The association between trichotillomania symptoms and emotion regulation difficulties: A systematic review and meta-analysis.

BACKGROUND: Emotion regulation is postulated to play an important role in Trichotillomania (TTM). Whilst a growing number of studies have examined the relationship between emotion regulation difficulties and TTM symptoms, there have been no attempts to evaluate the overall strength of this association or the quality of the evidence base. METHOD: This systematic review and meta-analysis aimed to synthesise findings from studies that have examined the relationship between emotion regulation difficulties and TTM symptoms, to inform future TTM treatment targets. We identified 17 studies that met inclusion criteria. From these studies, 32 correlation coefficients were extracted for meta-analysis. The Joanna Briggs Institute Checklist for Analytical Cross Sectional Studies was used to assess risk of bias amongst the included studies. RESULTS: There was a moderately sized association between TTM symptoms and ER difficulties, (r adjusted = 0.32, 95 % CI [0.28, 0.37], t = 15.58 (df = 11.86), p < 0.0001) that was moderated by sample size (F(df1 = 1, df2 = 30) = 4.597, b = -0.0001, SE = 0.0001, 95 % CI [-0.0002; 0.0000], p = 0.040) and differences between types of emotion regulation measures (Q(df = 1) = 4.06, p = 0.044). LIMITATIONS: The data analysed was correlational, therefore causality was unable to be determined. Comorbidities were not able to be examined as a moderator. CONCLUSION: This study provided a preliminary integration of the evidence and demonstrated that individuals with higher levels of TTM severity appear to exhibit decreased overall emotion regulation abilities and strategies.

Recent advances in trichotillomania: a narrative review.

Trichotillomania, defined as the compulsive pulling out of one's hair, is a psychocutaneous condition associated with functional impairment and decreased quality of life. The pathophysiology of trichotillomania is poorly understood and likely multifactorial, involving alterations in both neural activity and cognitive function. Behavioral treatment options for trichotillomania are limited and are often only modestly effective. Moreover, there are no medications currently approved by the U.S. Food and Drug Administration for its treatment. The gaps in knowledge regarding the neurological underpinnings and behavioral markers of trichotillomania and effective treatment options for it highlight the importance of ongoing research in this field. For this narrative review, PubMed was searched to identify articles related to trichotillomania published until July 2023. Recent advances in research on trichotillomania pathophysiology, diagnosis, clinical associations, and treatment are presented, with particular focus on how this condition uniquely spans the disciplines of both psychiatry and dermatology.

Habit-reversal training: a psychotherapeutic approach in treating body-focused repetitive behaviour disorders.

Body-focused repetitive behaviours (BFRBs) are recurrent, compulsive, destructive behaviours directed towards the body. Although studies have demonstrated a 12-14% prevalence rate, researchers found that dermatologists and psychiatrists show a lack of knowledge regarding psychodermatology resources and information about BFRB disorders (BFRBDs) such as trichotillomania (TTM). There is limited research about treatments including ones investigating the clinical applications of various self-help training such as decoupling (DC) and DC in sensu (DC-is) as well as about habit-reversal training (HRT). HRT is a five-component behavioural intervention that aims to develop a competing response to a specific unwanted behaviour. Studies have found substantial support for HRT's efficacy in treating a variety of maladaptive repetitive behaviours including onychotillomania, TTM, skin-picking disorder and chronic cheek biting. Additionally, many psychotherapies can augmented HRT. Psychotherapies include acceptance and commitment therapy, dialectical behaviour therapy, psychodynamic psychotherapy, mindfulness mediation and the cognitive psychophysiological model. A recently investigated variant of HRT, DC-is, resulted in consistently satisfactory objective and subjective improvement for treating BFRBDs, and HRT showed good subjective but poor objective improvement compared with standard DC. HRT and HRT variants are effective therapeutic treatments for BFRBDs; however, further randomized double-blinded and placebo-controlled trials are required to examine HRT's therapeutic profile.

