Group treatment for trichotillomania: behavior therapy versus supportive therapy
Abstract
In this randomized controlled trial, group behavior therapy (BT; n=12) was compared to group supportive therapy (ST; n=12) in the treatment of trichotillomania (TTM). Both treatments were also compared to a naturally occurring waiting period, the time period that participants waited for groups to form. Participants completing group BT experienced significantly greater decreases in self-reported hair-pulling symptoms and clinician-rated hair loss severity than did those in group ST. Decreases were significantly greater after treatment than after the naturalistic waiting period. In addition, a significantly higher percentage of those in the BT than ST condition were rated as much improved or very much improved on the Clinical Global Impression scale at posttreatment. However, despite substantial symptom improvement, TTM severity remained problematic at posttreatment. Specifically, few participants in either treatment met criteria for clinically significant change at posttreatment. In addition, relapse of symptoms occurred over the 6-month follow-up period. Results provided partial support for the short-term efficacy of group BT. However, the group format may not maximize the efficacy of BT for TTM. Thus, it is recommended that future BT research test either individual therapy or a combination of group and individual formats for TTM.
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There are a number of previous studies that have reported elevated relapse rates for patients with TTM.
“There are a number of previous studies that have reported elevated relapse rates for patients with TTM (Woods et al., 2006b; Diefenbach et al., 2006; Keijsers et al., 2006)”
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 Diefenbach et al., 2006
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“Figure 1 describes the participant flow through the trial, according to the Consolidated Standards of Reporting Trials (CONSORT) (Eldridge et al., 2016).”
MethodComprehensive Behavioral Treatment of Trichotillomania
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“Supportive group therapy offers social support that addresses the shame, embarrassment, low self-esteem, and fears of rejection associated with TTM (Diefenbach et al., 2006; Rehm, Nedeljkovic, & Moulding, 2013).”
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Computerized response inhibition training for children with trichotillomania
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Validating indicators of treatment response: application to trichotillomania
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“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.”
MethodInfluentialThe Influence of Hair Pulling Styles in the Treatment of Trichotillomania.
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“The CGI is one of subscales of the Clinical Global Impressions (CGI) Scale (Guy, 1976) utilizing a 7-point Likert scale scoring frequently used to measure improvement in clinical trials for many psychological disorders (Diefenbach et al., 2006).”
MethodReliability and validity of the Trichotillomania Dimensional Scale (TTM-D)
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Psychometric Properties of Trichotillomania Severity Measures
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“The CGI-S has good psychometric properties (Berk et al., 2008; Leon et al., 1993) and is often used as an outcome measure in TTM treatment studies (Diefenbach et al., 2006; Grant et al., 2009; Woods et al., 2022).”
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“The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) classifies it as an impulse control disorder [23].”
BackgroundTreating Tics and Tourette’s Disorder in School Settings
Sulkowski, M. L., Mcguire, J. F., & Tesoro, A. (2015) · Canadian Journal of School Psychology · doi:10.1177/0829573515601820 · Cited by 8 · see citing works
A brief, residential peer‐support retreat for trichotillomania: A mixed methods evaluation
Slikboer, R., Rehm, I. C., Lam, S., Maloney, A., & Nedeljkovic, M. (2019) · Australian Psychologist · doi:10.1111/ap.12420 · Cited by 8 · see citing works
“The effectiveness of group therapy (Diefenbach et al. 2006; Mouton & Stanley, 1996) for TTM may occur via group cohesion, social support, addressing shame and stigma, and the”
BackgroundHoughton, D., Balsis, S., Stein, D., Compton, S., Twohig, M., Saunders, S., Franklin, M., Neal-Barnett, A., & Woods, D. W. (2015) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2015.04.011 · Cited by 8 · see citing works
“The scale has good psychometric properties [30,31] and has been used to measure treatment outcome in adults with TTM [32,33].”
Psychosocial Treatment of Trichotillomania: A Review
Capel, L., Woolley, M. G., & Twohig, M. (2024) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2024.05.003 · Cited by 9 · see citing works
Shareh, H., & Yazdanian, M. (2023) · Clinical Child Psychology and Psychiatry · doi:10.1177/13591045231163068 · Cited by 7 · see citing works
“For many psychological disorders, the CGI rating scale is a clinician-administered measure of symptom severity, treatment response, and the efficacy of treatments in clinical trials (Diefenbach et al., 2006).”
