Hair Pulling Behavior Research Articles

Reliability, Validity and Factor Structure of the Polish Version of the Massachusetts General Hospital Hair Pulling Scale

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.

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

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

Untroubled pullers: An examination of nonclinical hair-pulling

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

Sleep-isolated trichotillomania as an ictal symptom of complex partial seizure in a 12-year-old girl: a case report

Sleep-isolated trichotillomania (TTM) is the unconscious and automatic pulling of one's hair only while sleeping. In previous case reports, sleep-isolated TTM has been categorized as a sleep-related disorder or a sleep-related dissociative disorder in case reports, and a treatment strategy in this direction has been implemented. However, to our knowledge, no reports have been published describing hair pulling during sleep as a symptom of epilepsy and its pharmacological treatment. In this case report, we present the hair-pulling behavior during sleep as an ictal manifestation of complex partial seizure in a 12-year-old girl and its successful treatment with levetiracetam. We suggest that epilepsy should be suspected in addition to parasomnias and sleep-related dissociative disorder in the differential diagnosis, especially in cases presenting with isolated TTM behavior during sleep.

Trichotillomania in Dementia: A Case Report and Literature Review

Introduction: Dementia presents with a variety of behavioral and psychiatric disorders, including a range of psychosis, anxiety, depression, behavioral aggression, and delirium. Case Presentation: This study aimed to report a 74-year-old man showing gradually progressive deterioration in his memory for five years. The patient developed trichotillomania (TTM) subsequent to his dementia. Neuropsychological examination indicated the deficits to be more predominantly in the frontal lobe. Conclusions: This study reviewed the literature on TTM in dementia case reports that had mostly investigated the cases of right-handed men aged > 65 years. TTM Patients with underlying disease had not any improvement. Although there was some heterogeneous evidence for the presence of brain abnormalities in individuals with hair-pulling behavior, no definitive conclusion was drawn. Mild to severe generalized atrophy in the cerebral cortex was observed in the frontal, parietal, temporal, occipital, and cingulate lobes.

Prevalence and gender distribution of trichotillomania: A systematic review and meta-analysis

Epidemiological studies have provided varying prevalence estimates of trichotillomania (TTM) and other hair-pulling behaviors. We performed a systematic review and meta-analysis to provide data-driven prevalence estimates of TTM and hair-pulling. PubMed, PsycInfo and Embase were searched on June 2020 (updated in November 2021). Studies reporting the frequency of TTM defined by Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria or hair-pulling behaviors were included. Prevalence data was extracted for both genders, and female-to-male odds ratios (OR) were computed for TTM and any hair-pulling behaviors. Data were pooled through random-effects meta-analyses. Of the 713 records identified through database searches, 30 studies involving 38,526 participants were included. Meta-analyses indicated TTM had a prevalence of 1.14% (95% CI 0.66%, 1.96%), while any hair-pulling behavior had a prevalence of 8.84% (95% CI 6.33%, 12.20%). Meta-analyses demonstrated females were at an increased risk of any hair-pulling when noticeable hair loss was required (OR = 2.23, 95% CI 1.60, 3.10, p < 0.0001), but not of any hair-pulling when noticeable hair loss was not required (OR = 0.90, 95% CI 0.72, 1.64, p = 0.33). Meta-analyses did not indicate female preponderance in TTM (k = 10; N = 22,775; OR = 1.29; 95% CI 0.91, 1.83; I2 = 28%, p = 0.15), although there was considerable heterogeneity across studies. This study demonstrates that TTM impacts ∼1% of the population, while general hair-pulling behaviors affects ∼8%, highlighting the significant public health impact of this understudied condition. Additional research should clarify the gender distribution of TTM in epidemiological samples.

