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.     

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.     

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.     

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.     

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.     

School-Based Acceptance and Commitment Therapy for Adolescents With Anxiety: A Pilot Trial

Anxiety disorders are one of the most prevalent diagnoses in youth, often resulting in impaired social and school functioning. Research on treatments for youth anxiety is primarily based in traditional clinical settings. However, integrating youth psychotherapies into the school environment improves access to evidence-based care. The present study is a pilot, randomized waitlist-controlled trial of a school-based, group Acceptance and Commitment Therapy–based (ACT) intervention for adolescents with anxiety. Students at two separate schools (N = 26) with elevated anxiety were randomized to a 12-week waitlist or to immediate treatment. Participants in the immediate treatment condition reported statistically significant decreases in anxiety and class absences at posttreatment and follow-up compared to the waitlist group. No statistically significant differences were found between groups for depression, psychological flexibility, positive mental health, and student well-being. However, medium within-condition effect sizes were seen in the treatment group for all outcomes. Participants reported the treatment as favorable with good acceptance ratings. Overall, this study supports ACT as a viable intervention for schools and other clinical settings providing services to adolescents with anxiety.     

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.     

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.     

Perfectionism,Distress, and Irrational Beliefs in High School Students: Analyses with an Abbreviated Survey of Personal Beliefs for Adolescents

The current study examined the associations between dimensions of perfectionism and irrational beliefs in an adolescent sample. In addition, we tested the association between psychological distress and irrational beliefs in adolescents and we evaluated the feasibility of creating a modified version of the Survey of Personal Beliefs for use with adolescents. A sample of 250 adolescents (108 males, 142 females) completed the Child-Adolescent Perfectionism Scale, the Survey of Personal Beliefs, and the CES-D Depression Scale. Initial psychometric analyses yielded an abbreviated 30-item Survey of Personal Beliefs with adequate internal consistency for four of the five subscales. Our results showed that self-oriented perfectionism was associated significantly with all five irrational belief subscales, while the associations between socially prescribed perfectionism and irrational belief subscales were much smaller in magnitude. Self-oriented perfectionism, socially prescribed perfectionism, and irrational beliefs were all associated significantly with elevated distress among adolescents, and irrational beliefs predicted unique variance in distress, over and above the variance attributable to the trait perfectionism dimensions. The findings confirmed the association between perfectionism and irrational beliefs and their respective roles in psychological distress among adolescents.     

Utilizing DBT Skills to Augment Traditional CBT for Trichotillomania: An Adult Case Study

Traditional cognitive-behavioral interventions for trichotillomania have had modest acute treatment outcomes and poor maintenance of gains over time. Techniques adopted from dialectical behavior therapy (DBT) can potentially enhance treatment outcomes by specifically addressing issues of impulsivity, emotion regulation, and distress tolerance. In this paper we discuss the application of a DBT-enhanced treatment and its outcome in a single-case study.     

Use of Multisystemic Therapy to Improve Regimen Adherence Among Adolescents with Type 1 Diabetes in Poor Metabolic Control: A Pilot Investigation

The purpose of the current study was to conduct a pilot investigation to determine the effectiveness of Multisystemic Therapy (MST) for improving regimen adherence and metabolic control among adolescents with poorly controlled Type 1 diabetes. Thirty-one adolescents were randomly assigned to either MST or a control condition. MST treatment lasted approximately six months. Data were collected at study entry and at a six-month posttest. Twenty-five adolescents completed the study. Adolescents who received MST had significantly improved adherence to blood glucose testing and metabolic control from study entry to the six-month posttest, whereas controls did not. Adolescents receiving MST also had a decreased number of inpatient admissions at the six-month posttest. Improvements in metabolic control were related to improvements in parent report of adolescent adherence. Results suggest that MST holds promise as an intervention for improving adherence behavior and health outcomes among adolescents in poor metabolic control.     

