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BEHAVIOR THERAPY 29, 157-171, 1998

Effectiveness of a Cognitive Behavioral Treatment Program for Trichotillomania: An Uncontrolled Evaluation

JULIE LERNER

MARTIN E. FRANKLIN

ELIZABETH A. MEADOWS

ELIZABETH HEMBREE

EDNA B. FOA

Allegheny University of the Health Sciences

The effectiveness of a cognitive behavioral treatment program for trichotillomania was examined in an uncontrolled study. Immediately following treatment, 12 of 14 treatment completers were classified as responders (>50% improvement on NIMH Trichotillomania Severity Scale). However, only 4 of 13 treated patients were classified as responders at follow-up (M = 3 years, 9 months); one posttreatment responder was lost to follow-up. Long-term symptom severity was also assessed in a subset of treatment refusers and dropouts; 4 of 10 available treatment refusers and dropouts were classified as improved at follow-up (M = 3 years, 2 months). Our findings suggest a significant risk for relapse following successful cognitive behavioral treatment of trichotillomania. Recommendations to address this problem include extending treatment length to achieve greater initial symptom reduction and expanding the focus on relapse prevention strategies.

Trichotillomania (TTM) has been recognized in the medical and psychiatric literature for over a century (e.g., Hallopeau, 1889). It is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) as an impulse-control disorder characterized

Elizabeth A. Meadows is now at the Department of Psychology, Central Michigan University. Correspondence concerning this article should be directed to: Martin Franklin, Center for

the Treatment and Study of Anxiety, Allegheny University of the Health Sciences, 3200 Henry Avenue, Philadelphia, PA 19129; (215) 842-4010; e-mail: [email protected].

This article is based in part on the first author's dissertation; we would like to thank the dissertation committee chair, Ragmar Storaasli, for his valuable assistance. We also wish to thank Arthur Sturm, who facilitated data entry by designing a database for this study.

This research was supported in part by NIMH Grant No. MH 45404 awarded to the last author.

157 0005-7894/98/0157-017151.00/0 Copyright 1998 by Association for Advancement of Behavior Therapy

All rights of reproduction in any form reserved.

158 LERNER ET AL.

by recurrent hair pulling resulting in noticeable hair loss, increasing tension immediately prior to pulling, and gratification or relief when engaging in pulling. The latter criteria are controversial, however, as not all hair pullers report experiencing mounting tension preceding hair pulling or gratification or relief when engaging in hair pulling (Christenson, Pyle, & Mitchell, 1991). The characterization of TTM as an impulse-control disorder has also been a source of recent debate (e.g., Stanley, Swann, Bowers, Davis, & Taylor, 1992), as some theorists suggest that it is more accurately viewed as an obsessive-compulsive "spectrum" disorder (e.g., Swedo & Leonard, 1992).

Once thought to be extremely rare (Adam & Kashani, 1990), TTM is now believed to be much more prevalent than previously estimated, with subsyndromal TTM appearing relatively common. Christenson, Pyle, et al. (1991) reported a 0.6% lifetime prevalence rate of DSM-III-R (American Psychiatric Association, 1987) trichotillomania for both males and females in a large non- clinical sample of college students. Moreover, when hair pulling not meeting full diagnostic criteria was estimated, prevalence rates increased to 1.5% for males and 3.4% for females. Consistent with these estimates, Rothbaum, Shaw, Morris, and Ninan (1993) found prevalence rates of 1% and 2%, respec- tively, for hair pullers with visible hair loss in two college samples.

TTM is often associated with significant psychological and medical complications. In addition to the time spent on hair pulling, many sufferers spend time concealing resultant large bald areas (Swedo & Leonard, 1992) and experience guilt, shame, and low self-esteem (Stanley & Mouton, 1996). TTM can also lead to avoidance of activities in which hair loss might be exposed (e.g., swimming), avoidance of activities that may lead to direct physical con- tact with others (e.g., intimate relationships, sports) and, in extreme cases, social isolation (Winchel, Jones, Molcho, et al., 1992). Significant medical complications may include skin irritation, infections, and, when patients ingest pulled hair (trichophagia), serious gastrointestinal problems (Swedo & Leonard; Winchel, Jones, Stanley, Molcho, & Stanley, 1992).

