Styles of pulling in youths with trichotillomania: exploring differences in symptom severity, phenomenology, and comorbid psychiatric symptoms

To date, no studies have examined possible phenomenological differences between the automatic and focused styles of pulling in youths with TTM. The aims of the current study were to examine differences in TTM severity, phenomenology, comorbid psychiatric symptoms, and functional impact across youths with varying degrees of these pulling styles. Youths between the ages of 10 and 17 years (and their parent) were recruited via an Internet-based survey. A total of 186 youths with chronic hair pulling was classified as “high-focused” or “low-focused” and either “high-automatic” or “low-automatic” based upon scores obtained on the Milwaukee Inventory for Styles of Trichotillomania-Child Version (MIST-C) using a median-split procedure. Results demonstrated significant differences between pulling styles. More specifically, “high-focused” pullers reported more severe TTM and greater symptoms of anxiety and depression than “low-focused” pullers, and “high-automatic” pullers reported greater symptoms of depression than “low-automatic” pullers. Subsequent analyses suggest that, in comparison to youths with low levels of both automatic and focused pulling, those experiencing high levels of focused pulling but low levels of automatic pulling reported phenomenological differences and were more likely to engage in additional repetitive behaviors (i.e., skin picking, lip/cheek biting). Clinical and research implications, study limitations, and future areas of research are discussed.     

The Milwaukee Inventory for Subtypes of Trichotillomania-Adult Version (MIST-A): Development of an Instrument for the Assessment of “Focused” and “Automatic” Hair Pulling

This article describes the development of the Milwaukee Inventory for Subtypes of Trichotillomania-Adult Version (MIST-A), which was designed to assess “automatic” and “focused” pulling subtypes of trichotillomania (TTM). Participants reporting symptoms of TTM (n = 1,697) completed an internet survey; participants were later randomly assigned to either Exploratory (n = 848) or Confirmatory (n = 849) Analyses. Exploratory Analyses examined the development and psychometric properties of the MIST-A. Results of an exploratory factor analysis revealed a two-factor solution. Factor 1 (“focused” pulling scale) and 2 (“automatic” pulling scale) consisted of ten and five items respectively, with both scales demonstrating adequate internal consistency and good construct and discriminant validity. Subsequent confirmatory factor analysis demonstrated support for the scale’s underlying factor structure. The MIST-A provides researchers with a reliable and valid assessment of “automatic” and “focused” pulling, although replication using a clinically ascertained sample is necessary.

Affective regulation in trichotillomania: Evidence from a large-scale internet survey

Trichotillomania (TTM), a repetitive hair-pulling disorder, is underrepresented in the clinical literature. The current project explores the relationship between affective regulation and disordered hair-pulling. Previous research suggests that cycles of emotional states are correlated with the disorder and may induce, reinforce, or otherwise contribute to hair-pulling behavior. We use anonymous internet survey responses from 1162 self-identified hair-pullers to address four questions about affective regulation in people with TTM: (1) Do hair-pullers experience greater difficulty “snapping out” of affective states than non-pullers? (2) Does difficulty with emotional control correlate with TTM severity? (3) Are subtypes identifiable based on the emotions that trigger hair-pulling behavior? (4) Does difficulty “snapping out” of an emotion predict whether that emotion triggers pulling behavior? The results showed a small-to-moderate relationship between affective regulation and problematic hair-pulling. In addition, individual patterns of emotion regulation were systematically related to emotional cues for hair-pulling as well as overall hair-pulling severity. These findings contribute to an understanding of the phenomenology of TTM and provide empirical support for treatments focused on affect regulation.     

Parent-Youth Rating Concordance for Hair Pulling Variables,Functional Impairment,and Anxiety Scale Scores in Trichotillomania

ABSTRACT

Knowledge of cross-informant rating concordance is critical for the assessment of child and adolescent problems in clinical and research settings. We explored parent-youth rating concordance for hair pulling variables, functional impairment, and anxiety symptoms in a sample of child and adolescent hair pullers (n = 133) satisfying conservative diagnostic criteria for trichotillomania (TTM). Whole group analyses reveal significant parent-youth agreement on all study variables. Split group analyses, however, reveal superior parent-youth concordance for the adolescent (15–17 years old) versus younger (10–12 years old) hair pullers for awareness of hair pulling and anxiety scale scores. These results highlight the need for both parent and youth ratings when assessing younger children with TTM.     