Hazardous Alcohol Use in Trichotillomania.

Trichotillomania is a prevalent mental health condition characterized by repetitive hair-pulling. Its relationship to alcohol use problems has received virtually no research scrutiny. Adults with trichotillomania (n = 121) were recruited from the general community, along with 66 healthy controls for reference purposes (in terms of overall levels of hazardous drinking). Participants undertook structured clinical interview and completion of self-report instruments to characterize clinical profiles and associated characteristics. In the trichotillomania sample, we compared variables of interest between those with past-year hazardous alcohol use and those without. Of the 121 adults with trichotillomania, 16 (13.2%) scored ≥ 8 on the AUDIT indicating hazardous alcohol use as compared to 5 (7.5%) of the healthy controls - this difference was not statistically significant. In trichotillomania cases, past year hazardous drinking was associated with significantly higher trait impulsivity, but not with differences in the other variables that were examined. This study highlights the importance of screening for alcohol use problems in people with trichotillomania. More research is needed into this comorbid presentation, including work to explore the impact of hazardous alcohol use on clinical treatment outcomes, as well as how treatments might best be adapted to treat individuals affected by both disorders.

Self-Help Habit Replacement in Individuals With Body-Focused Repetitive Behaviors: A Proof-of-Concept Randomized Clinical Trial.

Importance: Body-focused repetitive behaviors (BFRBs; eg, skin picking) encompass a set of conditions at the interface of dermatology and psychiatry/psychology. The disorder is prevalent but currently underdiagnosed and undertreated. Objective: To compare a new self-help intervention, habit replacement, against a wait-list control condition for the treatment of BFRBs. Design, Setting, and Participants: This randomized clinical trial was conducted online in 2022. Participants were a population-based nonclinical sample with BFRBs and were recruited via social media. Initially, 481 individuals entered the assessment; 213 were excluded blind to results. A final sample of 268 participants were randomized. The intervention period was 6 weeks. Interventions: Participants were randomized to a self-help intervention, habit replacement, or a wait-list control condition (each n = 134). Main Outcomes and Measures: The Generic BFRB Scale-45 (GBS-45, self-report) represented the primary outcome. Results: Individuals in the 2 conditions (n = 268; 241 [89.9%] women; mean [SD] age, 36.8 [11.1] years; skin picking, 68.3%; trichotillomania, 28.4%; nail biting, 36.6%; lip-cheek biting, 26.1%; other, 20.1%) did not differ on any baseline characteristics. The experimental group significantly improved on the primary outcome (GBS-45) for both the per-protocol (technique was used at least once weekly, ηp2 = 0.068, P = .001) and the intention-to-treat analyses relative to the wait-list control group (expectation-maximization algorithm; ηp2 = 0.019, P = .02). The interaction of group and time yielded statistical trends in favor of the experimental condition only on the Patient Health Questionnaire-9 and quality of life. For the Clinical Global Impressions scale, more individuals in the habit replacement group reported improvement (52.8% vs 19.6%; P < .001). User satisfaction in the habit replacement group was high. Moderation analyses that included all baseline variables showed that those who exhibited nail biting particularly benefited from the new technique. Conclusions and Relevance: The present proof-of-concept randomized clinical trial tentatively demonstrates that habit replacement is a feasible and effective self-help strategy against BFRBs, especially for nail biting. Study limitations include the lack of external assessment and verified diagnoses. In addition, the study is missing follow-up data. Self-help habit replacement shows promise in reducing BFRBs but not concomitant symptoms. Trial Registration: German Clinical Trials Register Identifier: DRKS00030511.

Latent class analysis of emotions experienced during compulsive hair-pulling episodes.