While pharmacotherapy with serotonergic medications is frequently rec- ommended for TTM, results of the few controlled studies of these com- pounds have been mixed. In a controlled double-blind crossover study, fluoxetine was not found superior to pill placebo (Christenson, Mackenzie, Mitchell, & Callies, 1991). However, clomipramine (CMI) was found superior to desipramine in a small double-blind study (Swedo et al., 1989), although effectiveness upon medication withdrawal was not examined. Inter- estingly, Pollard et al. (1991) found that of four TTM patients treated with CMI who had experienced significant reductions in self-reported pulling, three had relapsed completely at 3-month follow-up despite being maintained on previously effective levels of CMI. This finding underscores the need for follow-up investigations with this population, even after seemingly effective treatment. Generally, conclusions from existing pharmacotherapy studies are limited because of methodological problems (e.g., small sample sizes, absence of follow-up data).

CBT FOR TRICHOTILLOMANIA 159

The most extensive literature on the treatment of TTM relates to cognitive behavioral therapy (CBT). A variety of techniques have been applied, including self-monitoring, aversion, covert sensitization, negative practice, relaxation training, habit reversal, competing response training, and overcor- rection. Although successful reports following many of these interventions are reported in the literature, the vast majority of these studies are uncontrolled case reports or small case series (see Friman, Finney, & Christoph- erson, 1984, for a review). In one controlled study (Azrin, Nunn, & Frantz, 1980), habit reversal was found more effective than negative practice, with habit reversal patients experiencing a 99% reduction in self-reported number of hair-pulling episodes compared to a 58% reduction for negative practice patients. Moreover, treatment gains for the habit reversal group were maintained at 22-month follow-up, with number of hair-pulling episodes reduced by 87% compared to pretreatment. A significant limitation of this study is that symptom reduction was measured only by self-reported decrease in hair- pulling episodes, which may overestimate benefit.

Since Azrin et al's (1980) study, several case reports and small comparison studies have supported the effectiveness of habit reversal and related interventions in the treatment of TTM (e.g., De Luca & Holborn, 1984). More- over, in a small placebo-controlled trial, Rothbaum and Ninan (1996) found a CBT program that included habit reversal more effective than either CMI or pill placebo at posttreatment; CMI was also found more efficacious than placebo. Follow-up data were not reported; thus, long-term effectiveness could not be examined. Mouton and Stanley (1996) examined the effectiveness of habit reversal training conducted in a group format and found that 4 of 5 patients experienced TTM symptom reductions at posttreatment. Two of these 4 treatment responders, however, exhibited some regression at 6-month follow-up.

In general, the existing CBT outcome studies are limited by small sample sizes, lack of random assignment to treatment, lack of long-term follow-up data, reliance on patient self-report measures instead of clinician-rated interview data, and lack of information regarding rates of treatment refusal and dropout. The present study evaluates the effectiveness of a CBT program in a series of 14 patients with recurrent hair pulling. These 14 patients received fee-for-service treatment at our clinic and were not randomly assigned to condition. Despite the clear limitations intterent in uncontrolled trials, the present study contributes to the literature because of the use of a manualized CBT program, assessment of symptoms by independent evaluators, and long- term follow-up data on treated patients.

In addition to examining the immediate and long-term effectiveness of a CBT program for TTM, two additional issues are addressed in the present study. First, what is the long-term outcome for treatment refusers and treatment dropouts? Second, what are the predictors of TTM symptom severity at long-term follow-up for treatment completers, treatment refusers, and treatment dropouts together?

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Method Participants

Participants were 36 individuals (32 females, 4 males) experiencing recurrent hair pulling and hair loss associated with an inability to resist urges to pull. All patients were evaluated for treatment at Allegheny University of the Health Sciences' (AUHS; formerly the Medical College of Pennsylvania) Center for the Treatment and Study of Anxiety between 1990 and 1996.

Patients ranged in age from 8 to 61 years (M = 28.5, SD = 13.4), with a reported mean symptom duration of 11 years, 2 months (SD = 8 years, 7 months; range: 5 months to 30 years). Thirty-one patients reported having received previous psychosocial and/or pharmacotherapy for hair pulling.

