Massachusetts General Hospital Hairpulling Scale Research Articles

Impulsivity in adolescent girls diagnosed with trichotillomania: an evaluation of clinical and neuropsychological characteristics

The aim of this study is to compare the clinical and neuropsychological features of impulsivity in adolescent girls with trichotillomania (TTM) and healthy controls, and to assess the relationships between the severity of TTM and the impulsivity/concomitant symptoms of anxiety and depression. The study sample consisted of 43 adolescent girls who were 12 to 18 years old. The Kiddie-Schedule for Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime Version DSM-5 (K-SADS-PL) was administered to the adolescents and their parents. All of the participants completed a sociodemographic data form, the Revised Children’s Anxiety and Depression Scale-Child Version (RCADS-CV), the Barratt Impulsiveness Scale-Brief (BIS-Brief), and the Massachusetts General Hospital Hairpulling Scale (MGH-HPS). The Eriksen Flanker task, the Stop Signal Reaction Time (SSRT) task, the Go/No-Go task, and the Balloon Analog Risk Task (BART) were used to assess behavioral impulsivity. The adolescents with TTM reported higher levels of impulsivity and anxiety/depression symptoms than the healthy controls, and they also performed worse on the behavioral tasks. While there were no relationships between clinical and behavioral impulsivity and TTM severity, social anxiety symptoms were the most important predictor of the severity of TTM. It seems important to better understand the role of impulsivity in the onset and persistence of TTM symptoms in adolescents.

Prevalence and Factors Influencing Trichotillomania Among Healthcare Workers and Students in Saudi Arabia: A Cross-Sectional Analytical Study.

Trichotillomania (TTM) is a psychiatric disorder characterized by repetitive pulling out of one's own hair, in which the scalp, brows, and eyelids are the most common sites. This study aimed to measure the prevalence of TTM among healthcare workers and students and to determine its association with psychiatric disorders. This cross-sectional study was conducted among healthcare workers and students in Saudi Arabia. Data were collected through an online self-administered questionnaire. The questionnaire consisted of sociodemographic characteristics, the Massachusetts General Hospital (MGH) Hairpulling Scale to measure TTM, and the Depression and Anxiety Stress Scale (DASS-21) to measure the psychiatric disorders of the participants. A convenience sampling technique was implemented. The sample size was calculated to be 385. Of the total 460 participants, 62% (n = 285) were students, 55% were females and 61.7% (n = 284) were aged between 18 and 24 years. The most commonly associated chronic disease was diabetes (n = 34, 7.4%), followed by asthma (n = 30, 6.5%). The prevalence of TTM was 4.8% (n = 22), which was higher among medical students (n = 15, 5.3%) as compared to medical workers (n = 7, 4%). While taking psychiatric medication (AOR = 0.197; 95% CI = 0.076-0.508 p = 0.001) was identified as the protective factor for TTM, previous diagnoses of psychiatric illness (AOR = 4.298; 95% CI = 1.759-10.499; p = 0.001), stress (AOR = 4.759; 95% CI = 1.541-14.695; p = 0.007), and depression (AOR = 3.149; 95% CI = 1.190-8.334; p = 0.021) were recognized as independent risk factors of TTM. Trichotillomania was less common among health workers and students in Saudi Arabia. However, if trichotillomania is present, the disorder was found to be more common among those with associated psychiatric illnesses, including those who wereanxious and depressed. Hence, further research is required to validate the impact of psychiatric conditions on the prevalence of TTM in the study region.

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.

N-acetylcysteine (NAC) and in psychodermatological conditions. Is it useful?

