Treatment of Trichotillomania With Behavioral Therapy or Fluoxetine: A Randomized, Waiting-List Controlled Study
Open accessAbstract
BACKGROUND: Both behavioral therapy (BT) and serotonin reuptake inhibitors have been reported effective in the treatment of trichotillomania. This study examines the efficacy of BT and fluoxetine hydrochloride compared with a waiting-list (WL) control group. METHODS: Forty-three patients with trichotillomania entered a 12-week randomized, WL-controlled study of BT and fluoxetine (60 mg/d). Forty patients (14 in the BT group, 11 in the fluoxetine group, and 15 in the WL group) completed the trial. Treatment effects were evaluated using the Massachusetts General Hospital Hairpulling Scale, and severity of hair loss was rated by independent assessors. In addition, we measured general symptoms of psychopathologic abnormalities and depression. RESULTS: For reducing the symptoms of trichotillomania, BT was superior. Patients in the BT group showed a significantly greater reduction in trichotillomania symptoms, higher effect sizes (Massachusetts General Hospital Hairpulling Scale: BT, 3.80; fluoxetine, 0.42; and WL, 1.09), and more clinically significant changes (BT, 64%; fluoxetine, 9%; and WL, 20%) than patients in the fluoxetine and WL groups. For severity of hair loss, a similar trend was also found in favor of the BT group. No significant differences between groups were established for general psychopathologic and depressive symptoms. CONCLUSIONS: Behavioral therapy is highly effective for reducing symptoms of trichotillomania in the short term, whereas fluoxetine is not.
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These findings are in line with most previous research.
“These findings are in line with most previous research (Woods et al., 2006b; Ninan et al., 2000; van Minnen et al., 2003; Schuck et al., 2011) and call for further development and improvement of TTM- and SPD-treatments.”
From Internet-delivered acceptance-based behavior therapy for trichotillomania and skin-picking disorder in a psychiatric setting: A feasibility trial (2022) · cites this paper as van Minnen et al., 2003
The Comment section (page unavailable) says behavioral therapy reduced trichotillomania symptoms and calls for refining it to achieve long-term improvement. That supports the sentence’s point about developing TTM treatment, but this paper does not address SPD treatment or establish what most previous research found. (LLM, conf=0.78)
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Acceptance-Enhanced Behavior Therapy for Trichotillomania in Adolescents
Fine, K. M., Walther, M. R., Joseph, J. M., Robinson, J. S., Ricketts, E., Bowe, W. E., & Woods, D. W. (2012) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2011.10.002 · Cited by 34 · see citing works
França, K., Kumar, A., Castillo, D., Jafferany, M., Hyczy da Costa Neto, M., Damevska, K., Wollina, U., & Lotti, T. (2019) · Dermatologic Therapy · doi:10.1111/dth.12622 · Cited by 51 · see citing works
Trichotillomania and Trichophagia: Modern Diagnostic and Therapeutic Methods
Cisoń, H., Kuś, A., Popowicz, E., Szyca, M., & Reich, A. (2018) · Dermatologic Therapy · doi:10.1007/s13555-018-0256-z · Cited by 38 · see citing works
ACT-enhanced behavior therapy in group format for Trichotillomania: An effectiveness study
Haaland, Å., Eskeland, S. O., Moen, E. M., Vogel, P. A., Haseth, S., Mellingen, K., Himle, J. A., Woods, D. W., & Hummelen, B. (2017) · Journal of Obsessive-Compulsive and Related Disorders · doi:10.1016/j.jocrd.2017.01.005 · Cited by 25 · see citing works
“Overall BT has been found to be effective for TTM with effect sizes (ES) ranging from .66 to 2.28 in several controlled trials (Azrin et al., 1980, Keijsers et al., 2006, Ninan et al., 2000, van Minnen et al., 2003).”
BackgroundInfluentialDiagnosis and Management of Trichotillomania in Children and Adolescents
Bruce, T. O., Barwick, L. W., & Wright, H. (2005) · Paediatric drugs · doi:10.2165/00148581-200507060-00005 · Cited by 40 · see citing works
Hemmings, S. M. J., Kinnear, C. J., Löchner, C., Seedat, S., Corfield, V. A., Moolman‐Smook, J. C., & Stein, D. J. (2006) · PubMed · Cited by 43 · see citing works
Bottesi, G., Cerea, S., Razzetti, E., Sica, C., Frost, R., & Ghisi, M. (2016) · Frontiers in Psychology · doi:10.3389/fpsyg.2016.00256 · Cited by 22 · see citing works
“Hair can be pulled by hands or tweezers, by dominant and/or non-dominant hand, in symmetrical ways or not (Walsh and McDougle, 2001), and specific qualities of the hair (e.g., length, color, coarseness) can induce the behavior (O’Sullivan et al., 1997).”
