Christopher A. Flessner

Phenomenological Characteristics, Social Problems, and the Economic Impact Associated With Chronic Skin Picking

In this study, the authors collected data on the demographic characteristics, phenomenology, and social and economic impact of skin picking. A total of 92 participants completed an anonymous, Internet-based survey through a link to the Trichotillomania Learning Center’s home page. Results indicated that skin pickers experienced social, occupational, and academic impairment, a number of medical or mental health concerns, and financial burdens, which they attributed to skin picking. Results also revealed moderate, statistically significant relationships between skin picking severity and symptoms of depression, anxiety, and experiential avoidance. Subsequent mediational analyses demonstrated that the relationship between skin picking severity and symptoms of anxiety and depression was partially mediated by experiential avoidance. Implications, conclusions, and future areas of research are discussed.

The child and adolescent trichotillomania impact project: descriptive psychopathology, comorbidity, functional impairment, and treatment utilization.

Objective: Trichotillomania (TTM) is associated with significant morbidity, comorbidity, and functional impairment in adults. Despite the fact that TTM is typically a pediatric onset disorder, important questions remain about its phenomenology, comorbid symptoms, functional impact, and treatment utilization in youth. The current study was designed to provide an initial description of these factors using a convenience sample. Method: An internet-based survey. Results: Surveys completed by 133 youth ages 10 to 17 were analyzed. Scalp hair was the most common pulling site, followed by eyelashes and eyebrows. The majority reported tension before pulling and gratification/relief immediately after pulling. Severity of anxiety and depressive symptoms were somewhat elevated, as measured by standard instruments, and correlated positively with the severity of TTM symptoms. Moderate impairment in social and academic functioning was reported. For those who had received treatment specifically for TTM, parent ratings indicated that few (17%) children and adolescents were either very much improved or much improved after intervention. Conclusions: This study represents the largest survey of youth with TTM conducted thus far, and thus provides the most comprehensive description of TTM in youth to date. Limitations: Data was obtained from an anonymous, Internet-based sample, and thus may not be generalizable to all youth with TTM.

The Skin Picking Impact Project: Phenomenology, interference, and treatment utilization of pathological skin picking in a population-based sample

The current study examined the characteristics of pathological skin picking (PSP) in a population-based sample. Participants were recruited through several online resources for PSP and related conditions to complete a web-based survey assessing the functional and topographical phenomenology, physical and psychosocial impact, treatment utilization, and associated psychopathology of PSP. A total of 1663 participants consented, of whom 760 were over 18 and met study criteria for PSP. Results showed considerable heterogeneity in picking methods, body sites, and function (e.g., regulation of emotional, sensory, and cognitive states). Participants generally reported moderate psychosocial and physical impact from picking and tended to perceive available treatment as poor in quality. Severity of associated symptoms of psychopathology (depression, anxiety, and stress) was comparable to severity levels found in previous samples of persons with trichotillomania and obsessive-compulsive disorder. Severity of PSP was a statistically significant predictor of overall impairment after controlling for depression and anxiety symptoms. Results suggest that PSP is a significant public health concern in need of further rigorous investigation.

Predictors of parental accommodation in pediatric obsessive-compulsive disorder: findings from the Pediatric Obsessive-Compulsive Disorder Treatment Study (POTS) trial.

OBJECTIVE Few studies have examined predictors of parental accommodation (assessed with the Family Accommodation Scale-Parent Report) among families of children with obsessive-compulsive disorder (OCD). No studies have examined this phenomenon using empirically derived subscales of the Family Accommodation Scale-Parent Report (i.e., Caregiver Involvement, Avoidance of Triggers). METHOD Ninety-six youths (and their families) were included in the present study. Parents were asked to complete the Family Accommodation Scale-Parent Report. Families also completed several additional measurements assessing child- and parent-level variables of interest. Regression analyses were used to examine potential predictors of accommodation. RESULTS Results support prior research suggesting that accommodation is ubiquitous among the families of children with OCD. Analyses revealed that several child-level (i.e., compulsion severity, oppositional behavior, and frequency of washing symptoms) and one parent-level (i.e., symptoms of anxiety) predictors work jointly to provide significant predictive models of parental accommodation. CONCLUSIONS Clinicians and researchers should be aware of the impact of specific child- and parent-level variables on family accommodation in pediatric OCD and in turn their implications for treatment compliance, adherence, and, by extension, outcome. Study limitations warrant replication and extension of these findings; in particular, researchers may seek to obtain a better understanding of how the various facets of parental accommodation may differentially affect treatment.

