DBT-enhanced habit reversal treatment for trichotillomania: 3-and 6-month follow-up results

Background: Maintenance of gains with cognitive‐behavioral treatment for trichotillomania (TTM) has historically been problematic. Methods: We conducted follow‐up assessments 3 and 6 months after completion of a 3‐month maintenance phase on 10 individuals with DSM‐IV‐TR TTM who participated in an open trial of a dialectical behavior therapy (DBT)‐enhanced habit reversal treatment (HRT). Results: Significant improvement from baseline was reported at 3‐and 6‐month follow‐up on all measures of hair pulling severity and emotion regulation, although some worsening was reported on some measures from earlier study time points. At 6‐month follow‐up, five and four participants were full and partial responders, respectively. Significant correlations were reported at both follow‐up time points between changes in hair pulling severity and emotion regulation capacity. Conclusions: DBT‐enhanced HRT offers promise for improved long‐term treatment results in TTM. Changes in TTM severity from baseline to 3‐and 6‐month follow‐up is correlated with changes in emotion regulation capacity. Depression and Anxiety, 2011. © 2010 Wiley‐Liss, Inc.     

Evidence for reduced cerebellar volumes in trichotillomania.

BACKGROUND: Limited knowledge exists regarding the neurobiology of trichotillomania (TTM). Cerebellum (CBM) volumes were explored, given its role in complex, coordinated motor sequences. METHODS: Morphometric magnetic resonance imaging (MRI) scans were obtained for 14 female subjects with DSM-IV diagnoses of TTM and 12 age-, education-, and gender-matched normal control (NC) participants. Parcellation was performed utilizing a recently developed methodology to measure subterritory volumes of the CBM. Regions were defined based on knowledge of the structural and functional subunits of the CBM. RESULTS: As predicted, significant group differences were reported for CBM raw cortical volumes (p = .008) that survived correction for total brain volume (TBV; p = .037) and head circumference (HC; p = .011). A priori and post hoc group raw volume comparisons for CBM subterritories and functional clusters revealed many significant differences. However, most differences failed to withstand correction for total CBM volumes (TCV). Smaller volumes were consistently reported for the TTM versus NC cohorts. Total Massachusetts General Hospital Hair Pulling Scale (MGHHPS) scores were significantly inversely correlated with left primary sensorimotor cluster volumes (p = .008), with smaller volumes associated with more severe TTM symptoms. CONCLUSIONS: These findings implicate the CBM in the neurobiology of TTM, with reduced subterritory volumes reported for the TTM versus NC groups.     

Trichotillomania (hair pulling disorder), skin picking disorder,and stereotypic movement disorder: toward DSM‐V

In DSM‐IV‐TR, trichotillomania (TTM) is classified as an impulse control disorder (not classified elsewhere), skin picking lacks its own diagnostic category (but might be diagnosed as an impulse control disorder not otherwise specified), and stereotypic movement disorder is classified as a disorder usually first diagnosed in infancy, childhood, or adolescence. ICD‐10 classifies TTM as a habit and impulse disorder, and includes stereotyped movement disorders in a section on other behavioral and emotional disorders with onset usually occurring in childhood and adolescence. This article provides a focused review of nosological issues relevant to DSM‐V, given recent empirical findings. This review presents a number of options and preliminary recommendations to be considered for DSM‐V: (1) Although TTM fits optimally into a category of body‐focused repetitive behavioral disorders, in a nosology comprised of relatively few major categories it fits best within a category of motoric obsessive–compulsive spectrum disorders, (2) available evidence does not support continuing to include (current) diagnostic criteria B and C for TTM in DSM‐V, (3) the text for TTM should be updated to describe subtypes and forms of hair pulling, (4) there are persuasive reasons for referring to TTM as “hair pulling disorder (trichotillomania),” (5) diagnostic criteria for skin picking disorder should be included in DSM‐V or in DSM‐Vs Appendix of Criteria Sets Provided for Further Study, and (6) the diagnostic criteria for stereotypic movement disorder should be clarified and simplified, bringing them in line with those for hair pulling and skin picking disorder. Depression and Anxiety, 2010. © 2010 Wiley‐Liss, Inc.     

Reliability and validity of the DBT-VLCS: A measure to code validation strategies in dialectical behavior therapy sessions

Objective: There are six strategies or validation levels in dialectical behavior therapy (DBT), yet there are no measures designed to code for them. This absence limits our understanding of the relationship between validation strategies and treatment outcome. The DBT-Validation Level Coding Scale (DBT-VLCS) was developed to overcome this limitation. Method: This research reports on the interrater reliability and content validity for the DBT-VLCS. Results: Overall, interrater reliability was excellent for all items, with the exception of two items that demonstrated good reliability. Good content validity was demonstrated for six of the seven items. Conclusions: This preliminary study suggests that the DBT-VLCS is a reliable and valid measure to code the presence of validation in DBT. This measure creates the opportunity for research that has not previously been possible.     

