibitors (SSRIs) demonstrated strong evidence of a treatment effect on any of the outcomes of interest. The unpublished naltrexone study did not provide strong evidence of a treatment effect. Two studies, an olanzapine study and a N-acetylcysteine (NAC) study, reported statistically significant treatment effects. One study of clomipramine demonstrated a treatment effect on two out of three measures of response to treatment. AUTHORS' CONCLUSIONS No particular medication class definitively demonstrates efficacy in the treatment of trichotillomania. Preliminary evidence suggests treatment effects of clomipramine, NAC and olanzapine based on three individual trials, albeit with very small sample sizes.
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Affiliation(s)
- Rachel Rothbart
- Department of Psychiatry, University of British Columbia, 2775 Laurel St, Vancouver, British Columbia, Canada, V5Z 1M9
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Odlaug BL, Chamberlain SR, Schreiber LRN, Grant JE. Where on the obsessive impulsive-compulsive spectrum does hair-pulling disorder belong? Int J Psychiatry Clin Pract 2013; 17:279-85. [PMID: 23899226 DOI: 10.3109/13651501.2013.828079] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Hair-pulling disorder (HPD) is a putative obsessive-compulsive spectrum disorder, but proper categorization is challenging. Distinct subgroups of HPD may exist, depending on the primary motivation in the act of pulling. Two notable proposed subgroups are "relief pullers" (pulling primarily to reduce anxiety- a "compulsive" subgroup) and "pleasure/gratification pullers" (pulling primarily for reward- an "impulsive" subgroup) which we sought to examine in order to contribute to conversations on the categorization of HPD. METHODS A total of 111 HPD subjects (mean age 33.7 ± 10.7 [range 18-61] years; 87.4% female) were included. Demographic and clinical characteristics were compared between subgroups (pleasure: n = 51; relief: n = 60); and cognitive performance where data were available (n = 29 per group) and 32 matched healthy controls. RESULTS No significant demographic differences were noted between groups. Pleasure pullers were significantly more conscious of their pulling. Response inhibition and set shifting deficits were noted in HPD versus controls; however, pleasure and relief pullers did not differ significantly from each other on neurocognitive measures. CONCLUSIONS The results suggest common clinical features and associated neural dysfunction between relief and pleasure/gratification pullers, rather than supporting their existence as discrete clinical entities. Selection of appropriate treatment may focus on other aspects of hair pulling, including family history and comorbidity.
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Affiliation(s)
- Brian Lawrence Odlaug
- Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen , Copenhagen , Denmark
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Roberts S, O'Connor K, Bélanger C. Emotion regulation and other psychological models for body-focused repetitive behaviors. Clin Psychol Rev 2013; 33:745-62. [DOI: 10.1016/j.cpr.2013.05.004] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 05/08/2013] [Accepted: 05/08/2013] [Indexed: 11/26/2022]
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Panza KE, Pittenger C, Bloch MH. Age and gender correlates of pulling in pediatric trichotillomania. J Am Acad Child Adolesc Psychiatry 2013; 52:241-9. [PMID: 23452681 PMCID: PMC3745006 DOI: 10.1016/j.jaac.2012.12.019] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 12/19/2012] [Accepted: 12/26/2012] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Kaitlyn E Panza
- Child Study Center, Yale University, New Haven, CT 06520, USA
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Acceptance and Commitment Therapy and Habit Reversal Training for the Treatment of Trichotillomania. COGNITIVE AND BEHAVIORAL PRACTICE 2012. [DOI: 10.1016/j.cbpra.2012.02.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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How related are hair pulling disorder (trichotillomania) and skin picking disorder? A review of evidence for comorbidity, similarities and shared etiology. Clin Psychol Rev 2012; 32:618-29. [DOI: 10.1016/j.cpr.2012.05.008] [Citation(s) in RCA: 111] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Revised: 05/15/2012] [Accepted: 05/16/2012] [Indexed: 01/27/2023]
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Acceptance-Enhanced Behavior Therapy for Trichotillomania in Adolescents. COGNITIVE AND BEHAVIORAL PRACTICE 2012. [DOI: 10.1016/j.cbpra.2011.10.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Labouliere CD, Storch EA. Pediatric trichotillomania: clinical presentation, treatment, and implications for nursing professionals. J Pediatr Nurs 2012; 27:225-32. [PMID: 22525810 DOI: 10.1016/j.pedn.2011.01.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Revised: 12/24/2010] [Accepted: 01/13/2011] [Indexed: 10/18/2022]
Abstract
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.