BACKGROUND AND OBJECTIVES: Reasons for compulsive hair pulling are heterogeneous and not fully understood. Given that many people who experience compulsive hair pulling do not respond to treatment, identifying subgroups can inform potential mechanisms and treatment design. METHODS: We sought to identify empirical subgroups among participants in an online treatment program for trichotillomania (N = 1728). A latent class analysis was used to identify patterns of emotions associated with compulsive hair-pulling episodes. RESULTS: Six classes of participants were found which reflected three predominant themes. One theme reflected expected patterns, where emotional changes were seen following pulling. Two other themes were more surprising, where one reflected high overall emotional activation that did not show consistent change in response to pulling, and another showed low emotional activation overall. These results suggest that there are multiple types of hair-pulling and a sizeable group of people may benefit from treatment adjustments. LIMITATIONS: Participants did not receive semi-structured diagnostic assessment. A majority of participants were Caucasian, and future research would benefit from increased participant diversity. Emotions associated with compulsive hair-pulling were measured across an entire treatment program, but the relationship between specific intervention components and change in specific emotions was not systematically collected. CONCLUSIONS: While previous research has addressed overall phenomenology and comorbidity, the present study is the first to identify empirical subgroups of people who experience compulsive hair-pulling at the level of individual pulling episodes. Identified participant classes had distinguishing features that can aid in personalizing treatment to individual symptom presentations.

The role of psychological flexibility in acceptance-enhanced behavior therapy for trichotillomania: Moderation and mediation findings.

Trichotillomania is characterized by recurrent pulling out of one's hair, leading to significant hair loss and accompanied by clinically significant distress and/or functional impairment. The current study used data from a randomized controlled trial comparing the effectiveness of acceptance-enhanced behavior therapy (AEBT) to psychoeducation plus supportive therapy (PST; active control) for trichotillomania in an adult sample. The objectives were to examine the moderating and mediating influence of trichotillomania-specific psychological flexibility in treatment for trichotillomania. Participants with lower baseline flexibility performed better in AEBT than PST in terms of greater symptom reduction and quality of life. Lower baseline flexibility also predicted higher likelihood of disorder recovery in AEBT relative to PST. In addition, relative to PST, symptom reduction in AEBT was mediated by psychological flexibility, controlling for anxiety and depression. These findings suggest that psychological flexibility is a relevant process of change in the treatment of trichotillomania. Clinical implications and directions for future research are discussed.

Temperament in trichotillomania and skin picking disorder.

BACKGROUND: Trichotillomania (TTM) and skin picking disorder (SPD) result in significant psychosocial burden. Despite this burden, however, risk factors related to the development of these disorders remain unclear. The present study assessed temperament in a well-characterized sample of adults with TTM or SPD. METHODS: A total of 202 adults age 18 to 65 were enrolled; 44 had TTM, 30 had SPD, and 128 served as controls. Participants completed the self-report Tridimensional Personality Questionnaire (TPQ) to examine the severity of TTM and SPD symptoms, quality of life, and temperament. Group differences were characterized and correlations with other measures were examined. RESULTS: Compared to controls, those with TTM or SPD scored significantly higher on harm avoidance and its subscales, with TTM associated with higher scores than SPD. Those with TTM or SPD scored significantly higher on only 1 measure of novelty seeking (extravagance). Higher TPQ harm avoidance correlated with worse hair pulling severity and worse quality of life. CONCLUSIONS: The temperament traits of participants with TTM or SPD differed in significant ways from controls; those with TTM or SPD generally demonstrated similar trait profiles. A dimensional approach to the personalities of those with TTM or SPD may offer insight and provide clues to treatment strategies.

Body Focused Repetitive Behavior Disorders: Behavioral Models and Neurobiological Mechanisms. / Beden Odakli Tekrarlayici Davranis Bozukluklari: Davranis Modelleri ve Nörobiyolojik Mekanizmalar.