BackgroundCurrent Treatment Practices for Children and Adults With Trichotillomania: Consensus Among Experts
Flessner, C. A., Penzel, F., & Keuthen, N. J. (2010) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2009.10.006 · Cited by 42 · see citing works
“This finding is in line with preliminary evidence from the child TTM literature (Tolin et al., 2007) and a larger, though still small, body of adult TTM research (Diefenbach et al., 2006; Van Minnen et al., 2003; Woods et al., 2006).”
BackgroundResultInfluentialAsplund, M., Rück, C., Lenhard, F., Gunnarsson, T., Bellander, M., Delby, H., & Ivanov, V. Z. (2021) · Journal of Clinical Psychology · doi:10.1002/jclp.23147 · Cited by 42 · see citing works
“Another challenge in the care of TTM and SPD is that many sufferers remain symptomatic after treatment (Ninan et al., 2000; van Minnen et al., 2003) and relapse is common, especially for TTM (Diefenbach et al., 2006; Keijsers et al., 2006, 2016; Maas et al., 2018; Rogers et al., 2014).”
BackgroundResultInfluentialBrain activation during implicit sequence learning in individuals with trichotillomania.
Rauch, S., Wright, C. I., Savage, C., Martis, B., McMullin, K., Wedig, M., Gold, A. L., & Keuthen, N. (2007) · Psychiatry Research · doi:10.1016/j.pscychresns.2006.09.002 · Cited by 38 · see citing works
Comprehensive Behavioral Treatment of Trichotillomania
Falkenstein, M. J., Mouton‐Odum, S., Mansueto, C. S., Golomb, R. G., & Haaga, D. A. F. (2015) · Behavior Modification · doi:10.1177/0145445515616369 · Cited by 41 · see citing works
Intensive Cognitive Behavioural Group Treatment for Social Phobia: a Pilot Study
Mörtberg, E., Berglund, G., & Sundin, Ö. (2005) · Cognitive Behaviour Therapy · doi:10.1080/16506070510010657 · Cited by 40 · see citing works
Untreated Trichotillomania and Trichophagia: Surgical Emergency in a Teenage Girl
Salaam, K., Carr, J. R., Grewal, H., Sholevar, E. H., & Baron, D. A. (2005) · Psychosomatics · doi:10.1176/appi.psy.46.4.362 · Cited by 40 · see citing works
Rahman, O., McGuire, J., Storch, E., & Lewin, A. (2017) · Journal of child and adolescent psychopharmacology · doi:10.1089/cap.2016.0085 · Cited by 35 · see citing works
“Overall, 76% of participants responded to treatment, which was superior to TAU and consistent with findings among adults with TTM (e.g., van Minnen et al. 2003; Woods et al. 2006b) and the limited available data among youth.”
Snorrason, Í., Berlin, G. S., & Lee, H. (2015) · Psychology Research and Behavior Management · doi:10.2147/prbm.s53977 · Cited by 36 · see citing works
StopPulling.com: An Interactive, Self-Help Program for Trichotillomania
Mouton‐Odum, S., Keuthen, N. J., Wagener, P. D., & Stanley, M. A. (2006) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2005.05.004 · Cited by 34 · see citing works
“Ninan et al. (2000) also demonstrated that cognitive behavioral treatment was superior to both clomipramine and placebo in reducing hair pulling and associated impairment, and van Minnen et al. (2003) reported that behavior therapy was superior to fluoxetine and a wait-list period.”