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Franklin ME, Zagrabbe K, Benavides KL. Trichotillomania and its treatment: a review and recommendations. Expert Rev Neurother 2012; 11:1165-74. [PMID: 21797657 DOI: 10.1586/ern.11.93] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Martin E Franklin
- Child and Adolescent OCD, Tics, Trichotillomania and Anxiety Group, The University of Pennsylvania School of Medicine, 3535 Market Street, Suite 600, Philadelphia, PA 19104, USA.
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Lochner C, Stein DJ, Woods D, Pauls DL, Franklin ME, Loerke EH, Keuthen NJ. The validity of DSM-IV-TR criteria B and C of hair-pulling disorder (trichotillomania): evidence from a clinical study. Psychiatry Res 2011; 189:276-80. [PMID: 21813182 DOI: 10.1016/j.psychres.2011.07.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Revised: 07/06/2011] [Accepted: 07/11/2011] [Indexed: 11/26/2022]
Abstract
In both DSM-IV-TR and the ICD-10, hair-pulling disorder (trichotillomania, or TTM) is described as hair-pulling, with a rising urge or tension prior to pulling or when attempting to resist, and pleasure, relief or gratification during or after pulling. However, it has been questioned whether all patients with hair-pulling experience these other phenomena, and whether they occur with all pulling episodes. The objective of this study was to examine the DSM-IV-TR requirement of criteria B and C for a diagnosis of TTM in a sample of people with hair-pulling. A multi-site sample of adults with hair-pulling who met both DSM-IV-TR diagnostic criteria B and C (n=82, 89.13%) were compared to those who failed to satisfy both B and C (n=10, 10.87%) on a number of clinical variables. There were no differences in hair-pulling severity, levels of comorbid depressive and anxiety symptoms, number of comorbid body-focused repetitive behaviors, or impairment between those patients who did and did not meet criteria B and C. Our study does not provide convincing support for the inclusion of the current diagnostic criteria B and C for TTM in DSM-5.
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Affiliation(s)
- Christine Lochner
- Department of Psychiatry, University of Stellenbosch, Tygerberg, South Africa.
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Franklin ME, Edson AL, Ledley DA, Cahill SP. Behavior therapy for pediatric trichotillomania: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry 2011; 50:763-71. [PMID: 21784296 PMCID: PMC3143367 DOI: 10.1016/j.jaac.2011.05.009] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Revised: 05/19/2011] [Accepted: 05/20/2011] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Martin E Franklin
- Child/Adolescent OCD, Tics, Trichotillomania and Anxiety Group (COTTAGe), Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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Treatment of Recurrent Rapunzel Syndrome and Trichotillomania: Case Report and Literature Review. PSYCHOSOMATICS 2010. [DOI: 10.1016/s0033-3182(10)70728-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Franklin ME, Edson AL, Freeman JB. Behavior therapy for pediatric trichotillomania: Exploring the effects of age on treatment outcome. Child Adolesc Psychiatry Ment Health 2010; 4:18. [PMID: 20584275 PMCID: PMC2909953 DOI: 10.1186/1753-2000-4-18] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Accepted: 06/28/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A randomized controlled trial examining the efficacy of behavior therapy for pediatric trichotillomania was recently completed with 24 participants ranging in age from 7 - 17. The broad age range raised a question about whether young children, older children, and adolescents would respond similarly to intervention. In particular, it is unclear whether the younger children have the cognitive capacity to understand concepts like "urges" and whether they are able to introspect enough to be able to benefit from awareness training, which is a key aspect of behavior therapy for trichotillomania. METHODS Participants