Habit reversal training for trichotillomania: A group approach

COGNITIVE AND BEHAVIORAL PRACTICE

3, 159-182,

1996

Habit Reversal Training for Trichotillomania: A Group Approach

Suzanne G. Mouton Melinda A. Stanley University of Texas Health Science Center, Houston

The efficacy of Habit Reversal Training (HRT) in a group format for the treatment of trichotillomania was investigated. Original HRT procedures described by Azrin and Nunn (1973) were modified for use in a group context. Five patients were treated over a 6-week period. Treatment included self-monitoring, awareness training, competing response training, and homework assignments. Posttreatment data indicated decreases in measures of global severity of symptoms, severity of thoughts about hair-pulling, and severity of hair-pullingbehavior, relative to pretreatment measures. Three of the 5 patients maintained improvement at 1-month follow-up, and 2 patients maintained treatment gains at 6 months. Follow-up scores for all patients continued to be lower than pretreatment scores. These case illustrations replicate and extend prior data, lending support to the viability of HRT in a group format as a meaningful approach to treating trichotillomania.

Definition and Incidence of Trichotillomania Trichotillomania ( T M ) is a behavioral disorder with significant social, emotional, a n d physical consequences. As such, the t r e a t m e n t c o m m u n i t y may look to the behavior therapist for t r e a t m e n t consultation. However, because T M has not been widely examined, the behavior therapist may have little background in its treatment. Although investigation of the prevalence and treatment of T M has received little attention in the past, it has recently become the focus of greater study. As defined by the fourth edition of the Diagnostic and Statistical Manual of 159 1077-7229/96/159-18251.00/0 Copyright 1996 by Association for Advancement of Behavior Therapy All rights of reproduction in any form reserved.

160

MOUTON & STANLEY

Mental Disorders (DSM-IV; American Psychiatric Association, 1994), T M is characterized by the following: (a) repetitive hair-pulling that results in noticeable hair loss; (b) increased tension prior to hair-pulling or when an individual is resisting the behavior; (c) pleasure, gratification, or relief during hair-pulling; (d) the disturbance is not attributed to another psychiatric condition or medical illness (i.e., a dermatological disorder); and (e) the symptoms cause significant distress or impairment in the individual's social or occupational functioning. Psychosocial and medical sequelae of chronic hair-pulling can be quite severe. For example, individuals may pull hair for up to several hours a day (Stanley, Swann, Bowers, Davis, & Taylor, 1992), or make extraordinary attempts to conceal resultant hair loss (Christenson, Mackenzie, & Mitchell, 1991), either of which can significantly interfere with daily living. Other individuals avoid certain social situations (e.g., swimming, other exercise) or intimate interpersonal relationships to prevent discovery of their symptoms (Mansueto, 1991). Further, hair-pulling accompanied by skin picking may lead to painful skin irritations or infections, and hair ingestion can cause potentially dangerous gastrointestinal symptoms. To date, no large-scale epidemiological investigations have been conducted to estimate the prevalence of TM. In a preliminary examination of this issue in a college population, Christenson, Pyle, and Mitchell (1991) found a prevalence rate of 0.6% utilizing DSM-III-R criteria (APA, 1987). When 2 criteria (tension prior to pulling and gratification during the behavior) were removed, and diagnosis of T M required only noticeable hair loss as a result of pulling, prevalence rates were estimated to be 2.5 % to 3.0% in college samples (Christenson, Pyle, et al.; Rothbaum, Shaw, Morris, & Ninan, 1993). Further, prevalence rates of hair-pulling that do not lead to noticeable hair loss range from 10% to 15% in college populations (Graber & Arndt, 1993; Rothbaum et al.; Stanley, Borden, Bell, & Wagner, 1994). Estimates of T M in the community suggest that twice as many women as men suffer from this disorder (Christenson, Pyle, et al.; Graber & Arndt). Prevalence rates in clinical samples are even more skewed in a similar direction (Christenson, Mackenzie, & Mitchell, 1991; Stanley et al., 1992), although it is possible that women are more likely than men to present in mental health centers for treatment of TM, resulting in inflated prevalence rates for women in these settings. Conceptualizations and Related Treatment Approaches T M has been conceptualized from a variety of perspectives. Initially, hairpulling was seen as a manifestation of psychodynamic conflict (Greenberg & Sarner, 1965; Oguchi & Miura, 1977). As a result, treatment focused on uncovering and resolving these underlying issues. More recently, hair-pulling has been classified as a tension-reducing habit control disorder (Azrin & Nunn, 1973), an impulse-control disorder (APA, 1980, 1987, 1994), a variant of obsessive-

HRT FOR GROUPS

161

compulsive disorder (Jenike, 1990; Tynes, White, & Steketee, 1990), and a disorder of excessive grooming (Swedo & Leonard, 1992). Classification of T M as a variant of obsessive-compulsive disorder (OCD) has led to empirical studies suggesting areas of both overlap and dissimilarity. Overlap with OCD is suggested by the following: (1) apparent similarity in the nature of the symptoms (both disorders describe repetitive, maladaptive behaviors over which patients have no control); (2) a trend toward increased rates of OCD in the families of people who suffer from T M (Lenane et al., 1992); and (3) initial psychopharmacological investigations suggesting that clomipramine, a serotonergic reuptake inhibitor (SSRI) with demonstrated efficacy in OCD, also showed superior efficacy for the treatment of T M (Swedo et al., 1989). Although T M may have some phenomenological overlap with OCD, recent data have suggested significant differences between these two disorders. First, T M is not typically characterized by intrusive, repetitive thoughts or obsessions about hair-pulling (Stanley, Prather, Wagner, Davis, &Swann, 1993). Second, people with T M do not report multiple obsessions and compulsions, and in fact, they generally score within normal limits on standardized measures of O C D symptoms (Stanley et al., 1992). Third, unipolar affective disorders and generalized anxiety disorder, rather than OCD, are the most common coexistent diagnoses in T M patients. Finally, more recent pharmacotherapy outcome data have not supported a preferential effect for all SSRIs in the treatment of TM. Specifically, two recent, controlled trials of fluoxetine found no benefit from this medication in treating hair-pulling symptoms (Christenson, Mackenzie, Mitchell, & Callies, 1991; Streichenwein & Thornby, 1995"~."Generally, despite some phenomenological overlap, available data do not clearly support the conceptualization of T M as a variant of OCD. Another approach to understanding this disorder is to view it as a habit-control disorder. Conceptualization of T M as a habit-control disorder views hair-pulling as originating with a normal response to stress. If the behavior continues beyond the initial onset, it can become associated with a range of internal and external cues, thus strengthening the response. Over time, the behavior becomes so frequent and "habitual" that it escapes personal and social awareness altogether (Azrin & Nunn, 1973). This model accounts nicely for the relationship between hair-pulling and the range of associated cues through a variety of conditioning mechanisms. However, the habit-control disorder perspective neglects explanation of the initial origin of the hair-pulling behavior, and as such, has been integrated with an ethological hypothesis described by Swedo and Leonard (1992). This integration hypothesizes that a fixed action pattern (e.g., hair-pulling) may be released initially during times of stress through some genetically coded biological mechanism, autoimmune reaction, or environmental change (Swedo & Leonard). The pattern generalizes as it becomes associated with various internal and external stimuli through the processes of classical and operant conditioning (Mansueto, 1993). As a result, hair-pulling may be conditioned