OBJECTIVE: Body Focused Repetitive Behaviors (BFRB) is an umbrella term for undesirable, repetitive motor activities such as Trichotillomania (TTM), Skin Picking Disorder (SPD), nail biting, cheek chewing, lip biting, finger sucking, finger cracking and teeth grinding. Such behaviors are engaged in to eliminate a part of the body and may result in impaired functionality. The frequency of presentation to clinicians is low since BFRB are defined as harmless, although the number of studies on this condition has increased rapidly recently, including those making a clear determination of epidemiological data, those investigating the etiopathogenesis and those providing treatment guidelines, although they remain inadequate. The present study provides a review of studies investigating the etiology of BFRB to date. METHOD: Articles published between 1992 and 2021 stored in the Pubmed, Medline, Scopus and Web of Science databases were reviewed, and the prominent research studies of the condition identified were included in the evaluation. RESULTS: Studies investigating the etiopathogenesis of BFRB were found in most cases to investigate adult populations, and were hampered by such confounding factors as clinical heterogeneity, high rates of comorbid psychiatric diseases and small sample sizes. The identified studies reveal that attempts have been made to explain BFRB based on behavioral models, and that the condition is inherited at a high rate. Treatment planning is mostly associated with monoamine systems (especially glutamate and dopamine) and interventions were directed to addiction elements. Furthermore, cognitive flexibility and motor inhibition defects in neurocognitive area and cortico-striato-thalamocortical cycle abnormalities in neuroimaging studies have been reported. CONCLUSION: Studies investigating the clinical features, incidence, etiopathogenesis and treatment of BFRB, which holds a controversial place in psychiatric classification systems, would contribute to a better understanding of the disease and a more appropriate definition of the condition.

Sleep Disturbances in Pediatric Body-Focused Repetitive Behaviors: A Preliminary Investigation.

Body-focused repetitive behaviors (BFRBs) are repeated actions to one's body resulting in physical damage. Limited research has examined sleep, a known factor in psychological health, within the context of pediatric BFRBs. The current study sought to explore the connection between disordered sleep and BFRBs in a community sample. Aim 1 of the study was to determine the predictive power of group membership [control group (no BFRB symptoms reported), subthreshold BFRB group (mild BFRB symptoms reported; severity score of 2 or less out of 9), and those with symptoms characteristic of BFRBs (more than mild BFRB symptoms reported; severity score of 3 or higher out of 9)] for level of sleep disturbance. A hierarchical regression revealed that there was a significant effect of group membership after controlling for anxiety (F (3, 410) = 152.976, p < .001). Aim 2 of the study was to test whether there was a relationship between sleep disturbance and BFRB severity. The hierarchical regression revealed that at Step 1, anxiety accounted for 23.1% of the variance in BFRB severity (ß = 0.48, t = 8.87, p < 0.001). At Step 2, sleep disturbance total score accounted for an additional 7.2% of the variance, suggesting this variable makes a unique contribution to overall BFRB severity (SDSC: ß = 0.40, t = 5.18, p < 0.001). The findings of this study suggest that sleep could be a clinical factor to consider when conceptualizing a child with BFRBs.

Mapping the future of interventional psychiatry for the obsessive-compulsive related disorders: A scoping review.

Body dysmorphic disorder (BDD), hoarding disorder (HD), skin-picking disorder (SPD), and hair-pulling disorder (HPD) are characterized by compulsive behaviours leading to distress and impairment. Current treatments attain only partial or non-response. Interventional psychiatric approaches may target specific regions of the brain for treatment. This scoping review maps the current literature and synthesizes key findings. Databases were searched up to June 27, 2022 for studies examining interventional psychiatric treatments for BDD, HD, SPD, and HPD, producing 910 results. Twenty were included; 16 were case reports, two were case series, and two were randomized controlled trials. Studies reported on electroconvulsive therapy (ECT) (n=7), deep brain stimulation (DBS) (n=1), and intermittent theta-burst stimulation repetitive transcranial magnetic stimulation (rTMS) (n=1) for BDD; rTMS (n=1) and transcranial direct current stimulation (n=1) for HD; gamma knife capsulotomy (n=1) and rTMS (n=1) for SPD; and rTMS (n=2) and ECT (n=1) for HPD. Four studies reported on DBS for other indications complicated by SPD or HPD. The current literature consists mainly of case reports. Future studies should be randomized, controlled, adequately powered and blinded, examining rTMS localized to the anatomical targets for each disorder. Presently, the mainstay of treatment remains disorder-specific psychotherapy with limited evidence for medications.