IntroductionPathologic grooming disorders can lead to clinically significant distress and functional impairment. Various psychopharmacological and nonpharmacological treatments have been used to ameliorate the symptoms of these disorders. N-Acetylcysteine (NAC) is a newer modality in the treatment of these disorders and has shown promise in treatment of obsessive-compulsive and related disorders.ObjectivesTo determine whether NAC is useful in the treatment of body-focused repetitive behavior disorders.MethodsA literature review was carried out in PubMed using the descriptors: “body-focused repetitive behaviour disorders” “grooming disorders” AND “N-Acetylcysteine”.Six results were obtained when using the time limit of 5 years. We selected two of them for their relevance to the PICO question. Subsequently, the search was repeated using the same descriptors and the time limit in the Cochrane Library, Epistemokinos and Tripdatabase, in which no additional results were found.ResultsOverall, thirty-three articles were included in these systematic reviews that we studied, which consisted of 23 case reports, one case series, and seven randomized controlled trials. Dosing of oral NAC ranged from 450 to 3,000 mg per day, and treatment periods lasted from 1 to 8 months. Side effects were uncommon, mild, and usually gastrointestinal in nature, with severe aggression reported in one child. Two randomized controlled trials showed a significant improvement in trichotillomania and excoriation disorder in adults. The other two were performed in pediatric population, showing no statistical difference. Two randomized controlled trials and six case reports studying the effects of NAC in patients suffering from trichotillomania (one performed in adults and the other one in infants) were included. Only the one performed in adults showed improvement when adding NAC to the treatment using the Massachusetts General Hospital, Hairpulling Scale (MGH-HPS). Four case reports and two randomized controlled trials included patients with excoriation disorder showed statistical differences in all of them. Three case reports and one randomized controlled trial in patients with onicotylomania showed a difference that wasn’t consistent after two months of treatment.ConclusionsThere are multiple case reports an several clinical trials supporting both the safety and efficacy of NAC in the treatment of body-focused repetitive behavior disorders. Based on these positive preliminary results and the absence of serious adverse effects, carrying out a therapeutical trial with NAC is a plausible option in the management of this pathology, especially in those in which other therapeutic options have not been effective. Further studies are needed to develop a treatment algorithm and elucidate the difference in the efficacy of NAC between children and adults with this disorder.Disclosure of InterestNone Declared

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.

Acceptance-enhanced behavior therapy for trichotillomania in adults: A randomized clinical trial

Given the limited treatment options for trichotillomania (TTM), or Hair Pulling Disorder, this large randomized clinical trial evaluated the efficacy of acceptance-enhanced behavior therapy for TTM (AEBT-TTM) in reducing TTM severity relative to psychoeducation and supportive therapy (PST). Eighty-five adults (78 women) with TTM received 10 sessions (over 12 weeks) of either AEBT-TTM or PST. Independent evaluators masked to treatment assignment assessed participants at baseline (week 0), midpoint (week 6), and endpoint (week 12). Consistent with a priori hypotheses, 64% of the adults treated with AEBT-TTM were classified as clinical responders at post-treatment relative to 38% treated with PST. Clinical responders were identified by a score of 1 or 2 on the Clinical Global Impressions-Improvement (CGI-I) scale. Relative to the PST group, the AEBT-TTM group demonstrated significantly greater pre-to post-treatment reductions on the self-report Massachusetts General Hospital-Hairpulling Scale (MGH-HS) and the evaluator-rated National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS). There were no significant post-treatment group differences on the Clinical Global Impressions-Severity (CGI-S) scale, or rate of TTM diagnoses. Results suggest AEBT-TTM provides greater treatment benefit than PST. Future research should continue to investigate AEBT-TTM along with mediators and moderators of its efficacy.

Trichotillomania Prevalence in an Arab Middle Eastern Population.

Trichotillomania (TTM) (hair-pulling disorder) is a relatively rare psychiatric condition. We are aware of no studies of this disorder in Arab Middle Eastern populations. We examine the prevalence and correlates of TTM in a community sample of individuals living in a large port city in western Saudi Arabia. An observational cross-sectional study of 511 adults aged 18 years or over living in Jeddah, Saudi Arabia, was conducted. After inquiring about demographic information and self-reported psychiatric disorders, the Massachusetts General Hospital Hair-Pulling Scale (MGH-HPS) was administered to assess symptoms of TMM. A total of 9 of 511 participants (1.8%) scored above the cutoff for suspected TTM on the MGH-HPS, whereas 203 (39.7%) had a history of hair-pulling. Those with suspected TTM were more likely to be female (2.8% vs 0.4% in males, P = 0.047) and somewhat more likely to have a history of obsessive-compulsive disorder (OCD) (6.7% vs 1.5%, P = 0.093). Hair pulling was also more common in unmarried, not living with family, and unemployed. Among those with a history of hair-pulling, the most frequent locations were from the face (62.7%), head (55.7%), and legs (15.3%). While a history of hair-pulling is common in this community sample (40%), suspected TTM is much less prevalent (<2%), although not rare by any means. When present, the condition is more common in women and possibly in those with OCD.

