Massachusetts General Hospital Hairpulling 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.

Skin Picking and Trichotillomania Disorders in the Era of COVID-19: Cross-Sectional Study

Background: Trichotillomania and skin picking are two forms of body focused repetitive behaviors [BFRBs] classified among Obsessive Compulsive Disorders. Socio-governmental changes which had accompanied COVID-19 overwhelmed patients with BFRBs whom already experienced anxiety and social isolation. Our study was designed to determine if there is an association between COVID-19 pandemic and worsening of symptoms of BFRB disorders ( in particular, trichotillomania and skin picking patients).Methods: Cross-sectional online survey-based study conducted from June to August 2021. The survey collected data about participants sociodemographic, knowledge, concerns, and psychological impacts by using Massachusetts General Hospital Hair Pulling Scale (MGH-HPS) and/or modified skin picking scale-revised (SPS-R).Results: A total of 171 participants joined the study including 34 (19.9%) male and 137 (80.1%) females. There was a significant difference of the total modified SPS-R (max 32), the mean score has increased by 7.62 during COVID-19 (t=6.42, p<0.001). Also, 7 parameters (subscales) are statistically significant. There was a significant difference of Frequency of urges, the mean score has increased during COVID-19 by 1.33 (t=3.16, p<0.05=0.025).Conclusion: Throughout COVID-19 pandemic in Saudi Arabia, results revealed clearly the significant negative psychological impact of it on the population, specifically on those with BFRBs. The study gives a clue that both diseases are under-diagnosed, hence, the authors suggest conducting community screening programs for early and proper management. We suggest providing more attention and further protective psychological strategies during such stressful situations that go parallel with the physical health care plans.

Comprehensive Behavioral (ComB) Treatment of Trichotillomania: A Randomized Clinical Trial

ObjectiveThis study is the first controlled trial of comprehensive behavioral (ComB) treatment of trichotillomania (TTM). ComB provides individualized treatment based on factors triggering and maintaining hair pulling. Method: Participants (N = 36) were adults (M = 34.08 years old, SD = 12.26) meeting DSM5 criteria for TTM. A majority were female (80%) and Caucasian (75%), whereas 17% were African American and 19% Hispanic/Latinx. In a parallel-group design, participants were randomly assigned to (a) Immediate ComB (12 sessions) or (b) Minimal Attention Control (MAC), followed by delayed ComB after week 12. Follow-up continued through week 38. Primary outcomes were self-report (Massachusetts General Hospital Hair pulling Scale; MGH-HPS) and interviewer-rated (NIMH-Trichotillomania Impact Scale and Trichotillomania Severity Scale; TIS/TSS) TTM symptom severity, as well as diagnosis (Trichotillomania Diagnostic Interview). ResultsImmediate efficacy of ComB (vs. MAC) was statistically significant (p = .03) for self-reported symptoms, with an effect size d = −.78, but not significant for interviewer-rated symptoms or diagnostic status. Immediate ComB was significantly more likely than MAC (27% vs. 0%) to lead to complete abstinence from hair pulling at week 12. Follow-ups showed good maintenance of effects. ConclusionsEfficacy of ComB was established for self-reported symptoms. Future research is needed to establish whether the lack of more widespread effects stems from limitations of the model or to a need for more extensive therapist training, as secondary analyses suggested stronger results among therapists with more TTM experience.