The Phenomenology of Hairpulling in College Students

This study examined the phenomenology of hairpulling in a large nonclinical college student sample. Given that hairpulling is conceptualized as occurring on a continuum of severity, we expected to inform the assessment and treatment of Trichotillomania (TTM) by examining hairpulling behavior across its range of presentation. Hairpulling occurred at a rate of 9.7%, while average age of onset was 13.57 years. Self-reported hairpulling styles were identified with 31.3% endorsing focused hairpulling, while 68.7% endorsed an automatic hairpulling style. The most commonly endorsed ritual was “examine the root (37.3%) while the scalp was the most frequently endorsed hairpulling site (49%). Eyelashes were more frequently endorsed as a pulling site by focused (43.8) compared to automatic (5.7%) hairpullers. The hairpulling environments most often endorsed were “while reading” and “while studying” (75%). Affective states were found to change across the pulling cycle in support of hairpulling serving in an emotion regulation capacity. Focused hairpullers endorsed significantly higher trait anxiety than automatic hairpullers. Depression scores (BDI) were elevated for hairpullers compared to non-hairpullers. Implications for assessment and treatment were discussed and directions for future research were provided.     

The Influence of Hair Pulling Styles in the Treatment of Trichotillomania

This report investigated the improvement in Automatic and Focused styles of hair pulling among youth with trichotillomania (TTM). Youth with TTM (N = 40) participated in a clinical trial that compared habit reversal training (HRT) to treatment-as-usual (TAU). Participants completed a baseline assessment to characterize hair pulling severity, self-reported hair pulling styles, and co-occurring psychiatric conditions. Youth were randomly assigned to receive eight weekly sessions of HRT or eight weeks of TAU. Afterward, youth completed a post-treatment assessment of hair pulling severity and hair pulling styles. Youth in the TAU condition then received eight weekly sessions of HRT and completed another post-treatment assessment. Analyses revealed that the Focused pulling style largely improved with HRT (d = 0.73) compared to TAU (d = 0.11). However, there was limited improvement for the Automatic pulling style following either HRT (d = 0.10) or TAU (d = -0.31). This same pattern of effects was also found during open-label treatment with HRT. Although behavior therapies such as HRT are the principle treatment for youth with TTM, the Automatic pulling style exhibited limited improvement to this therapeutic approach. Therefore, therapeutic strategies that enhance awareness to pulling behaviors may produce more robust outcomes to behavior therapy for youth with TTM.     

Trichotillomania: impact on psychosocial functioning and quality of life

This study explored the impact of hair pulling on psychosocial functioning for patients diagnosed with trichotillomania (TTM; n = 28). TTM patients were compared to age and gender-matched groups of psychiatric patients without TTM (n = 28) and nonpsychiatric control volunteers (NC, n = 28) on measures of psychological distress, functioning/quality of life, and self-esteem. Results indicated that TTM patients reported more severe psychosocial impairments than did NC volunteers; however, these differences were mediated by differences in level of depression. Regression analyses indicated significant relationships between some measures of psychosocial functioning and severity of hair pulling, independent of level of depression. Finally, an interview of the impact of hair pulling on 6 domains of daily functioning (negative affect/negative self-evaluations, grooming, recreational activities, social interaction, work/housework productivity, and physical health) indicated common and wide-ranging impairments for both lifetime and current (i.e., past week) ratings. These results highlight the importance of promoting and improving resources for the clinical care of TTM patients, and provide some directions for clinicians to enhance assessment of interference caused by TTM.     

