Treatment of obsessive-compulsive hair pulling (Trichotillomania) by behavioral and cognitive contingency manipulation

A case of trichotillomania of 11 yr duration in a 21-yr-old female was successfully treated using contingency management for both hair pulling behavior and the urge to pull hair. During treatment of approximately two months, the hair pulling behavior was associated with a mild aversive procedure and her awareness of the urge to pull hair was used as a cue to initiate hair grooming. She remains essentially symptom free of hair pulling and has a markedly reduced awareness of urges to pull her hair at 7-months follow-up.     

Positive reinforcement and punishment in the treatment of childhood trichotillomania

A comprehensive behavioral treatment package was developed during 13 treatment sessions and was communicated to a mother of a five year old girl with a four year history of hair pulling which had resulted in almost total baldness. Treatment consisted of a variety of positive reinforcement procedures which resulted in a gradual decrease in the hair pulling behavior, and finally the use of punishment which led to a rapid decrease and virtual elimination of the problem. The child was symptom free with shoulder length hair at a 16 month follow-up. The growing literature on behavioral treatment of trichotillomania and the ethical implications of the use of punishment are reviewed.     

A comparison of relaxation training and competing response training to eliminate hair pulling and nail biting

A 17-year-old female with a 14-year history of hair pulling and nail biting was treated with relaxation training and competing response training. While introduction of relaxation training produced an initial decline in hair pulling, there was a gradual recovery of the maladaptive behavior to baseline levels. The competing response procedure consisted of clenching fists for 3 min whenever hair pulling or nail biting occurred or were likely to occur. By the use of the competing response hair pulling and nail biting decreased, eventually to zero. Follow-up over a 2-year period revealed that the treatment effects were maintained.     

Behavioral treatment of chronic hair pulling in a two year old

Chronic hair pulling, exhibited by a 27 month-old boy was ameliorated in a 15-week treatment. The methodology focused on teaching the parents to apply a specific combination of differential reinforcement and response-chain interruption procedures. Follow-ups at 6 and 12 months revealed neither the recurrence of hair pulling nor the appearance of other problematic behaviors.     

The role of serotonin (5-HT) in the control of TSH and prolactin release in euthyroid subjects as assessed by the administration of ketanserin (5-HT2 antagonist) and zimelidine (5-HT re-uptake inhibitor)

We have studied the effects of ketanserin, a specific 5-HT2 antagonist, and zimelidine, a selective inhibitor of 5-HT re-uptake into central nervous system presynaptic terminals, upon basal and TRH stimulated serum TSH and prolactin levels in euthyroid individuals. Ten normal volunteers were studied (five male and five female), each receiving oral ketanserin and oral zimelidine during respective seven day periods, separated by an interval of at least two weeks. A standard TRH test (200 micrograms i.v.) was carried out before and after each period of drug administration, serum samples being obtained for TSH and prolactin estimation. We were unable to demonstrate any modification of basal or TRH-stimulated TSH and prolactin levels by the oral administration of either ketanserin or zimelidine, suggesting that 5-HT has no significant role in the physiological release of either TSH or prolactin.     

A novel approach to assessment in the treatment of childhood trichotillomania

The present study describes the successful treatment of a 9-year-old girl with trichotillomania. Intervention involved (1) praising attractive hair and ignoring hair loss, (2) education in hair hygiene, (3) response prevention for night-time hair pulling, and (4) a variable schedule of monetary rewards for criterion hair growth. Progress was assessed by counting hairs in random scalp areas and measuring bald areas. Hair growth increased from three hairs per area sampled at baseline to such dense hair growth that individual hairs could not be counted and no bald spots were noted. Results maintained at 2, 6 and 10 months follow-up.     