Hair-Pulling Does Not Necessarily Serve an Emotion Regulation Function in Adults With Trichotillomania.

Background: Trichotillomania (TTM) has been associated with childhood trauma and perceived stress. While it has been hypothesized that hair-pulling regulate negative emotions, the relationship between childhood trauma, perceived stress, emotion regulation, and hair-pulling has not been well-studied.Methods: Fifty-six adults with TTM and 31 healthy controls completed the Childhood Trauma Questionnaire (CTQ), Perceived Stress Scale (PSS), and Difficulties in Emotion Regulation Scale (DERS). Hair-pulling severity was measured with the Massachusetts General Hospital-Hair Pulling Scale. CTQ, PSS, and DERS total scores were compared across groups using ANCOVA and the correlation between hair-pulling severity and emotion dysregulation was determined. Regression analyses were used to estimate the association of CTQ and PSS totals with DERS, and to determine whether associations between predictors and dependent variable (DERS) differed across groups.Results: TTM patients reported higher rates of childhood trauma (p <= 0.01), perceived stress (p = 0.03), and emotion dysregulation (p <= 0.01). There was no association between emotion dysregulation and pulling severity (r = −0.02, p = 0.89). Perceived stress was associated with emotion dysregulation in both groups (p < 0.01), and no association between childhood trauma and emotion dysregulation in either group. Perceived stress was the only significant predictor of emotion dysregulation in both groups (F = 28.29, p < 0.01).Conclusion: The association between perceived stress and emotion dysregulation is not specific to TTM, and there is no association between emotion dysregulation and hair-pulling severity, suggesting that key factors other than emotion dysregulation contribute to hair-pulling. Alternative explanatory models are needed.

ACT-enhanced group behavior therapy for trichotillomania and skin-picking disorder: A feasibility study.

To evaluate the feasibility and efficacy of ACT-enhanced Group Behavior Therapy (AEGBT) for mixed diagnosis groups including patients with trichotillomania (TTM) and skin-picking disorder (SPD) in routine psychiatric care. Adult patients (N = 40) with TTM and/or SPD received 10 weeks of AEGBT followed by five booster sessions. The primary outcome measure for TTM was the Massachusetts General Hospital Hairpulling Scale (MGH-HPS) and for SPD the Skin Picking Scale-Revised(SPS-R), assessed at posttreatment and at booster sessions. Results showed significant reductions in hair pulling and skin-picking severity from baseline to posttreatment and large effect sizes at posttreatment. Improvements remained significant at the 12-month follow-up for patients with SPD, but not for patients with TTM. Group attendance was high and few patients dropped out from treatment. The group format enabled therapists to see 25% more patients compared with an individual format. The results provide initial support for the feasibility and efficacy of an adapted treatment approach for TTM and SPD.

Massachusetts General Hospital Hairpulling Scale: Validity and Reliability Study of the Turkish Form.

The aim of this study is to analyze the validity and reliability of the Turkish form of Massachusetts General Hospital Hairpulling Scale (MGH-HPS), which is used to measure the severity of Trichotillomania (TTM). Fifty patients diagnosed with TTM according to the DSM-5 diagnostic criteria and fifty healthy controls participated in the study. The participants were asked to complete a sociodemographic questionnaire, the MGH-HPS-TR, the Clinical Global Impression (CGI), the Beck Depression Inventory (BDI), the Beck Anxiety Inventory (BAI) and the Barratt Impulsiveness Scale (BIS-11). The construct validity and the criterion validity of the MGH-HPS-TR were determined by means of exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), respectively. The reliability analysis of the MGH-HPS-TR was assessed by calculating the Cronbach's α coefficient and the item total correlation coefficient. The values for the area under the curve (AUC), sensitivity and specificity were based on the ROC analysis. AFA and CFA results indicated a single factor structure with 7 items explaining 82.5% of the variance. The item/factor loadings were satisfactory with the best fit indeces. Correlations were found between the scores on the MGH-HPS-TR and the other scales used for criterion validity analyses. The internal consistency and the item-total correlation coefficients of the scale were found to be satisfactory. Based on a cut of point of ≥ 9, the scale had high power for discriminating between the patient and the control groups and high sensitivity and specificity. This study showed that the MGH-HPS-TR can be used as a valid and reliable psychometric tool in Turkey.