Assessment of Trichotillomania: A Psychometric Evaluation of Hair-Pulling Scales

Currently there is no gold standard treatment outcome measure for trichotillomania (TTM), a disorder characterized by repetitive hair pulling resulting in noticeable hair loss. The goal of the current study was to evaluate the psychometric properties of TTM measures of differing assessment methods: self-report, clinician-rated summary scales, and clinician-rated global severity scales. Data collected from 28 patients with TTM indicated mixed psychometric properties for current scales. Internal consistency was strong for self-report but not clinician-rated summary scales. One clinician-rated summary scale total and subjective ratings of hair loss demonstrated good interrater agreement. Although convergent validity was good within measurement type, self-report did not correlate with clinician-rated global severity scales, perhaps because of absence of hair loss severity assessment on the self-report measure. A multimethod assessment including one of each type of measure reviewed in this paper, along with self-monitoring and measures of hair loss severity, is recommended for a comprehensive best practice approach to TTM assessment.     

DBT-Enhanced Cognitive Behavioral Therapy for Adolescent Trichotillomania: An Adolescent Case Study

Results and a case study for a DBT-enhanced habit reversal treatment (HRT) for adult trichotillomania (TTM) (Keuthen & Sprich, 2012) is adapted for use with adolescents. Trichotillomania in adolescence is a very important but understudied problem. Onset often occurs in adolescence, and yet very little treatment research exists. DBT-enhanced habit reversal has shown promise in adult samples (Keuthen et al., 2008) and may prove useful as a model for further study in adolescents. Here, we provide a case study using DBT-enhanced HRT with an adolescent girl. The treatment emphasizes traditional CBT for TTM and also includes a focus on emotion regulation, mindfulness, and distress tolerance to help manage both focused and automatic pulling.     

A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania

This randomized trial compared a combined Acceptance and Commitment Therapy/Habit Reversal Training (ACT/HRT) to a waitlist control in the treatment of adults with trichotillomania (TTM). Twenty-five participants (12 treatment and 13 waitlist) completed the trial. Results demonstrated a significant reduction in hair pulling severity, impairment ratings, and hairs pulled, along with significant reductions in experiential avoidance and both anxiety and depressive symptoms in the ACT/HRT group compared to the waitlist control. Reductions generally were maintained at a 3-month follow-up. Decreases in experiential avoidance and greater treatment compliance were significantly correlated with reductions in TTM severity, implying that targeting experiential avoidance may be useful in the treatment of TTM. Other implications and suggestions for future research are noted.     

The social and economic impact of trichotillomania: results from two nonreferred samples

Behavior therapy has been widely used as a treatment for trichotillomania. However, behavioral treatments for TTM have tended to focus on behavior reduction, while not paying as much attention to social and economic impact. The current study sought to clarify the social and economic impact of Trichotillomania (TTM) in two samples of persons with TTM. Members of the first sample attended a TTM patient conference (N = 36) and members of the second responded to an online survey (N = 381). Both samples completed self‐report measures that examined the impact of TTM on avoiding activities and relationships, as well as financial costs. Results indicated that both groups reported similar amounts of avoidance in social situations, sought help from multiple health professionals, spent considerable time engaged in hair pulling activities, and had interference in both work and school. The study suggests a number of ways to decrease the negative impact of TTM. Copyright © 2006 John Wiley & Sons, Ltd.     

StopPulling.com: An Interactive, Self-Help Program for Trichotillomania

Despite the widespread nature and significant impact of trichotillomania (TTM), relatively few controlled studies have evaluated treatment options for people with this disorder. Pharmacological treatment and behavior therapy are the two most widely accepted approaches to treating TTM, but few mental health professionals with appropriate expertise are available to provide care. The cost of treatment also is prohibitive in some cases. A number of self-help books are available for people with TTM, but no empirical data have documented associated outcomes. This paper describes the development and two phases of program evaluation for an alternative, Internet-based self-help treatment strategy for repetitive hair pulling. StopPulling.com is an on-line, interactive self-help approach derived from evidence-based cognitive behavioral models of treatment for TTM. Following program development, an initial test phase elicited feedback from individuals with repetitive hair pulling and professionals with expertise in the treatment of TTM or Web site development. StopPulling.com was modified in accordance with feedback from this initial test phase, and a revised version was made available to the public in January 2003. Preliminary data from 265 users of the program during the first year of public availability suggested significant improvement in symptoms, with some evidence that duration of program use accounted for reductions in symptom severity. Response rates were comparable to long-term follow-up after more intense cognitive behavioral treatment. StopPulling.com may provide a potentially useful self-help alternative or adjunctive strategy for repetitive hair pulling.     