Demographic information was collected at pretreatment, as were self- report measures of anxiety and depression. Attempts were made to collect Beck Depression Inventory (BDI; Beck, Ward, Mendeleson, Mock, & Erbaugh, 1961) and Stait Trait Anxiety Inventory (STAI; Spielberger, Gor- such, & Lushene, 1970) questionnaires at pretreatment from all participants, but not all data were collected (see Table 1 for ns per measure). With the available BDI and STAI data, means, standard deviations, and percentages were calculated for the entire available sample, and then for the available initial treatment refusers, treatment entrants, treatment completers, and treatment dropouts. These data, presented in Table 1, indicate that the sample as a whole was Caucasian, relatively young, predominately female, and evidenced slightly elevated levels of anxiety and depression. Examination of group differences in age, symptom duration, BDI, STAI-S, and STAI-T indicated

T A B L E 1

SAMPLE CHARACTERISTICS, SYMPTOM DURATION, AND PRETREATMENT MEASURES

OF ANXIETY AND DEPRESSION

Entire Treatment Treatment Treatment Treatment Sample Refusers Entrant s Completers Dropouts

(n = 36) (n = 14) (n = 22) (n = 14) (n = 8)

Characteristics Age (years) 28 .5 (13.4) Gender (% female) 89% Race (% Caucasian) 100% Symptom duration

(months)

Depression/Anxiety BDI

STAI-S

STAI-T

31 .6 (12.2) 26.5 (14.0) 25 .6 (12.2) 28 .0 (17.6)

92% 86% 86% 87% 100% 100% 100% 100%

1 3 4 . 4 ( 1 0 3 . 8 ) 1 3 1 . 1 ( 1 0 0 . 6 ) 1 3 6 . 5 ( 1 9 7 . 1 ) 135 .4 (95 .7 ) 138 .7 (135 .7 )

13.0 (10.4) 19.7 (14.9) 10.3 (7.0) 9 .8 (7.9) 11.5 (5.2) n = 25 n = 7 n --- 18 n = 12 n = 6

45.1 (12.3) 50 .9 (16.5) 42.7 (9.7) 43.3 (19.3) 41 .4 (9.2) n = 24 n = 7 n --- 17 n = 12 n = 5

45 .9 (13.1) 52.2 (19.9) 43 .9 (10.3) 45 .0 (11.7) 40 .5 (3.4) n = 21 n = 5 n = 16 n = 12 n = 4


that treatment refusers had higher BDI scores than did treatment entrants, t(23) = 2.17, p < .05. No other significant differences were found between treatment refusers and entrants. No significant differences were found between treatment completers and dropouts on any of these variables.

Of the 36 individuals evaluated at AUHS, 14 did not enter CBT treatment. Of those, 3 were referred for medication at their request, 2 were referred else- where for outpatient psychotherapy after discussion indicated that the patient did not want CBT or pharmacotherapy, and 9 deferred making a decision about treatment at the time of the evaluation and subsequently chose not to return for treatment.

The remaining 22 patients enrolled in the center's CBT program and 14 completed treatment; 8 patients terminated treatment after a mean of four sessions and did not participate in posttreatment evaluation. Of the 14 treatment completers, 10 received CBT alone. The other 4 treatment completers had been taking CMI for several months when they presented for evaluation. Three of these patients continued to take CMI throughout treatment, and one discontinued CMI after the fifth treatment session.

Assessment

Diagnostic and assessment interview. Diagnosis of TTM or subsyndromal TTM was established during a 1.5-hour semistructured interview conducted either by a doctoral-level clinical psychologist or a predoctoral clinical psychology intern supervised by a doctoral level clinical psychologist. The interview consisted of extensive questioning of patients regarding their hair- pulling behaviors, including response description, response detection, response precursors, and high-risk situations. In order to be considered for entry into the CBT program, patients had to report significant hair pulling within the month preceding the intake, had to have considerable hair loss and significant distress associated with pulling, and could not have their disturb- ance better accounted for by another mental disorder nor a general medical condition. The more controversial diagnostic criteria for TTM, increasing tension prior to pulling, and pleasure, gratification, or relief when pulling, were not required for entry. Clinicians also completed the NIMH Trichotil- lomania Questionnaire ratings during this evaluation.