Hypnosis as a vehicle for choice and self-agency in the treatment of children with Trichotillomania

Three pediatric cases of Trichotillomania were treated with direct hypnotic suggestion with exclusive emphasis on sensitizing and alerting the patients to impending scalp hair pulling behaviors. These children had presented with total lack of awareness of their scalp hair pulling behaviors until they had actually twisted and pulled off clumps of hair. It was also suggested, under hypnosis, that upon learning to recognize impending scalp hair pulling behaviors, the patients would become free to choose to willfully pull their hair or to resist the impulse and not pull. At no point was the explicit suggestion given that they stop pulling their hair. A preliminary condition was agreed to by the parents that redefined the patients' hair as their own property and affirmed their sole responsibility for its care and maintenance. An element of secondary gain was identified in each of these cases. Scalp hair pulling was hypothesized to provide these particular patients with a vehicle with which to oppose their overbearing and over-involved parents. The technique of direct suggestion under hypnosis, aimed at alerting the patients to impending scalp hair pulling behaviors was combined with forming contracts with the parents to relinquish their authority over matters regarding the patients' hair. This combination provided an effective treatment that extinguished the scalp hair pulling in 7 visits or less. These cases received follow-up at intervals up to 6 months and no evidence of relapse was found.     

Severe obsessive-compulsive disorder with and without comorbid hair pulling: comparisons and clinical implications

OBJECTIVE: Chronic hair pulling and trichotillomania are putative obsessive-compulsive spectrum disorders. This study determined the prevalence of hair pulling in an inpatient obsessive-compulsive disorder (OCD) population and compared clinical characteristics and treatment response between subgroups with and without comorbid hair pulling. METHOD: Patients with severe DSM-IV-diagnosed OCD (N = 154) who were consecutively admitted to an OCD residential treatment facility between August 2000 and July 2003 were included. Clinician-rated (Yale-Brown Obsessive Compulsive Scale) and patient-rated (Massachusetts General Hospital Hairpulling Scale, Beck Depression Inventory, and Posttraumatic Diagnostic Scale) measures were administered at index evaluation. OCD patients with and without moderate to severe hair pulling were statistically compared on clinical and treatment characteristics and treatment response. RESULTS: Of the OCD subjects, 18.8% (N = 29) endorsed any hair pulling, 15.6% (N = 24) had moderate to severe hair pulling, and 7.8% (N = 12) had severe hair pulling comparable to that of a specialty trichotillomania clinic population. OCD patients with moderate to severe hair pulling were more likely to be women (p < .001), endorse > 1 comorbid tic (p < .05), and have earlier-onset OCD (p = .001). This cohort also had fewer contamination obsessions (p = .04) and checking compulsions (p = .04) and was more likely to be receiving stimulant (p = .006) or venlafaxine (p = .02) medication than those patients without hair pulling. Posttraumatic Diagnostic Scale scores were nearly significantly higher in the OCD + hair pulling group (p = .08). OCD treatment response was unaffected by the presence of comorbid hair pulling. CONCLUSION: Hair pulling is a highly common comorbidity in severe OCD. Women and early-onset OCD patients appear to be more vulnerable to comorbid hair pulling. OCD sufferers with comorbid hair pulling also exhibit an increased risk for tics and may present with different OCD symptomatology.     

Pilot trial of dialectical behavior therapy‐enhanced habit reversal for trichotillomania

Background: Not all hair pullers improve acutely with cognitive–behavioral treatment (CBT) and few maintain their gains over time. Methods: We conducted an open clinical trial of a new treatment that addresses affectively triggered pulling and emphasizes relapse prevention in addition to standard CBT approaches. Ten female participants satisfying DSM‐IV criteria for trichotillomania (TTM) at two study sites received Dialectical Behavior Therapy (DBT)‐enhanced CBT consisting of 11 weekly sessions and 4 maintenance sessions over the following 3 months. Independent assessors rated hair pulling impairment and global improvement at several study time points. Participants completed self‐report measures of hair pulling severity and emotion regulation. Results: Significant improvement in hair pulling severity and emotion regulation, as well as hair pulling impairment and anxiety and depressive symptoms, occurred during acute treatment and were maintained during the subsequent 3 months. Significant correlations were reported between changes in emotion regulation and hair pulling severity during both the acute treatment and maintenance phases. Conclusions: This study offers preliminary evidence for the efficacy of DBT‐enhanced CBT for TTM and suggests the importance of addressing emotion regulation during TTM treatment. Depression and Anxiety, 2010. © 2010 Wiley‐Liss, Inc.     

