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.     

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.     

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.     

Group treatment for trichotillomania: behavior therapy versus supportive therapy

In this randomized controlled trial, group behavior therapy (BT; n = 12) was compared to group supportive therapy (ST; n = 12) in the treatment of trichotillomania (TTM). Both treatments were also compared to a naturally occurring waiting period, the time period that participants waited for groups to form. Participants completing group BT experienced significantly greater decreases in self-reported hair-pulling symptoms and clinician-rated hair loss severity than did those in group ST. Decreases were significantly greater after treatment than after the naturalistic waiting period. In addition, a significantly higher percentage of those in the BT than ST condition were rated as much improved or very much improved on the Clinical Global Impression scale at posttreatment. However, despite substantial symptom improvement, TTM severity remained problematic at posttreatment. Specifically, few participants in either treatment met criteria for clinically significant change at posttreatment. In addition, relapse of symptoms occurred over the 6-month follow-up period. Results provided partial support for the short-term efficacy of group BT. However, the group format may not maximize the efficacy of BT for TTM. Thus, it is recommended that future BT research test either individual therapy or a combination of group and individual formats for TTM.     

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.     

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.     

Comprehensive Behavioral (ComB) Treatment of Trichotillomania: A Randomized Clinical Trial

ObjectiveThis study is the first controlled trial of comprehensive behavioral (ComB) treatment of trichotillomania (TTM). ComB provides individualized treatment based on factors triggering and maintaining hair pulling. Method: Participants (N = 36) were adults (M = 34.08 years old, SD = 12.26) meeting DSM5 criteria for TTM. A majority were female (80%) and Caucasian (75%), whereas 17% were African American and 19% Hispanic/Latinx. In a parallel-group design, participants were randomly assigned to (a) Immediate ComB (12 sessions) or (b) Minimal Attention Control (MAC), followed by delayed ComB after week 12. Follow-up continued through week 38. Primary outcomes were self-report (Massachusetts General Hospital Hair pulling Scale; MGH-HPS) and interviewer-rated (NIMH-Trichotillomania Impact Scale and Trichotillomania Severity Scale; TIS/TSS) TTM symptom severity, as well as diagnosis (Trichotillomania Diagnostic Interview).ResultsImmediate efficacy of ComB (vs. MAC) was statistically significant (p = .03) for self-reported symptoms, with an effect size d = −.78, but not significant for interviewer-rated symptoms or diagnostic status. Immediate ComB was significantly more likely than MAC (27% vs. 0%) to lead to complete abstinence from hair pulling at week 12. Follow-ups showed good maintenance of effects.ConclusionsEfficacy of ComB was established for self-reported symptoms. Future research is needed to establish whether the lack of more widespread effects stems from limitations of the model or to a need for more extensive therapist training, as secondary analyses suggested stronger results among therapists with more TTM experience.     

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.     

APPARENT COVARIATION BETWEEN CHILD HABIT DISORDERS: EFFECTS OF SUCCESSFUL TREATMENT FOR THUMB SUCKING ON UNTARGETED CHRONIC HAIR PULLING

We evaluated the effects of aversive taste treatment of thumb sucking on untreated trichotillomania (habitual hair pulling) in two children who chronically pulled their hair and sucked their thumbs. A combination of withdrawal and nonconcurrent multiple baseline designs showed that, concomitant with the successful treatment of thumb sucking, hair pulling was also eliminated. The results suggest an efficient method for changing behaviors that are difficult to treat directly.     

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.     

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 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 (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.     

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.     

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.     

Effects of comorbid psychopathy on criminal offending and emotion processing in male offenders with antisocial personality disorder

Antisocial personality disorder (ASPD) and psychopathy are two syndromes with substantial construct validity. To clarify relations between these syndromes, the authors evaluated 3 possibilities: (a) that ASPD with psychopathy and ASPD without psychopathy reflect a common underlying pathophysiology; (b) that ASPD with psychopathy and ASPD without psychopathy identify 2 distinct syndromes, similar in some respects; and (c) that most correlates of ASPD reflect its comorbidity with psychopathy. Participants were 472 incarcerated European American men who met Diagnostic and Statistical Manual (4th ed., American Psychiatric Association, 1994) criteria for ASPD and Psychopathy Checklist criteria for psychopathy, who met the criteria for ASPD but not for psychopathy, or who did not meet diagnostic criteria for either ASPD or psychopathy (controls). Both individuals with ASPD only and those with ASPD and psychopathy were characterized by more criminal activity than were controls. In addition, ASPD with psychopathy was associated with more severe criminal behavior and weaker emotion facilitation than ASPD alone. Group differences in the association between emotion dysfunction and criminal behavior suggest tentatively that ASPD with and ASPD without prominent psychopathic features may be distinct syndromes.     

Clinically Significant Depressive Symptoms in African American Adolescent Females in an Urban Reproductive Health Clinic

Adolescent depression is a major public health concern. Depression and depressive symptoms are more prevalent in adolescent females and are associated with high-risk sexual behavior. Only one third of adolescents receive professional help for their depression, although about 90% visit their primary care providers on average 2–3 times per year. It is imperative that health professionals seek additional methods in the identification and treatment of depressive symptoms. This paper presents findings of the presence of clinically significant depressive symptoms in African American female adolescents receiving routine health care services within an adolescent primary care reproductive health clinic. Results revealed higher rates of depressive symptoms in this subsample of African American adolescent females when compared to the national sample, suggesting that primary care reproductive health clinics are a viable setting for the identification of depressive symptoms among low income, African American female adolescents. Psychosocial interventions and recommendations for the integration of primary care reproductive health, and behavioral health consultation services are presented.     

Hair pulling (trichotillomania)

Based on the findings in this case and common elements reported in other articles on trichotillomania, there seems to be evidence that the "irresistible urge" to pull out the hair has its beginnings in the early years of a child's life. The nature of the parent-child relationships appears to be especially important in establishing psychological antecedents for the later development of trichotillomania. Specifically, the trichotillomanic's mother sets the stage for the emergence of this symptom by extending the child's dependence upon her as the primary need-gratifier beyond early childhood into latency, adolescence, and adulthood. As a result the child is not gradually propelled to participate in newer and more complex learning experiences that ultimately lead to a sense of mastery and independent functioning in the environment. Important developmental stimuli are not presented at the appropriate times and the child is not exposed to certain types of interactions at the optimal times so that some very important ego functions do not develop, or develop minimally, or in a distorted manner. Simply, the mother cannot "let go" of her child, apparently deriving gratification of her own needs through infantilization of the child; as a result the child develops a limited or illusory sense of self sufficiency. Continuation of such an unhealthy symbiotic relationship, however, is found in many forms of psychopathology and the fact that it also underlies trichotillomania may partially account for hair pulling as a symptom associated with such a wide range of nosological categories. It is the main contention of this study, however, that the quality of the parent-child relationships impairs the ego development and causes failure of the trichotillomanic patient to establish object constancy. Without the establishment of object constancy an individual requires visible evidence that the object/person capable of gratifying basic security needs is present or available. In trichotillomania the hair seems to symbolize the need-gratifying object/person who is lost when the hair is pulled out and, more importantly, regained when it is eaten or restored. It appears to be this latter component of trichotillomania, i.e., reincorporation of the need-gratifying object/person, which reassures the patient that infantile needs can be gratified and security can be reestablished. Unfortunately, the trichotillomanic is driven to repeatedly and compulsively remove hair so that it can be regained temporarily since object constancy is never really established.     

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.