NIMH Trichotillomania Questionnaire (Swedo et at., 1989). Derived from the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; Goodman, Price, Rasmussen, Mazure, Delgado, et al., 1989; Goodman, Price, Rasmussen, Mazure, Fleischmann, 1989) and the Leyton Obsessional Inventory (LOI; Cooper, 1970), this semistructured interview consists of two clinician-rated scales: the NIMH Trichotillomania Severity Scale (NIMH-TSS) and the NIMH Trichotillomania Impairment Scale (NIMH-TIS). The NIMH-TSS consists of five questions related to the following aspects of trichotillomania: average time spent pulling, time spent pulling on the previous day, resistance to urges, resulting distress, and daily interference. NIMH-TSS scores range from 0 to 25. The NIMH-TIS is an impairment scale with scores ranging

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from 0 to 10. Higher scores on both scales indicate greater severity/impairment. Reliability data for the NIMH Trichotillomania Questionnaire are unavailable. However, the NIMH Trichotillomania Questionnaire has been shown to be sensitive to changes in symptom severity and impairment following treatment (Rothbaum, 1992; Rothbaum & Ninan, 1996; Swedo et al., 1989). Mean pretreatment NIMH-TSS scores reported in studies that have used this instrument have been 14.8 (Rothbaum & Ninan) and 15.9 (Swedo et al.); mean pretreatment NIMH-TIS scores were 6.8 in both studies.

BDI. The BDI is a 21-item self-report inventory measuring depressive symptoms. The BDI has been found sensitive to treatment effects with clinical populations. Reliability and validity of this instrument are adequate (Beck, Steer, & Garbin, 1988). A measure of depression was included in light of previous research indicating a lifetime prevalence of mood disorders in 65% of a treatment-seeking sample of female chronic hair pullers (Chris- tenson, Mackenzie, & Mitchell, 1991).

STAL The STAI consists of 20 state anxiety and 20 trait anxiety items. Both forms of the instrument have been found to be reliable, valid, and sensitive to treatment effects (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983). Measures of general anxiety were included in light of previous research indicating a lifetime prevalence of anxiety disorders in 57% of a treatment-seeking sample of female chronic hair pullers (Christenson, Mackenzie, & Mitchell, 1991).

Procedure

Symptoms were assessed at pretreatment using the BDI, STAI, NIMH- TSS, and NIMH-TIS. NIMH-TSS and NIMH-TIS scores were also obtained at posttreatment and at follow-up by a clinician not otherwise involved in the patient's treatment. The NIMH-TSS was the primary measure of symptom severity. Attempts were made to collect BDI and STAI questionnaires at posttreatment and follow-up as well, but a large percentage of data was not collected, precluding subsequent analyses of these data.

Following a complete evaluation of hair pulling and discussion of treatment options, patients were offered either CBT at our center or a referral for pharmacotherapy or psychotherapy at other treatment facilities.

Treatment

Treatment consisted of a CBT program that included self-monitoring, habit reversal, stimulus control, relaxation training, cognitive restructuring, and relapse prevention methods. Treatment was adapted from a protocol devel- oped by Rothbaum (1992). The treatment package consists of nine 1-hour sessions, conducted individually and weekly. Homework related to the various treatment components was assigned on a weekly basis; self-monitoring of hair pulling was assigned throughout treatment. Although flexibility in implementing the treatment protocol is typical for any uncontrolled evaluation in


the clinical setting, the following is a general session-by-session-by-session guide to the treatment:

Session 1: Information gathering. This session is typically completed soon after the initial intake; the treating clinician had access to intake information and frequently referred back to these data in beginning the process of helping the patient to describe in detail when, where, and how pulling is executed. The clinician tries to determine factors such as whether the patient is aware of his or her pulling, whether he or she can identify early warning signs that they might pull, and whether the pulling occurs in many different venues or only in one or two (e.g., upstairs bathroom). The concept and details of self-monitoring of hair pulling are introduced during this session. Patients are asked to save all pulled hairs and to write down the circumstances surrounding pulling episodes on a monitoring sheet.

Session 2: Habitreversal training. Following inspection of self-monitoring data, the therapist explains the rationale for habit reversal and begins to work with the patient to establish procedures to interrupt the chain of pulling move- ments, preferably with a physically competing response. Competing responses that are used include playing with clay, shelling peanuts, and making tight fists and holding for several minutes. Patients are instructed to imple- ment the habit reversal training procedures with competing responses at the first sign of their pulling urges. Patients are also instructed in stimulus control procedures, in which patients are taught to decrease opportunities to pull by wearing gloves or bandages on fingers in high-risk situations, prohibiting touching face with bare hands or looking into mirrors in well-lit areas such as bathrooms, and placing signs that have meaning to the patient in places formerly associated with pulling (e.g., telephone table).