Acceptance-enhanced behavior therapy for trichotillomania in adults: A randomized clinical trial.

Given the limited treatment options for trichotillomania (TTM), or Hair Pulling Disorder, this large randomized clinical trial evaluated the efficacy of acceptance-enhanced behavior therapy for TTM (AEBT-TTM) in reducing TTM severity relative to psychoeducation and supportive therapy (PST). Eighty-five adults (78 women) with TTM received 10 sessions (over 12 weeks) of either AEBT-TTM or PST. Independent evaluators masked to treatment assignment assessed participants at baseline (week 0), midpoint (week 6), and endpoint (week 12). Consistent with a priori hypotheses, 64% of the adults treated with AEBT-TTM were classified as clinical responders at post-treatment relative to 38% treated with PST. Clinical responders were identified by a score of 1 or 2 on the Clinical Global Impressions-Improvement (CGI-I) scale. Relative to the PST group, the AEBT-TTM group demonstrated significantly greater pre-to post-treatment reductions on the self-report Massachusetts General Hospital-Hairpulling Scale (MGH-HS) and the evaluator-rated National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS). There were no significant post-treatment group differences on the Clinical Global Impressions-Severity (CGI-S) scale, or rate of TTM diagnoses. Results suggest AEBT-TTM provides greater treatment benefit than PST. Future research should continue to investigate AEBT-TTM along with mediators and moderators of its efficacy.

The Generic BFRB Scale-8 (GBS-8): a transdiagnostic scale to measure the severity of body-focused repetitive behaviours.

BACKGROUND: Body-focused repetitive behaviours (BFRBs) such as skin picking and hair pulling are frequent but under-diagnosed and under-treated psychological conditions. As of now, most studies use symptom-specific BFRB scales. However, a transdiagnostic scale is needed in view of the high co-morbidity of different BFRBs. AIMS: We aimed to assess the reliability as well as concurrent and divergent validity of a newly developed transdiagnostic BFRB scale. METHOD: For the first time, we administered the 8-item Generic BFRB Scale (GBS-8) as well as the Repetitive Body Focused Behavior Scale (RBFBS), modified for adults, in 279 individuals with BFRBs. The GBS-8 builds upon the Skin Picking Scale-Revised (SPS-R), but has been adapted to capture different BFRBs concurrently. A total of 170 participants (61%) were re-assessed after 6 weeks to determine the test-retest reliability of the scale. RESULTS: Similar to the SPS-R, factor analysis yielded two dimensions termed symptom severity and impairment. The test-retest reliability of the scale was satisfactory (r = .72, p<.001). Concurrent validity (r = .74) with the RBFBS was good (correlational indexes for concurrent validity were significantly higher than that for discriminant validity). DISCUSSION: The GBS-8 appears to be a reliable and valid global measure of BFRBs. We recommend usage of the scale in combination with specific BFRB scales to facilitate comparability across studies on obsessive-compulsive spectrum disorders.

The Potential of N-Acetylcysteine for Treatment of Trichotillomania, Excoriation Disorder, Onychophagia, and Onychotillomania: An Updated Literature Review.