Use of a habit reversal treatment for temporomandibular pain in a minimal therapist contact format

Previous research has suggested that a habit reversal treatment might be used effectively in a home-based minimal therapist contact (MTC) protocol to facilitate flexibility and increase treatment completion rates. Recent reviews of MTC interventions have found it to be generally efficacious, cost-effective, and generalizable. While MTC has been used for certain health-related disorders (e.g., headache), almost no research has evaluated the effectiveness of a MTC protocol with a population suffering from temporomandibular disorder (TMD). The current study utilized an oral habit reversal treatment in a MTC format in an attempt to reduce attrition and increase treatment flexibility. Twenty females suffering from TMD were randomly assigned to either a treatment (n=10) or a wait-list control (n=10) condition. Six individuals in each group used telephone contact while 4 used e-mail for weekly communication with the therapist. Results demonstrated that a habit reversal treatment in a MTC format led to statistically and clinically significant improvements in mean weekly pain ratings, number of pain-free days per week, and highest weekly pain ratings. Also, a significant reduction in maladaptive oral habits occurred from pre- to post-treatment and significant reductions in life stress and pain interference were observed. Results were maintained at follow-up. The implications for the use of MTC for treatment of facial pain are discussed, as are the implications of these findings for the role of oral habits in the etiology of TMD.     

Waitlist‐controlled trial of cognitive behavior therapy for hoarding disorder

Objective: This study investigated a multicomponent cognitive behavioral treatment (CBT) for hoarding based on a model proposed by Frost and colleagues and manualized in Steketee and Frost (2007). Method: Participants with clinically significant hoarding were recruited from the community and a university‐based anxiety clinic. Of the 46 patients randomly assigned to CBT or waitlist (WL), 40 completed the 12‐week assessment and 36 completed 26 sessions. Treatment included education and case formulation, motivational interviewing, skills training for organizing and problem solving, direct exposure to nonacquiring and discarding, and cognitive therapy. Measures included the Saving Inventory‐Revised (self‐report), Hoarding Rating Scale‐Interview, and measures of clinical global improvement. Between group repeated measures analyses using general linear modeling examined the effect of CBT versus WL on hoarding symptoms and moodstate after 12 weeks. Within group analyses examined pre‐post effects for all CBT participants combined after 26 sessions. Results: After 12 weeks, CBT participants benefited significantly more than WL patients on hoarding severity and mood with moderate effect sizes. After 26 sessions of CBT, participants showed significant reductions in hoarding symptoms with large effect sizes for most measures. At session 26, 71% of patients were considered improved on therapist clinical global improvement ratings and 81% of patients rated themselves improved; 41% of completers were clinically significantly improved. Conclusions: Multicomponent CBT was effective in treating hoarding. However, treatment refusal and compliance remain a concern, and further research with independent assessors is needed to establish treatment benefits and durability of gains. Depression and Anxiety, 2010. © 2010 Wiley‐Liss, Inc.     

Dialectical behavior therapy in the Asia‐Pacific Rim region

Background: Borderline personality disorder (BPD) contributes to suicide‐related morbidity and mortality and requires more intensive psychotherapeutic resources due to its high mental health service usage. Accessibility to an evidence‐based treatment program is a cornerstone to support patients with BPD and part of broader suicide prevention efforts as well as improving their quality of life. Aims: In this article, the authors aim to discuss and review available dialectical behavior therapy (DBT) and DBT‐informed services of selected countries in the Asia‐Pacific Rim, namely Singapore, Malaysia, and Mexico. Materials & Methods: We contacted providers of different services and gathered information on the process of setting up the service and adapting the treatment, in addition to reviewing the available literature published in the countries. Results: To date, there have been a pair of DBT‐informed services in Singapore, four in Malaysia, and several in Mexico with a few of them offering standard DBT. Different efforts have been put in place to increase the accessibility to training and also the number of DBT practitioners. Discussion: Important considerations during the process of setting up new services include the use of domestic examples and local language that are contextually appropriate for the local community. Selected challenges faced in common include shortage of workforce, affordability of training programs, and the need for language adaptation with or without translation. Conclusion: Further long‐term evaluation of locally adapted DBT‐informed mental health services will help to elucidate the effectiveness and efficacy of the program which will potentially serve as a guide for other resource‐scarce regions.     

辩证行为治疗在青少年非自杀性自伤行为中的应用

本文目的是分析辩证行为治疗(DBT)在青少年非自杀性自伤(NSSI)行为治疗中的有效性,以期为我国青少年NSSI行为的干预提供参考。NSSI行为是青少年常见的心理健康威胁,近年来已经成为全球范围内不容忽视的精神卫生问题,目前对于NSSI行为的干预主要采用心理治疗,其中越来越多的证据显示DBT在减少NSSI行为方面有效。本文从NSSI行为发生的危险因素、DBT的概述及DBT在NSSI应用中的疗效等方面进行阐述。     