Psychosocial morbidity in the first three months following stoma surgery

One hundred and six consecutive subjects were seen in hospital a few days after undergoing surgery for bowel disease that necessitated the formation of a stoma. They consisted of patients with cancer (74), colitis (17) and diverticular disease (15). At this initial assessment details of psychological and social functioning were obtained for the proceeding three months before operation. At 3 months post-operatively the subjects were interviewed in their own homes, 87 subjects were available (12 died, 7 refused) and again psychological and social assessments were made. Seventeen per cent of males and 19% of females had moderate or severe psychiatric disturbance and there was also a significant number of patients with various social disturbances. Physical diagnosis did not significantly affect psychiatric outcome. There was, however, high pre-operative psychiatric disturbance and the relevance of this in assessing post-operative symptoms is discussed.     

Lithium treatment of chronic hair pulling

Ten patients with chronic hair pulling received trials of lithium carbonate of 2 to 14 months' duration. Eight patients demonstrated decreased hair pulling and mild to marked hair regrowth. Three responders experienced increased hair pulling subsequent to discontinuation of lithium treatment. Lithium's effect on hair pulling may be related to its observed benefits in treating aggressivity, impulsivity, and mood instability.     

磁力牵拉对骨增长影响的动物实验模型设计*

背景：自由状态下实现运动性牵拉对骨骼变化趋势的影响研究较为少见,归纳其原因是求证方法困难。进行其相关研究最重要的是设计实现自然状态下动态牵拉动物实验模型系统。 目的：建立一种新型的、自然状态下的、动态磁力牵拉动物实验模型系统,分析自然运动牵拉力下骨骼应力性变化趋势。 设计、时间及地点：分组对照观察,于2002-06/2003-06在河北科技师范学院动物科学系动物实验室完成。 材料：7周龄近交系日本大耳白兔24只,体质量（2.5±0.3）kg,雌雄不限。永磁片16枚由沈阳钕铁硼永磁材料有限公司提供。 方法：利用实验动物、磁体、粘扣和铁质垫板等器材建立了“磁力牵拉对骨增长影响的动物实验模型系统”。将24只兔分为3组,每组8只。牵拉组采用磁力牵拉系统,放在有铁质垫板的饲养笼内饲养。磁力组仅将磁片固定于兔子右后腿脚底部,将兔放在有铁质垫板的饲养笼内饲养。对照组不附加任何装置放入普通竹条垫板笼饲养。 主要观察指标：各组兔经不同处理4个月胫骨和股骨增长变化。 结果：各组兔分别处理4个月时,与对照组比较,牵拉组胫骨增长2.61 mm,股骨增长1.56 mm,磁力组胫骨增长0.728 mm,股骨增长0.41 mm,差异均有显著性意义（P < 0.01）。 结论：“模型系统”在可控制实验条件下模拟实现了自然运动状态下骨磁力牵拉全过程,且成本低、操作便捷、重复性强,能够满足运动牵拉对骨骼影响方面研究的实际需要。     

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.     

三叉神经痛微血管减压术中右美托咪啶应用观察

目的研究右美托咪啶在微血管减压术治疗三叉神经痛合并高血压患者麻醉中的应用效果。方法本研究对象为合并Ⅰ~Ⅱ级高血压的三叉神经痛患者100例,随机分成研究组(50例)与对照组(50例),分别在麻醉诱导前静脉输注右美托咪啶以及等量生理盐水。手术期间,研究组持续泵注右美托咪啶,对照组实施等量生理盐水持续泵注,采取靶控输注丙泊酚以及瑞芬太尼麻醉维持,并以罗库溴铵作为肌肉松弛药,采用乌拉地尔辅助控制血压。于输注右美托咪啶或生理盐水前、麻醉诱导前、气管插管前、气管插管后1min、手术切皮时以及拔出气管导管前和拔出气管导管后1min,对患者的心率及平均动脉压进行统计,并记录乌拉地尔以及瑞芬太尼、丙泊酚的总用量,观察患者麻醉后的恢复情况。结果气管插管后1min时,对照组心率、平均动脉压与气管插管前对比显著提升(P0.05);拔出气管导管后,两项指标与拔出气管导管前相比显著提升(P0.05)。研究组麻醉诱导前患者的心率以及平均动脉压明显低于输注右美托咪啶或生理盐水前(P0.05),丙泊酚及瑞芬太尼、乌拉地尔用量与对照组相比明显较少(P0.05)。与对照组相比,研究组拔出气管导管时呛咳及拔管后躁动、术后寒战的发生情况明显较低(P0.05)。结论三叉神经痛合并高血压患者微血管减压术期间应用右美托咪啶,围麻醉期能够对血流动力学状态进行良好的维持,显著减少麻醉用药量。     