162

MOUTON & STANLEY

to occur in response to a variety of environmental, sensory, cognitive, and affective cues. Conceptualizations of T M have led to the use of two primary treatment modalities. First, viewing T M as a variant of O C D has sparked two controlled investigations into the use of SSRIs for the treatment of TM. These studies have produced equivocal findings. For example, as noted above, Swedo et al. (1989) demonstrated that clomipromine was superior to desipramine for the treatment of T M , providing indirect support for an overlap between O C D and T M . Christenson, Mackenzie, Mitchell, et al. (1991) and Streichenwein and Thornby (1995), however, failed to demonstrate the superiority of fluoxetine to placebo for the treatment of this disorder. In each of these studies, subjects were recruited in similar fashion and exhibited comparable demographic backgrounds and symptom severity. However, these investigations utilized different outcome measures. In the study conducted by Swedo et al., outcome data were all clinician-rated, whereas the 2 studies using fluoxetine utilized only selfmonitoring measures. As such, it is difficult to compare these investigations adequately, and the viability of SSRIs for the treatment of T M has yet to be established. Second, conceptualization of T M as a habit-control disorder inspired the development of a behavioral approach known as Habit Reversal Training ( H R ~ Azrin & Nunn, 1973). This technique employs behavioral strategies aimed at increasing awareness and teaching coping skills (e.g., competing responses and relaxation) for the purpose of interrupting sequences of behavior. Specifically, environmental, sensory, cognitive, and affective cues that have been conditioned to precipitate hair-pulling are identified through self-monitoring. Efforts then are aimed at breaking or interrupting these conditioned sequences and replacing the hair-pulling behavior with new, more adaptive responses. Preliminary studies have suggested the utility of HRT. A controlled investigation by Azrin, Nunn, and Frantz (1980), for example, found that 34 subjects treated with H R T exhibited greater symptom reduction than those who received negative practice (another behavioral approach). Subjects with a variety of types of hair-pulling received a single, 2-hour session of H R T followed by telephone contact over the following 2 to 3 days. Results demonstrated the superiority of H R T over negative practice at post-treatment, with 97% reduction in hairpulling symptoms after 4 weeks. These subjects continued to exhibit significant symptom reduction after 22 months. Further preliminary data have suggested the potential utility of an individual treatment approach that integrates H R T with various stress-management techniques (Rothbaum, 1992) as well as the efficacy of H R T as opposed to pill placebo for the treatment of T M (Rothhaum & Ninan, 1992). Given these initial data regarding the impact of H R T with patients who suffer from chronic hair-pulling, the efficacy of H R T as a treatment modality may be promising. There are, however, significant gaps in the literature. Spe-

HRT FOR GROUPS

163

cifically, only 1 controlled comparison has examined the effects of H R T and an alternative psychosocial intervention (Azrin et al., 1980), and this study is limited by methodological weaknesses, including the failure to incorporate a standardized approach to assessment, treatment, or follow-up. Specifically, H R T was not defined clearly in terms of actual treatment procedures. Further, unspecified amounts of telephone contact following the initial 2-hour treatment session make replication difficult. Finally, sole reliance on unstandardized selfreport of symptom reduction for measure of outcome is problematic. Thus, additional controlled investigations are needed to examine further the efficacy of a standardized H R T treatment package for TM. The following is a description of such an approach. Group therapy was selected as the treatment modality as it is an efficient and economic means for providing therapy. Specifically, several patients may be treated simultaneously in a time- and cost-effective manner. More importantly, however, due to the isolation and societal rejection that T M patients describe as a result of their symptoms, the authors felt that a group format would provide a sense of community and universality for their experiences. Further, within the group, patients learned about the disorder both from the therapists who provided direct instruction and from the other group members through "symptom sharing." As a result, a group format was selected to provide this type of supportive experience in addition to the specific behavioral techniques that are a part of HRT.

Habit Reversal Training in a Group Format The standardized H R T framework to be described here is based upon principles outlined by Azrin and his colleagues (Azrin & Nunn, 1973; Azrin et al., 1980) and includes the following components: (a) self-monitoring of the frequency and duration of hair-pulling; (b) review of the inconveniences of hairpulling; (e) awareness training to identify the specific movements involved in hair-pulling, and behavioral movements that immediately precede hair-pulling; (d) competing response training to identify an inconspicuous response (e.g., fist clenching) to be used to interrupt the hair-pulling when it occurs or to prevent the behavio r in "high-risk" situations; (e) relaxation training through deep breathing and postural adjustments; and (f) generalization training to identify and imagine high-risk situations in preparation for future episodes of hair-pulling. Several modifications to H R T procedures outlined by Azrin et al. (1980) were incorporated into a manual described by Stanley and Mouton (1996). First, treatment was modified to take place in a group format for the reasons noted above. Treatment was conducted in 6 weekly sessions, each of which lasted 1½ hours. The purpose of extending the treatment beyond a single, 2-hour session was to increase time allotted for awareness training, as well as to allow patients to practice the coping strategies learned during H R T over several weeks. Second,

164

M O U T O N & STANLEY

awareness training was broadened to include not only identification of situations that commonly lead to hair-pulling, but also thoughts and moods associated with this behavior. Third, imaginal and in vivo exposure procedures were incorporated to allow practice of coping responses. Finally, homework was assigned each week to provide a structure for increasing awareness of thoughts, feelings, and situational correlates of hair-pulling, as well as to aid patients in exposing themselves to "high risk" situations. As a preliminary investigation, the authors evaluated the efficacy of the H R T group treatment procedure with 2 men and 1 woman (see Stanley & Mouton, 1996). Following 6 weeks of treatment, all 3 participants demonstrated decreases in both clinician-rated severity of symptoms and time spent hair-pulling, and maintained these gains at 1-month follow-up. The investigators concluded that the H R T group treatment merited further evaluation with a larger, more diverse group. O f particular importance was the inclusion of more women, with greater variability of symptoms, as twice as m a n y women as men suffer from T M (Christenson, Pyle, et al., 1991; Graber & Arndt, 1993). The following case illustration is a description of a second group application of HRT, with a slightly larger group consisting of 4 women and 1 man. The illustration was designed to describe in detail H R T procedures that can be used in a group context. Such a description also might set the stage for a well-controlled empirical trial of this standardized approach to the treatment of T M . Case Illustration To illustrate further the techniques reviewed above (Stanley & Mouton, 1996), the H R T group treatment protocol was utilized to treat 5 additional patients who presented for treatment of T M . Patients entered the study in response to local advertisements announcing a research project aimed at evaluation and treatment of hair-pulling symptoms. Prior to the onset of the group, patients were interviewed by clinicians utilizing the Anxiety Disorders Interview ScheduleRevised (ADIS-R; DiNardo, Moras, Barlow, Rapee, & Brown, 1993) and an abbreviated form of the Minnesota Trichotillomania Assessment Inventory (MTAI; Christenson, Mackenzie, & Mitchell, 1991) to establish the DSM-III-R diagnosis of T M and coexistent anxiety and/or affective disorders. Severity of each disorder as defined on the A D I S - R and the M T A I was based on a scale of 0 (no symptoms) to 8 (very severe symptoms), based upon frequency of hairpulling, amount of hair loss, strength of urges to pull, distress associated with symptoms, and interference with daily activities caused by actual hair-pulling or associated difficulties. A s u m m a r y of the anchors and corresponding descriptions can be found in Table 1. A revised version of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS; G o o d m a n et al., 1989), created to assess the severity of hair-pulling, also was used to establish clinician ratings (Stanley et al., 1993). T h e original Y-BOCS

