Habit Reversal Training in Trichotillomania: A Case Series Based Practical Psychotherapy

Cross-sectional survey examining skin picking and hair pulling disorders during the COVID-19 pandemic

The purpose of this study was to examine the factor structure, validity and reliability of the Massachusetts General Hospital Hair pulling Scale. Participants (304 male and 331 female) selected and the instruments of this study administered on them. Convergent validity of Massachusetts General Hospital Hair pulling Scale with the Obsessive–Compulsive Inventory-Revised, Yale –Brown Obsessive Compulsive Scale modified For BDD, Health Anxiety Inventory—Short Form and Skin Picking Impact Survey respectively were r=0.20, r=0.47, r=0.17 and r=0.47. Confirmatory factor analyses revealed total factor, one assessing impairment and the other symptom severity. The Cronbach's alpha for the total factor was 0.82. It can be concluded that this instrument is a useful measure for assess Hair pulling disorder symptoms in clinical assessment.

ACT-enhanced behavior therapy in group format for Trichotillomania: An effectiveness study

Vitamin D deficiency has been correlated with non-scarring alopecia including alopecia areata or female pattern hair loss. It was theorized that hair loss secondary to vitamin D deficiency in patients susceptible to trichotillomania may exacerbate this obsessive-compulsive disorder. Though vitamin D deficiency is common, especially among patients suffering from neuropsychiatric disorders, its correlation with trichotillomania is not well reported. Two female patients suffering from trichotillomania defined by noticeable hair loss on the scalp through the Massachusetts General Hospital Hair Pulling Scale were treated to promote hair growth. Treatment included dietary supplementation with vitamin D3 1000 IU every day. It was found that in both patients treated with vitamin D3, marked improvements occurred over the span of 3 to 4 months. These included a reduction in obsessive compulsive disorder related hair loss as measured using the Massachusetts General Hospital Hair Pulling Scale, which correlated to their serum 25-hydroxyvitamin D levels. Experimental and clinical evidence is available to explain the underlying physiology and its probable relationship to trichotillomania's pathophysiology.

Trichotillomania is characterized by repetitive hair pulling that causes noticeable hair loss. Data on the pharmacologic treatment of trichotillomania are limited to conflicting studies of serotonergic medications. N-acetylcysteine, an amino acid, seems to restore the extracellular glutamate concentration in the nucleus accumbens and, therefore, offers promise in the reduction of compulsive behavior. To determine the efficacy and tolerability of N-acetylcysteine in adults with trichotillomania. Twelve-week, double-blind, placebo-controlled trial. Ambulatory care center. Fifty individuals with trichotillomania (45 women and 5 men; mean [SD] age, 34.3 [12.1] years). N-acetylcysteine (dosing range, 1200-2400 mg/d) or placebo was administered for 12 weeks. Patients were assessed using the Massachusetts General Hospital Hair Pulling Scale, the Clinical Global Impression scale, the Psychiatric Institute Trichotillomania Scale, and measures of depression, anxiety, and psychosocial functioning. Outcomes were examined using analysis of variance modeling analyses and linear regression in an intention-to-treat population. Patients assigned to receive N-acetylcysteine had significantly greater reductions in hair-pulling symptoms as measured using the Massachusetts General Hospital Hair Pulling Scale (P < .001) and the Psychiatric Institute Trichotillomania Scale (P = .001). Fifty-six percent of patients "much or very much improved" with N-acetylcysteine use compared with 16% taking placebo (P = .003). Significant improvement was initially noted after 9 weeks of treatment. This study, the first to our knowledge that examines the efficacy of a glutamatergic agent in the treatment of trichotillomania, found that N-acetylcysteine demonstrated statistically significant reductions in trichotillomania symptoms. No adverse events occurred in the N-acetylcysteine group, and N-acetylcysteine was well tolerated. Pharmacologic modulation of the glutamate system may prove to be useful in the control of a range of compulsive behaviors. clinicaltrials.gov Identifier: NCT00354770.

Evidence for Reduced Cerebellar Volumes in Trichotillomania

In this article, we discuss the use of venlafaxine, an antidepressant with predominant effects at both noradrenergic and serotonergic reuptake sites, in the treatment of trichotillomania (TTM), a complex psychiatric condition manifested by chronic, severe hair pulling. We review case examples of 10 consecutive patients exhibiting moderately severe TTM symptoms, as judged by self-report, extent of hair loss, and duration of remission, and discuss our observations regarding the effects of venlafaxine therapy (mean dose, 274 mg/day) on these patients over the course of several months (mean, 15.1 weeks). The Massachusetts General Hospital Hair Pulling Scale, Massachusetts General Hospital Trichotillomania Impact Scale (MGH TIS), Psychiatric Institute Trichotillomania Scale (PITS), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and Clinical Global Improvement (CGI) scale were used to appraise the patients' condition during routine clinical visits. A retrospective chart review of clinical data demonstrated significant improvement in TTM symptoms from baseline to last clinical visit in both behavioral (MGH HPS, P=.02; PITS, P=.02) and psychosocial (MGH TIS, P=.009) terms. Mean improvement on the CGI scale was 2.38±1.51, between “much improved” (2) and “slightly improved” (3). There were no significant differences from baseline to endpoint scores on the BDI or BAI. This retrospective treatment review indicates that short-term treatment with venlafaxine improved TTM symptoms; however, longer controlled trials with extended baseline periods are needed for optimal assessment of pharmacologic treatment of TTM. We look to future studies to confirm and supplement our initial positive findings.