Sessions 3 and 4: Relaxation. Sessions begin with inspection of self- monitoring, and recommendations and reinforcement regarding implementa- tion of habit reversal training procedures. Based on a theoretical association between stress and pulling behaviors, relaxation training is designed to help the patient reduce stress and thereby indirectly influence pulling. Patients are taught a deep muscle relaxation technique, following differential relaxation techniques for specific muscle groups that are more readily applied in work- related and other stressful situations.

Session 5: Thought stopping. Designed to counter continual thinking about pulling or about its consequences, the patient is taught to think delib- erately about these troubling thoughts and then to yell "Stop!" in order to counter this thinking process. The patient is also taught to visualize "Stop" signs to aid in the practical application of this technique, and is instructed to try replacing the unpleasant thoughts with less aversive thoughts or images.

Session 6: Cognitive restructuring. The rationale for cognitive restructuring is introduced, examples from the patient's own experience are dis- cussed, and the therapist uses Socratic questioning to teach patients to chal- lenge distorted thinking. Patients are given recording sheets on which they are instructed to record negative automatic thoughts, the situations in which

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they arose, resulting emotions, and a replacement rational response derived from the Socratic questioning procedures taught in session.

Session 7: Guided self-dialogue. A further expansion on the previous session's theme, the therapist teaches the patient to replace irrational or negative self-dialogue with responses that are more adaptive and task-enhancing. These techniques are designed to help patients take action, especially around pulling-related tasks, instead of becoming overwhelmed and less vigilant about implementing those behavioral procedures that have been helpful for him or her up to that point.

Sessions 8 and 9: Covert modeling~relapse prevention. Patients are taught to imagine themselves coping effectively with stressful situations, instead of seeing themselves return to pulling as a means to cope with stress. Discussion of relapse prevention begins in Session 8, focusing on how to control setbacks, to differentiate "lapses" from "relapses" and to teach the patient that occasional setbacks are a natural occurrence rather than an uncontrollable catastrophe. Typically, when a patient has experienced ups and downs during the treatment, discussion can also focus on how the patient got him or herself back on track during the active treatment phase when a lapse was encoun- tered. Patients are also reminded that they are more equipped to deal with future lapses because of what they learned in treatment. Patients and therapists also design a written list of procedures that the patient can use if he or she senses a return to previous functioning; calling the therapist for assistance is typically included on that list.

Chart evaluations of treatment completers indicated a range of 6 to 11 sessions, with a mean of 8 sessions. No formal assessment of treatment integrity was conducted.

Therapists CBT was conducted by six doctoral-level clinical psychologists trained

extensively in the treatment of anxiety and impulse-control disorders and by one predoctoral clinical psychology intern supervised by one of these clinical psychologists.

Results NIMH-TSS and NIMH-TIS data were available for all 36 patients at

intake. At pre- and posttreatment, 14 treatment completers were assessed using the NIMH-TSS and NIMH-TIS. Thirteen of 14 treatment completers were assessed using the NIMH-TSS and NIMH-TIS at follow-up (M = 3 years, 9 months; range: 3 months to 5 years, 11 months), as were 4 of 8 treatment dropouts (M = 2 years, 10 months; range: 7 months to 5 years) and 6 of 14 treatment refusers (M = 3 years, 5 months; range: 1 year, 1 month, to 5 years, 4 months). See Tables 1 and 2 for Ns.

Severity of TTM symptoms and associated impairment were evaluated using the NIMH Questionnaire. Data on pretreatment symptom severity


TABLE 2 PRETREATMENT TRICHOTILLOMANIA SYMPTOM SEVERITY, ASSOCIATED IMPAIRMENT,

AND CURRENT PULLING SITES

Entire Treatment Treatment Treatment Treatment Sample Refusers Entrants Completers Dropouts

(n = 36) (n = 14) (n = 22) (n = 14) (n = 8)

NIMH measures NIMH-TSS NIMH-TIS

Pulling sites (% yes) Scalp 83 % Eyelashes 31% Eyebrows 25 % Pubic 3 % Other (e.g., leg) 8% Multiple sites 36%

14.0 (4.0) 15.4 (4.3) 13.1 (3.7) 12.8 (4.2) 13.8 (2.7) 6.4 (1.7) 6.7 (1.5) 6.1 (1.9) 5.7 (2.2) 6.8 (1.0)

86% 82% 79% 88% 14% 41% 43% 38% 14% 32% 36% 25% 7% 0% 0% 0% 7% 9% 7% 13%

29% 41% 38% 42%

(NIMH-TSS), pretreatment associated impairment (NIMH-TIS), and reported location of pulling (e.g., scalp) are presented in Table 2.

