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.     

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.     

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.     

Current Treatment Practices for Children and Adults With Trichotillomania: Consensus Among Experts

Very little is known regarding the efficacy of pharmacological and psychosocial treatments for children and adults with trichotillomania (TTM). Given this dearth of information, the present investigation sought to examine the treatment practices of members of the nationally recognized Trichotillomania Learning Center–Scientific Advisory Board (TLC-SAB) and practitioners known by members of the TLC-SAB to possess extensive experience working with this population. The responses of 67 practitioners to an Internet-based survey were examined. Our results clearly indicate that cognitive-behavioral treatment (CBT) is the treatment of choice for both children and adults with TTM. In particular, several components of CBT (i.e., awareness training, self-monitoring, competing response training, habit reversal training, and stimulus control) are implemented most often. Selective serotonin reuptake inhibitors (SSRIs, e.g., citalopram, fluoxetine) and serotonin-norepinepherine reuptake inhibitors (SNRIs, e.g., venlafaxine, duloxetine) were prescribed most frequently; however, these results are preliminary given our small sample of prescribing practitioners (n = 11). Taken together, these findings are a critical starting point to advancing the understanding of efficacious interventions for the treatment of individuals with TTM. Clinical and research implications, future areas of research, and study limitations are discussed.     

Cognitive-Behavioral Therapy for Adolescent Body Dysmorphic Disorder

The onset of appearance-related concerns associated with body dysmorphic disorder (BDD) typically occurs in adolescence, and these concerns are often severe enough to interfere with normal development and psychosocial functioning. Cognitive behavioral therapy (CBT) is an effective treatment for adults with BDD. However, no treatment studies focusing on adolescents with BDD have been conducted. The need for an effective treatment in this population led to the development of a brief CBT protocol with family involvement. The treatment focuses on enhancing an adolescent's quality of life through the reduction of maladaptive thoughts and behaviors, and incorporates skills training and parent training. Similar treatment packages have already been shown to be efficacious for children and adolescents with similar disorders, such as obsessive-compulsive disorder and social phobia. The following case illustrates the application of this brief CBT protocol for BDD in an adolescent, and highlights clinical considerations needed when adapting CBT for a pediatric population. Treatment was associated with clinically significant improvement in symptoms of BDD, self-esteem, depression, and quality of life. This report extends extant literature by suggesting that CBT may be a helpful treatment for adolescents with BDD.     

Exposure and Response Prevention and Habit Reversal Training: Commonalities, Differential Use, and Combined Applications

Obsessive-compulsive spectrum disorders (OCSDs) have compulsive (i.e., anxiety reductive) and impulsive (i.e., driven by emotional or involuntary impulses) features. The best established psychological treatments for these disorders are behavioral/cognitive-behavioral in nature. More specifically, exposure and response prevention (ERP) (with or without cognitive therapy) and habit reversal training (HRT) are commonly indicated in the treatment of OCSDs. This paper reviews the use of various components of these therapeutic approaches to treat compulsive and impulsive symptomology in individuals with variants of these disorders. Specifically, ERP monotherapy for compulsive (e.g., obsessive-compulsive, body dysmorphic) and impulsive symptoms (e.g., tics, trichotillomania) is discussed as well as a combined treatment approach that integrates elements of ERP and HRT for individuals displaying mixed symptomology. A case example is also provided that illustrates the successful application of various components of ERP and HRT to treat OCSD symptoms. Lastly, other potential OCSD treatments are discussed.     

Differentiating Adolescent Self-Injury from Adolescent Depression: Possible Implications for Borderline Personality Development

Self-inflicted injury (SII) in adolescence marks heightened risk for suicide attempts, completed suicide, and adult psychopathology. Although several studies have revealed elevated rates of depression among adolescents who self injure, no one has compared adolescent self injury with adolescent depression on biological, self-, and informant-report markers of vulnerability and risk. Such a comparison may have important implications for treatment, prevention, and developmental models of self injury and borderline personality disorder. We used a multi-method, multi-informant approach to examine how adolescent SII differs from adolescent depression. Self-injuring, depressed, and typical adolescent females (n = 25 per group) and their mothers completed measures of psychopathology and emotion regulation, among others. In addition, we assessed electrodermal responding (EDR), a peripheral biomarker of trait impulsivity. Participants in the SII group (a) scored higher than depressed adolescents on measures of both externalizing psychopathology and emotion dysregulation, and (b) exhibited attenuated EDR, similar to patterns observed among impulsive, externalizing males. Self-injuring adolescents also scored higher on measures of borderline pathology. These findings reveal a coherent pattern of differences between self-injuring and depressed adolescent girls, consistent with theories that SII differs from depression in etiology and developmental course.     

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.     