Working memory training in adults with trichotillomania: A 5-week, single-blind, randomized controlled study

ObjectiveThis randomized controlled study investigated the effect of the Cogmed Working Memory Training (CWMT) program on hair-pulling severity and working memory in trichotillomania (TTM). Methods36 adults with TTM were assigned to CWMT or active control (25 sessions, 5 weeks). Data from intention-to-treat [ITT] (CWMT: N = 21; control: N = 15) and per-protocol (CWMT: N = 16; control: N = 13) samples were analyzed. The primary and secondary outcomes were the totals on the Massachusetts General Hospital Hair-Pulling Scale (MGH-HPS) and the Digit Span (Backward) subtest of the Wechsler Adult Intelligence Scale. Assessments occurred at baseline, at 5 weeks, and 3 months post-training. A mixed-model repeated measures ANOVA was done, with the interaction of group x time as primary effect of investigation. ResultsRegarding hair-pulling severity, the interaction effect of group x time was not significant (p = 0.27). Regarding working memory, there was a significant group × time interaction in favour of CWMT (p = 0.03), with improvement in working memory from baseline to 5 weeks (p < 0.001, LS mean difference −1.98). ConclusionsCWMT is not superior to active control in reducing hair-pulling. Working memory improved significantly over the short term with CWMT. The findings are a novel contribution to work on cognitive training effects on problematic repetitive behaviours.

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.

White matter volume alterations in hair-pulling disorder (trichotillomania).

Trichotillomania (TTM) is a disorder characterized by repetitive hair-pulling resulting in hair loss. Key processes affected in TTM comprise affective, cognitive, and motor functions. Emerging evidence suggests that brain matter aberrations in fronto-striatal and fronto-limbic brain networks and the cerebellum may characterize the pathophysiology of TTM. The aim of the present voxel-based morphometry (VBM) study was to evaluate whole brain grey and white matter volume alteration in TTM and its correlation with hair-pulling severity. High-resolution magnetic resonance imaging (3T) data were acquired from 29 TTM patients and 28 age-matched healthy controls (CTRLs). All TTM participants completed the Massachusetts General Hospital Hair-Pulling Scale (MGH-HPS) to assess illness/pulling severity. Using whole-brain VBM, between-group differences in regional brain volumes were measured. Additionally, within the TTM group, the relationship between MGH-HPS scores, illness duration and brain volumes were examined. All data were corrected for multiple comparisons using family-wise error (FWE) correction at p < 0.05. Patients with TTM showed larger white matter volumes in the parahippocampal gyrus and cerebellum compared to CTRLs. Estimated white matter volumes showed no significant association with illness duration or MGH-HPS total scores. No significant between-group differences were found for grey matter volumes. Our observations suggest regional alterations in cortico-limbic and cerebellar white matter in patients with TTM, which may underlie deficits in cognitive and affective processing. Such volumetric white matter changes may precipitate impaired cortico-cerebellar communication leading to a reduced ability to control hair pulling behavior.

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.

Trichotillomania: the impact of treatment history on the outcome of an Internet-based intervention.

BackgroundMany patients suffering from trichotillomania (TTM) have never undergone treatment. Without treatment, TTM often presents with a chronic course. Characteristics of TTM individuals who have never been treated (untreated) remain largely unknown. Whether treatment history impacts Internet-based interventions has not yet been investigated. We aimed to answer whether Internet-based interventions can reach untreated individuals and whether treatment history is associated with certain characteristics and impacts on the outcome of an Internet-based intervention.MethodsWe provided Internet-based interventions. Subjects were characterized at three time points using the Massachusetts General Hospital Hairpulling Scale, Hamilton Depression Rating Scale, and the World Health Organization Quality of Life questionnaire.ResultsOf 105 individuals, 34 were untreated. Health-related quality of life (HRQoL) was markedly impaired in untreated and treated individuals. Symptom severity did not differ between untreated and treated individuals. Nontreatment was associated with fewer depressive symptoms (P=0.002). Treatment history demonstrated no impact on the outcome of Internet-based interventions.ConclusionResults demonstrate that Internet-based interventions can reach untreated TTM individuals. They show that untreated individuals benefit as much as treated individuals from such interventions. Future Internet-based interventions should focus on how to best reach/support untreated individuals with TTM. Additionally, future studies may examine whether Internet-based interventions can reach and help untreated individuals suffering from other psychiatric disorders.