Trauma Informed Guilt Reduction Therapy With Combat Veterans

Guilt related to combat trauma is highly prevalent among veterans returning from Iraq and Afghanistan. Trauma-related guilt has been associated with increased risk for posttraumatic psychopathology and poorer response to treatment. Trauma Informed Guilt Reduction (TrIGR) therapy is a 4-module cognitive-behavioral psychotherapy designed to reduce guilt related to combat trauma. The goals of this study were to describe the key elements of TrIGR and report results of a pilot study with 10 recently deployed combat veterans.Ten combat veterans referred from a VA Posttraumatic Stress Disorder (PTSD) or mental health clinic completed TrIGR over 4 to 7 sessions. Nine veterans completed the posttreatment assessment.This initial pilot suggests that TrIGR may help to reduce trauma-related guilt severity and associated distress. Changes in trauma-related guilt were highly correlated with reductions in PTSD and depression symptoms over the course of treatment, suggesting a possible mechanistic link with severity of posttraumatic psychopathology.TrIGR warrants further evaluation as an intervention for reducing guilt related to traumatic experiences in combat.     

An Intensive Summer Treatment Program for ADHD Reduces Parent–Adolescent Conflict

There are currently almost no treatment efforts to reduce parent–adolescent conflict in adolescents with ADHD. As such, this study investigated the effect of an intensive Summer Treatment Program for Adolescents with ADHD (STP-A) on parent–adolescent conflict. Twenty adolescents and their parents completed the 8 week behavioral treatment program, which included 320 hours of adolescent-directed treatment, 15 hours of parent behavior management training, and daily feedback from staff on parent implementation of a home-based behavioral contract. Results indicated that 70–85 % of adolescents who attended the STP-A demonstrated reliable improvement in parent–adolescent conflict from baseline to post-treatment. Treatment response was associated with higher levels of conflict at baseline, but not adolescent ODD severity or parent ADHD severity. Several patterns of treatment non-response were detected through visual examination of weekly conflict scores during the STP-A. Discussion suggests that intensive, parent-involved treatment programs may be necessary to improve home-conflict in adolescents with ADHD.     

The influence of violent behavior and victimization at school on psychological distress: the role of parents and teachers

This study examined the role of adolescents' interactions with both parents and teachers in the relationship between violent behavior/victimization at school and adolescent psychological distresss (depression and stress). Participants were 983 Spanish adolescents (mean age 13.7 years) from four public schools in the Valencian Community. Statistical analyses were carried out using structural equation modeling. Results showed victimization to be directly and positively related to psychological distress. Moreover, victimization was associated with negative father-adolescent communication, which mediated a part of the influence of victimization on distress. Regarding school-based violent behavior, no direct effect on psychological adjustment was found. Results showed, however, an indirect effect: violent behavior negatively influenced communication with parents and interaction with teachers which, in turn, was related to poor psychological adjustment. This model accounted for 47.7% of the variance in psychological distress. Findings are discussed in relation to previous research on adolescent psychosocial adjustment, and directions for future research are suggested.     

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.     

A randomised worksite comparison of acceptance and commitment therapy and stress inoculation training

In this comparative intervention study, 107 working individuals with above average levels of distress were randomly assigned to one of three conditions: acceptance and commitment therapy (ACT; n = 37); stress inoculation training (SIT; n = 37); or a waitlist control group (n = 33). The interventions were delivered to small groups in the workplace via two half-day training sessions. ACT and SIT were found to be equally effective in reducing psychological distress across a three month assessment period. Mediation analysis indicated that the beneficial impact of ACT on mental health resulted from an increase in psychological flexibility rather than from a change in dysfunctional cognitive content. Contrary to hypothesis, a reduction in dysfunctional cognitions did not mediate change in the SIT condition. Results suggest that the worksite may offer a useful, yet underutilised, arena for testing cognitive-behavioural theories of change.     