HRT FOR GROUPS

165

TABLE 1 CLINICAL SEVERITY FOR TRICHOTILLOMANIA

0 -- No symptoms of trichotillomania. 2 --Mild Symptoms. Hair-pulling occurs intermittently and/or number of hairs pulled is low. Hair loss is minimal and easily camouflaged with modifications in hair style (e.g., barrettes, combing). Urges to pull are mild or occur intermittently. Hair-pulling causes mild distress (related to behavior or appearance) and creates minimal disturbance in social (e.g., awareness of appearance during social interactions) or occupational (e.g., occasionally distracted at work by thoughts or urges related to hair-pulling) functioning. 4-Moderate Symptoms. Hair-pulling occurs with some regularity and has resulted in moderate hair loss that can be hidden only with particular hair styles (e.g., hair must be styled into a top knot). Urges to pull are moderate and occur with some regularity, but at times can be controlled. Hair-pulling leads to moderate, but manageable, distress (related to behavior or appearance) and interferes to some degree with social (e.g., reluctant to engage in certain activities, such as swimming, because others might notice hair loss) or occupational (e.g., regularly distracted at work by thoughts or urges to pull) functioning. 6-Marked Symptoms. Hair-pulling occurs regularly and has resulted in hair loss that requires the use of a hair piece or scarf to camouflage. Urges to pull occur regularly and at times are difficult to control. Hair-pulling leads to significant, and at times unmanageable, distress (about appearance or behavior) and creates noticeable impairment in social (e.g., avoids some social interactions) or occupational (e.g., is less productive at work given time spent hair-pulling or thinking about symptoms) functioning. 8-- Very Severe Symptoms. Hair-pulling occurs regularly, with very little natural hair remaining. Urges to pull occur more often than not and always are intense and extremely difficult to control. Hair-pulling leads to extremely severe, unmanageable distress and social/occupational impairment (e.g., rarely leaves home given hair loss/is unable to work because of time spent on hair-pulling symptoms).

was r e v i s e d s u c h t h a t t h e p h r a s e s " t h o u g h t s a b o u t h a i r - p u l l i n g " a n d " h a i r - p u l l i n g " w e r e s u b s t i t u t e d for t h e w o r d s % b s e s s i o n s " a n d " c o m p u l s i o n s . " T h e r e v i s e d ins t r u m e n t , t h e Y - B O C S - T M , yields a t o t a l score a n d 2 s u b s c a l e scores m e a s u r i n g t h e s e v e r i t y o f r e l a t e d t h o u g h t s a b o u t h a i r - p u l l i n g a n d a c t u a l h a i r - p u l l i n g beh a v i o r s . N u m e r i c a l s e v e r i t y r a t i n g s for t h e Y - B O C S - T M w e r e c o n s i s t e n t w i t h t h e p r i o r v e r s i o n s u c h t h a t t o t a l scores r a n g e d f r o m 0 - 4 0 a n d s u b s c a l e scores r a n g e d f r o m 0 - 2 0 . P r e l i m i n a r y d a t a r e v e a l e d s u p p o r t for t h e p s y c h o m e t r i c p r o p erties o f this i n s t r u m e n t ( S t a n l e y et al.). All i n s t r u m e n t s w e r e r a t e d b y t h e g r o u p t h e r a p i s t s . A l t h o u g h p o t e n t i a l p r o b l e m s w i t h b i a s exist in this p r o c e d u r e , S t a n l e y et al. (1992) r e p o r t e d h i g h i n t e r r a t e r a g r e e m e n t for t h e s e i n s t r u m e n t s . T h e A D I S R, MTAI, and Y-BOCS-TM were repeated at the completion of the group, as well as at 1- a n d 6 - m o n t h follow-ups. Description of the Patients T h e p a t i e n t s w e r e 5 a d u l t s , 4 w o m e n a n d 1 m a n , d i a g n o s e d w i t h T M . All 5 p a t i e n t s w e r e C a u c a s i a n a n d b e t w e e n t h e ages o f 17 a n d 44. N o n e o f t h e p a t i e n t s h a d ever b e e n t r e a t e d for t h e i r s y m p t o m s , e i t h e r w i t h t h e r a p y or psy-

166

MOUTON & STANLEY

chotropic medications. Patient 1 was a 17-year-old young woman who had dropped out of high school just prior to her senior year, earned a general equivalency diploma (GED), and planned to attend college the following fall semester. She began pulling her eyelashes when she was in the sixth grade and remembered that she consistently had lashes missing since onset. She associated hair-pulling behavior with feeling stressed or when studying for an exam. At pretreatment, Patient 1 was pulling from her eyelashes 1 to 2 times a day and had almost no eyelashes left. She had been wearing false eyelashes for seve r n years and would not go anywhere without these lashes and additional eye makeup. Administration of the A D I S - R and the abbreviated MTAI revealed a diagnosis of T M with a severity of 5 (range of 1-8), indicating moderate symptoms that resulted in some interference with usual activities. Interference included avoidance of activities that would require her to remove false eyelashes (e.g., swimming, camping, and crying in public). No other coexistent Axis I disorders were diagnosed. Pretreatment Y-BOCS-TM scores yielded a score of 11 for severity of thoughts about hair-pulling and a score of 8 for severity of the behavior. Each of these scores is based on a possible score of 20. Patient 2, a 25-year-old woman who worked as an auditor for a large corporation, began pulling from her scalp while in college (at age 19) because of the "pressure of being a business major." She described herself as a "classic overachiever" and indicated that she constantly placed unnecessary stress upon herself to strive for higher goals. At pretreatment, Patient 2 reported that she pulled her hair for about 1 to 2 hours each day, usually while at work, and believed that it would be impossible for her to stop. She had a moderate degree of hair loss on the back of her head and at the top of her neck, which she reported was quite disturbing to her. The ADIS-R and MTAI results revealed a diagnosis of T M with a severity of 5 (range of 1-8), indicating moderate symptoms resulting in daily interference with work and social activities. Specifically, the time she spent in hair-pulling prevented her from completing her work on time. She also reported stress and negative self-talk following episodes of her hairpulling behavior. The coexistent Axis I diagnosis of generalized anxiety disorder (GAD) also was given. Pretreatment Y-BOCS-TM scores yielded a score of 12 for severity of thoughts about hair-pulling and a severity of 10 for the actual behavior. Patient 3, a 37-year-old woman who worked at home, pulled exclusively from her scalp. Hair-pulling began for this individual at age 17, when she was in high school. She described wanting to pull her hair when she felt "out of control" usually when she was in arguments with people or feeling overwhelmed with housework. She described the behavior as relaxing and very pleasurable to her. She very much wanted to stop pulling her hair because the behavior in and of itself resulted in her feeling "out of control~' increasing further the urge to pull. Patient 3 exhibited mild hair-loss that was noticeable on the sides of her scalp, just behind her ears. Administration of the ADIS-R and MTAI