BackgroundLong-term follow-up of acceptance-enhanced behavior therapy for trichotillomania
Barber, K. E., Woods, D. W., Ely, L. J., Saunders, S. M., Compton, S. N., Neal-Barnett, A. M., Franklin, M. E., Capriotti, M. R., Conelea, C. A., & Twohig, M. P. (2024) · Psychiatry Research · doi:10.1016/j.psychres.2024.115767 · Cited by 6 · see citing works
Assessment Instruments for Impulsivity and Impulse Control Disorders
Matusiewicz, A. K., Reynolds, B. A., & Lejuez, C. W. (2012) · Oxford University Press eBooks · doi:10.1093/oxfordhb/9780195389715.013.0141 · Cited by 6 · see citing works
The role of psychological stress in hair loss: A review
Bai, J. Q. A., McMullen, E. P., Sibbald, C., Dumont, S., Mainville, L., Julanon, N., & Donovan, J. C. H. (2025) · JAAD reviews. · doi:10.1016/j.jdrv.2025.10.002 · Cited by 4 · see citing works
Morris, S. H., Kratz, H. E., Antinoro, D., Zickgraf, H. F., Coogan, C., Woods, D., & Franklin, M. E. (2016) · Journal of Obsessive-Compulsive and Related Disorders · doi:10.1016/j.jocrd.2016.04.004 · Cited by 4 · see citing works
“…been utilized to treat TTM in adults, including psychodynamic approaches (e.g., Koblenzer, 1999), hypnosis (e.g., Hynes, 1982), and a wide array of behavioral and cognitive-behavioral treatments (for a review see Franklin, Tolin, & Diefenbach, 2006; Keuthen, Aronowitz, Badenoch, & Wilhelm, 1999).”
MethodHoughton, D., Franklin, M., Twohig, M., Franklin, M. E., Compton, S., Neal-Barnett, A., Saunders, S., & Woods, D. W. (2016) · Journal of Psychopathology and Behavioral Assessment · doi:10.1007/s10862-016-9536-z · Cited by 3 · see citing works
“1993) and has been used to measure outcome in adult TTM (Diefenbach et al. 2006; Grant et al. 2009; Ninan et al. 2000).”
MethodReliability and Validity of a Photo Rating Measure of Alopecia
Haaga, D., Falkenstein, M. J., Banis, M., Malloy, E., McDonough, L., & Rogers, K. (2015) · Journal of Psychopathology and Behavioral Assessment · doi:10.1007/s10862-015-9487-9
Maas, J., Keijsers, G. P. J., Rinck, M., & Becker, E. S. (2018) · Journal of Cognitive Psychology · doi:10.1080/20445911.2018.1503278 · Cited by 4 · see citing works
Domínguez, Z. E. M. (2012) · Acción Psicológica · doi:10.5944/ap.9.2.4111 · Cited by 3 · see citing works
Diagnosis and treatment of trichotillomania
Schreiber, L. R. N., Odlaug, B., & Grant, J. (2011) · Neuropsychiatry · doi:10.2217/npy.11.8 · Cited by 3 · see citing works
Woolley, M. G., Sahdra, B. K., Bowers, E. M., Capel, L. K., Twohig, M. P., & Levin, M. E. (2025) · Behavior Therapy · doi:10.1016/j.beth.2025.01.006 · Cited by 3 · see citing works
Rehm, I. C., Moulding, R., & Nedeljkovic, M. (2024) · Australian Psychologist · doi:10.1080/00050067.2024.2376881 · Cited by 2 · see citing works
“…et al., 2016), perfectionism (Pélissier & O’Connor, 2004; Toledo et al., 2014), and a range of specific facil-itative thoughts have been targeted (e.g., “If you pull one, you might as well pull all of them”, Ottens, 1981; and “Pulling is the only way to feel good”, Diefenbach et al., 2006, p. 356).”