Randomised controlled trial of group cognitive behavioural therapy for comorbid anxiety and depression in older adults

Anxiety and depression are commonly comorbid in older adults and are associated with worse physical and mental health outcomes and poorer response to psychological and pharmacological treatments. However, little research has examined the effectiveness of psychological programs to treat comorbid anxiety and depression in older adults. Sixty-two community dwelling adults aged over 60 years with comorbid anxiety and depression were randomly allocated to group cognitive behavioural therapy or a waitlist condition and were assessed immediately following and three months after treatment. After controlling for cognitive ability at pre-treatment, cognitive behaviour therapy resulted in significantly greater reductions, than waitlist, on symptoms of anxiety and depression based on a semi-structured diagnostic interview rated by clinicians unaware of treatment condition. Significant time by treatment interactions were also found for self-report measures of anxiety and depression and these gains were maintained at the three month follow up period. In contrast no significant differences were found between groups on measures of worry and well-being. In conclusion, group cognitive behavioural therapy is efficacious in reducing comorbid anxiety and depression in geriatric populations and gains maintain for at least three months.     

The Contributions of Child Behavioral Functioning and Parent Distress to Family Functioning in Pediatric Inflammatory Bowel Disease

The objective of this study was to examine the relative contributions of both parental and adolescent functioning to family functioning in adolescent patients with inflammatory bowel disease (IBD) and their families. Participants were 45 adolescents (27 male, 18 female) 13-17?years old (M?=?15.41?years, SD?=?1.32) with IBD and their parents. Families completed measures of patient behavioral functioning and depression, parent distress and family functioning. Disease severity assessments were completed via data provided by patients' gastroenterologists. Results indicated that parent-reported patient behavioral problems accounted for a significant 26% of variance in family functioning. Post-hoc analysis revealed that externalizing behavior problems accounted for the majority of this variance compared to internalizing behavior problems. These results suggest that externalizing problems may have a more significant impact on these families than previous research indicates. Moreover, externalizing behaviors may significantly impact family adaptation and should be taken into consideration during routine clinical care. Further research is needed to replicate and expand upon these findings.     

A Short‐Term,Prospective Test of the Interpersonal–Psychological Theory of Suicidal Ideation in an Adolescent Clinical Sample

The present prospective study tested a portion of the interpersonal–psychological theory of suicide (IPTS) in an adolescent clinical sample. Participants were 143 adolescents consecutively admitted to a partial hospitalization program who completed assessments at intake and discharge from the program. Results partially supported the IPTS and suggest that (1) perceived burdensomeness may be an important socially based cognition for understanding concurrent risk for suicidal ideation (SI); (2) thwarted belongingness affects depression symptom severity over time, which indirectly predicts SI over a short follow‐up time frame; and (3) the IPTS constructs may function differently in a high‐risk clinical adolescent sample, compared to adults, although findings are preliminary.     

School-aged Children’s Psychobiological Divergence as a Prospective Predictor of Health Risk Behaviors in Adolescence

Recent attachment research suggests that children with avoidant attachment often underreport their psychological distress compared to their physiologic indicators of distress (neuroendocrine reactivity, startle response, event-related potentials). This pattern of behavior (referred to as psychobiological divergence) may confer risk for suboptimal coping behaviors, including substance use, sexual risk-taking, and non-suicidal self-injury (NSSI), because individuals who are not aware of or cannot express their emotional needs may engage in maladaptive strategies to regulate their emotions. In the current pilot study (N?=?45 youth), we investigate whether psychobiological divergence of neuroendocrine and self-reported reactivity in middle childhood prospectively predicts health risk behaviors (HRBs) in adolescence. The results revealed that divergence was significantly associated with adolescents’ substance use and non-suicidal self-injury (NSSI), but not with their sexual behavior. Among adolescents currently reporting low levels of attachment security, divergence was associated with greater self-reported NSSI. Our results provide initial evidence that psychobiological divergence confers risk for substance use and NSSI in combination with current relational distress. We discuss the implications of our findings for adolescent development and clinical risk.