Acceptance-Enhanced Behavior Therapy (AEBT) for Trichotillomania and Chronic Skin Picking: Exploring the Effects of Component Sequencing

This pilot study examined the utility of acceptance-enhanced behavior therapy (AEBT) for trichotillomania (TTM) and chronic skin picking (CSP) and the impact of altering treatment sequence on overall treatment efficacy. Participants referred to a TTM and CSP specialty clinic were assessed by an independent evaluator within separate, nonconcurrent, multiple-baseline designs across participants. The first group of three participants received habit-reversal training (HRT) followed by acceptance and commitment therapy (ACT), and the second group of two participants received ACT followed by HRT. Results indicated that AEBT greatly reduced pulling/picking for all five participants and that the order in which ACT and HRT were implemented made little or no difference in short-term treatment outcome. Conclusions, limitations, and future areas of research are discussed.

Comparison of two programs to teach firearm injury prevention skills to 6- and 7-year-old children.

Background. Each year, hundreds of children unintentionally kill or injure other children while playing with firearms in the United States. Although the numbers of these deaths and injuries are distressing, few prevention programs have been developed to prevent gun play among children. Objective. This study compared the efficacy of 2 programs designed to prevent gun play among young children. Design. A posttest-only, control group design with 2 treatment groups was used. Children were randomly assigned to 1 of 2 treatment groups or a control group. For all children who did not exhibit the skills after training, 1 in situ (ie, real-life situation) training session was conducted. Setting. Participant recruitment, training sessions, and assessments were all conducted in the children’s after-school program facility. Participants. Forty-five children, 6 or 7 years of age, were recruited for participation. Interventions. The efficacy of the Eddie Eagle GunSafe Program, developed by the National Rifle Association, and a behavioral skills training program that emphasized the use of instruction, modeling, rehearsal, and feedback was evaluated. Main Outcome Measures. The criterion firearm safety behaviors included both motor and verbal responses, which were assessed in a naturalistic setting and then assigned a numerical value based on a scale of 0 to 3. Results. Both programs were effective for teaching children to verbalize the safety skills message (don’t touch the gun, get away, and tell an adult). However, children who received behavioral skills training were significantly more likely to demonstrate the desired safety skills in role-playing assessments and in situ assessments than were children who received Eddie Eagle program training. In addition, in situ training was found to be effective for teaching the desired safety skills for both groups of children. Conclusions. Injury prevention programs using education-based learning materials are less effective for teaching children the desired safety skills, compared with programs incorporating active learning approaches (eg, modeling, rehearsal, and feedback). The efficacy of both types of injury prevention programs for teaching the desired skills could be significantly enhanced with the use of in situ training. This program, when implemented with 6- and 7-year-old children, was effective in teaching the desired safety skills.

The Milwaukee Inventory for Styles of Trichotillomania-Child Version (MIST-C) : Initial development and psychometric properties

This article describes the development and initial psychometric properties of the Milwaukee Inventory for Styles of Trichotillomania-Child Version (MIST-C), a self-report scale designed to assess styles of hair pulling in children and adolescents diagnosed with trichotillomania (TTM). Using Internet sampling procedures, the authors recruited 164 parent–child dyads, the children of whom met modified diagnostic criteria for TTM. The MIST-C was administered in the context of a larger survey examining functional impairment experienced by children with TTM. Results of an exploratory factor analysis on MIST-C items revealed a two-factor solution. Factors 1 (“focused” pulling scale) and 2 (“automatic” pulling scale) consisted of 21 and 4 items, respectively, with both scales demonstrating acceptable internal consistency and good construct and discriminant validity. The development of the MIST-C provides researchers with a reliable and valid assessment of “automatic” and “focused” pulling, and provides a means by which to examine the developmental trajectory and treatment implications of these pulling styles.