Convergence and Non-convergence in the Quality of Adolescent Relationships and its Association with Adolescent Adjustment and Young Adult Relationship Quality

With the aim of identifying and examining both converging (matched relationship quality across one's set of relationships) and non-converging (mixed relationship quality across one's set of relationships), the present study used a pattern-centered approach to examine the different ways adolescent relationships pattern together among a large, national sample of U.S adolescents (aged 13-19). The study also examined how adolescent adjustment and young adult relationship quality varied across the different relationship patterns or constellations. The current study used latent class analysis and data from Add Health (n = 4,233), a national U.S. longitudinal study that spans adolescence and young adulthood, to uncover heterogeneity in adolescent relations with parents, friends, romantic partners, peers, and teachers. As predicted, patterns of both convergence and non-convergence were found, though patterns of non-convergence were more common than expected. Some patterns of non-convergence appear more stable (i.e., similar pattern found during both adolescence and young adulthood) than others. Also, no "high" converging pattern was found, indicating that few adolescents have "first-rate" relations in every relational domain.     

Cognitive-Behavioral Therapy for Adolescent Body Dysmorphic Disorder: A Pilot Study

Body dysmorphic disorder (BDD) is a relatively common and severe disorder that typically onsets in adolescence, but often goes unrecognized. Despite BDD’s severity and early onset, treatment outcome research on adolescent BDD is scarce. Cognitive-behavioral therapy is the gold-standard psychosocial treatment for BDD in adults and has shown promise in adolescents. The current study examined the development and testing of a new CBT for adolescents with BDD. We tested feasibility, acceptability, and treatment outcome in a sample of 13 adolescents (mean age 15.23 years, range: 13–17) with primary BDD. Treatment was delivered in 12–22 weekly individual sessions. Standardized clinician ratings and self-report measures were used to assess BDD and related symptoms pre- and posttreatment and at 3- and 6-months follow-up. At posttreatment, BDD and related symptoms (e.g., insight, mood) were significantly improved. Scores on the Yale–Brown Obsessive Compulsive Scale for BDD indicated a 50% (intent-to-treat) and 68% (completer) improvement in BDD symptoms. Seventy-five percent of adolescents who started treatment and 100% of completers were considered treatment responders. Treatment gains were maintained at follow-up. High patient satisfaction ratings and patient feedback indicated that treatment was acceptable. This represents the largest study of a psychosocial treatment for adolescent BDD.     

Adolescent identity--a qualitative approach: self-concept, existential questions and adult contacts

In-depth interviews were performed with 12 adolescents (Swedish students, 16-19 years). Three questions were probed; what do adolescents say on the subjects of (a) themselves, (b) their existential questions, and (c) their adult contacts. The first two questions were aimed at elucidating the process of identity development, the last one at factors that may be influencing this process. The results showed that (a) balancing and controlling one's own needs and wishes in relation to others' was a central issue, (b) existential questions mainly concerned the personal future, (c) adult contacts outside the family were scarce and (d) all respondents expressed a need for adult contacts as sources of knowledge and experience. The conclusions are that identity formation during late adolescence consists of integrative issues where adults play a specific and important role.     

A Web-Based Contingency Management Program With Adolescent Smokers

The present study evaluated a new 30-day Web-based contingency management program for smoking abstinence with 4 daily-smoking adolescents. Participants made 3 daily video recordings of themselves giving breath carbon monoxide (CO) samples at home that were sent electronically to study personnel. Using a reversal design, participants could earn money for continued abstinence during the treatment phases (CO ≤ 5 ppm). All participants were compliant with the treatment (submitting 97.2% of samples), and all achieved prolonged abstinence from smoking.     

Adolescent personality antecedents of adult cigarette smoking: a longitudinal study

Comprehensive personality assessments, made independently for early and late adolescence, were employed to predict smoking onset and maximum number of cigarettes smoked per day as reported by adult smokers. Also, comparisons were made between adult smokers and nonsmokers. The results indicate that men who had been more sexually active as adolescents smoked more but that women who had been more emotionally constricted and under more conflict as adolescents were heavier smokers. Smoking started earlier for men who had showed little self-awareness and a rather macho orientation during their adolescence; early-smoking women tended to have been conventionally feminine. Personality differences between future smokers and nonsmokers were few but showed similar sex differences. The results suggest that manifesting once traditional sex-role characteristics for both adolescent boys and girls presages early onset and heavier adult cigarette smoking. Preventive antismoking educational campaigns aimed at youth might be guided by these findings because they suggest some motivational bases that may find later expression in smoking practices.     

Adolescent Personality Antecedents of Adult Cigarette Smoking: A Longitudinal Study

Comprehensive personality assessments, made independently for early and late adolescence, were employed to predict smoking onset and maximum number of cigarettes smoked per day as reported by adult smokers. Also, comparisons were made between adult smokers and nonsmokers. The results indicate that men who had been more sexually active as adolescents smoked more but that women who had been more emotionally constricted and under more conflict as adolescents were heavier smokers. Smoking started earlier for men who had showed little self-awareness and a rather macho orientation during their adolescence; early-smoking women tended to have been conventionally feminine. Personality differences between future smokers and nonsmokers were few but showed similar sex differences. The results suggest that manifesting once traditional sex-role characteristics for both adolescent boys and girls presages early onset and heavier adult cigarette smoking. Preventive antismoking educational campaigns aimed at youth might be guided by these findings because they suggest some motivational bases that may find later expression in smoking practices.     