HRT FOR GROUPS

167

revealed a diagnosis of T M with a severity of 3 (range of 1-8). Interference for Patient 3 primarily included self-deprecation and loss of self-esteem due to her symptoms. Patient 3 reported no avoidance due to her symptoms. She also met DSM-III-R criteria for the diagnosis of GAD. Pretreatment Y-BOCST M scores yielded a score of 6 for severity of thoughts about hair-pulling and a score of 3 for engaging in the behavior. Patient 3 exhibited the mildest symptoms in terms of objective symptom measures, amount of hair loss, and selfreported interference in daily life of the 5 patients included in this investigation. Patient 4, a 39-year-old woman who worked outside the home, had pulled her eyelashes consistently since age nine. She remembered beginning to pull when she saw another, older child pull her hair. She remembered perceiving that child as "pretty" and thought that she too would be pretty if she engaged in similar behavior. At pretreatment, Patient 4 had few eyelashes left, using eye makeup to conceal the loss. She reported that she pulled 4 to 5 times each day in response to a physical sensation that would not go away until she had pulled several lashes. Administration of the ADIS-R and MTAI showed a T M diagnosis with a severity of 4 (range of 1-8). Patient 4 reported significant interference in her daily routine due to her symptoms. She reported that once a thought about hair-pulling entered her mind, she was unable to dispel it until she had pulled her hair. As a result, she would become obsessed with the thought and had trouble concentrating on her work. No other Axis I diagnosis was given. Pretreatment Y-BOCS-TM scores yielded a score of 9 for thoughts about hairpulling and a score of 9 for hair-pulling behavior. Patient 5 was a 44-year-old man who worked as an electrical engineer. He recalled beginning to pull his pubic hair at age 12, armpit hair at age 14, and eyebrow hair at age 19. At pretreatment, he was primarily biting his arm hair using his mouth, and occasionally pulling from his eyebrows with his fingers. He reported that hair-pulling increased his ability to concentrate; he felt that he would not be able to work if he discontinued this activity. Patient 5 ate his hair after pulling it out, and he reported pulling constantly while working, but never when away from his stressful work environment. In fact, he stated that the only time he ever stopped pulling for a long period of time was when he went on vacation. Patient 5 had no arm hair left in areas reachable with his mouth. He also had significant eyebrow loss resulting in very thin, patchy eyebrows. The ADIS-R and MTAI indicated the diagnosis of T M with a severity of 6 (range of 1-8), indicating moderate to severe symptoms that resulted in significant interference in work and leisure activities. Patient 5 was also diagnosed with social phobia. Pretreatment Y-BOCS-TM scores yielded a score of i for severity of thoughts about hair-pulling, which were almost nonexistent, and a score of 11 for the behavior, which was quite severe. All 5 patients reported distress as a result of their symptoms and each had a strong desire to stop pulling. None had sought treatment for hair-pulling in the past, and none were on medication of any kind, or were participating

168

MOUTON & STANLEY

in any form of psychotherapy at pretreatment or during the course of the group. Interestingly, none of the patients had ever met another person with hair-pulling symptoms. They were each surprised and pleased to find out that other "hairpullers" existed, and each reported positively anticipating the commencement of the group. Habit Reversal Training Procedures The H R T group treatment manual as described in Stanley and Mouton (1996) was used as the model of treatment. The model includes 6 training sessions to be carried out over a 6-week period by 2 therapists trained in cognitive behavioral therapy. Sessions I - I I I are intended to increase patients' awareness of hair-pulling through awareness training. Session I focuses on preliminary situational awareness of the behavior and the inconveniences of TM. Educational information about T M is also provided. Session II focuses on specific cues and environmental factors that result in or contribute to hair-pulling, and Session III highlights associated thoughts and moods. Sessions IV and V are used to teach two competing responses (fist clenching and relaxation techniques), and Session VI focuses on review and generalization. Prior to the onset of the group, participants were told by the therapists that this would be a time-limited group focusing on the treatment of hair-pulling symptoms. Attendance and participation were stressed as important elements of the group. The participants were also advised that they would be asked to participate in several followup sessions after the completion of treatment. All 5 patients stated that they understood and agreed to these guidelines. Session I: Inconvenience review, education, and overview of treatment. Session I began with introductions and a brief review of each subject's symptoms. Although each patient's history and profile were unique, members quickly identified similarities with regard to both phenomenology of symptoms and feelings of isolation and self-reproach resulting from hair-pulling. The therapists facilitated this discussion by pointing out similar experiences of the patients and illustrating common themes among the five unique stories. In reviewing the inconveniences of hair-pulling, the most commonly reported consequences included selfdeprecation and guilt, as well as self-consciousness regarding appearance. Patients stated that they felt both "ashamed" and "horrified" by their behavior. Other inconveniences included time spent on the disorder (up to several hours a day); interference with interpersonal relationships; avoidance of certain activities such as biking, swimming, and camping; and dishonesty with friends and professionals such as physicians and hair stylists. Patients had constructed elaborate stories throughout their lives to explain to others how their hair had "fallen" out. Educational information about T M , presented during Session I, covered topics such as the onset, prevalence, and etiology of the disorder. Patients were particularly receptive to the learning theory upon which H R T is based. Con-