Preliminary Randomized Controlled Trial of Habit Reversal Training for Treatment of Hair Pulling in Youth.

This study evaluated the treatment efficacy of habit reversal training (HRT) relative to treatment as usual (TAU) for children and adolescents aged 7-17 years with a primary diagnosis of trichotillomania (TTM). An initial assessment consisting of semistructured interviews and rating scales was conducted. Participants (N = 40, 85% female) meeting diagnostic criteria for TTM were randomized to either 8 weekly sessions of HRT by trained therapists or 8 weeks of TAU. One week after the final HRT session or final TAU week, patients completed a posttreatment assessment, followed by 1- and 3-month follow-up assessments. All assessments were conducted by a trained rater who was blinded to treatment condition. The group by time analysis of variance yielded a significant interaction on the National Institute of Mental Health-Trichotillomania Severity Scale Total Score (F1,38 = 16.47, p < 0.001, η2p = 0.30). The mean score decreased from 12.67 ± 4.60 at baseline to 5.62 ± 4.38 at posttreatment in the HRT group (t20 = 5.99, p < 0.001, d = 1.31), whereas the TAU group changed from 10.42 ± 4.35 to 9.32 ± 4.11 (t18 = 1.34, p = 0.20, d = 0.31). The Massachusetts General Hospital-Hair Pulling Scale Total Score decreased from 15.14 ± 3.86 at baseline to 7.14 ± 5.54 at posttreatment in the HRT group (t20 = 6.16, p < 0.001, d = 1.34); the TAU group changed from 14.16 ± 4.51 to 12.26 ± 4.34 (t18 = 1.50, p = 0.15, d = 0.34). On the Clinical Global Impressions-Improvement, 16/21 participants (76%) were rated as treatment responders in the HRT group versus 4/19 (21%) in the TAU group (χ2 = 12.13, p < 0.001, V = 0.55). At 1-month follow-up, 10-12 treatment responders who completed the assessment maintained improvement. At 3-month follow-up, six of eight maintained improvement. HRT can be an effective treatment for TTM in youth.

Affective regulation in trichotillomania before and after self-help interventions

ObjectiveTrichotillomania (TTM) is characterized by recurrent hair-pulling behaviours that cause significant distress. Deficits in affective regulation have been reported in individuals with TTM. We aimed to investigate temporal stability of affective regulation in TTM individuals. MethodsEighty-one TTM individuals underwent an online intervention. Affective Regulation Scale (ARS), Massachusetts General Hospital Hair-Pulling Scale (MGH-HPS), and Beck Depression Inventory (BDI) scores were obtained at baseline, post-treatment (4 weeks), and follow-up (6 months). We examined the effect of phenotypes including hair-pulling severity and depressive symptoms on absolute and relative stability of affective regulation over time, using multiple linear and hierarchical regression analyses. ResultsThe ARS total-score from the present TTM sample was significantly lower than the score from non-hair pullers (p < 0.001). ARS total-scores inversely correlated with the MGH-HPS total-scores at baseline (p = 0.001) and post-treatment (p = 0.02), and with BDI total-scores at all time-points (p < 0.001). Although ARS total-scores significantly increased, all ARS sub-scores, except guilt sub-scores, did not change over time, indicating absolute stability. Baseline ARS total-, and sub-scores (except tension) were found to predict their ARS follow-up scores (all p < 0.01), confirming relative stability (i.e., the extent to which the inter-individual differences remained the same over time). The relative stability of ARS total-scores and all but two sub-scores (irritability and guilt) were independent from BDI baseline scores. ConclusionsIndividuals with TTM reported deficits in affective regulation that demonstrated mostly high relative stability and partly absolute stability. Therefore, targeting to improve affective regulation in individuals with TTM during therapy is warranted.