BACKGROUND: Trichotillomania (TTM), excoriation disorder, onychophagia, and onychotillomania are categorized as body focused repetitive behavior (BFRB) disorders, causing damage to the skin, hair, and/or nails with clinically significant psychosocial consequences. Currently, there are no standardized treatments for these compulsive, self-induced disorders. Studies on treatment of these disorders using psychotropic drugs (i.e., selective serotonin reuptake inhibitors, tricyclic antidepressants, anticonvulsants) have shown variable efficacy. Recently, there is a growing interest in N-acetylcysteine (NAC) for treating BFRBs. NAC is a glutamate modulator that has shown promise in successfully reducing the compulsive behaviors in BFRB disorders. This article provides an updated review of the literature on the use of NAC in TTM, excoriation disorder, onychophagia, and onychotillomania. METHODS: Relevant articles were searched in the PubMed/MEDLINE database. RESULTS: Twenty-four clinical trials, retrospective cohort studies, and case reports assessing the efficacy of NAC in TTM, excoriation disorder, and onychophagia were included. No studies for onychotillomania were found in our search. CONCLUSIONS: Although NAC has proven successful for treatment of BFRB disorders, data is derived from few clinical trials and case reports assessing small numbers of patients. Larger studies with longer durations are needed to fully establish the efficacy of NAC in these disorders.

Comorbid trichotillomania and attention-deficit hyperactivity disorder in adults.

BACKGROUND: Individuals with trichotillomania (TTM), a disorder characterized by repetitive pulling out of one's own hair, often have co-occurring ADHD, but little is known about this comorbidity. Additionally, there have been intimations in the literature that treatment of ADHD with stimulants may worsen TTM symptoms. This study aims to examine clinical aspects of individuals with TTM and co-occurring ADHD. METHODS: 308 adults with a current diagnosis of TTM were assessed for ADHD using the Mini International Neuropsychiatric Interview 7.0.2 and Adult ADHD Self Report Scale. Participants also completed clinical measures related to TTM severity, impulsivity, quality of life, and psychosocial dysfunction. A series of analyses of variance were used to calculate differences in scale scores among subjects with and without co-occurring ADHD. RESULTS: Of the 308 participants, 47 (15.3%) met the clinical threshold for ADHD. Participants with ADHD reported significantly higher scores in all first and second factor traits of impulsivity, including attentional impulsiveness (p < .0001), motor impulsiveness (p < .0001), and non-planning impulsiveness (p < .0001). Interestingly, participants with ADHD did not report significant differences in TTM severity, perceived quality of life, or functional impairment, regardless of medication status. DISCUSSION: The data suggest that ADHD is common in adults with TTM, and the comorbidity is associated with heightened impulsivity. The co-occurrence of ADHD does not affect individuals' quality of life, symptom severity, or functionality. Taking stimulant medications for ADHD also did not appear to affect TTM severity, despite past case reports suggesting these medications may lead to onset or worsening of TTM.

Statistical predictors of psychosocial impairment in body-focused repetitive behaviors.

BACKGROUND: Skin picking disorder and trichotillomania, also characterized as body-focused repetitive behaviors (BFRBs), often lead to functional impairment. Some people with BFRBs, however, report little if any psychosocial dysfunction. There has been limited research as to which clinical aspects of BFRBs are associated with varying degrees of functional impairment. METHODS: Adults (n = 98), ages 18 to 65 with a current diagnosis of trichotillomania (n = 37), skin picking disorder (n = 32), trichotillomania plus skin picking disorder (n = 10), and controls (n = 19) were enrolled. Partial least squares regression (PLS) was used to identify variables associated with impairment on the Sheehan Disability Scale. RESULTS: PLS identified an optimal model accounting for 45.8% of variation in disability. Disability was significantly related to (in order of descending coefficient size): severity of picking, perceived stress, comorbid disorders (specifically, anxiety disorders / obsessive-compulsive disorder), trait impulsivity, family history of alcohol use disorder, atypical pulling/picking sites, and older age. CONCLUSIONS: At present mental disorders are viewed as unitary entities; however, the extent of impairment varies markedly across patients with BFRBs. These data suggest that whereas symptom nature/severity is important in determining impairment, so too are other variables commonly unmeasured in clinical practice. Outcomes for patients may thus be maximized by rigorously addressing comorbid disorders; as well as integrating components designed to enhance top-down control and stress management. Interestingly, focused picking and emotional pulling were linked to worse disability, hinting at some differences between the two types of BFRBs, in terms of determinants of impairment.