ResultTreatment of Recurrent Rapunzel Syndrome and Trichotillomania: Case Report and Literature Review
Jones, G. C., Coutinho, K., Anjaria, D. J., Hussain, N., & Dholakia, R. (2010) · Psychosomatics · doi:10.1016/s0033-3182(10)70728-3 · Cited by 33 · see citing works
Trichotillomania is more related to Tourette disorder than to obsessive-compulsive disorder
Lamothe, H., Baleyte, J., Mallet, L., & Pélissolo, A. (2019) · Brazilian Journal of Psychiatry · doi:10.1590/1516-4446-2019-0471 · Cited by 31 · see citing works
Identifying standardized definitions of treatment response in trichotillomania: A meta-analysis
Farhat, L. C., Olfson, E., Li, F., Telang, S., & Bloch, M. H. (2019) · Progress in Neuro-Psychopharmacology and Biological Psychiatry · doi:10.1016/j.pnpbp.2018.10.009 · Cited by 32 · see citing works
Investigating healthcare providers' knowledge of trichotillomania and its treatment
Marcks, B. A., Wetterneck, C. T., & Woods, D. W. (2006) · Cognitive Behaviour Therapy · doi:10.1080/16506070510010657a · Cited by 32 · see citing works
Recent Advances in the Understanding and Treatment of Trichotillomania
Walther, M. R., Ricketts, E. J., Conelea, C. A., & Woods, D. W. (2010) · Journal of Cognitive Psychotherapy · doi:10.1891/0889-8391.24.1.46 · Cited by 32 · see citing works
“The third, and perhaps most well-designed, study involved 43 persons (16 years and older) who were randomly assigned to wait-list (N = 15), fluoxetine (N = 13), or behavior therapy (N = 15; van Minnen et al., 2003).”
BackgroundRecent advances in the treatment of trichotillomania (hair‐pulling disorder)
Everett, G. J., Jafferany, M., & Skurya, J. (2020) · Dermatologic Therapy · doi:10.1111/dth.13818 · Cited by 14 · see citing works
“Behavioral therapy however was effective.(37) As comorbid psychiatric conditions such as depression and anxiety are common in patients with TTM, and SSRIs have shown efficacy”
Pharmacotherapy for trichotillomania
Hoffman, J., Williams, T., Rothbart, R., Ipser, J., Fineberg, N. A., Chamberlain, S. R., & Stein, D. J. (2021) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd007662.pub3 · Cited by 32 · see citing works
Structural Equation Modeling Approaches for Analyzing Partially Nested Data
Sterba, S. K., Preacher, K. J., Forehand, R., Hardcastle, E. J., Cole, D. A., & Compas, B. E. (2014) · Multivariate Behavioral Research · doi:10.1080/00273171.2014.882253 · Cited by 29 · see citing works
Candel, M. J. J. M., & van Breukelen, G. (2009) · Statistics in Medicine · doi:10.1002/sim.3620 · Cited by 28 · see citing works
Krooks, J., Weatherall, A., & Holland, P. (2018) · Journal of dermatological treatment (Print) · doi:10.1080/09546634.2017.1395389 · Cited by 21 · see citing works
Predictors of Relapse Following Treatment of Trichotillomania
Falkenstein, M. J., Rogers, K., Malloy, E., & Haaga, D. (2014) · Journal of Obsessive-Compulsive and Related Disorders · doi:10.1016/j.jocrd.2014.09.001 · Cited by 27 · see citing works
“The MGH-HPS was chosen as the primary outcome measure in these calculations because of its widespread use and validation (e.g., Diefenbach et al., 2006; van Minnen et al., 2003).”
Affective and Sensory Correlates of Hair Pulling in Pediatric Trichotillomania
Meunier, S. A., Tolin, D., & Franklin, M. (2009) · Behavior Modification · doi:10.1177/0145445508326260 · Cited by 28 · see citing works
Shareh, H. (2018) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465817000546 · Cited by 25 · see citing works
Slikboer, R., Nedeljkovic, M., Bowe, S., & Moulding, R. (2017) · Clinical Psychologist · doi:10.1111/cp.12074 · Cited by 26 · see citing works
“Ninan et al. (2000) used a combination of HRT and stress management versus Clomipramine (ES = 2.60); Van Minnen et al. (2003) compared BT with fluoxetine (ES = 1.60).”
MethodInfluentialFlessner, C. (2011) · Child and Adolescent Psychiatric Clinics of North America · doi:10.1016/j.chc.2011.01.007 · Cited by 19 · see citing works
Pharmacotherapy for trichotillomania
Rothbart, R., Amos, T., Siegfried, N., Ipser, J. C., Fineberg, N., Chamberlain, S. R., & Stein, D. J. (2013) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd007662.pub2 · Cited by 106 · see citing works
Golubchik, P., Sever, J., Weizman, A., & Zalsman, G. (2011) · Clinical neuropharmacology · doi:10.1097/wnf.0b013e31821f4da9 · Cited by 22 · see citing works
Pediatric Psychocutaneous Disorders
Hawsawi, K. A. A., & Pope, E. (2011) · American Journal of Clinical Dermatology · doi:10.2165/11589040-000000000-00000 · Cited by 24 · see citing works
Keijsers, G. P. J., Maas, J., van Opdorp, A., & van Minnen, A. (2016) · Cognitive Therapy and Research · doi:10.1007/s10608-016-9754-4 · Cited by 24 · see citing works
“The MGHHS (Keuthen et al. 2007) and its Dutch adaptation (Van Minnen et al. 2003) have good psychometric properties.”