Trichotillomania – An Ayurvedic Perspective

Trichotillomania (TTM) also known as a hair-pulling disorder is a debilitating psychiatric condition characterized by the recurrent pulling out of one's own hair, leading to hair loss and functional impairment. If untreated, TTM may lead to life-threatening medical problems. In DSM-5-TR, TTM is kept under the category of “Obsessive-compulsive and related disorders.” As there is no established treatment in contemporary medicine for TTM, many patients seek other interventions such as Ayurveda (traditional Indian system of medicine). There is no clarity regarding ayurvedic diagnosis and management of TTM. This has created a major diagnostic and management dilemma in clinical ayurvedic psychiatry practice while approaching a patient of TTM. The aim of the present study is to understand TTM according to Ayurveda and to propose an ayurvedic diagnosis and treatment protocol for it. The present study has explored the similarity between Bhutonmada/Grahonmada (psychiatric condition having idiopathic manifestation) and TTM. Although some references related to hair-pulling behavior are available in ayurvedic texts, they may not represent TTM exactly as an independent disease entity. There is some similarity between Bhutonmada and TTM in terms of etiology, pathology, course and prognosis, and clinical features. Hair-pulling behavior and other self-injurious behaviors can be understood as Bhutonmada with the intention of Himsa. Spiritual or divine therapies, ayurvedic psychotherapy, and virtuous code of conduct, along with ayurvedic medicines, may provide relief to TTM patients. The present study provides new insights for diagnosing and managing the patients of TTM according to Ayurveda.

Abstract- Poster

Background-Hair pulling behavior associated with a bald patch is rarely reported in a geriatric population.Aim- To describe the psychopathological intricacies posing diagnostic and therapeutic challenges.Case PresentationA 90-year-old lady, presented with insidious onset of repetitive hair-pulling behavior resulting in a huge area of baldness measuring 10*20 cm2 over the parieto-central region. On evaluation, a history of ‘as if insects are crawling under the skin and producing itching sensations’ was reported. Ward-observation was notable for the anxious distress preceding hair pulling and feeling of relief after completion of the act. No history was notable for amnesia, delusions, hallucinations, obsessions, and compulsions, or any organicity. Brain imaging, viral markers, and nutritional parameters were within normal limits. No family history of neuropsychiatric condition was noted. Premorbid personality was suggestive of anankastic personality traits. The patient had bilateral senile cataracts and presbycusis. Hair-root examination of the bald patch revealed the absence of telogen hairs. A provisional diagnosis of Trichotillomania was considered. Because, she was not amenable for therapy, a trial of Tab Escitalopram 10mg/day was started, with reduction in the scores on Psychiatric Institute Trichotillomania Scale (PITS) from 36 to 20 in 4 weeks.Conclusion-This is the first report on isolated hair-pulling behavior in the geriatric population. The age-associated sensory impairments pose a significant challenge in dissecting the phenomenology of hair-pulling behavior. However, effective use of behavioral observation with the help of a caregiver and proper use of pharmacotherapy can be helpful in the management of the condition.

10.2 HABIT REVERSAL TRAINING FOR HAIR PULLING DISORDER

Hair-pulling behaviors are relatively common among youth with mental health disorders and can result in significant distress and impairment. Habit reversal training (HRT) has demonstrated efficacy for reducing hair-pulling behaviors across several randomized, controlled trials. This has led experts to recommend HRT as a first-line treatment for youth with hair-pulling disorder (formerly called trichotillomania). This presentation describes the empirical support of HRT and delves into the implementation of its clinical components.

Behavioral Treatment of Trichotillomania in a College Woman: A Case Study

Trichotillomania (TTM) is a disorder that involves repetitive pulling of one’s hair to the point of hair loss and clinically significant distress or functional impairment. Using Diagnostic and Statistical Manual of Mental Disorders-5 ( DSM-5) criteria, which include repeated attempts to decrease or stop pulling, the 12-month prevalence of TTM is 1% to 2%. Treatment commonly involves behavior therapies. These behavior therapies conceptualize TTM using operant learning theory and explain hair-pulling behavior as caused and maintained by environmental antecedents and consequences interacting with an individual’s biological makeup. This clinical case study describes use of an Acceptance and Commitment Therapy Enhanced Behavior Therapy for Trichotillomania (AEBT-T) protocol to facilitate treatment of a 20-year-old woman who was referred for TTM. The client remained in treatment for 14 months. After the completion of 32 therapy sessions, the client reported significantly reduced hair-pulling and anxiety, as well as increased engagement in valued activities. Implications of these findings are discussed, with an emphasis on the challenges of treating TTM in a college population.

