Reducing Trichotillomania in a Three-Year-Old Girl

The frequent hair pulling by a three-year-old girl was targeted in the current study. After a baseline period, the child's parents instituted a treatment program which included hugs and praise for periods of not pulling, a loud “No,” for movements toward her hair, and “No,” with holding her arms to her side for 15-20 seconds for pulling. Immediate reductions in hair pulling were obtained. A delayed consequences procedure was instituted in order to reduce hair pulling that did not occur in the parent's presence. Follow-up indicates maintenance f reduced hair pulling for 12 months following the completion of treatment.     

Hair pulling in African Americans--only your hairdresser knows for sure: an exploratory study

The authors examined whether African American hair care professionals saw individuals who met general criteria for trichotillomania, chronic hair pulling that results in significant hair loss. Thirty-eight African American hair care professionals and 1 Caucasian hair care professional were interviewed about their customers' hair-pulling behavior and condition of their hair. Sixteen African American hair care professionals saw 21 individuals who met general criteria for trichotillomania and reportedly perceived the behavior to be problematic. Four African American hair care professionals saw 6 individuals who met general criteria for trichotillomania but did not reportedly perceive the behavior to be problematic. Hair care professionals attributed most customers' hair-pulling behavior to bad nerves, stress, habit, and worry. Hair care professionals appeared adept at treating the consequences of chronic hair pulling but offered little assistance for the actual pulling behavior. Hair care professionals' contact with individuals who engage in chronic hair pulling raises interesting implications for prevention.     

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.     

Evaluation of an awareness enhancement device for the treatment of thumb sucking in children

An evaluation of the awareness enhancement device (AED) described by Rapp, Miltenberger, and Long (1998) was conducted with 2 children who engaged in thumb sucking past the age at which it was developmentally appropriate. The AED effectively suppressed thumb sucking for both children. Future research evaluating the AED is discussed.     

Functional analysis and treatment of hair twirling in a young child.

A young child participated in a functional analysis and treatment of hair twirling, a frequently occurring precursor to hair pulling. The functional analysis showed that hair twirling occurred mostly when the child was alone at bedtime. Noncontingent application of mittens decreased hair twirling to near‐zero levels in two settings (home and day care).     

Affective correlates of trichotillomania

Affective correlates of hair pulling were investigated in a sample of 44 participants diagnosed with trichotillomania (TM). Participants completed the Hair Pulling Survey on which they rated the intensity of ten different affective states across three different phases of hair pulling (before, during and after). Repeated measures analysis of variance was used to examine the change of emotional experience across the hair pulling cycle. Results indicated significant decreases in boredom, anxiety and tension, and significant increases in guilt relief, sadness and anger across time (p<0.005). The role of co-existent anxiety and mood disorders also was examined using repeated measures analysis of variance. Results of these analyses indicated that patients with and without co-existent disorders differed only on patterns of anger across time, and therefore do not support affective subtypes of TM patients based on co-existent diagnosis. Implications of these findings for conceptualization and treatment of TM are discussed.     

Pediatric trichotillomania: descriptive psychopathology and an open trial of cognitive behavioral therapy

In study 1, 46 children and adolescents with trichotillomania who sought treatment at 2 specialty outpatient clinics were assessed. Most children reported pulling hair from multiple sites on the body, presented with readily visible alopecia, reported spending 30-60 minutes per day pulling or thinking about pulling, and reported experiencing significant distress about their symptoms. Most were described by their parents as having significant problems in school functioning. Few children met criteria for obsessive-compulsive disorder or tic disorder. Child and family rates of other forms of psychopathology were high. In study 2, 22 of these children were enrolled in an open trial of individual cognitive behavioral therapy with particular attention to relapse prevention. Trichotillomania severity decreased significantly and 77% of children were classified as treatment responders at post-treatment and 64% at 6-month follow-up.     

A FUNCTIONAL ANALYSIS OF HAIR PULLING

We experimentally assessed the functions of hair pulling and hair manipulation of a 19-year-old woman (Kris) with moderate mental retardation and cerebral palsy. In Phase 1 a functional analysis revealed that Kris pulled and manipulated hair for the greatest amount of time in the alone condition, suggesting that the behaviors were maintained by some form of automatic reinforcement (Vaughan & Michael, 1982). In Phase 2 we assessed the nature of the sensory stimulation that maintained hair pulling by providing continuous access to previously pulled or cut hair and, thereafter, by having Kris wear a rubber glove. The results suggested that hair pulling was maintained by digital-tactile stimulation (automatic positive reinforcement). These findings are discussed, and recommendations for further analyses of automatically reinforced habit behaviors are provided.     

AUGMENTING SIMPLIFIED HABIT REVERSAL WITH AN AWARENESS ENHANCEMENT DEVICE: PRELIMINARY FINDINGS

The chronic hair pulling of a 36-year-old woman with moderate mental retardation was initially treated with a simplified habit-reversal (SHR) procedure that consisted of awareness training, competing response training, and social support. When SHR did not produce large and sustained reductions in hair pulling, an awareness enhancement device was added, and it reduced hair pulling to near-zero levels in two settings. The results are discussed, and directions for future research with this device are provided.     

Trichotillomania: Identification and Treatment

Trichotillomania is a disorder distinguished by recurrent hair pulling resulting in hair loss ( American Psychiatric Association, 2000 ). This review of the literature provides a broad overview of the disorder so that counselors can better understand, describe, identify, and implement effective treatment for clients with trichotillomania. Phenomenology, impairment, etiology, multicultural considerations, differentiation, comorbidity, and current treatment approaches are presented.     

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.     