Defining treatment response in trichotillomania: a signal detection analysis

The Massachusetts General Hospital Hairpulling Scale (MGH-HPS) and the NIMH Trichotillomania Severity Scale (NIMH-TSS) are two widely used measures of trichotillomania severity. Despite their popular use, currently no empirically-supported guidelines exist to determine the degrees of change on these scales that best indicate treatment response. Determination of such criteria could aid in clinical decision-making by defining clinically significant treatment response/recovery and producing accurate power analyses for use in clinical trials research. Adults with trichotillomania (N=69) participated in a randomized controlled trial of psychotherapy and were assessed before and after treatment. Response status was measured via the Clinical Global Impressions-Improvement Scale, and remission status was measured via the Clinical Global Impressions-Severity Scale. For treatment response, a 45% reduction or 7-point raw score change on the MGH-HPS was the best indicator of clinically significant treatment response, and on the NIMH-TSS, a 30–40% reduction or 6-point raw score difference was most effective cutoff. For disorder remission, a 55–60% reduction or 7-point raw score change on the MGH-HPS was the best predictor, and on the NIMH-TSS, a 65% reduction or 6-point raw score change was the best indicator of disorder remission. Implications of these findings are discussed.

Internet-Based Self-Help for Trichotillomania: A Randomized Controlled Study Comparing Decoupling and Progressive Muscle Relaxation

Background: Trichotillomania (TTM) is characterized by recurrent hair-pulling that results in substantial hair loss. A previous pilot study demonstrated that the online self-help intervention ‘decoupling' (DC) might be effective at reducing hair-pulling symptoms, with a stronger effect than progressive muscle relaxation (PMR). We aimed to extend these findings using a more robust randomized clinical trial design, including diagnostic interviews by phone, a 6-month follow-up and e-mail support. Methods: One hundred five adults with TTM were recruited online and randomly allocated to either DC (n = 55) or PMR (n = 50). The intervention lasted 4 weeks, with severity of TTM assessed at 3 time points (before intervention, immediately after intervention and at the 6-month follow-up) using the Massachusetts General Hospital Hair-Pulling Scale (MGH-HPS). Both intention-to-treat and completer analyses were conducted. Results: Intention-to-treat analysis demonstrated highly significant and comparable symptom reductions (MGH-HPS) in both the DC and PMR groups (p < 0.001, partial η² = 0.31) that persisted through 6 months of follow-up. Participants' subjective appraisals favoured DC in some areas (e.g. greater satisfaction with DC than PMR). Completer analyses demonstrated the same pattern as the intention-to-treat analyses. Conclusions: Despite subjective appraisals in favour of DC, symptom reduction was comparable in the two groups. While the results suggest that even short Internet-based interventions like DC and PMR potentially help individuals with TTM, a partial effect of unspecific factors, like regression towards the mean, cannot be ruled out. Therefore, longitudinal studies with non-treated controls are warranted.

Cognitive flexibility differentiates young adults exhibiting obsessive-compulsive behaviors from controls

The National Institute of Mental Health has proposed a shift toward classifying clusters of disorders on the basis of underlying biomarkers and neurological correlates. The present study sought to determine whether cognitive flexibility represents one such construct underlying obsessive-compulsive behaviors (OCBs), a cluster of behaviors characteristic of OCD and other body-focused repetitive behaviors (BFRBs), including trichotillomania, pathological skin picking, nail biting, and tic disorders. One-hundred and twenty-four undergraduate students completed the Depression Anxiety and Stress Scales, Padua Inventory—Washington State University Revision, Massachusetts General Hospital—Hairpulling Scale, Skin Picking Scale, and an Intradimensional/Extradimensional Shift (IDED) Test. Analyses were performed using a subsample of participants who met criteria for inclusion in the OCB group and a control group (N=56). Results indicated that young adults in the OCB group demonstrated significantly poorer performance on the IDED compared to controls. However, hierarchical regression analyses revealed that increased deficits in cognitive flexibility failed to predict worsened OCB severity—as assessed via a composite score. These results suggest that while cognitive flexibility differentiates those exhibiting OCBs from controls, it does not appear to be related to OCB severity. Future research is needed to replicate these results in larger clinical samples.