The Trichotillomania Impact Project in Young Children (TIP-YC): Clinical Characteristics,Comorbidity, Functional Impairment and Treatment Utilization

The aim was to investigate clinical characteristics of young children with a hair pulling problem. Parents/caregivers of young children (0–10 years old) with a hair pulling problem (N = 110) completed an online survey. The majority reported that their child experienced mild to moderate impairment/distress due to hair pulling, and overall clinical characteristics were similar to adult samples, although some differences were noted (e.g., less awareness of pulling). We also compared preschool-aged and school-aged children within the sample. Symptom severity, pleasure during pulling and gender ratio remained stable across the age groups. The preschool-aged children demonstrated less impairment/distress, comorbidity, and treatment seeking; pulled from fewer body areas; and were less likely to be aware of the act or experience tension prior to pulling. In conclusion, clinical characteristics of childhood hair pulling are largely similar to adult/adolescent hair pulling problems, but there are some notable differences, particularly among pre-school aged children.     

Treatment of early onset hair pulling as a simple habit

The authors evaluated the effects of response prevention, a treatment previously shown to be effective for routine thumb sucking and suggested to be effective for early onset trichotillomania, applied to hair pulling in a 2-year-old. Response prevention was used alone in two settings (bedtime and naptime) and combined with a brief time out in another (daytime). The authors also used a novel assessment, weight of hairs pulled, and the results indicated complete cessation of hair pulling. Corresponding photographic evidence indicated complete regrowth of hair lost to pulling. These results add to a growing literature suggesting early onset hair pulling may be more appropriately classified as a benign habit than as trichotillomania.     

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.     

Nail picking disorder (onychotillomania): A case report

Nail picking disorder (onychotillomania) is characterized by excessive picking or pulling at one's own finger- or toenails. This condition has received scant research attention and may be related to other body focused repetitive behaviors such as pathological nail biting, skin picking and hair pulling. We present a case of a male client with a chronic and severe nail picking habit treated with acceptance-enhanced behavior therapy. The client showed clinical characteristics similar to other body focused repetitive behaviors and responded moderately well to the treatment.     

Clinical characteristics and psychiatric comorbidity in children with trichotillomania.

Ten children with trichotillomania (hair pulling) were systematically evaluated with structured psychiatric interviews and rating scales assessing anxiety, depression, life events, self-esteem, and family functioning. Six of the subjects met diagnostic criteria for overanxious disorder on the Diagnostic Interview for Children and Adolescents--Revised--Child or Adolescent Version and/or Diagnostic Interview for Children and Adolescents--Revised--Parent Version. Two met the criteria for dysthymia, including one of the subjects with overanxious disorder. No children reported associated obsessions or compulsions. Only one subject experienced tension before hair pulling and relief associated with hair pulling. The DSM-III-R criteria for trichotillomania, which currently require an increasing sense of tension before hair pulling and gratification with hair pulling, may be overly restrictive and in need of redefinition. Additional research with increased sample size is necessary to define diagnostic criteria for trichotillomania and clarify its relationship with other psychiatric diagnoses.     

Emotion regulation and trichotillomania: a comparison of clinical and nonclinical hair pulling

This study investigated the emotion regulation hypothesis of trichotillomania (TTM) using a retrospective self-report measure and an experimental hair-pulling task. Participants diagnosed with TTM (n=34) and nonclinical control (NC) volunteers (n=32) were compared on ratings of emotional experiences associated with hair pulling. Data from the retrospective self-report measure supported the emotion regulation hypothesis of TTM. The TTM group reported larger decreases than the NC participants in boredom, sadness, anger, and tension, and larger increases in relief and calm from before to during pulling. The TTM group also reported significantly higher ratings of pleasure while pulling. When exploring changes in emotions from during to after pulling, the TTM group reported larger increases than the NC participants in guilt, sadness, and anger; and larger decreases in boredom; while the NC group reported larger increases than the TTM group in happiness, calm, and relief. On the experimental hair-pulling task, the TTM group reported larger decreases in anxiety from before to after pulling, but this effect was only found for a nontypical hair-pulling site. Methodological limitations may account for the lack of group differences on the experimental hair-pulling task.