were randomly assigned to receive either behavior therapy (N = 12) or minimal attention control (N = 12), which was included to control for repeated assessments and the passage of time. Primary outcome measures were the independent evaluator-rated NIMH-Trichotillomania Severity Scale, a semi-structured interview often used in trichotillomania treatment trials, and a post-treatment clinical global impression improvement rating (CGI-I). RESULTS The correlation between age and change in symptom severity for all patients treated in the trial was small and not statistically significant. A 2 (group: behavioral therapy, minimal attention control) x 2 (time: week 0, 8) x 2 (children < 9 yrs., children > 10) ANOVA with independent evaluator-rated symptom severity scores as the continuous dependent variable also detected no main effects for age or for any interactions involving age. In light of the small sample size, the mean symptom severity scores at weeks 0 and 8 for younger and older patients randomized to behavioral therapy were also plotted. Visual inspection of these data indicated that although the groups appeared to have started at similar levels of severity for children = 9 vs. children >/= 10; the week 8 data show that the three younger children did at least as well as if not slightly better than the nine older children and adolescents. CONCLUSIONS Behavior therapy for pediatric trichotillomania appears to be efficacious even in young children. The developmental and clinical implications of these findings will be discussed. TRIAL REGISTRATION Clinicaltrials.gov NCT00043563.
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Affiliation(s)
- Martin E Franklin
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Aubrey L Edson
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jennifer B Freeman
- Department of Psychiatry, Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Stein DJ, Grant JE, Franklin ME, Keuthen N, Lochner C, Singer HS, Woods DW. Trichotillomania (hair pulling disorder), skin picking disorder, and stereotypic movement disorder: toward DSM-V. Depress Anxiety 2010; 27:611-26. [PMID: 20533371 DOI: 10.1002/da.20700] [Citation(s) in RCA: 141] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
In DSM-IV-TR, trichotillomania (TTM) is classified as an impulse control disorder (not classified elsewhere), skin picking lacks its own diagnostic category (but might be diagnosed as an impulse control disorder not otherwise specified), and stereotypic movement disorder is classified as a disorder usually first diagnosed in infancy, childhood, or adolescence. ICD-10 classifies TTM as a habit and impulse disorder, and includes stereotyped movement disorders in a section on other behavioral and emotional disorders with onset usually occurring in childhood and adolescence. This article provides a focused review of nosological issues relevant to DSM-V, given recent empirical findings. This review presents a number of options and preliminary recommendations to be considered for DSM-V: (1) Although TTM fits optimally into a category of body-focused repetitive behavioral disorders, in a nosology comprised of relatively few major categories it fits best within a category of motoric obsessive-compulsive spectrum disorders, (2) available evidence does not support continuing to include (current) diagnostic criteria B and C for TTM in DSM-V, (3) the text for TTM should be updated to describe subtypes and forms of hair pulling, (4) there are persuasive reasons for referring to TTM as "hair pulling disorder (trichotillomania)," (5) diagnostic criteria for skin picking disorder should be included in DSM-V or in DSM-Vs Appendix of Criteria Sets Provided for Further Study, and (6) the diagnostic criteria for stereotypic movement disorder should be clarified and simplified, bringing them in line with those for hair pulling and skin picking disorder.
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Affiliation(s)
- Dan J Stein
- Department of Psychiatry, University of Cape Town, Rondebosch, Cape Town, South Africa.
