Erin M. Altenburger

DBT-enhanced cognitive-behavioral treatment for trichotillomania: A randomized controlled trial

Background and aims Limited treatment options are available for trichotillomania (TTM) and most have modest outcomes. Suboptimal treatment results may be due to the failure of existing approaches to address all TTM styles. Methods Thirty-eight DSM-IV TTM participants were randomly assigned across two study sites to Dialectical Behavior Therapy (DBT) -enhanced cognitive-behavioral treatment (consisting of an 11-week acute treatment and 3-month maintenance treatment) or a minimal attention control (MAC) condition. MAC participants had active treatment after the 11-week control condition. Follow-up study assessments were conducted three and six months after the maintenance period. Results Open trial treatment resulted in significant improvement in TTM severity, emotion regulation (ER) capacity, experiential avoidance, anxiety and depression with changes generally maintained over time. In the randomized controlled trial, those with active treatment had greater improvement than those in the MAC condition for both TTM severity and ER capacity. Correlations between changes in TTM severity and ER capacity were not reported at post-treatment but did occur in maintenance and follow-up indicating reduced TTM severity with improved ER capacity. Conclusions DBT-enhanced cognitive-behavioral treatment is a promising treatment for TTM. Future studies should compare this approach to other credible treatment interventions and investigate the efficacy of this approach in more naturalistic samples with greater comorbidity.

A family study of trichotillomania and chronic hair pulling

Little is known about the etiology of hair pulling (HP) and its relationship to other obsessive compulsive (OC) spectrum disorders. In a large‐sample family study, we examined the familial aggregation of HP and co‐transmission of obsessive compulsive disorder (OCD) and skin picking (SP). Our sample consisted of 110 proband cases with HP and 48 controls without HP, plus 128 first‐degree case relatives and 50 first‐degree control relatives. Case versus control relatives had higher recurrence risk estimates for both HP and OCD but not SP. The finding that HP is familial is consistent with the only existing twin study. Additional analyses suggest that there may be a familial subtype of HP with comorbid OCD. Those adult proband cases with HP + OCD had more anxiety and depression than cases without OCD. Probands with HP + OCD also had earlier onset of OCD. Identification of an HP subtype with comorbid OCD may have significant theoretical and treatment implications. The data did not provide evidence for an etiologic relationship between HP and SP. Replication of these findings in future studies with larger cohorts of case and control relatives is warranted.

Trichotillomania and personality traits from the five-factor model

OBJECTIVE To examine whether personality traits have predictive validity for trichotillomania (TTM) diagnosis, pulling severity and control, and hair pulling style. METHODS In study 1, logistic regression was used with TTM cases (n=54) and controls (n=25) to determine if NEO Five-Factor Inventory (NEO-FFI) personality domains predicted TTM case vs. control classification. In study 2, hierarchical multiple regression was used with TTM cases (n=164) to determine whether NEO-FFI personality domains predicted hair pulling severity and control as well as focused and automatic pulling styles. RESULTS TTM case vs. control status was predicted by NEO-FFI neuroticism. Every 1-point increase in neuroticism scores resulted in a 10% greater chance of TTM diagnosis. Higher neuroticism, higher openness, and lower agreeableness were associated with greater pulling severity. Higher neuroticism was also associated with less control over hair pulling. Higher neuroticism and lower openness were associated with greater focused pulling. None of the personality domains predicted automatic hair pulling. CONCLUSIONS Personality traits, especially neuroticism, can predict TTM diagnosis, hair pulling severity and control, and the focused style of pulling. None of the personality traits predicted automatic pulling. Longitudinal studies are needed to determine whether personality variables predispose to TTM onset, impact disorder course, and/or result from hair pulling behavior.

Subtle Threats to Moral Self-Perceptions Trigger Obsessive–Compulsive Related Cognitions

Obsessive–compulsive (OC) symptoms are often associated with cognitive biases and can cause significant distress and impairment in daily functioning. In this study, we examine whether threat to moral self-perceptions can trigger cognitive biases linked with obsessive–compulsive disorder (OCD). Participants were 124 non-clinical adults randomized to four conditions (negative-morality, negative-sports, positive-morality, and positive-sports) of the Subtle Priming Computerized Task. To examine the influence of subtle priming of morality-related information on OCD-related cognitive biases, participants completed the Obsessive Beliefs Questionnaire-20 (OBQ-20). Participants also completed the obsessive–compulsive inventory-revised, the Depression Anxiety Stress Scale and the Single-Item Self-Esteem Scale as baseline measures. Results revealed that subtle suggestions of incompetence in the morality self-domain were associated with stronger activation of OCD-related cognitive biases as measured by the OBQ-20. These effects were specific to negative information about the morality self-domain. Findings were not related to pre-existing variations in OC symptom levels, self-esteem, stress, anxiety, or depression. We suggest that self-sensitivities in the morality self-domain may be linked with the activation of cognitive biases related to OCD. Future research should explore these self-sensitivities in a clinical sample to further substantiate this phenomenon.

Replication Study of the Milwaukee Inventory for Subtypes of Trichotillomania–Adult Version in a Clinically Characterized Sample

In the present study, we evaluated the Milwaukee Inventory for Subtypes of Trichotillomania–Adult Version (MIST-A) in a replication sample of clinically characterized hair pullers using exploratory factor analysis (EFA; N = 193). EFA eigenvalues and visual inspection of our scree plot revealed a two-factor solution. Factor structure coefficients and internal consistencies suggested a 13-item scale with an 8-item “Intention” scale and a 5-item “Emotion” scale. Both scales displayed good construct and discriminant validity. These findings indicate the need for a revised scale that provides a more refined assessment of pulling phenomenology that can facilitate future treatment advances.

Body esteem in adolescent hair pullers

Background and aims: Trichotillomania (TTM) often first presents in adolescence, a developmental period marked by vulnerability in body image. To date, no one has studied the relationship between this disorder and body esteem. Methods: 49 adolescents with DSM-IV TTM or chronic hair pulling (HP) and 23 control adolescents were administered diagnostic assessments and self-report measures of hair pulling and body esteem. Results: HP youth vs. controls reported lower levels of body esteem on all Body-Esteem Scale for Adolescents and Adults (BESAA) subscales (appearance, attribution and weight satisfaction). HP contributed to lowered body esteem, independent of comorbid anxiety or depression. As expected, HP youth with vs. without comorbid anxiety or depression reported lowered levels of body esteem. Further, greater HP severity and distress were significantly associated with lower levels of body esteem. HP severity alone but not distress/impairment predicted lower levels of body esteem, independent of comorbid anxiety and depression. Conclusions: Both hair pulling and comorbid anxiety and depression can independently impact body esteem in adolescent hair pullers.