Adolescent Bereavement Following Suicide: An Examination of Relevant Literature

For adolescents, a loved one's death by suicide is a tragic event linked with increased morbidity, death fears, and psychopathology. For these reasons, the links between bereavement after suicide and the subsequent development of adolescents (including increased suicide risks) require further study. In the existing literature, inconsistent definitions of adolescence are used, samples of adolescents are drawn from those in psychotherapy, and other methodological problems exist.     

The Emerging Field of Adolescent Romantic Relationships

Romantic relationships are central in adolescents' lives. They have the potential to affect development positively, but also place adolescents at risk for problems. Romantic experiences change substantially over the course of adolescence; the peer context plays a critical role as heterosexual adolescents initially interact with the other sex in a group context, then begin group dating, and finally have dyadic romantic relationships. Adolescents' expectations and experiences in romantic relationships are related to their relationships with their peers as well as their parents. Although research on adolescents' romantic relationships has blossomed in the past decade, further work is needed to identify the causes and consequences of romantic experiences, examine the diversity of romantic experiences, and integrate the field with work on sexuality and adult romantic relationships.     

An "Epidemic" Model of Adolescent Cigarette Smoking

The prevalence of regular smoking increases rapidly during adolescence. We applied modeling methods from the study of epidemic infectious disease to smoking behavior. Our "epidemic" models dealt with the process of transition among four states: nonsmoker (susceptible), trier (exposed), regular smoker (infected), and ex-smoker (recovered). The best fitting model was one in which the transition from nonsmoker to trier was a social contagion process where nonsmokers contacted either triers or regular smokers. All other transitions were treated as constant rate processes in which a constant proportion of eligible individuals made the transition in a given year. The recursive equation model embodying these assumptions was able to predict accurately the proportion of adolescents in each state in Grades 6–11. Our results support a "stage" model of smoking, suggesting that different psychological and physiological processes are involved in the initiation of smoking than in developing a habit of regular smoking. A possible sex difference was found in the non-contact transition between trier and smoker states, with the transition being more probable in females than in males.     

Early childhood trichotillomania: Initial considerations on phenomenology,treatment, and future directions

Historically, trichotillomania (TTM) in young children (0–3 years old) generally has been considered to be a benign habit that is clinically distinct from the TTM seen in older children and adults. However, early childhood TTM can be an impairing pathological disorder that merits formal intervention. The present article reviews the extant literature on TTM in young children, highlighting the limited available phenomenological data. We discuss a behavioral approach to conceptualization and treatment, highlighting core intervention strategies in three early childhood TTM cases seen in our clinic. We conclude by discussing areas in need of further empirical attention.     

Dialectical Behavior Therapy Modified for Adolescent Binge Eating Disorder: A Case Report

Given the lack of empirically supported treatments available for adolescents with eating disorders, it is important to investigate the clinical utility of extending treatments for adults with eating disorders to younger populations. Dialectical behavior therapy for binge eating disorder, based on the affect-regulation model, conceptualizes binge eating as a behavioral attempt to influence, change, or control painful emotional states. With promising research findings in adult women, it is of clinical interest whether the dialectical behavior therapy for binge eating disorder treatment manual could be usefully adapted for an adolescent population. This report describes adolescent-specific modifications (including the use of family sessions) to standard dialectical behavior therapy for binge eating disorder, with an illustrative case study. While more rigorous case studies are needed prior to establishing justification for a randomized trial, this pilot case provides preliminary support for a modified version of dialectical behavior therapy for binge eating disorder as a therapeutic option for adolescents with binge eating disorder.     

Adolescent Precursors of Intensity of Marijuana and Other Illicit Drug Use Among Adult Initiators

This study examined (a) adolescent psychosocial risk factors for frequency (intensity) of marijuana use and for other illicit drug use among those who started using these drugs in early adulthood (adult initiators) and (b) the protective role of parent-adolescent relations in reducing or preventing drug use when adolescents enter early adulthood. The study's participants were male and female youth from a longitudinal prospective study. The participants' mean ages were 17 and 22 years at late adolescence and early adulthood, respectively. Independent measures assessed personality, parental, peer, and self-drug-use factors during late adolescence; dependent measures assessed frequency of marijuana use and other illicit drug use during early adulthood for initiators of the respective drug categories. The authors found that intensity of marijuana use was directly associated with the personality, parental, and self-drug-use domains and indirectly associated with the peer domain. Intensity of other illicit drug use was directly associated with personality and self-drug use. Analyses also revealed that some parent-adolescent relations factors buffered the effects of risk factors for both marijuana and other illicit drug-use intensity, whereas others enhanced the effects of protective factors against other illicit drug-use intensity. The results indicate that there are both commonalities and differences in precursors of marijuana and other illicit drug-use intensity among initiators of these drugs during early adulthood.