BackgroundMethodInfluentialSelf-citationAsplund, M., Lenhard, F., Andersson, E., & Ivanov, V. Z. (2022) · Internet Interventions · doi:10.1016/j.invent.2022.100573 · Cited by 25 · see citing works
Rozenman, M. S., Peris, T. S., González, A., & Piacentini, J. C. (2015) · Child Psychiatry & Human Development · doi:10.1007/s10578-015-0550-2 · Cited by 22 · see citing works
Computerized response inhibition training for children with trichotillomania
Lee, H., Espil, F. M., Bauer, C. C., Siwiec, S. G., & Woods, D. W. (2018) · Psychiatry Research · doi:10.1016/j.psychres.2017.12.070 · Cited by 21 · see citing works
Psychological treatments for trichotillomania: Update and future directions
Rehm, I., Moulding, R., & Nedeljkovic, M. (2015) · Australasian Psychiatry · doi:10.1177/1039856215590029 · Cited by 16 · see citing works
Kuzma, J. M., & Black, D. W. (2004) · Current Psychiatry Reports · doi:10.1007/s11920-004-0040-x · Cited by 19 · see citing works
Franklin, M. E., Tolin, D. F., & Diefenbach, G. J. (2007) · Elsevier eBooks · doi:10.1016/b978-008044701-8/50010-3 · Cited by 18 · see citing works
Unmet Needs in Psychodermatology: A Narrative Review
Christensen, R. E., & Jafferany, M. (2024) · CNS Drugs · doi:10.1007/s40263-024-01068-1 · Cited by 17 · see citing works
Pharmacotherapy of trichotillomania (hair pulling disorder): an updated systematic review
Rothbart, R., & Stein, D. J. (2014) · Expert Opinion on Pharmacotherapy · doi:10.1517/14656566.2014.972936 · Cited by 16 · see citing works
Pharmacological strategies for trichotillomania
Walsh, K. H., & McDougle, C. (2005) · Expert Opinion on Pharmacotherapy · doi:10.1517/14656566.6.6.975 · Cited by 12 · see citing works
“’ In a more recent study [48], 41 patients were randomised into a wait-list control study comparing 12 weeks behaviour therapy to 12 weeks open FLX therapy (to a maximum of 60 mg/day).”
BackgroundValidating indicators of treatment response: application to trichotillomania
Nelson, S. O., Rogers, K., Rusch, N., McDonough, L., Malloy, E. J., Falkenstein, M. J., Banis, M., & Haaga, D. A. F. (2014) · Psychological Assessment · doi:10.1037/a0036333 · Cited by 17 · see citing works
“Previous TTM treatment studies reporting recovery of normal functioning based on the MGH–HPS have used cutoffs from 6.70 (Diefenbach et al., 2006; van Minnen et al., 2003) to 12.74 (Woods, Wetterneck, & Flessner, 2006), so our cutoff of 9 was in the middle of the range.”
MethodInfluentialGawłowska-Sawosz, M., Wolski, M., Kamiński, A., Albrecht, P., & Wolańczyk, T. (2016) · Psychiatria Polska · doi:10.12740/pp/59513 · Cited by 13 · see citing works
“Similar results were obtained in a study of fluoxetine, indicators of improvement in the group treated with CBT and receiving SSRIs were 64% and 9% respectively [37].”
MethodResultAn ethological analysis of barbering behavior
Dufour, B. D., & Garner, J. P. (2010) · Cambridge University Press eBooks · doi:10.1017/cbo9780511676109.011 · Cited by 18 · see citing works
Neal-Barnett, A. M., Woods, D. W., Espil, F. M., Davis, M., Alexander, J. R., Compton, S. N., Walther, M. R., Twohig, M. P., Saunders, S. M., Cahill, S. P., et al. (2019) · Bulletin of the Menninger Clinic · doi:10.1521/bumc_2019_83_04 · Cited by 15 · see citing works
The Influence of Hair Pulling Styles in the Treatment of Trichotillomania.