On the whole, the sample evidenced moderately severe symptoms and associated impairment; their pretreatment NIMH-TSS and NIMH-TIS scores were similar to those reported in other treatment studies using these measures (Rothbaum & Ninan, 1996; Swedo et al., 1989). The vast majority were currently pulling scalp hair, although a significant minority also reported pulling eyelashes and eyebrows. Over one-third of the sample reported pulling from more than one site. Group differences in NIMH-TSS, NIMH- TIS; percentages reporting current pulling of scalp hair, eyelashes, eyebrows, pubic hair, and other hair (e.g., leg); and percentages of reporting current pulling from more than one site were examined. Results suggesting a higher percentage of treatment entrants endorsing current pulling of eyelashes compared to treatment refusers approached significance, chi-square = (1, n = 36) = 2.86, p = .09. No other significant differences between treatment refusers and entrants were found. No significant differences were found" between treatment completers and'dropouts on any of these variables.

Correlations Among Measures at Pretreatment

Pearson correlation coefficients were calculated to examine the relationships at pretreatment between measures of TTM symptom severity and impairment (NIMH-TSS, NIMH-TIS) and more general measures of psychopathology (BDI, STAI-S, STAI-T). These analyses were conducted using data only from those participants (n = 21) who had completed all five measures. Results indicated that NIMH-TSS scores were significantly correlated with NIMH-TIS scores, r = .64, p < .05; STAI-T, r = .59, p < .05; and

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BDI, r = .57, p < .05. The correlation with STAI-S approached significance, r = .43; p = .053. None of the correlations between NIMH-TIS and the general psychopathology measures were significant: BDI, r = .36; STAI-S, r = .28; and STAI-T, r = .29; all ns.

Treatment Outcome To examine immediate and long-term outcome for treatment completers,

multivariate (NIMH-TSS, NIMH-TIS) repeated measures (pre-, post-, and follow-up) analyses of variance (ANOVA) were conducted, followed by uni- variate ANOVAs and post hoc tests where appropriate. The alpha level for all statistical tests was set at .05.

Immediate Effectiveness of CBT Means and standard deviations of the 14 completers on the NIMH-TSS

were as follows: pretreatment: 12.8 (4.2); posttreatment: 4.2 (4.2). On the NIMH-TIS, means and standard deviations were as follows: pretreatment: 5.7 (2.2); posttreatment: 2.4 (2.4). A repeated-measures multivariate analysis of variance (MANOVA) indicated a significant time effect, F(2, 12) = 17.62, p < .05. Follow-up dependent t tests indicated significant reductions from pre- to posttreatment in both TTM symptom severity, t(13) = 6.08, p < .05, and in associated impairment, t(13) = 4.41, p < .05.

Patients were classified as responders if they evidenced at least a 50% reduction in NIMH-TSS scores, which is consistent with the relatively con- servative response criterion utilized in other treatment outcome studies (e.g., Hiss, Foa, & Kozak, 1994). Twelve of 14 treatment completers were classified as responders at posttreatment, with a mean NIMH-TSS reduction of 67% for the treatment completers as a whole.

Long-term Outcome for Treatment Completers Thirteen of 14 treatment completers were available for follow-up assess-

ments. Means and standard deviations of these 13 patients on the NIMH- TSS were as follows: pretreatment: 12.5 (4.2); posttreatment: 4.5 (4.3); follow-up: 9.1 (6.6). On the NIMH-TIS, means and standard deviations were as follows: pretreatment: 5.9 (2.2); posttreatment: 2.5 (2.5); follow-up: 4.5 (3.5).

To examine long-term outcome, a repeated measures (pre-, post-, follow- up) MANOVA was conducted on NIMH-TSS and NIMH-TIS scores. Results indicated a significant time effect, F(4, 9) = 6.71, p < .05. Follow-up ANOVAs were then conducted for NIMH-TSS and NIMH-TIS scores, re- spectively. Results indicated a significant time effect for both NIMH-TSS, F(2, 11) = 15.88, p < .05, and NIMH-TIS, F(4, 9) = 8.22, p < .05. Planned post-hoc comparisons indicated that pretreatment scores did not differ significantly from follow-up scores on either NIMH-TSS, t(12) = 2.08, p = .06, or NIMH-TIS t(12) = 1.35,p = .20. Planned post-hoc comparisons also indicated that the mean NIMH-TSS score at follow-up was significantly higher


than at posttreatment, t(12) = 3.28, p < .05; mean NIMH-TIS score at follow- up was also significantly higher than at posttreatment, t(12) = 2.30, p < .05.