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

To the Editor: Body-focused repetitive behaviors (BFRBs) include repetitive hair pulling (trichotillomania), nail biting, and skin picking (excoriation disorder). The ritualized behaviors are distinct and classified among obsessive-compulsive and related disorders in the Diagnostic and Statistical Manual of Mental Disorders. BFRBs can cause distress, visible damage, and lead to social impairment. Societal changes from the COVID-19 pandemic present a unique challenge to those with BFRBs. Individuals with BFRBs have high baseline levels of anxiety and report a correlation between anxiety and symptom severity.1Keuthen N.J. Deckersbach T. Wilhelm S. et al.Repetitive skin-picking in a student population and comparison with a sample of self-injurious skin-pickers.Psychosomatics. 2000; 41: 210-215Crossref PubMed Scopus (156) Google Scholar Rapid implementation of changes to daily life, including COVID-19 social distancing directives, have the potential to compound the increased social isolation already experienced by those with BFRBS.1Keuthen N.J. Deckersbach T. Wilhelm S. et al.Repetitive skin-picking in a student population and comparison with a sample of self-injurious skin-pickers.Psychosomatics. 2000; 41: 210-215Crossref PubMed Scopus (156) Google Scholar We created a survey to examine how changes during the COVID-19 pandemic have affected those with BFRBs, including symptom severity and access to treatment. This study was exempted by the University of Minnesota Institutional Review Board. An online survey link was shared among BFRB Facebook groups and in a newsletter sent to consumers of a BFRB awareness device (HabitAware, Minneapolis, MN). Responses were collected between July 1 and July 31, 2020. Participants who indicated hair-focused BFRBs completed a modified Massachusetts General Hospital Hairpulling Scale and those with skin-focused BFRBs completed a modified Skin Picking Scale-Revised comparing symptoms before and during the pandemic.2Keuthen N.J. O'Sullivan R.L. Ricciardi J.N. et al.The Massachusetts General Hospital (MGH) Hairpulling Scale: 1. Development and factor analyses.Psychother Psychosom. 1995; 64: 141-145Crossref PubMed Scopus (296) Google Scholar,3Snorrason I. Ólafsson R.P. Flessner C.A. Keuthen N.J. Franklin M.E. Woods D.W. The Skin Picking Scale-Revised: factor structure and psychometric properties.J Obsessive Compuls Relat Disord. 2012; 1: 133-137Crossref Scopus (66) Google Scholar Paired-samples t tests were used to compare means. A total of 460 individuals with a self-reported BFRB diagnosis completed the survey (Table I). Skin picking was reported by 133 (28.9%) participants, hair pulling was reported by 181 (39.3%) participants, and 141 (30.7%) participants reported both. A majority (67.2%) reported increased BFRB symptoms during COVID-19. Of the 145 (31.5%) participants receiving active treatment for BFRBs, 55 (37.9%) experienced an interruption in therapy because of COVID-19. Those with skin picking disorders reported a significant (2.2) increase on the modified Skin Picking Scale-Revised (P = .00). Participants with hair pulling disorders reported a 1.6 point increase on the Massachusetts General Hospital Hairpulling Scale (P = .01; Table II).Table IDemographics, therapy, and dermatologic careCategoryAge, y, mean (SD)32.5 ± 12.4Diagnosis, n Formal BFRB diagnosis460 No formal BFRB diagnosis, excluded25Location, n (%) United States342 (74.3) Outside of the United States118 (25.7)Race, ethnicity, or origin, n (%)Asian or Pacific Islander15 (3.3)Black or African American7 (1.5) Hispanic or Latino15 (3.3) Middle Eastern or North African4 (0.9) White411 (89.3) Other race, ethnicity, or origin8 (1.7)Gender/gender identity, n (%) Transgender11 (2.4) Nonbinary9 (2.0) Genderqueer∗Genderqueer is as a term for self-identification and includes those who have a gender identity that does not align with sex assigned at birth. For more information, see the American Academy of Dermatology Lesbian, Gay, Bisexual, Transgender, and Queer Sexual and Gender Minority Expert Resource Group position statement on Sexual and Gender Minority Health in Dermatology, available at https://server.aad.org/Forms/Policies/Uploads/PS/PS-Sexual%20and%20Gender%20Minority%20Health%20in%20Dermatology.pdf?.5 (1.1) Female457 (99.3) Male13 (2.8) Chose not to disclose1 (0.2)BFRB classification, n (%) Repetitive skin picking133 (28.9) Repetitive hair pulling181 (39.3) Both141 (30.7) Other BFRB5 (1.1)Self-rated impact of COVID on BFRB, n (%) Improved60 (13.0) No change81 (17.6) Worsened309 (67.2) No answer10 (2.2)BFRB therapy, n (%) Active treatment for BFRB before COVID145 (31.5)Interruption to active treatment because of COVID55 (37.9)No active treatment for BFRB before COVID315 (68.5) Desire to start therapy since COVID127 (40.3)Dermatologic care, n (%) History of dermatologic care249 (54.1) History of dermatologic care for BFRB55 (12.0)∗ Genderqueer is as a term for self-identification and includes those who have a gender identity that does not align with sex assigned at birth. For more information, see the American Academy of Dermatology Lesbian, Gay, Bisexual, Transgender, and Queer Sexual and Gender Minority Expert Resource Group position statement on Sexual and Gender Minority Health in Dermatology, available at https://server.aad.org/Forms/Policies/Uploads/PS/PS-Sexual%20and%20Gender%20Minority%20Health%20in%20Dermatology.pdf?. Open table in a new tab Table IIModified Skin Picking Scale-Revised and modified Massachusetts General Hospital Hairpulling Scale scores before and after COVIDScale and scorePre-COVID meanCOVID meanMean differenceP valueSPS-R (modified) scale item (0-4) Overall urge1.82.20.4.00 Intensity of urges1.82.30.4.00 Time spent picking skin1.61.90.3.00 Control over skin picking behavior2.12.50.3.00 Emotional distress from skin picking1.71.90.2.02 Social impairment caused by skin picking1.11.20.2.05 Social avoidance behavior0.81.00.2.00 Physical damage to skin from skin picking1.61.70.2.00Total modified SPS-R (max 32)12.514.72.2.00MGH-HPS (modified) scale item (0-4) Frequency of urges2.22.60.4.00 Intensity of urges2.32.60.4.00 Ability to control the urges2.02.30.2.02 Frequency of hairpulling1.82.00.3.01 Control over hairpulling2.93.00.11.03 Associated distress2.32.50.2.02Total modified MGH-HPS (max 24)13.515.11.6.01MGH-HPS, Massachusetts General Hospital Hair Pulling Scale; SPS-R, Skin Picking Scale-Revised. Open table in a new tab MGH-HPS, Massachusetts General Hospital Hair Pulling Scale; SPS-R, Skin Picking Scale-Revised. For those with BFRBs, the COVID-19 pandemic has led to increased symptoms. Although this study was limited by modification of standardized scales and its self-reported survey design, it suggests that anticipated psychologic effects of the pandemic are, in fact, materializing. Respondents with both skin and hair BFRBs reported increased distress and functional impairment. BFRBs are psychiatric disorders with dermatologic manifestations. While only 12.0% of those surveyed in our study reported seeing a dermatologist for their BFRB before COVID-19, the rapid spread of telemedicine may change that. Dermatologists should be aware that those with BFRBs may be experiencing increased skin picking and hairpulling during COVID-19. Proactive outreach to existing patients with BFRBs may be helpful. Although there are no treatments for BFRBs approved by the US Food and Drug Administration, treatment options include serotonin reuptake inhibitors, N-acetylcysteine, behavioral therapies, and wearable devices.4Sani G. Gualtieri I. Paolini M. et al.Drug treatment of trichotillomania (hair-pulling disorder), excoriation (skin-picking) disorder, and nail-biting (onychophagia).Curr Neuropharmacol. 2019; 17: 775-786Crossref PubMed Scopus (22) Google Scholar,5Himle J.A. Perlman D.M. Lokers L.M. Prototype awareness enhancing and monitoring device for trichotillomania.Behav Res Ther. 2008; 46: 1187-1191Crossref PubMed Scopus (14) Google Scholar In addition, many health systems have expanded telemedicine capabilities. In the context of lessened geographic and social barriers (eg, appearance stigma), patients with BFRBs may have greater access to treatment. Thus, it is more important than ever for dermatologists to consider BFRBs in their differential diagnosis and management. Ms Idnani is the cofounder and president of HabitAware. HabitAware did not provide any funding for this study. The remaining authors have no disclosures. We acknowledge the members of the body-focused repetitive behaviors social media community who helped disseminate the survey.