Aripiprazole in the Treatment of Trichotillomania: A Case Report
Ak, M., & Gülsün, M. (2010) · Klinik Psikofarmakoloji Bülteni-Bulletin of Clinical Psychopharmacology · doi:10.1080/10177833.2010.11790655 · Cited by 2 · see citing works
“In the treatment of TM, various drugs like Quetiapine (8), Aripiprazole (9), Risperidone (10), Haloperidol (11), Lithium (12), Valproic acid (13), Naltrexone (14), Topiramate (15), SSRIs and tricyclic antidepressants (16) belonging to different groups and group therapy and cognitive behavioral therapies (17,18) have b…”
BackgroundLa trichotillomanie des cils: à propos d’un cas
Touzani, K. D., Lamari, Z., Chraïbi, F., Abdellaoui, M., & Andaloussi, I. B. (2017) · Pan African Medical Journal · doi:10.11604/pamj.2017.28.142.13822 · Cited by 2 · see citing works
Vigorexia y terapia de aceptación y compromiso: a propósito de un caso.
Gómez, N. N., & Trigueros, R. (2021) · Análisis y Modificación de Conducta · doi:10.33776/amc.v47i175.5076 · Cited by 1 · see citing works
Dixon, M. M. (2016) · J. Willard Marriott Library · doi:10.26053/0h-6086-d8g0 · Cited by 1 · see citing works
Development of a measure of cognitions and beliefs in trichotillomania
Rehm, I. C. (2016) · Swinburne figshare (Swinburne University of Technology) · doi:10.25916/sut.26269711 · Cited by 1 · see citing works
Trichotillomania: Clinical Aspects
Walther, M. R., Tucker, B. T. P., & Woods, D. W. (2010) · Cambridge University Press eBooks · doi:10.1017/cbo9780511711930.009 · Cited by 1 · see citing works
Chandran, N., Novak, J., Iorizzo, M., Grimalt, R., & Oranje, A. (2016) · Springer eBooks · doi:10.1007/978-3-319-32159-2_15
The Assessment and Treatment of Trichotillomania
Christenson, G. (2012) · Oxford University Press eBooks · doi:10.1093/oxfordhb/9780195389715.013.0095
From OC Spectrum to Anxiety Disorders
Hellberg, S. N., Jacoby, R. J., & Wilhelm, S. (2019) · Current clinical psychiatry · doi:10.1007/978-3-030-30687-8_6
Queiroz, C., Barbosa, J. D. V., Soares, M. B. P., Rodrigues, L. D. S., Schooley, R. T., & Badaró, R. J. D. S. (2025) · International Journal of Clinical Dermatology · doi:10.11648/j.ijcd.20250801.13
Fisak, B., Shorb, C., Patel, D., & Ezcurra, V. (2026) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2026.02.029
Greining og meðferð hárplokkunar- og húðkroppunaráráttu
Snorrason, Í., & Bjorgvinsson, T. (2012) · Læknablaðið · doi:10.17992/lbl.2012.03.421
The Effectiveness of Behavioral Therapy versus Medicines When Treating Trichotillomania
Diaz, M. (2015) · UC Merced Undergraduate Research Journal · doi:10.5070/m472027444
- Authors
- Diefenbach, G. J., Tolin, D. F., Hannan, S., Maltby, N., & Crocetto, J.
- Affiliations
- Hartford Hospital (US)
- Corresponding author
- Diefenbach, Gretchen J.
- Venue
- Behavior Therapy
- Publisher
- Elsevier BV
- Published
- 2006-12
- Volume
- 37
- Issue
- 4
- Pages
- 353-363
- ISSN
- 0005-7894 (ISSN-L)
- OpenAlex
- W2037839288
- Cited by
- 73
- References
- 48
- Citations by year
- 2026: 1 · 2025: 3 · 2024: 3 · 2023: 2 · 2022: 2 · 2021: 4 · 2020: 1 · 2019: 3 · 2018: 5 · 2017: 4 · 2016: 6 · 2015: 11 · 2014: 4 · 2013: 2 · 2012: 6
- FWCI
- 2.58
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Behavior Therapy (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Obsessive-Compulsive Spectrum Disorders
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
- Keywords
- trichotillomania, relapse, treatment efficacy, waiting period, Clinical Global Impression Scale
- MeSH terms
- Adult, Behavior Therapy, Female, Humans, Male, Psychotherapy, Group, Surveys and Questionnaires, Recurrence, Severity of Illness Index, Social Support, Trichotillomania, Diagnostic and Statistical Manual of Mental Disorders
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