At follow-up, only 4 of the 13 available treatment completers were classified as responders, with a mean NIMH-TSS reduction of 27% for the treatment completers as a whole.

Ten of the 13 treatment completers available at follow-up were asked if they pursued additional treatment after completing CBT at our center. Three of these were classified as responders at follow-up, and each reported receiving no additional treatment after completing CBT. Of the 7 classified as nonre- sponders, 6 had attempted additional treatment after completing CBT: All of these had received pharmacotherapy, and 5 also received psychotherapy.

Long-term Symptom Severity for Treatment Refusers and Dropouts To examine long-term symptom status in the 22 individuals who refused

treatment or dropped out of CBT, follow-up interviews were conducted. Ten (45%) of these individuals participated in follow-up evaluations (M = 3. years, 2 months; range = 7 months to 5 years, 4 months). Results of a dependent t test indicated that their mean NIMH-TSS score at follow-up (M = 10.10, SD = 6.0) was significantly lower than at pretreatment (M = 15.10, SD = 3.5), t(9) = 3.40, p < .05. Using the 50% improvement criterion defined above, 4 of 10 were classified as improved, with a mean NIMH-TSS symptom reduction of 33% for the 10 individuals who did not complete treatment yet were available at follow-up.

The 10 treatment dropouts and treatment refusers available at follow-up were asked if they pursued additional treatment after being evaluated at our center. Three of the 4 patients classified as improved at follow-up reported receiving no treatment after evaluation at our center, while one improved patient reported receiving pharmacotherapy. Of the 6 patients not classified as improved at follow-up, 2 received no treatment of any kind. The remaining 4 patients received either pharmacotherapy (n = 1), psychotherapy (n = 1), or both (n = 2).

Predictors of Long-term Outcome To determine whether TTM symptom severity at follow-up was related to

pretreatment symptom measures and other variables, Pearson correlations were calculated for continuous variables using data from all patients who participated in follow-up assessments (N = 23; 13 treatment completers, 4 treatment dropouts, 6 treatment refusers).

NIMH-TSS scores at follow-up were significantly related to pretreatment scores on BDI, r = .59, p < .05; NIMH-TSS, r = .55, p < .05; NIMH-TIS, r = .53, p < .05; and STAI-T, r = .49, p < .05. There was no significant relationship between NIMH-TSS scores at follow-up and age (r = - .08 ) , symptom duration (r = - .18) , and STAI-S (r = .29). A step-wise multiple regression was performed to examine whether general psychopathology could predict long-term outcome above and beyond what could be accounted

168 LERNER ET AL.

for by pretreatment TTM severity. Pretreatment NIMH-TSS scores were entered into the regression equation first, accounting for approximately 30% of the variance. At step 2, all of the general psychopathology measures failed to account for any significant increment in variance.

Discussion The primary goal of this uncontrolled study was to examine the immediate

and long-term effectiveness of a CBT program for TTM. Although the methodological issues inherent in uncontrolled trials preclude any strong conclusions, our results suggest the immediate effectiveness of CBT in the present sample: TTM symptoms were substantially reduced at posttreatment (67% mean NIMH-TSS reduction) for the sample as a whole, with 86% of treatment completers classified as responders. For the most part, however, these immediate treatment gains were not maintained over time. At long-term follow-up, the mean symptom reduction from pretreatment was down to 27%, with only 31% of the sample meeting the responder criterion.

Given these findings, the question remains as to what factors might enhance the long-term effectiveness of CBT for individuals with TTM. Foa and Kozak (1996) suggested that patients with obsessive-compulsive disorder (OCD) who showed great improvement immediately after CBT retained their gains more than patients who were moderately improved. Patients in the present sample evidenced substantial symptom reduction with the CBT program, yet on the whole remained symptomatic at posttreatment. Notably, 2 patients in the present sample achieved complete abstinence from pulling at posttreatment, and both of these patients evidenced little return of symptoms at long-term follow-up. Perhaps treatment that achieves complete abstinence from hair pulling would produce better long-term effects than treatment that brings about partial symptom reduction, even if the percentage of reduction is substantial. One approach is to extend the existing treatment program until greater symptom reduction is achieved.