Current controversies on the role of behavior therapy in Tourette syndrome

Comprehensive behavioral intervention for tics (CBIT) is a safe and effective treatment for managing the tics of Tourette syndrome (TS). In contrast to most current medications used for the treatment of tics, the efficacy of CBIT has been demonstrated in 2 relatively large, multisite trials. It also shows durability of benefit over time. Similar to psychopharmacological intervention, skilled practitioners are required to implement the intervention. Despite concerns about the effort required to participate in CBIT, patients with TS and parents of children with TS appear willing to meet the requirements of the CBIT program. Efforts are under way to increase the number of trained CBIT providers in the United States. Based on available evidence, recent published guidelines suggest that CBIT can be considered a first‐line treatment for persons with tic disorders. © 2013 Movement Disorder Society     

Movement decoupling: A self-help intervention for the treatment of trichotillomania

Trichotillomania (TTM) is classified as an impulse control disorder characterized by the recurrent urge to pull out one’s own hair resulting in noticeable hair loss. Cognitive-behavioral therapy, involving habit reversal training, currently represents the treatment of choice. The present study assessed the feasibility and effectiveness of a novel self-help technique, entitled decoupling (DC). DC aims at attenuating TTM by performing movements that decouple the behavioral elements involved in hair pulling. A total of 42 subjects with TTM were recruited via self-help forums for TTM and were randomized either to DC or progressive muscle relaxation (PMR). After four weeks, participants were asked to fill out the same questionnaires as before and rate the effectiveness of the intervention. The completion rate was high and the reliability of the assessments at least satisfactory. The DC group showed a significantly greater decline on the Massachusetts General Hospital – Hair-Pulling Scale, which served as the primary outcome, relative to PMR indicating a medium to strong effect size. Declines on scales tapping depression and obsessive–compulsive disorder were comparable between the two groups. Despite some methodological limitations and the need for replication including follow-up and expert ratings, the present study suggests that DC may prove beneficial to a substantial number of individuals affected with TTM.     

Efficacy of interpersonal therapy‐group format adapted to post‐traumatic stress disorder: an open‐label add‐on trial

Background: Post‐traumatic stress disorder (PTSD) is a highly prevalent condition, yet available treatments demonstrate only modest efficacy. Exposure therapies, considered by many to be the “gold‐standard” therapy for PTSD, are poorly tolerated by many patients and show high attrition. We evaluated interpersonal therapy, in a group format, adapted to PTSD (IPT‐G PTSD), as an adjunctive treatment for patients who failed to respond to conventional psychopharmacological treatment. Methods: Research participants included 40 patients who sought treatment through a program on violence in the department of psychiatry of Federal University of São Paulo (UNIFESP). They had received conventional psychopharmacological treatment for at least 12 weeks and failed to have an adequate clinical response. After signing an informed consent, approved earlier by the UNIFESP Ethics Review Board, they received a semi‐structured diagnostic interview (SCID‐I), administered by a trained mental health worker, to confirm the presence of a PTSD diagnosis according to DSM‐IV criteria. Other instruments were administered, and patients completed out self‐report instruments at baseline, and endpoint to evaluate clinical outcomes. Results: Thirty‐three patients completed the trial, but all had at least one second outcome evaluation. There were significant improvements on all measures, with large effect sizes. Conclusions: IPT‐G PTSD was effective not only in decreasing symptoms of PTSD, but also in decreasing symptoms of anxiety and depression. It led to significant improvements in social adjustment and quality of life. It was well tolerated and there were few dropouts. Our results are very preliminary; they need further confirmation through randomized controlled clinical trials. Depression and Anxiety, 2010. © 2009 Wiley‐Liss, Inc.     

Comparing the effectiveness of similar and dissimilar competing responses in evaluating the habit reversal treatment for oral-digital habits in children

In the present study 26 children with chronic oral–digital habits were randomly assigned to 1 of 3 conditions. Group 1 received habit reversal using a similar competing response. Group 2 received habit reversal using a dissimilar competing response, and Group 3 served as a wait-list control group. Three videotaped observations were taken at pretreatment and again at posttreatment. In addition, social acceptability data were collected on the treatment groups at posttreatment. Results showed that the similar and dissimilar groups were engaging in significantly less oral–digital behavior at posttreatment when compared to the control group. However, the two treatment groups did not differ from each other in terms of treatment gains or acceptability. These results suggest that habit reversal is an effective treatment for oral digital habits in children. In addition, it appears that the competing response does not function as a physically incompatible behavior. Implications of the findings are discussed.     

Predictors of dropout from inpatient dialectical behavior therapy among women with borderline personality disorder

Inpatient dialectical behavior therapy (DBT) is an effective treatment for borderline personality disorder (BPD), but often treatment is ended prematurely and predictors of dropout are poorly understood. We, therefore, studied predictors of dropout among 60 women with BPD during inpatient DBT. Non-completers had higher experiential avoidance and trait anxiety at baseline, but fewer life-time suicide attempts than completers. There was a trend for more anger–hostility and perceived stigma among non-completers. Experiential avoidance and anxiety may be associated with dropout in inpatient DBT. Low life-time suicidality and high anger could reflect a subtype at risk for discontinuation of inpatient treatment.