HRT FOR GROUPS

169

ceptualizing the behavior as a normal reaction to stressful events, or as an infrequent behavior that had become conditioned to occur under a wide variety of circumstances, seemed to serve two purposes: (1) it allowed the patients to view their behavior as normal rather than "bizarre" or "abnormal;' and (2) it enhanced their feelings of control over the behavior (e.g., if the behavior was indeed "learned" then it could be "unlearned"). Patients responded to this explanation with enthusiasm for the approach and a desire to "learn the techniques immediately:' As a result, patients were somewhat resistant to spending time with awareness training and wanted to "skip right to the competing responses:' The importance of awareness training was emphasized, however, with an explanation that competing responses would not be maximally effective if the patients were not completely aware of their behaviors. Patients accepted this explanation as a reason to begin with awareness training. Credibility and expectancy ratings based on the format proposed by Borkovec and Nau (1972) were collected at the end of Session I after all H R T procedures were explained. Specifically, patients were asked to rate on various 10-point scales how logical the treatment seemed, their confidence in undergoing the treatment and recommending it to others, and their expectations for the treatment's success. Based on these ratings, the mean credibility score for H R T across all subjects was 6.9 (SD = 1.76; range = 1-10), indicating moderately high levels of credibility. In addition, patients rated the percentage of improvement expected as a result of treatment on a 0-100% scale. Across patients, an average of 68% improvement in symptoms (SD = 7.0) was expected as a result of the treatment. Two homework activities were assigned to correspond with Session I and to aid patients in increasing awareness of hair-pulling. First, patients were asked to record on daily self-monitoring forms the number and duration of thoughts about hair-pulling, the number and duration of episodes of hair-pulling, and the number of hairs pulled (see Table 2). In other words, they recorded each day how many times they thought about hair-pulling and how long the thoughts lasted; how many times they pulled their hair and for how long; and how many hairs were pulled. This monitoring continued throughout the 6 weeks of therapy. Second, patients were asked to record the date, time, place, circumstance, and preceding event for each episode of pulling during the upcoming week (see Table 3). The purpose of this assignment was to help the patients to become more aware of various aspects of their hair-pulling behavior in order to begin to build a functional analysis of their symptoms. Session II: Identification of preceding behaviors and sequence of movements. Session II and the corresponding homework focused on identifying situations that put the subjects at risk for hair-pulling behaviors and environmental stimuli that precede hair-pulling. As with every subsequent session, Session II began with a review of the self-monitoring procedures and the prior homework assignment. At this session, Patient 1 reported that she had a "good week" and had

170

MOUTON & STANLEY

TABLE 2 EXAMPLE SELF-MONITORING FORM

Self-Monitoring Instructions A. Four times daily list: 1) Number of thoughts about hair-pulling 2) Time thinking about hair-pulling 3) Number of episodes of hair-pulling 4) Time spent hair-pulling B, At day's end, list daily average for:

1) Degree of pleasure from hair-pulling 2) Degree of anxiety prior to hair-pulling 3) Degree of anxiety after hair-pulling 0 .... 1 .... 2 .... 3 .... 4 .... 5 .... C. At day's end, record total number of hairs pulled.

6 .... 7 ....

8 ....

Monitoring Form (I) Date Thoughts about #

Hair-pulling

Hair-pulling Time

#

Time

8 am 12 pm 4 pm 8 pm Degree of Pleasure (0-8) Degree of Anxiety Prior (0-8) Degree of Anxiety After (0-8) Number of Hairs Pulled

n o t p u l l e d any hair. Patient 2 r e p o r t e d 62 episodes of h a i r - p u l l i n g d u r i n g the p r i o r week, w h i c h o c c u r r e d a l m o s t exclusively w h e n she was at w o r k o r while d r i v i n g . She identified p r e c i p i t a t i n g situations such as h a v i n g a m e e t i n g w i t h h e r boss, w o r r y i n g a b o u t a project, a n d t y p i n g on the c o m p u t e r . Patient 3 d o c u m e n t e d 14 episodes t h a t h a d o c c u r r e d p r i m a r i l y while r e a d i n g or t a l k i n g on the phone. Patient 4 r e c o r d e d 4 episodes that were all in r e s p o n s e to stressful events o c c u r r i n g w i t h h e r c h i l d r e n (e.g., p u t t i n g h e r c h i l d r e n to b e d w h e n t h e y did n o t w a n t to go). Patient 5 d o c u m e n t e d 56 episodes of h a i r - p u l l i n g that occ u r r e d exclusively while he was at w o r k on his c o m p u t e r . H e even d e s i g n e d a c o m p u t e r p r o g r a m to h e l p h i m keep track of his behavior. As a result of initial awareness t r a i n i n g h o m e w o r k , 3 of the g r o u p m e m b e r s r e p o r t e d that t h e y h a d p r e v i o u s l y not r e a l i z e d the different situations a n d prec e d i n g events that led t h e m to pull. All 5 p a t i e n t s n o t e d t h a t t h e y w e r e b e g i n -

171

HRT FOR GROUPS

TABLE 3 HOMEWORkFORM, S~SSlONI For each episode of hair-pulling during the week, please record the following: Situational Correlates Date

Day

Time

Where?

With w h o m ?

Preceding event?

ning to view their behavior as a reaction to various stimuli, rather than as a r a n d o m event. The remainder of Session II discussion and the corresponding homework extended awareness training and produced rich information regarding the fine elements of each patient's pulling sequence. H o m e w o r k for this Session asked patients to monitor when and where the hair-pulling occurred, what was happeningjust before they began pulling, as well as the specific movements leading up to pulling (e.g., stroking the hair, touching the face, searching for a hair; see Table 4). Information gleaned from the discussion and the homework exercise illustrated the complexity of each patient's behaviors, most of which patients were previously unaware. For example, Patient 2 identified that she stroked her long hair until she located a coarse, thick hair to pull, while Patient 1 noted that she rubbed the hair between her fingers and pulled with quick, jerky motions. Patient 4 felt a physical sensation to pull a specific hair, and after pulling that hair, felt the physical sensation move to the next hair. Patient 3 reported that her behavior occurred exclusively while playing with her hair, which she described as "soothing:' and noted that both playing and pulling increased if

TABLE 4 HOMEWORKFORM, SESSIONII For each episode of hair-pulling during the week, please record the following: Date

Time

SituationalCorrelates

Preceding Behaviors

Sequenceof Movements

172

MOUTON & STANLEY

her hair was dirty. Finally, Patient 5 reported that he raised his arm to his mouth and pulled with his teeth until his concentration was solid. All 5 patients reported an increased sense of control regarding their behavior as a result of identifying more detailed patterns of hair-pulling and precipitating cues. Session Ill." Awareness of associated thoughts and moods. Session I I I and the corresponding homework focused on the identification of moods and thoughts experienced before, during, and after hair-pulling. Specifically, patients were asked to discuss and then to record what they were thinking about and feeling before they began to pull, while they were pulling, and after the episode had ended (see Table 5). The therapists explained the differences between thoughts (cognitions) and feelings (moods) and provided examples of possible thoughts, as well as a list of "feeling words" to the patients to facilitate the discussion. Regarding thoughts, Patient 1 noted no specific thoughts until the behavior was completed, at which time she asked herself, "Why did I do that?" Patient 2 noted that she tried unsuccessfully to talk herself out of hair-pulling throughout the sequence. Patient 3 reported thinking about wanting to relax prior to pulling. During the behavior, however, she thought, "You're out of control" After pulling, she asked herself, "Why am I doing this to myself?." Patient 4 noted that her thoughts prior to pulling were about needing to pull a specific eyelash that was bothering her. During pulling she thought, "I got it; but afterward she told herself, '~lust one more" Patient 5 reported no thoughts associated with hair-pulling other than, "If I stop, I will not be able to work:' Patients were able to examine their thoughts and identify how they were able to justify their behavior, talk themselves into the behavior, or berate themselves for having engaged in the behavior. With regard to associated moods, Patients 1 and 3 reported feeling bored before hair-pulling, relaxed or soothed during the behavior, and anxious and guilty afterward. Patient 2 reported feeling stressed prior to pulling, uneasy or anxious during the behavior, and worried or relaxed afterward. Patient 4