McGuire, J., Myers, N., Lewin, A., Storch, E., & Rahman, O. (2020) · The Behavior Therapist · doi:10.1016/j.beth.2019.12.003 · Cited by 11 · see citing works
Pharmacotherapy for trichotillomania in adults
Baczynski, C., & Sharma, V. (2020) · Expert Opinion on Pharmacotherapy · doi:10.1080/14656566.2020.1761324 · Cited by 5 · see citing works
Prototype awareness enhancing and monitoring device for trichotillomania
Himle, J. A., Perlman, D. M., & Lokers, L. M. (2008) · Behaviour Research and Therapy · doi:10.1016/j.brat.2008.06.013 · Cited by 18 · see citing works
“…randomized trials comparing HRT to psychosocial control treatments (Azrin et al., 1980), anti-depressant medication (van Minnen, Hoogduin, Keijsers, Hellenbrand, & Hendriks, 2003; Ninan, Rothbaum, Marsteller, Knight, & Eccard, 2000), and placebo pills (van Minnen et al., 2003; Ninan et al., 2000).”
BackgroundRahman, S. M., Jafferany, M., & Barkauskaite, R. (2023) · Clinical and Experimental Dermatology · doi:10.1093/ced/llad247 · Cited by 14 · see citing works
Psychometric Properties of Trichotillomania Severity Measures
Barber, K. E., Woods, D. W., Bauer, C. C., Twohig, M. P., Saunders, S. M., Compton, S. N., & Franklin, M. E. (2023) · Cognitive Therapy and Research · doi:10.1007/s10608-023-10406-4 · Cited by 14 · see citing works
“In other TTM research, the internal consistency of the MGH-HS has ranged from α = 0.74 to 0.95 (Carlson et al., 2021; Chesivoir & Grant, 2022; Cheyne et al., 2018; Haaga et al., 2015; Haaland et al., 2017; Lee et al., 2018a, b; Rogers et al., 2014; Valle et al., 2022; van Minnen et al., 2003).”
InfluentialPark, J. M., Rahman, O., Murphy, T., & Storch, E. (2012) · Infant Mental Health Journal · doi:10.1002/imhj.21317 · Cited by 13 · see citing works
“…of behavioral therapy for TTM (Diefenbach et al., 2006; Ninan et al., 2000; van Minnen et al., 2003; Woods, Wetterneck & Flessner, 2006). van Minnen et al. (2003) found that TTM symptoms were significantly more reduced with the HRT condition relative to clomipramine or wait-list conditions.”
Turk, T., Liu, C., Fujiwara, E., Straube, S., Hagtvedt, R., Dennett, L., Abba-Aji, A., & Dytoc, M. (2023) · Journal of Cutaneous Medicine and Surgery · doi:10.1177/12034754231155888 · Cited by 14 · see citing works
- Authors
- van Minnen, A., Hoogduin, K. A. L., Keijsers, G. P. J., Hellenbrand, I., & Hendriks, G.-J.
- Venue
- Archives of General Psychiatry
- Publisher
- American Medical Association (AMA)
- Published
- 2003-05-01
- Volume
- 60
- Issue
- 5
- Pages
- 517
- ISSN
- 0003-990X (ISSN-L)
- OpenAlex
- W2142814663
- Cited by
- 234
- References
- 38
- Citations by year
- 2026: 3 · 2024: 6 · 2023: 7 · 2022: 4 · 2021: 7 · 2020: 3 · 2019: 10 · 2018: 10 · 2017: 10 · 2016: 8 · 2015: 13 · 2014: 14 · 2013: 6 · 2012: 40
- FWCI
- 11.99
- Type
- journal article
- Language
- en
- Open access
- green
- hdl.handle.net
- Locations
- Archives of General Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Radboud Repository (Radboud University) (submittedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Obsessive-Compulsive Spectrum Disorders
- Health Sciences › Medicine › Urology › Hair Growth and Disorders
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- trichotillomania, behavior therapy, fluoxetine, serotonin reuptake inhibitors, hair pulling, treatment efficacy, depression, psychopathology
- MeSH terms
- Adolescent, Adult, Ambulatory Care, Behavior Therapy, Female, Fluoxetine, Follow-Up Studies, Humans, Male, Middle Aged, Psychiatric Status Rating Scales, Research Design, Severity of Illness Index, Trichotillomania, Waiting Lists, Treatment Outcome, Selective Serotonin Reuptake Inhibitors, Patient Selection
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