Implementing self-monitoring to reduce inappropriate vocalizations of an adult with autism in the workplace

Individuals with autism spectrum disorder (ASD) are capable of competitive employment and can work successfully in community businesses. However, it is common for individuals with ASD to be unemployed or underemployed at higher rates than other groups with disabilities and the population at large. ASD encompasses a range of behaviors with the potential to interfere with productivity within the workplace. Research has supported management of these behaviors, through methods such as self-monitoring, may improve community access and employment. A singlesubject withdrawal design was utilized to evaluate the functional relationship between implementation of the I-Connect self-monitoring intervention and inappropriate vocalizations, with secondary measurement of work engagement and hair pulling behaviors. An adult female with ASD received training on the use of the I-Connect self-monitoring application in her work place medical records setting. Introduction of the I-Connect self-monitoring application resulted in an immediate decrease in inappropriate vocalizations. Social validity measures suggest the application was easy to utilize and may be beneficial in increasing a person's perceived ability to regulate inappropriate vocalizations in a work environment.

33.3 Understanding and Implementing Behavior Therapy for Hair-Pulling Disorders

Hair-pulling behaviors are relatively common among youth with mental health disorders, and they can result in significant distress and impairment. Behavior therapy has demonstrated efficacy in reducing hair-pulling behaviors across several RCTs, which has resulted in experts recommending it as a first-line treatment for youth with hair-pulling disorder (formerly called trichotillomania). This presentation briefly describes the empirical support for behavior therapy and delves into the implementation of its core, clinical components.

Awareness enhancing and monitoring device plus habit reversal in the treatment of trichotillomania: An open feasibility trial

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

Trichotillomania in celiac disease patient refractory to iron replacement

Trichotillomania is characterized by recurring hair pulling behavior and repeated attempts to decrease or stop the behavior. This behavior can cause a trichobezoar, which is a mass of hair found in the stomach. Patients with diagnosed celiac disease may have an urge to swallow their hair due to iron or folat deficiency, which is called pica. We report a case of an 11-year old girl with celiac disease who has had trichotillomania for a duration of 2 years, and required an operation due to residual gastric hair mass. In this case trichotillomania was more likely caused by behavioral disorders secondary to celiac disease, rather than the iron deficiency due to malabsorption.

Psychological treatment of trihotillomania: A case study

This paper presents a clinical case of trichotillomania. Therefore, the aim of this study is to present in detail the procedure followed in a case of trichotillomania in a public health context, using cognitive-behavioral techniques, in order to deepen the knowledge of the efficacy of these treatment procedures and demonstrate the feasibility of implementation.The results obtained show significant improvements in different clinical aspects: first, the hair pulling behavior disappeared completely; moreover, anxiety diminished significantly and mood normalized. All these results allow us to conclude that the intervention was successful.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Trichotillomania and co-occurring anxiety

BackgroundTrichotillomania appears to be a fairly common disorder, with high rates of co-occurring anxiety disorders. Many individuals with trichotillomania also report that pulling worsens during periods of increased anxiety. Even with these clinical links to anxiety, little research has explored whether trichotillomania with co-occurring anxiety is a meaningful subtype. MethodsOne hundred sixty-five adults with trichotillomania were examined on a variety of clinical measures including symptom severity, functioning, and comorbidity. Participants also underwent cognitive testing assessing motor inhibition and cognitive flexibility. Clinical features and cognitive functioning were compared between those with current co-occurring anxiety disorders (i.e. social anxiety, generalized anxiety disorder, panic disorder, and anxiety disorder NOS) (n=38) and those with no anxiety disorder (n=127). ResultsParticipants with trichotillomania and co-occurring anxiety reported significantly worse hair pulling symptoms, were more likely to have co-occurring depression, and were more likely to have a first-degree relative with obsessive compulsive disorder. Those with anxiety disorders also exhibited significantly worse motor inhibitory performance on a task of motor inhibition (stop-signal task). ConclusionsThis study suggests that anxiety disorders affect the clinical presentation of hair pulling behavior. Further research is needed to validate our findings and to consider whether treatments should be specially tailored differently for adults with trichotillomania who have co-occurring anxiety disorders, or more pronounced cognitive impairment.