The Trichotillomania Scale for Children: Development and Validation

Trichotillomania (TTM) is a chronic impulse control disorder characterized by repetitive hair-pulling resulting in alopecia. Although this condition is frequently observed in children and adolescents, research on pediatric TTM has been hampered by the absence of validated measures. The aim of the present study was to develop and test a new self-report measure of pediatric TTM, the Trichotillomania Scale for Children (TSC), a measure that can be completed by children and/or their parents. One hundred thirteen children meeting self-report criteria for TTM, and 132 parents, provided data over the internet. An additional 41 child–parent dyads from an outpatient clinic also provided data. Replicated principal components analysis, with elimination of poorly-loading items, yielded two components, which we labeled Severity (five items) and Distress/Impairment (seven items). The TSC total score and subscales showed adequate internal consistency and test-retest reliability. Parent–child agreement was good in the internet sample, but more modest in the clinic sample. Children’s TSC scores correlated significantly with other measures of TTM severity, although some exceptions were noted. Parents’ TSC scores correlated significantly with other measures of parent-rated TTM severity in the internet sample, but showed more attenuated relationships with child- and interviewer-rated TTM severity in the clinic sample. The present results suggest that the TSC may be a useful measure of TTM for child and adolescent samples, although additional clarification of convergent validity is needed.

Cross-Sectional Study of Women with Trichotillomania: A Preliminary Examination of Pulling Styles, Severity, Phenomenology, and Functional Impact

The current study utilized a cross-sectional design to examine pulling severity, phenomenology, functional impact, and “focused” and “automatic” pulling styles in women with TTM across a wide age spectrum. “Automatic” pulling refers to pulling occurring primarily out of one’s awareness, while “focused” pulling refers to pulling with a compulsive quality that may include pulling in response to a negative emotional state (e.g., anxiety, stress, anger, etc.), an intense thought or urge, or in an attempt to establish symmetry. In the present study, data were collected from 1,471 female participants (age 10–69) meeting modified diagnostic criteria for TTM via two separate online surveys (one for children/adolescents, one for adults). Pulling severity remained stable across the different developmental cohorts. However, fluctuations in functional impact (e.g., social and interpersonal impairment) were noted. “Automatic” pulling showed relatively little fluctuation from adolescence to adulthood, while “focused” pulling demonstrated considerable fluctuation coinciding with psychological distress and typical ages of important biological changes (e.g., pubertal onset) in children/adolescents and adults (e.g., perimenopause). Conclusions, treatment implications, limitations, and future areas of research are discussed.

Is Trichotillomania a Stereotypic Movement Disorder? An Analysis of Body-Focused Repetitive Behaviors in People with Hair-Pulling

BACKGROUND Stereotypic movement disorder (SMD) is characterized by nonfunctional repetitive movements, is typically diagnosed in people with intellectual disability, and by definition excludes people with trichotillomania (TTM). Nevertheless, hair-pulling may be one of a number of body-focused repetitive behaviors (BFRBs) that are seen in the general population. Comorbidity of symptoms might support the idea that they are indicative of an underlying stereotypic disorder, and we therefore explored their frequency in people with hair-pulling. METHODS Participants were recruited with the help of the Trichotillomania Learning Center, the largest advocacy group for people with hair-pulling. Participants completed a self-report survey on the Internet, which included questions about the presence of both hair-pulling and other BFRBs. Measures included the Massachusetts General Hospital Hairpulling Scale (MGH-HS), the Milwaukee Inventory for Subtypes of Trichotillomania-Adult Version (MIST-A), the Depression and Anxiety Stress Scale (DASS), and the Sheehan Disability Scale (SDS). RESULTS The majority of participants with hair-pulling (70%) report the presence of other BFRBs, most commonly skin-picking and nail-biting. There were particularly strong associations between the total number of BFRBs and increased scores on ratings of focused hair-pulling, depression, anxiety, stress, and functional impairment. Similar results were found in participants who met more rigorous criteria for trichotillomania. CONCLUSIONS This study is limited by its self-report nature, and by the lack of detailed information on the phenomenology of comorbid BFRBs. While further nosological research is needed, the high rates of these behaviors in people with hair-pulling, and their association with increased disability, is consistent with previous clinical observations, and supports the argument that trichotillomania can usefully be conceptualized as a stereotypic disorder. Speculatively, this argument may be especially valid in trichotillomania patients with more focused hair-pulling symptoms.