Subtyping eating disordered patients along drive for thinness and depression

Subtyping individuals who binge eat by “diet-DT” and “depression” has yielded two valid and clinically useful subtypes that predict eating severity, comorbid psychopathology and outcome. The present study aimed to find four subtypes based on these dimensions and test their validity. Besides, it explored the distribution of eating disorder (ED) diagnoses across subtypes given their known heterogeneity, crossover and binge-eating fluctuation.Cluster analysis grouped 1005 consecutively admitted ED adult women into four subtypes, those previously described “DT” (22%), “DT-depressive” (29%), and “mild DT” (25%) and “depressive-moderate DT” (24%). Overall “mild DT” presented lower and “DT-depressive” greater eating and comorbid psychopathology than the rest, whereas “pure DT” and “depressive-moderate DT” presented no differences on bulimic symptoms but in psychopathology (p < .01). Finally, while BN-P patients were mostly and similarly distributed in the “DT” and “DT-depressive” subtypes than in the other, AN were in the new “mild DT” and “depressive-moderate DT” (p < .01). However, BN-NP, BED and EDNOS were similarly represented across subtypes.Results are discussed with regard to 1) the newly emerged subtypes that may explain cases in which DT prevents or does not predict binge eating; 2) the confluence of DT-depression that signaled greater eating and comorbid pathology, particularly self-control problems; 3) ED-DSM-diagnostic criteria.     

Questions as Interventions: Perceptions of Socratic, Solution Focused, and Diagnostic Questioning Styles

A videotaped psychotherapy analogue compared psychology trainees' (n = 67) and undergraduate non-therapists' (n = 115) perceptions of three theoretically derived questioning styles: Socratic disputation in Rational Emotive Behavior Therapy (REBT), solution focused questioning (e.g. the miracle question), and diagnostic interviewing. Non-therapists rated REBT and diagnostic styles more highly than psychology trainees. All subjects rated solution focused questioning more highly than both other styles, perceiving it as more collaborative and conducive to the client's independent thinking. The constructs of collaborative empiricism and solution focused cooperation are discussed in relation to findings. The study also compared psychology trainees' and non-therapists' Big Five personality profiles, a topic which has not previously been addressed in the literature. Psychology trainees were higher in Big Five Openness and Agreeableness than non-therapists. Openness was negatively associated with ratings for solution focused and diagnostic questioning styles, replicating findings of previous analogue studies, in which undergraduate subjects preferred straightforward approaches to therapy.     

Exploring the impact of social judgeability concerns on the interplay of associative and deliberative attitude processes

Some recent research applying dual-systems logic suggests that different attitude measures reflect independent modes of evaluation with explicit measures primarily affected by deliberative processes and implicit measures primarily affected by automatic processes. In the current work we hypothesized that explicit attitude measures often do not reflect the outcome of automatic or associative processing because social judgeability concerns prevent people from reporting consciously inexplicable “gut feelings” towards the attitude object. To explore this possibility, we simultaneously presented participants with associative and deliberative information about a target person and manipulated their sensitivity to social judgeability concerns with different sets of task instructions. Although an explicit attitude measure was unaffected by subliminally presented associative information following a standard instruction set, this content did impact explicit judgments when social judgeability concerns were assuaged with a “go with your gut” instruction set.     