Cognitive–Behavior Therapy for Pediatric Trichotillomania

Trichotillomania (TTM) is a chronic disorder in which youth repeatedly pull their hair to the extent that they experience noticeable hair loss as well as clinically significant academic, social, and/or occupational impairment. Prevalence rates of TTM in children are largely unknown, although the onset of TTM primarily occurs in childhood. Modified habit reversal training is the current psychological treatment of choice for TTM in adults and researchers and clinicians have applied this approach to the treatment of pediatric TTM. This article describes cognitive–behavior therapy for pediatric TTM, with an emphasis on the application of standard interventions across the developmental age range. In particular, recent findings on the role of experiential avoidance in TTM and the manner with which the type of hair pulling changes across the developmental age range, recommends the flexible principle-driven application of treatment strategies with careful consideration of the developmental age of youth.     

Hair Pulling Behavior Reported by African American and Non-African American College Students

Of the few attempts to determine the prevalence rate of trichotillomania, virtually none have investigated potential ethnic differences. The present study provides data on the prevalence of hair twirling and hair pulling behavior among 176 African American and 422 non-African American students and systematically explores differences between these 2 groups. Fully 10.2% of the sample reported hair pulling that resulted in noticeable hair loss, with African American women reporting the highest rate (15.7%). Overall, 2% of participants responded consistently with Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000) criteria for trichotillomania; rates did not differ significantly among genders or ethnic backgrounds. African Americans, and especially African American women, were more likely than other participants to report hair pulling in response to skin irritation. Results are discussed in the context of previous research, the importance of hair care in the African American community, and directions for future research.     

Approach-avoidance,attentional and evaluation biases in hair pulling disorder and their relationship with symptom severity

The present study examined approach-avoidance, attentional and evaluation biases in Hair Pulling Disorder (HPD). Although none of the tasks showed indications of biased action tendencies in response to hair pulling-related pictures, or biased attention for hair pulling-related words, we found that patients were slower to react to hair pulling-related stimuli than to neutral stimuli. This slowing down may indicate that patients are ambivalent towards hair pulling. This “ambivalence” positively correlated with HPD symptom severity, but only on one of the three severity measures we assessed. Concerning action tendencies towards hair pulling-related words, patients were, however, faster to react to hair pulling-related words when compared to words related to resisting hair pulling. Future research is needed to disentangle this ambivalent response pattern in HPD.     

Prototype awareness enhancing and monitoring device for trichotillomania

Trichotillomania is an impairing condition that involves repetitive hair pulling. Habit reversal therapy is helpful for many persons with this disorder. Unfortunately, habit reversal therapy is not helpful for everyone and maintenance of gains is often problematic. Successful habit reversal therapy requires the individual to be aware of hair pulling and handling. Unfortunately, most people with trichotillomania report that much of their plucking occurs outside of awareness. Monitoring of trichotillomania behaviors is also problematic. The present project involved a pilot study of a prototype awareness enhancing and monitoring device aimed at increasing the effectiveness of habit reversal therapy. The device included a watch, bracelet, magnetic necklace, and a pager that was hard-wired for remote activation of a vibrating alert when hair pulling behaviors occurred. Following structured diagnostic assessment, three female participants were randomly assigned to be initially observed for varied lengths of time without the device followed by observation with the device in place. The results indicated a marked reduction in trichotillomania behaviors when the device was in place. Semi-structured interviews revealed that the device was very effective in enhancing awareness and monitoring of trichotillomania related behaviors and enthusiastic acceptance of the device was provided by all participants.     

Trichotillomania (hair pulling) in toddlers

Although the clinical diagnosis of trichotillomania has been observed for more than a century, not until the last decade has there been a focus on this diagnosis in early childhood. This small case series focuses on the clinical evaluation of 10 toddlers, average of 26 mo., presenting at a specialty child and adolescent psychiatry clinic with hair pulling. Authors suggest that hair pulling in this age group might better be conceptualized as an anxiety disorder.     

Photographic Assessment of Change in Trichotillomania: Psychometric Properties and Variables Influencing Interpretation

Although photographic assessment has been found to be reliable in assessing hair loss in Trichotillomania, the validity of this method is unclear, particularly for gauging progress in treatment. The current study evaluated the psychometric properties of photographic assessment of change in Trichotillomania. Photographs showing hair loss of adults with Trichotillomania were taken before and after participating in a clinical trial for the condition. Undergraduate college students (N?=?211) rated treatment response according to the photos, and additional archival data on hair pulling severity and psychosocial health were retrieved from the clinical trial. Photographic assessment of change was found to possess fair reliability (ICC?=?0.53), acceptable criterion validity (r?=?0.51), good concurrent validity (r?=?0.30–0.36), and excellent incremental validity (ΔR ²?=?8.67, p?<?0.01). In addition, photographic measures were significantly correlated with change in quality of life (r?=?0.42), and thus could be considered an index of the social validity of Trichotillomania treatment. Gender of the photo rater and pulling topography affected the criterion validity of photographic assessment (partial η ²?=?0.05–0.11). Recommendations for improving photographic assessment and future directions for hair pulling research are discussed.     

SIMPLIFIED HABIT REVERSAL TREATMENT FOR CHRONIC HAIR PULLING IN THREE ADOLESCENTS: A CLINICAL REPLICATION WITH DIRECT OBSERVATION

Three developmentally normal adolescents with chronic hair pulling were treated with a simplified habit reversal procedure consisting of awareness training, competing response training, and social support. Treatment resulted in an immediate reduction to near-zero levels of hair pulling, with one to three booster sessions required to maintain these levels. The results were maintained from 18 to 27 weeks posttreatment, although 1 participant reported difficulty at follow-up. The effectiveness of simplified habit reversal and suggestions for future research are discussed.     

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.     

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.