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Abstract
In the DSM-IV-TR, specific impulse control disorders not elsewhere classified (ICD) have been designated following four principles: (1) through the addition of an adjective that emphasizes the aberrant character of an otherwise normal behaviour (e.g., pathological gambling); (2) by means of metaphors (such as in intermittent explosive disorder); (3) according to the presumably quintessential nature of their main signs and symptoms, such as impulsive (e.g., impulse control disorders not elsewhere classified), compulsive (e.g., compulsive shopping), or addictive (e.g., internet addiction); or (4) using Greek suffix mania (e.g., kleptomania, pyromania, and trichotillomania). Given this flagrant inconsistency, we argue that time has come to adopt a less arbitrary way of describing these disorders, at least until it becomes clearer whether they are really impulsive, compulsive or addictive or if the preoccupation with this distinction is valid. In keeping with DSM's emphasis on descriptive phenomenology rather than on unsupported theory, a less biased terminology is in order. Therefore, we would like to suggest: (1) the substitution of the term ICD by the more neutral expression 'volitional disorders not elsewhere classified'; (2) the use of the classical Greek suffix mania, already present in some DSM-IV-TR ICDs, as the main naming principle to be adopted in the DSM-V; and (3) the creation of compulsive, impulsive, and mixed subtypes of the 'volitional disorders not elsewhere classified', since they are beginning to be validated by treatment trials.
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Affiliation(s)
- Leonardo F Fontenelle
- Anxiety and Depression Research Program, Institute of Psychiatry, Universidade Federal do Rio de Janeiro (IPUB/UFRJ), Rio de Janeiro, RJ, Brazil.
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Lochner C, Seedat S, Stein DJ. Chronic hair-pulling: phenomenology-based subtypes. J Anxiety Disord 2010; 24:196-202. [PMID: 19932593 DOI: 10.1016/j.janxdis.2009.10.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Revised: 09/28/2009] [Accepted: 10/19/2009] [Indexed: 11/16/2022]
Abstract
Distinct subtypes of trichotillomania (TTM)/chronic hair-pulling may exist. The aim of this study was to extend an earlier analysis by our group to a larger sample of patients with chronic hair-pulling, and to assess the validity and clinical utility of several putative subtypes. Eighty patients with various putative hair-pulling subtypes were compared on sociodemographic and clinical variables. Gender and disability due to pulling accounted for a number of important differences; for example, females more commonly had earlier age of onset of pulling, less comorbidity, and more disability than males. Also, those who met DSM-IV criteria B and C of TTM appeared to have a more disabling course of illness than those who did not. These data appear to support a dimensional rather than a categorical approach to subtyping. Future work, incorporating further investigation of the role of gender and psychobiological and treatment outcomes, is needed before definitive conclusions about hair-pulling subtypes can be drawn.
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Affiliation(s)
- Christine Lochner
- MRC Unit on Anxiety and Stress Disorders, Department of Psychiatry, University of Stellenbosch, South Africa.
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Walther MR, Ricketts EJ, Conelea CA, Woods DW. Recent Advances in the Understanding and Treatment of Trichotillomania. J Cogn Psychother 2010; 24:46-64. [PMID: 26658787 PMCID: PMC4674792 DOI: 10.1891/0889-8391.24.1.46] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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van Zeeland YR, Spruit BM, Rodenburg TB, Riedstra B, van Hierden YM, Buitenhuis B, Korte SM, Lumeij JT. Feather damaging behaviour in parrots: A review with consideration of comparative aspects. Appl Anim Behav Sci 2009. [DOI: 10.1016/j.applanim.2009.09.006] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Shusterman A, Feld L, Baer L, Keuthen N. Affective regulation in trichotillomania: Evidence from a large-scale internet survey. Behav Res Ther 2009; 47:637-44. [DOI: 10.1016/j.brat.2009.04.004] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2008] [Revised: 04/08/2009] [Accepted: 04/15/2009] [Indexed: 11/17/2022]
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Duke DC, Keeley ML, Ricketts EJ, Geffken GR, Storch EA. The Phenomenology of Hairpulling in College Students. JOURNAL OF PSYCHOPATHOLOGY AND BEHAVIORAL ASSESSMENT 2009. [DOI: 10.1007/s10862-009-9150-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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