TABLE 5 HOMEWORK FORM, SESSIONIII For each episode of hair-pulling during the week, please record the following: Mood Time/Date

Situation

Before

During

Thoughts After

Before

During

After

H R T FOR GROUPS

173

noted that she was sleepy and thoughtful before, anxious during, and disgusted after the behavior. Patient 5 could not identify any feelings associated with hairpulling, other than that the behavior helped him to focus and concentrate on his work. The purpose of identifying feelings associated with hair-pulling was to help the patients understand what feelings may have triggered and/or perpetuated an episode. In addition, this segment of treatment assisted patients in identifying how the resultant feelings may have reinforced the behavior (e.g., by decreasing stress or anxiety). Ultimately, several of the patients learned that they felt worse after the behavior, a consequence that oftentimes triggered another urge, creating a cycle of unpleasant feelings. Following Session III, Patients 1-4 reported almost complete awareness of hair-pulling, with the ability to identify "high-risk" situations as well as thoughts and feelings that tended to lead to the behavior. Relatedly, these individuals described a continued increase in perceived control over symptoms as a result of awareness training. Session IV." Competing responsetraining with exposure. Session IV focused on teaching an initial competing response to be used in high-risk situations as a means of preventing or discontinuing the hair-pulling behavior. Specifically, patients were instructed to clench their fists when they felt the urge to pull, were in identified high-risk situations, or found themselves engaging in the pulling behavior. Patients were encouraged to be creative with the fist-clenching (e.g., to use door handles, books, steering wheels, etc., for clenching). They were instructed to utilize a fist-clenching response for 3 minutes each time an urge was present. If after 3 minutes the urge had not decreased to a manageable level, they were instructed to repeat the competing response. The purpose of fist-clenching as a competing response was to provide an alternate response to the urge to pull their hair in an effort to prevent or discontinue the hair-pulling behavior. Fistclenching provides tactile stimulation and physically inhibits the patient from hair-pulling. At first, patients seemed hesitant to believe that this intervention could change their lifelong behavior. The therapists gently encouraged them to "give it a try" At this point, patients were guided through imaginal exposure to a high-risk situation and asked to implement the competing response. Patients were asked to close their eyes and imagine themselves in a previously identified high-risk situation. They were asked to visualize the situation, observing details of their surroundings, and then to notice the urge to pull becoming stronger and stronger until they wanted very much to pull their hair. At this point, they were asked to employ the competing response to interrupt the hair-pulling urge. Patients were asked to keep using the competing response until the urge had subsided considerably. All 5 patients reported that they were able to feel a decrease in the urge to pull following the competing response. As a subsequent homework assignment, patients were asked to practice the intervention by putting themselves in at least one high-risk situation per day during the upcoming week, employing the competing response, and recording the results (see Table 6).

174

MOUTON & STANLEY

TABLE 6 Homework Form, Session IV Part 1

For each episode of hair-pulling during the week, please record the following: Mood Date/Time

Situation

Before

Thoughts

During

After

Before

During

After

Part 2

At least once per day, practice the competing response procedure in a high-risk situation (preferably one that has been avoided previously). Day

Situation

Urge to pull before (0-8)

Competing Response

When Used

Urge to pull after (0-8)

In response to Session I V homework, Patient 1 r e p o r t e d that she was able to clench her books while reading, which was m a r k e d l y successful in r e d u c i n g her urge to pull. Patient 2 reported that she was able to use fist-clenching successfully at work to reduce the h a i r - p u l l i n g urges. Further, she found that rubb i n g the in-seam of the steering wheel while d r i v i n g gave her the tactile pleasure to satisfy her urge to pull. Patient 3 was able to grasp the telephone successfully while talking, b u t found herself still giving in to the urges at times. Patient 4 was very successful at using the c o m p e t i n g response to stop her behavior, r e p o r t i n g that this was the first week of her life since age 9 d u r i n g which she did not pull one hair. She noted, however, that the physical sensation leading to the urge to pull was not affected by the fist clenching. Patient 5 r e p o r t e d that he b e c a m e so anxious when he tried to stop pulling, that he did not employ the technique after 1 to 2 trials. Session V: Relaxation training with exposure. This session was used to teach two alternative coping responses, both of which involved relaxation strategies: deep b r e a t h i n g a n d postural a d j u s t m e n t s (muscle relaxation while sitting a n d standing). Patients were informed that although anxiety a n d tension are not the only emotions that precipitate hair-pulling, they do occur frequently. As

HRT FOR GROUPS

175

a result, learning to relax can be a useful control mechanism. Patients then were taught to breathe deeply, from their diaphragms, counting to five with each inhalation and exhalation. Patients practiced breathing several times. Next, patients were taught a different strategy for relaxation (e.g., adopting a relaxed posture by letting one's shoulders slouch forward slightly rather than remaining erect). Patients were asked to become aware of any tension or stiffness in their neck and shoulders and to relax these muscle groups in response to the tension. They also practiced this response in both sitting and standing positions. Imaginal exposure techniques again were used during the session to aid patients in practicing the relaxation techniques in high-risk situations. As in Session IV, patients were asked to close their eyes and imagine themselves in a high-risk situation. They were asked to visualize the situation, observing details of their surroundings, noticing the urge to pull becoming stronger and stronger until they wanted very much to pull their hair. In this session, they were asked to use one of the relaxation strategies to interrupt the hair-pulling urge. T h e y were instructed to continue to relax, by both breathing and postural adjustment, until the urge had subsided. Four of the 5 patients were able to use relaxation effectively to reduce their urges to pull. Homework for this session (see Table 7) again involved asking patients to put themselves in high-

TABLE 7 Homework Form, Session V Part 1

For each episode of hair-pulling during the week, please record the following: Time/Date

Comment

Coping Response Used

Pa# 2

At least once per day, practice the competing response procedure in a high-risk situation (preferably one that has been avoided previously). Record each practice below. Day

Situation

Urge to p u l l before (0-8)

Competing Response

When Used

Urge to pull after (0-8)