Measuring Treatment Response in Pediatric Trichotillomania: A Meta-Analysis of Clinical Trials.

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

Milk Thistle Treatment for Children and Adults with Trichotillomania: A Double-Blind, Placebo-Controlled, Crossover Negative Study.

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.

Identifying standardized definitions of treatment response in trichotillomania: A meta-analysis

BackgroundSymptom severity in trichotillomania clinical trials is typically rated using the Massachusetts General Hospital Hair Pulling Scale (MGH-HPS) and the National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS). There are no universal definitions of treatment response on these scales. The absence of empirically supported definitions of treatment response hampers advances in trichotillomania treatment. MethodsPubMed and CENTRAL databases were searched for trichotillomania clinical trials. A total of 14 studies were identified and 7 provided adequate data to be included in the meta-analysis (n = 270). Meta-DiSc software was employed. The Youden index and distance to corner were used to determine the optimal cut-point. Response was defined by the Clinical Global Impressions Improvement scale score ≤ 2. ResultsThe optimal cut-points for identifying response on the MGH-HPS was a 35% percent reduction [Youden Index 0.48; distance to corner 0.37] or a seven-point reduction [Youden Index 0.43; distance to corner 0.40]. The optimal cut-points for the NIMH-TSS was a 50% reduction [Youden Index 0.57; distance to corner 0.34] or a six-point reduction [Youden Index 0.53; distance to corner 0.36]. The optimal cut-points were similar when the analysis was confined to only trichotillomania trials involving adult subjects, but the scales appeared to have improved ability to define treatment response when pediatric subjects were excluded. ConclusionThis study provides empirically determined cut-points of treatment response on the MGH-HPS and NIMH-TSS. These data-driven cut-points will benefit future research in trichotillomania by providing definitions of treatment response that can be defined a priori in clinical trials.