Parental Bonding in Trichotillomania and Skin Picking Disorder.

BACKGROUND: One means of understanding the effect of environmental factors on psychiatric disorders is by examining perceived parenting behavior in the childhood of individuals with trichotillomania and skin picking disorder (i.e. body focused repetitive behaviors (BFRBs)). We hypothesized that adults with BFRBs would show higher scores on dimensions of "care" and "overprotection". Specifically, we predicted that adults with BFRBs would have parents in the "affectionate constraint" quadrant, based on a combination of high care and high protection scores. METHODS: We assessed demographic and clinical differences in 184 adults between the ages of 18 and 65 with Trichotillomania (TTM) (n = 43) and Skin Picking Disorder (SPD) (n = 75), and both (n = 66). The Parental Bonding Instrument (PBI) measured "care" and "overprotection" items. Results from the PBI were compared across groups and with normal control data using independent sample t-tests. RESULTS: Individuals in the BFRB group had significantly lower maternal and paternal care scores compared to controls. The TTM, SPD, and TTM + SPD (combined) groups all had lower maternal care scores than controls. The TTM + SPD (combined) group had significantly lower paternal care scores and higher maternal protection scores than the normative averages. The most common parenting patterns in subjects with BFRBs were maternal and paternal affectionless control (low care/high protection). From our sample, only 27 % reported optimal maternal parenting and 28 % reported optimal paternal parenting. DISCUSSION: These preliminary data suggest that low maternal and paternal care may be associated with BFRBs. However, the nature of this relationship should be further explored, as these results do not necessarily mean that affectionless control parenting leads to a predisposition to BFRBs, and there may in fact be other environmental factors at play. Identifying how individuals perceive familial relationships may provide direction for clinicians in developing tools to address the burden caused by BFRBs.

Automatic and focused hair pulling in trichotillomania: Valid and useful subtypes?

Prior work suggested that trichotillomania may have four subtypes based on the extent to which pulling is automatic or focused in nature. 238 adults with trichotillomania undertook clinical and cognitive assessments and were assigned into four subtypes based on k-means clustering of Milwaukee Inventory for Subtypes of Trichotillomania-Adult Version (MIST-A) scores. We examined whether a cluster solution was apparent using conventional metrics. Based on prior literature, we then force-fitted a four subtype model (low-low, low-high, high-low, high-high). Subtypes were compared and validity of the MIST-A subtyping approach was evaluated. A cluster solution did not converge based on conventional metrics. Following force-fitting, subtypes did not differ on demographic variables, age at symptom onset, nor duration of illness. The high-focused high-automatic subtype had worse symptom severity than other subtypes. Co-morbid depression was more common in the low-focused low-automatic and high-focused low-automatic subtypes. This study suggests that MIST-A subtypes may not be valid or clinically useful based on several issues. First, k-means models indicated that the MIST-A data did not generate any cluster solutions. Second, when a forced cluster solution was fitted, the subtypes did not differ on the vast majority of measures. Third, force-fitting four subtypes yielded findings that were logically inconsistent (e.g. worse quality of life in one group, but higher rates of comorbid anxiety/depression in others). Overall, we suggest that both focused and automatic pulling may characterize the same pulling episode, or certainly the same person across episodes. Thus they may be clinically relevant variables, but not forming coherent subtypes.

Trichotillomania and excoriation disorder: Primary care implications.

ABSTRACT: Trichotillomania and excoriation disorder are two psychiatric conditions that have similar origins to obsessive compulsive disorder. Both can cause patients significant distress and lead to medical consequences. It is important that primary care NPs identify and refer these individuals for psychiatric treatment.