El tratamiento psicológico de la tricotolomanía: un estudio de caso

This paper presents a clinical case of trichotillomania, thus aims to present in detail the procedure followed in a public health context, using cognitive-behavioral techniques, in order to deepen the knowledge of the efficacy of these treatment procedures and demonstrate the feasibility of their use. The results obtained showed significant improvements in different clinical aspects: first, the hair pulling behavior disappeared completely; moreover, anxiety diminished significantly and mood normalized. This allows us to conclude that the intervention was successful.

Trichotillomania as a Manifestation of Dementia.

Pathological hair-pulling or trichotillomania, which is commonly associated with anxiety and depression, obsessive-compulsive disorder, and neurodevelopmental disorders, has been rarely associated with dementing illnesses. Investigators have not clarified the neural correlates and treatment of trichotillomania in dementia. We report a patient who developed an early-onset cognitive decline with genetic, cerebrospinal fluid biomarker and structural and functional neuroimaging studies consistent with Alzheimer's disease. Eight years into her disease, she developed severe, repetitive hair-pulling behavior leading to marked hair loss, along with other repetitive and “frontal” behaviors. Selective serotonin reuptake inhibitors (SSRIs) were ineffective in controlling her hair-pulling behavior, which subsequently responded to quetiapine 150 mg/day. This patient and a review of the literature suggest that trichotillomania may be a compulsive-related symptom in dementias of different etiologies as they involve frontal areas and release primitive grooming behavior from frontostriatal dysfunction. Dopamine blockade, rather than SSRIs, may be effective in managing trichotillomania in dementia.

Trichotillomania and personality traits from the five-factor model.

To examine whether personality traits have predictive validity for trichotillomania (TTM) diagnosis, pulling severity and control, and hair pulling style. In study 1, logistic regression was used with TTM cases (n=54) and controls (n=25) to determine if NEO Five-Factor Inventory (NEO-FFI) personality domains predicted TTM case vs. control classification. In study 2, hierarchical multiple regression was used with TTM cases (n=164) to determine whether NEO-FFI personality domains predicted hair pulling severity and control as well as focused and automatic pulling styles. TTM case vs. control status was predicted by NEO-FFI neuroticism. Every 1-point increase in neuroticism scores resulted in a 10% greater chance of TTM diagnosis. Higher neuroticism, higher openness, and lower agreeableness were associated with greater pulling severity. Higher neuroticism was also associated with less control over hair pulling. Higher neuroticism and lower openness were associated with greater focused pulling. None of the personality domains predicted automatic hair pulling. Personality traits, especially neuroticism, can predict TTM diagnosis, hair pulling severity and control, and the focused style of pulling. None of the personality traits predicted automatic pulling. Longitudinal studies are needed to determine whether personality variables predispose to TTM onset, impact disorder course, and/or result from hair pulling behavior.

A hybrid artificial intelligence method to classify trichotillomania and obsessive compulsive disorder

Classification of psychiatric disorders is becoming one of the major focuses of research using artificial intelligence approach. The combination of feature selection and classification methods generates satisfactory outcomes using biological biomarkers. The use of quantitative electroencephalography (EEG) cordance has enhanced the clinical utility of the EEG in psychiatric and neurological subjects. Trichotillomania (TTM), a kind of body focused repetitive behavior, is defined as a disorder characterized by repetitive hair pulling that results in noticeable hair loss. Phenomenological observations underline similarities between hair-pulling behaviors and compulsions seen in obsessive-compulsive disorder (OCD). Despite the recognized similarities between OCD and TTM, there is evidence of important differences between these two disorders. In order to dichotomize the subjects of each disorder, artificial intelligence approach was employed using quantitative EEG (QEEG) cordance values with 19 electrodes from 10 brain regions (prefrontal, frontocentral, central, left temporal, right temporal, left parietal, occipital, midline, left frontal and right frontal) in 4 frequency bands (delta, theta, alpha and beta). Machine learning methods, artificial neural networks (ANN), support vector machine (SVM), k-nearest neighbor (k-NN) and Naïve Bayes (NB), were used in order to classify 39 TTM and 40 OCD patients. SVM, with its relatively better performance, was then combined with an improved ant colony optimization (IACO) approach in order to select more informative features with less iterations. The noteworthy performance of the hybrid approach underline that it is possible to discriminate OCD and TTM subjects with 81.04% overall accuracy.