BackgroundTrichotillomania is a chronic psychiatric and behavioral disorder characterized by recurrent hair-pulling, often leading to significant distress and impairment. Long-term psychotherapeutic case reports remain scarce, especially those integrating Narrative Therapy and the Satir Model in culturally-specific and resource-limited contexts.Case PresentationWe present a two-year integrated psychotherapy case for a 28-year-old woman with trichotillomania, utilizing Narrative Therapy and Satir Transformational Systemic Therapy. Assessments included the Massachusetts General Hospital Hair Pulling Scale (MGH-HPS), Self-Rating Anxiety Scale (SAS), Personal and Social Performance Scale (PSP), and Clinical Global Impression (CGI). Hair-pulling episodes decreased from 150 per day to 5, and MGH-HPS, SAS, and PSP scores improved substantially from baseline to end of treatment and one-year follow-up. The patient maintained gains post-treatment, with improved self-worth and social functioning.ConclusionsThis case supports the clinical utility of a Narrative Therapy–Satir Model integration for trichotillomania. The flexible, person-centered approach yielded lasting symptom and functional gains. Limitations include reliance on self-report and potential bias.

Trichotillomania is a functionally impairing, often overlooked disorder with no Food and Drug Administration-approved medications indicated for its treatment. The ability of clinical trials to detect the beneficial effects of pharmacologic treatment in trichotillomania has been hampered by the high placebo response rate. Very little is known about baseline demographic and clinical characteristics that may be predictive of placebo response in such patients. Overall, 104 participants assigned to placebo were pooled from five double-blind trials conducted at three sites in the USA and Canada. Participants were classified as placebo responders or nonresponders on the basis of a cutoff of a 35% reduction in symptom severity on the Massachusetts General Hospital Hair Pulling Scale. Baseline group differences were characterized using t-tests and equivalent nonparametric tests as appropriate. Thirty-one percent of individuals assigned to placebo treatment showed a significant clinical response to placebo. Placebo responders (n=32) and nonresponders (n=72) did not differ significantly on any demographic or clinical variable. Predictors of placebo response for trichotillomania remain elusive and do not appear to be similar to those reported for other mental health disorders.

Objectives: In clinical trials of pediatric trichotillomania (TTM), three instruments are typically employed to rate TTM severity: (1) the Massachusetts General Hospital Hair Pulling Scale (MGH-HPS), (2) the National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS), and (3) the Trichotillomania Scale for Children (TSC). These instruments lack standardized definitions of treatment response, which lead researchers to determine their own definitions of response post hoc and potentially inflate results. We performed a meta-analysis to provide empirically determined accuracy measures for percentage reduction cut points in these three instruments. Methods: MEDLINE was searched for TTM clinical trials. A total of 67 studies were initially identified, but only 5 were clinical trials focused on TTM in pediatric populations and therefore were included in this meta-analysis (n = 180). A Clinical Global Impressions Improvement score ≤2 was used to define clinical response. Receiver operating characteristic principles were employed to determine accuracy measures for percentage reduction cut points on each one of the instruments. Meta-DiSc software was employed to provide pooled accuracy measures for each cut point for each instrument. The Youden Index and the distance to corner methods were used to determine the optimal cut point. Results: The optimal cut points to determine treatment response were a 45% reduction on the MGH-HPS (Youden Index 0.40, distance to corner 0.20), a 35% reduction on the NIMH-TSS (Youden Index 0.42, distance to corner 0.17), a 25% reduction on the TSC child version (TSC-C; Youden Index 0.40, distance to corner 0.18), and a 45% (distance to corner 0.30) or 50% reduction (Youden Index 0.33) on the TSC parent version (TSC-P). The TSC-C had less discriminative ability at determining response in younger children in comparison to older children; no age-related differences were observed on the TSC-P. Conclusions: This study provides empirically determined cut points of treatment response on three instruments that rate TTM severity. These data-driven cut points will benefit future research on pediatric TTM.