Reliability and validity of the Trichotillomania Dimensional Scale (TTM-D)

Trichotillomania (TTM) is characterized by repetitive hair pulling resulting in hair loss. The Trichotillomania Dimensional Scale (TTM-D) is a newly developed DSM-5 scale that aims to assess the symptoms of TTM dimensionally. The aim of this current study was to examine the psychometric properties of the TTM-D in a sample of 483 participants. Principal Component Analysis indicated a single factor structure of the TTM-D. Internal consistency and test retest reliability was high (α = 0.89 and r = 0.91 respectively). The TTM-D demonstrated excellent convergent validity with the Massachusetts General Hospital Hair Pulling Scale (MGH-HPS; rs = 0.90) and divergent validity with the Depression Anxiety and Stress Scale (DASS-21; rs = 0.45). Further, the TTM-D demonstrated equivalence between online and pen-and-paper administrations (rs= 0.93). The findings suggest that the psychometric properties of TTM-D are sound and well supported within a community sample.

Salivary Inflammatory Markers in Trichotillomania: A Pilot Study

Background: Immune dysregulation has been hypothesized to be important in the development and pathophysiology of compulsive disorders such as obsessive compulsive disorder (OCD), which has a high comorbid overlap with trichotillomania (both are OC-related disorders). The role of inflammation in the pathophysiology of trichotillomania has garnered little research to date. Methods: Individuals with trichotillomania provided saliva sample for analysis of inflammatory cytokines. Additionally, these participants were examined on a variety of demographic variables (including body mass index [BMI], previously found to relate to inflammation) along with clinical measures (symptom severity, functioning, and comorbidity). Results: Thirty-one participants, mean age of 24.7 (±10.2) years, 27 (87.1%) females were ­included. The mean score on the Massachusetts General Hospital Hair Pulling Scale was 15.7 (±4.2), reflective of moderate symptom severity. Compared to normative data, the mean inflammatory marker levels in the trichotillomania sample had the following Z scores: interleukin-1β (IL-1β) Z = –0.26, IL-6 Z = –0.39, IL-8 Z = –0.32, and tumor necrosis factor-α Z = –0.83. Levels of inflammatory markers did not correlate significantly with BMI, depressive mood, symptom severity, or disability. Conclusions: The relatively low level of inflammatory saliva cytokines observed in the current study (negative z scores versus normative data with medium effect sizes) indicates that evaluation of blood inflammatory levels in trichotillomania versus matched controls would be valuable in future work. If a hypoinflammatory state is confirmed ­using blood samples, this would differentiate trichotillomania from other mental disorders (such as OCD, schizophrenia, and depression), which have typically been linked with high inflammatory measures in the literature, at least in some cases.

Placebo response in trichotillomania.

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.

A double-blind, placebo-controlled study of inositol in trichotillomania.

Trichotillomania is characterized by repetitive pulling that causes noticeable hair loss. Data on the pharmacological treatment of trichotillomania are limited, with no clear first-line agent. The aim of the current study was to determine the efficacy and tolerability of inositol in adults with trichotillomania. A total of 38 individuals (35 women; mean age: 28.9±11.4) with trichotillomania entered a 10-week, double-blind, placebo-controlled trial to evaluate the safety and efficacy of inositol (dosing ranging from 6 to 18 g/day). Patients were assessed using the Massachusetts General Hospital Hair Pulling Scale, the NIMH Trichotillomania Severity Scale, Clinical Global Impression Scale, and measures of depression, anxiety, and psychosocial functioning. Outcomes were examined using a linear mixed-effects model. Patients assigned to inositol failed to show significantly greater reductions on primary or secondary outcomes measures compared with placebo (all P>0.05). At study endpoint, 42.1% of patients were 'much or very much improved' on inositol compared with 35.3% on placebo. This is the first study assessing the efficacy of inositol in the treatment of trichotillomania, but found no differences in symptom reductions between inositol and placebo. Future studies should examine whether inositol may be beneficial in controlling pulling behavior in a subgroup of individuals with trichotillomania.