176

MOUTON

& STANLEY

risk situations during the week, and to practice relaxation strategies accordingly, monitoring their success. Session VI: Generalization, integration, termination. The goals of Session VI were to review the utility of the treatment, synthesize accumulated information, and assist patients in devising plans for continued management of symptoms. At this session, Patient 1 commented that after a week of using both the competing response and relaxation, she found the former to be more helpful. According to Patient 1, she pulled when she was feeling bored or relaxed, and therefore needed something to do with her hands. Patient 2 reported that relaxation greatly reduced her urge to pull while at work. She began taking breaks during the day to "breathe" and thus prevent future hair-pulling episodes. Further, she found that a combination of the two strategies was most helpful for her. Patient 3 reported that the deep breathing almost completely eliminated her urge to pull. Patient 4 found that relaxation helped to reduce physical sensations that invariably led to pulling. She noted that she first used the fist-clenching to reduce the urge to pull, and then used relaxation techniques if physical sensations were still present. Patient 5 reported that relaxation was extremely difficult for him and that he became more agitated as he tried to relax. As a result, he was unable to use the relaxation responses taught. Also during the final session, patients reflected upon their experiences and progress over the 6-week period. Despite some hesitancy at treatment onset, all patients agreed that increasing awareness of the behavior was the key to understanding, and thus changing, their behavior. Finally, patients brainstormed ways in which they could use H R T techniques in other situations and discussed strategies for maintaining their improvements. Results of H R T in a Group Format Mean clinician ratings of global severity of T M (based on the ADIS-R and MTAI), and the severity of thoughts and the behavior itself (based on the YBOCS-TM), are illustrated in Figures 1-3. Clinician ratings utilizing the ADIS-R and MTAI (see Figure 1) indicated clinically significant improvement in overall severity of T M for Patients 1-4 from pre- to posttreatment. At posttreatment, in fact, ratings for these participants indicated mild to minimal symptoms (ratings of 1 or 2). Patient 5, however, exhibited no change from pre- to posttreatment on this measure. Regarding thoughts about hair-pulling, notable decreases in symptom severity also were observed for Patients 1-4. Patient 1 demonstrated the most marked decrease in severity from pre- to posttreatment, falling from an 11 to a 0. Patients 2-4 exhibited more modest decreases on this rating. Finally, clinician ratings of hair-pulling severity according to the Y-BOCS-TM demonstrated decreases in scores for Patients 1-4. Patient l's severity dropped from a score of 8 to a 0. Patient 2's score fell from a 10 to a score of 5. Patient 3's rating dropped from a 3 to a 2. Patient 4 exhibited symptom reduction from a score of 9 to 3. Again, Patient 5 demonstrated no difference from pre- to posttreatment on this measure.

HRT FOR GROUPS

f

©

0 Pre

p,

177

,3

I

I

i

Post

1 mo

6 mo

Time Patient 1 Patient 2 Patient 3 Patient 4 Patient 5

FIGUREl. Clinician ratings of TM severity as measured by the MTAI at pretreatment, posttreatment, and follow-up.

Patients 1 and 2 exhibited maintenance of improvement in global severity as measured by the MTAI at the 1-month follow-up, while Patients 3 and 4 exhibited some regression at this time relative to posttreatment. At 6 months, Patients 1 and 3 had maintained treatment gains in overall severity of TM. At this time, symptom severity for Patients 2 and 4 indicated increased symptomatology relative to posttreatment, but scores continued to be lower than pretreatment. Regarding thoughts about hair-pulling, all patients maintained reduced severity at 1- and 6-month follow-up times. Finally, with respect to severity of hair-pulling behavior, Patients 1-3 demonstrated maintenance of gains at 1 month, while Patient 4 exhibited increased symptoms. Patients 1 and 3 exhibited continued maintenance at 6 months, while Patients 2 and 4 demonstrated some regression. Another important outcome of these case illustrations is the impact that the group environment had on the patients. Specifically, patients reported a sense of support and understanding that they had not previously experienced, perhaps because T M is a relatively "unknown" disorder to the lay public. Participants reported spontaneously that the group experience was helpful in terms of providing a sense of support to counter their feelings of"aloneness" with their

178

MOUTON & STANLEY

14

12

10

8

6

4

2

0 Pre

Post

1 mo

6 mo

Time Patient 1 Patient 2 Patient 3 Patient 4 Patient 5

FIGURE 2. Severity of patients' thoughts about hair-pulling as measured by the Y-BOCS-TM at

pretreatment, posttreatment, and follow-up.

symptoms; teaching them about the disorder through "symptom sharing"; and normalizing symptoms that were previously perceived to be bizarre. In fact, at 6-month follow-up, 4 group members asked about the possibility of forming an ongoing support group to continue with their self-monitoring and homework assignments. Self-monitoring data were not examined because of missing data due to incomplete records for Patients 1, 2, and 5. Because only 5 patients were involved in the investigation, an analysis of these data would not be meaningful. Discussion These case illustrations replicate and extend prior data, lending support to the viability of applying H R T in a group format as a meaningful approach to treating TM. This investigation utilized a standardized form of H R T as well as clinician-rated outcome measures in a group context. Although the available case report data support the potential viability of group HRT, future empirical

179

HRT FOR GROUPS

12 O

10

Pre

Post

1 mo

6 mo

Time

Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 -il--

~

~=

[]

o

FTGURE3. Severityof hair-pulling behavior as measured by the Y-BOCS-TM at pretreatment, posttreatment, and follow-up. investigations will need to examine in a well-controlled experimental design the effectiveness of this standardized approach relative to other group interventions. If results of these comparisons support the relative effects of HRT, the need to identify specific H R T components that are responsible for symptom improvement will become paramount. As Ladouceur (1979) has suggested, awareness training through self-monitoring may be the essential component of HRT. It is also possible, however, that coping-skills training is the key ingredient to HRT, or that the impact of H R T lies in its combination of these principal components. Future research also should address the utility of single versus multiplesession models of HRT, as well as the relative benefits of individual and group formats. Finally, the long-term effects of H R T will need to be explored. Two patients from this group treatment exhibited some regression after 6 months. Consequently, 6-month "booster" sessions may be necessary to continue positive maintenance of symptoms for some patients. At 6 months posttreatment, Patients 2 and 4 reported that they had gradually stopped using the techniques of HRT, and that without continued group contact, their incentives for ongoing monitoring of behavior were diminished. Thus, future research also might address the utility of providing booster sessions or systematic relapse-prevention approaches over a long-term interval.

180

MOUTON & STANLEY

A meaningful outcome of the present investigation was the value of the group experience. Specifically, the feedback provided by the patients regarding their sense of "community" and "shared experience" indicates that the group format is a powerful setting for this type of intervention. The group approach was selected over individual treatment presumably because it would maximize education and support for participants, while providing an economic means for conducting HRT. This latter goal also was achieved as 5 patients were seen in therapy for a total of 9 hours. From a managed care perspective, this approach is a more time-efficient strategy than providing individual sessions for each patient. Again, however, future research will need to compare the relative efficacy and cost-effectiveness of individual and group modalities. Individual group members seemed to utilize different aspects of the H R T treatment more effectively. For example, 2 patients benefited simply from the awareness training alone, while others needed the competing response to augment their therapy. Two of the patients were able to use the fist-clenching more successfully than the relaxation response; the other 2 patients benefited greatly from the anxiety reduction. Further investigation into why certain individuals benefit from different interventions might prove useful. Thus the treatment implications would be to provide a wide variety of "tools" for the patients to utilize across varying situations. Regarding Patient 5's lack of progress, several hypotheses can be offered. First, more cognitive therapy may have been beneficial in reducing his symptoms, as he seemed convinced that his hair-pulling helped him to concentrate. His fear of not being able to concentrate on work was perhaps greater than his motivation to stop pulling, thus therapy was not reinforcing to him. Exposure treatment also may have been effective in reducing anxiety associated with not pulling his hair. Second, because Patient 5 was so anxious and fearful of external evaluation, as demonstrated by his coexistent diagnosis of social phobia, H R T might have been more effective used in conjunction with alternative behavioral interventions, individual therapy, and psychotropic medication to contain his additional Axis I symptomatology. In sum, it appears that implementing H R T within a group context merits future investigation. Results of the case illustrations presented here suggest that education, self-awareness, and competing response training were useful tools in reducing symptoms of trichotillomania in 4 out of the 5 patients treated. Conclusions regarding the efficacy of HRT, however, await further controlled empirical research. References

American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author.