Trichotillomania is characterized by repetitive pulling causing noticeable hair loss. Pharmacological treatment data for trichotillomania are limited. Dronabinol appears to reduce the exocitotoxic damage caused by glutamate release in the striatum and offers promise in reducing compulsive behavior. Fourteen female subjects (mean age = 33.3 ± 8.9) with DSM-IV trichotillomania were enrolled in a 12-week open-label treatment study of dronabinol (dose ranging from 2.5-15 mg/day). The primary outcome measure was change from baseline to study endpoint on the Massachusetts General Hospital Hair Pulling Scale (MGH-HPS). In order to evaluate effects on cognition, subjects underwent pre- and post-treatment assessments using objective computerized neurocognitive tests. Data were collected from November 2009 to December 2010. Twelve of the 14 subjects (85.7%) completed the 12-week study. MGH-HPS scores decreased from a mean of 16.5 ± 4.4 at baseline to 8.7 ± 5.5 at study endpoint (p = 0.001). Nine (64.3%) subjects were "responders" (i.e., ≥ 35% reduction on the MGH-HPS and "much or very much improved" Clinical Global Impression scale). The mean effective dose was 11.6 ± 4.1 mg/day. The medication was well-tolerated, with no significant deleterious effects on cognition. This study, the first to examine a cannabinoid agonist in the treatment of trichotillomania, found that dronabinol demonstrated statistically significant reductions in trichotillomania symptoms, in the absence of negative cognitive effects. Pharmacological modulation of the cannabinoid system may prove useful in controlling a range of compulsive behaviors. Given the small sample and open-label design, however larger placebo-controlled studies incorporating cognitive measures are warranted.

PurposeThe Massachusetts General Hospital Hairpulling Scale (MGH-HPS) is a 7-item self-report tool that measures hair-pulling behaviors. The study aimed to assess the psychometric properties of the Polish version of the MGH-HPS in a sample of adults.MethodsThe online screening survey was completed by 1024 participants (777 women, 241 men, 6 non-binary), 92 of which (68 women, 24 men) were included in the study because they confirmed engaging in hair-pulling behaviors at least occasionally; 23 of those (2.25% of the initial sample) met the DSM-5 criteria for hair-pulling disorder. The participants were asked to complete the online version of the MGH-HPS, the Depression Anxiety Stress Scales-21-Item Version, the Obsessive Compulsive Inventory-Revised, and a scale containing the DSM-5 hair-pulling disorder criteria. The factor structure, reliability, validity, and diagnostic accuracy of the Polish version of the MGH-HPS were examined.ResultsThe confirmatory factor analysis demonstrated that both a one-factor and a two-factor model fit the data well; however, given the high correlation between the factors, the unidimensional model may be superior. High internal consistency and convergent and divergent validity were obtained for the total score of the MGH-HPS and the Severity and Resistance and Control factors (Cronbach’s alphas: 0.89, 0.85 and 0.84 respectively). The ROC analysis indicated adequate prognostic ability of the total score to discriminate subjects with clinical and non-clinical hair-pulling. The optimal cut-off value was 13 points (sensitivity = 100%, specificity = 62.22%).ConclusionsThe Polish version of the MGH-HPS is a valid, reliable tool which may be used to measure hair-pulling behaviors in adult samples.

Examination of the relationship between internalized stigma and coping strategies in patients with trichotillomania.

Objectives. Tricotillomania (TTM) is more common than expected. SSRI's are the treatment of choice in TTM. However, response rates are lower with SSRI's. The aim of our study is to explore other pharmacological interventions. Materials and Methods. Nine female TTM patients with SSRI treatment failure were included. Sample was treated with bupropion SR up to 450 mg/day. Results. Six out of nine patients responded well to bupropion SR. Massachusetts General Hospital Hair Pulling Scale (MGH) demonstrated a significant improvement at the twelve week point (f: 32.3, power: 1, lambda: 97.1, P<.0001) and the response rates remained stable at sixteen-month follow up visit. Conclusions. Bupropion SR could be an alternative pharmacological treatment for TTM. Larger samples with double blind placebo controlled design are needed to confirm our preliminary report.

Data on the pharmacological treatment of trichotillomania are limited. Milk thistle has antioxidant properties and showed promise in trichotillomania in a prior case report. The goal of the current study was to determine the efficacy and tolerability of silymarin in children and adults with trichotillomania. Twenty individuals (19 [95.0%] women; 16 adults; mean age, 27.9 [11.5] years) with trichotillomania entered a 12-week, double-blind, placebo-controlled crossover study (6 weeks of milk thistle and 6 weeks of placebo with a 1-week wash-out in between). Dosing of milk thistle ranged from 150 mg twice a day to 300 mg twice a day. Subjects were assessed with the National Institute of Mental Health Trichotillomania Severity Scale (primary outcome), the Massachusetts General Hospital Hair Pulling Scale, Clinical Global Impression scale, and measures of depression, anxiety, and psychosocial functioning. Outcomes were examined using linear mixed models with a random intercept for subject and t tests. There were no statistically significant treatment type-by-time interactions for the main outcome measure, but significant effects were seen for secondary measures (eg, time spent pulling per day for the past week). From baseline to week 6, there was a significant decrease in Clinical Global Impression severity for the milk thistle group but not in the placebo group. This trial failed to show that milk thistle was more effective than placebo on the main outcome measure, but milk thistle did demonstrate significant improvements on select secondary outcome measures. These findings may shed light on important neurochemical targets worthy of future investigation.