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

BackgroundThis study sought to investigate the effectiveness of group treatment for trichotillomania (TTM) in ordinary clinical settings. Treatment consisted of a combination of habit reversal training (HRT) and acceptance and commitment treatment (ACT). Both short- and long-term effects were explored, as well as individual change trajectories. MethodsThe sample consist of fifty-three patients with TTM. Treatment outcomes were evaluated at post-treatment and at one-year follow-up using self-report questionnaires (Massachusetts General Hospital Hair Pulling Scale, MGH-HS), structured clinical interviews (National Institute of Mental Health Trichotillomania Severity Scale, NIMH-TSS), and the Clinical Global Impression scale for TTM (CGI-TTM). ResultsAnalyses by mixed models for repeated measurements yielded a statistically significant effect of time (p<.001) for all outcome measures. There were large effect sizes, ranging from 1.76 to 2.33 at post-treatment and from 1.03 to 1.43 at one-year follow-up. Nearly 90% of patients scored below the diagnostic threshold at post-treatment on the CGI-TTM, and slightly more than 60% remained so at one-year follow-up. There were large and statistically significant differences in the change profiles across the patients from post-treatment to one year follow-up. ConclusionsACT-enhanced behavior therapy in a group format seems efficient for reducing symptoms of trichotillomania.

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

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.

Open-Label Trial of Aripiprazole in the Treatment of Trichotillomania

Serotonin reuptake inhibitors have been disappointing in the treatment of trichotillomania (TTM). Recent evidence suggests that medications that modulate dopamine may be helpful in this disorder. To determine if the D2 partial agonist aripiprazole would be effective in the treatment of TTM. Twelve subjects participated in an 8-week, open-label, flexible-dose study of aripiprazole treatment of TTM. Primary end points were reduction in the Massachusetts General Hospital Hair Pulling Scale (MGHHPS) and MGHHPS Actual Pulling Subscale (MGHHPS-APS). Secondary end points were the Clinical Global Impressions-Improvement Scale, Hamilton Anxiety Scale, Hamilton Depression Scale, Beck Depression Inventory, and Beck Anxiety Inventory. Eleven of 12 subjects had 2 or more assessments; one subject dropped out during the first week. For subjects with 2 or more assessments, there was a significant mean reduction in both primary end points, the MGHHPS score (mean change, 7.8; SD, ± 7.8; P ≤ 0.01) and the MGHHPS-APS score (mean change, 3.9; SD, ± 4.1; P ≤ 0.02). Seven subjects had a greater than 50% reduction in MGHHPS; 7 subjects had an exit Clinical Global Impressions-Improvement Scale of 2 or lower, and 5 participants had absolute exit scores of 3 or lower on the MGHHPS and 1 or lower on the MGHHPS-APS. There were no significant changes in mood-related secondary end points. The mean aripiprazole dose for all completers (N = 11) was 7.5 mg/d (± 3.4 mg/d). This small open-label study suggests that aripiprazole is a promising treatment for the treatment of trichotillomania. Larger double-blind, placebo-controlled studies are needed to follow up on these findings.

Dronabinol, a cannabinoid agonist, reduces hair pulling in trichotillomania: a pilot study

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.

Sustain Released Bupropion in the Treatment of Tricotillomania: Outpatient Follow Up Survey

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.

N-Acetylcysteine, a Glutamate Modulator, in the Treatment of Trichotillomania

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

Limited knowledge exists regarding the neurobiology of trichotillomania (TTM). Cerebellum (CBM) volumes were explored, given its role in complex, coordinated motor sequences. Morphometric magnetic resonance imaging (MRI) scans were obtained for 14 female subjects with DSM-IV diagnoses of TTM and 12 age-, education-, and gender-matched normal control (NC) participants. Parcellation was performed utilizing a recently developed methodology to measure subterritory volumes of the CBM. Regions were defined based on knowledge of the structural and functional subunits of the CBM. As predicted, significant group differences were reported for CBM raw cortical volumes (p = .008) that survived correction for total brain volume (TBV; p = .037) and head circumference (HC; p = .011). A priori and post hoc group raw volume comparisons for CBM subterritories and functional clusters revealed many significant differences. However, most differences failed to withstand correction for total CBM volumes (TCV). Smaller volumes were consistently reported for the TTM versus NC cohorts. Total Massachusetts General Hospital Hair Pulling Scale (MGHHPS) scores were significantly inversely correlated with left primary sensorimotor cluster volumes (p = .008), with smaller volumes associated with more severe TTM symptoms. These findings implicate the CBM in the neurobiology of TTM, with reduced subterritory volumes reported for the TTM versus NC groups.