HRT FOR GROUPS

181

American Psychiatric Association (1994). Diagnosticand statistical manual of mental disorders (4th ed.). Washington, DC: Author. Azrin, N. H,, & Nunn, R. G. (1973). Habit-reversal: A method of eliminating nervous habits and tics. Behaviour Research and Therapy, 11, 619-628. Azrin, N. H., Nunn, R. G., & Frantz, S. E. (1980). Treatment of hair-pulling (trichotillomania): A comparative study of habit reversal and negative practice training. Behavior Therapy and Experimental Psychiatry, H, 13-20. Borkovec, T. D., & Nau, S. D. (1972). Credibility of analogue therapy rationales. Journal (Behavior Therapy and Experimental Psychiatry, 3, 257-260. Christenson, G. A., Mackenzie, T. B., & Mitchell, J. E. (1991). Characteristics of 60 adult chronic hair pullers. AmericanJournal of Psychiatry, 148, 365-370. Christenson, G. A., Mackenzie, T. B., Mitchell, J. E., & Callies, A. L. (1991). A placebo-controlled, double-blind crossover study of flnoxetine in trichotillomania. AmericanJournal of Psychiatry, 148, 1566-1571. Christenson, G. A., Pyle, R. L., & Mitchell, J. E. (1991). Estimated lifetime prevalence of trichotillomania in college students. Journal of Clinical Psychiatry, 52, 415-417. DiNardo, R A., Moras, K., Barlow, D. H., Rapee, R. M., & Brown, "12 A. (1993). Reliability of DSM-III-R anxiety disorder categories. Archives of General Psychiatry, 50, 251-256. Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Leischmann, R , Hill, C., Henenger, G., & Charney, D. (1989). The Yale-Brown Obsessive Compulsive Scale (Y-BOCS). Part I. Development, use, and reliability. Archives of General Psychiatry, 46, 1006-1011. Graber, J., & Arndt, W. B. (1993). Trichotillomania. ComprehensivePsychiatry, 34, 340-346. Greenberg, H. R., & Sarner, C. A. (1965). Trichotillomania: Symptom and syndrome. Archives of General Psychiatry, 12, 482-489. Jenike, M. A. (1990). Obsessive-compulsive and related disorders. The New EnglandJournal of Medicine, 321, 539-541. Ladouceur, R. (1979). Habit reversal treatment: Learning an incompatible response or increasing subject's awareness? Behaviour Research and Therapy, 17, 313-316. Lenane, M. C., Swedo, S. E., Rapoport, J. L., Leonard, H., Sceery, W., & Guroff, J. j. (1992). Rates of obsessive compulsive disorder in first degree relatives of patients with trichotillomania: A research note. Journal of Child Psychologyand Psychiatry, 33, 925-933. Mansueto, C. (1991). Trichotillomania in focus. OCD Newsletter, 5, 10-11. Mansueto, C. (1993, April). 5qichotiltornaniaand life. Presented at the Massachusetts General Hospital Clinic Trichotillomania Conference, Boston. Oguchi, T., & Miura, S. (1977), Trichotillomania: Its psychopathological aspect. ComprehensivePsychiatry, 18, 177-182. Rothbaum, B. O. (1992). The behavioral treatment of trichotillomania. BehavioralPsychotherapy,20, 85-90. Rothbaum, B. O., & Ninan, E (1992, November). 7~eatmentoftrichotillomania: Behavior therapy versus clomipramine. Presented at the Association for Advancement of Behavior Therapy Annual Convention, Boston. Rothbaum, B. O., Shaw, L., Morris, R., & Ninan, E T. (1993). Prevalence of triehotillomania in a college freshman population. [Letter]. Journal of Clinical Psychiatry, 54, 72. Stanley, M. A., Borden, J. w., Bell, G. E., & Wagner, A. L. (1994). Nonclinical hair-pulling: Phenomenology and related psychopathology. Journal of Anxiety Disorders, 8, 119-130. Stanley, M. A., & Mouton, S. G. (1996). Trichotillomania treatment manual. In M. Hersen & V. VanHasselt (Eds.), Sourcebookof psychological treatment manualsfor adult disorders (pp. 657-687). New York: Plenum Press. Stanley, M. A., Prather, R. C., Wagner, A. L., Davis, M. L., &Swann, A. C. (1993). Can the Yale-Brown Obsessive Compulsive Scale be used to assess trichotillomania? A preliminary report. BehaviourResearch and Therapy, 31, 171-178. Stanley, M. A., Swann, A. C., Bowers, T. C., Davis, M. L., & Taylor, D.J. (1992). A comparison of clinical features in trichotillomania and obsessive-compulsive disorder. BehaviourResearchand Therapy, 30, 39-44. Streichenwein, S. M., & Thornby, J. I. (1995). A long-term, double-blind, placebo-controlled crossover trial of the efficacy of fluoxetine for trichotillomania. AmericanJournal of Psychiatry, 152(8), 1192-1196.

182

MOUTON & STANLEY

Swedo, S. E., & Leonard, H. L. (1992). Trichotillomania: An obsessive compulsive spectrum disorder? Psychiatric Clinics of North America, 15, 777-790. Swedo, S. E., Leonard, H. L., Rapoport, J. L., Lenane, M. C., Goldberger, B. A., & Cheslow, B. A. (1989). A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling). New England Journal of Medicine, 321, 497-501. Tynes, L. L., White, K., & Steketee, G. S. (1990). Toward a new nosology of obsessive compulsive disorder. ComprehensivePsychiatry, 31, 465-480. Preparation of this article was supported in part by Grant No. T01-MH19820-01 from the Substance Abuse and Mental Health Services Administration, and by funds from the Hogg Foundation, and Women's Fund for Health, Education, and Research awarded to the second author. The authors would like to acknowledge Doreen Brubaker, Ph.D., Rita Prather, Ph.D., and three anonymous reviewers for their assistance in preparation of this publication. Please address all correspondence to the first author at the Department of Behavioral Medicine, Kelsey-Seybold Clinic, 5757 Woodway, Houston, T X 77057. RECEIVED: April .5, 1996 ACCEPTED: Augtlsl 12, 1996