Another way to improve long-term outcome following CBT for TTM is to better integrate a comprehensive relapse prevention component into the treatment program. In the present study, relapse prevention was addressed only in the last two sessions. More discussion throughout treatment of how patients should combat urges to pull after treatment is completed may better prepare patients to anticipate and plan for setbacks. Because clinical experience suggests that TTM is particularly vulnerable to external stressors, booster sessions and scheduled telephone calls perhaps should become an integral part of the treatment program. These contacts could focus on lapses in order to prevent them from becoming full relapses.

A clearer conceptualization of TTM may also facilitate the development of a more effective treatment program. Currently, disagreement exists in the literature about whether TTM is a variant of OCD or an impulse-control disorder. Evidence in support of the former view includes a trend toward higher


rates of OCD in the family members of individuals with TTM (Lenane et al., 1992), positive response of TTM patients to CMI, a medication found to be effective in the treatment of OCD (e.g., De Veaugh-Geiss, Landau, & Katz, 1989), and apparent similarities in clinical presentation, as both disorders involve what patients describe as compulsive and uncontrollable behaviors (Swedo & Leonard, 1992). Despite these stated similarities, significant differences between the disorders have also been noted. Although some individuals with TTM experience obsessive-type thoughts prior to pulling, the disorder is generally not characterized by the intrusive, repetitive thoughts that are essential for a diagnosis of OCD (Stanley & Mouton, 1996; Stanley, Prather, Wagner, Davis, &Swann, 1993; Stanley et al., 1992). Furthermore, individuals with TTM do not report multiple obsessions and compulsions, which is characteristic of OCD (Stanley et al., 1992). Additional evidence suggesting that TTM and OCD are two separate entities is provided by the findings from a controlled pharmacological trial, in which fluoxetine was found to be ineffective in the treatment of TTM (Christenson, Mackenzie, Mitchell, & Callies, 1991), and by the findings of Pollard and colleagues (1991) of loss of responsiveness to CMI despite continued maintenance on previously effective dosages.

Our data and clinical impressions support the conceptualization of TTM as an impulse-control disorder. For example, the high relapse rotes in our study are more suggestive of an impulse-control disorder than OCD because individuals with OCD who are treated with CBT tend to maintain treatment gains over time. In a review of the OCD treatment outcome literature (Foa & Kozak, 1996), 83% of OCD patients treated with CBT were classified as treatment responders (OCD symptom reduction >50% on Y-BOCS) at posttreatment and 76% were classified as treatment responders at follow-up (M = 2.4 years). In contrast, only 31% of our sample were classified as treatment responders at follow-up. Additionally, previous research indicated that TTM patients were more likely to describe their target behavior as pleasurable than were OCD patients (Stanley et al., 1992), suggesting maintenance by positive rather than by negative reinforcement. Clinically, we feel that these differing mechanisms underlying the psychopathology of TTM and OCD should yield alternative recommendations for TTM patients battling urges to pull: Whereas OCD patients are typically instructed to remain in the feared situ- ation until their anxiety and urge to ritualize subsides, TTM patients should be encouraged to move from high- to low-risk situations in order to minimize likelihood of pulling. Further investigation into the psychopathology of TTM is likely to result in the development of more effective and durable treatments.

Because of the uncontrolled nature of this investigation, our findings should be interpreted with caution. Nonspecific treatment effects, patients' expectancy, and evaluators' biases may all contribute to the observed outcome. Also, in the absence of treatment integrity ratings, it cannot be determined that therapists adhered to the CBT protocol utilized in this study. Addi- tional reasons for viewing the results of the present study with caution

170 LERNER ET AL.

include the absence of information regarding comorbidity, the percentage of missing data on general psychopathology measures, and the lack of reliability data on the NIMH-TSS. The effects of medication on treatment outcome for a subset of patients receiving concurrent pharmacotherapy also cannot be determined. However, while 4 of the 14 treatment completers were also receiving CMI, it is unlikely that this contributed to their outcome since they were stabilized on the medication before entering the CBT program. These caveats notwithstanding, our findings provide some support for the immediate effectiveness of CBT while also indicating a high likelihood of relapse. Future research should aim at developing more effective treatments for TTM that will emphasize relapse prevention procedures.

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RECEIVED: December 23, 1996 ACCEPTED: October 24, 1997