Negational racial identity and presidential voting preferences

Previous research suggests that narrow identification with one’s own racial group impedes coalition building among minorities. Consistent with this research, the 2008 Democratic primary was marked by racial differences in voting preferences: Black voters overwhelmingly preferred Barack Obama, a Black candidate, and Latinos and Asians largely favored Hillary Clinton, a White candidate. We investigated one approach to overcoming this divide: highlighting one’s negational identity. In two experiments simulating primary polling procedures, Asians and Latinos randomly assigned to think of and categorize themselves in negational terms (i.e., being non-White) were more likely to vote for Obama than participants focused on their affirmational identity (i.e, being Asian or Latino), who showed the typical preference for Clinton. This shift in voting preference was partially mediated by warmer attitudes towards other minority groups. These results suggest that negational identity is a meaningful source of social identity and demonstrate that whether one thinks about “who one is” versus “who one is not” has far-reaching impact for real-world decisions.     

La psychologie contemporaine des « traits » dans le cadre de la recherche néogaltonienne : comment elle est censée fonctionner et pourquoi en réalité elle ne fonctionne pas

For its epistemic integrity as a framework for scientific personality studies, contemporary trait psychology requires the assumption that aggregate statistical patterns gleaned from correlational studies of individual differences constitute an epistemic “window” onto what is transpiring with the individuals comprising that aggregate. This assumption is the cornerstone of the “neogaltonian” paradigm for psychological research (Danziger, 1987) in terms of which Cronbach (1957) famously called for a merger of scientific psychology's experimental and the correlational disciplines. In the present contribution, this perspective on personality studies is submitted to close critical scrutiny and shown to be scientifically untenable. It is argued that a viable science of personality will be one focused on persons and not on individual differences variables.     

The embodied cognition theory and the motor component of “yes” and “no” verbal responses

Most of the experiments which give theories of embodied cognition their empirical anchorage only take into consideration the motor responses induced by the task or the motor component of the visual stimulus. And yet, these motor responses are often associated with a linguistic answer. Our hypothesis is that “YES” and “NO” verbal responses have a motor component. In a first experiment we showed that producing a verbal response (YES vs. NO) involves motor planning (pushing vs. pulling): participants push a lever more quickly when they have to answer “yes” than “no”, and conversely, they pull a lever more quickly when they have to answer “no” than “yes”. Moreover, in a second experiment, we showed that perceiving the words “YES” and “NO”, on its own, leads to the same motor planning than when “yes” and “no” answers actually have to be produced. Participants detect the word “YES” faster when they have to push a lever than when they have to pull it and conversely they detect the word “NO” faster when they have to pull the lever than when they have to push it down. These results are discussed in reference to “online” and “offline embodiment” concepts and to the cognitive linguistic theories.     

Acceptance-Enhanced Behavior Therapy for Trichotillomania in Adolescents

Although several studies have examined the efficacy of Acceptance Enhanced Behavior Therapy (AEBT) for the treatment of trichotillomania (TTM) in adults, data are limited with respect to the treatment of adolescents. Our case series illustrates the use of AEBT for TTM in the treatment of two adolescents. The AEBT protocol (Woods & Twohig, 2008) is a structured treatment manual that was adapted to the individual clients’ needs and clinical progress. Both clients reported clinically significant gains in treatment as determined by at least 2 weeks of abstinence from pulling, and subjective reports of decreased distress and impairment, although one required a booster session due to relapse. AEBT is worth further exploration as a treatment for adolescents with TTM.     

Three ways to resist temptation: The independent contributions of executive attention, inhibitory control, and affect regulation to the impulse control of eating behavior

It is generally assumed that impulse control plays a major role in many areas of self-regulation such as eating behavior. However, the exact mechanisms that enable the control of impulsive determinants such as automatic affective reactions toward tempting stimuli are not well understood. “The present research investigated the separate moderator effects of three factors of impulse control, executive attention, inhibitory control, and affect regulation on the relationship between automatic affective reactions toward candy and subsequent candy consumption.” Results showed that all three factors reduced the influence of automatic affective reactions on eating behavior, indicating improved impulse control. Implications for self-regulation research are discussed.