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Cited by 15Obsessive-Compulsive Spectrum DisordersSexuality, Behavior, and TechnologyAnxiety, Depression, Psychometrics, Treatment, Cognitive Processes

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

Open access
Ong, Clarissa W., Woods, Douglas W., Franklin, Martin E., Saunders, Stephen M., Neal-Barnett, Angela M., Compton, Scott N., Twohig, Michael P.·2023·Behaviour Research and Therapy
DOI 10.1016/j.brat.2023.104302PMC PMC10115155
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Abstract

Trichotillomania is characterized by recurrent pulling out of one's hair, leading to significant hair loss and accompanied by clinically significant distress and/or functional impairment. The current study used data from a randomized controlled trial comparing the effectiveness of acceptance-enhanced behavior therapy (AEBT) to psychoeducation plus supportive therapy (PST; active control) for trichotillomania in an adult sample. The objectives were to examine the moderating and mediating influence of trichotillomania-specific psychological flexibility in treatment for trichotillomania. Participants with lower baseline flexibility performed better in AEBT than PST in terms of greater symptom reduction and quality of life. Lower baseline flexibility also predicted higher likelihood of disorder recovery in AEBT relative to PST. In addition, relative to PST, symptom reduction in AEBT was mediated by psychological flexibility, controlling for anxiety and depression. These findings suggest that psychological flexibility is a relevant process of change in the treatment of trichotillomania. Clinical implications and directions for future research are discussed. © 2023 Elsevier Ltd

Integrity signals

Registry

Crossref · 10.1016/j.brat.2023.104302

Cites

49 of 49 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

20 of 39 cited sources checked · 13 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    Other acceptance and commitment therapy studies support mediation by the theory's proposed change processes, such as psychological flexibility, valued action, and mindfulness facets, for several outcomes.

    “Data from other ACT studies also support the mediating role of hypothesized processes of change, including psychological flexibility, valued action, and aspects of mindfulness, on various outcomes (e.g., symptom severity, functioning, quality of life; Cederberg et al., 2016; Hayes et al., 2010; Pots et al., 2016; Twohig et al., 2015).”
    Quote in the paperSubstantial claim3 of 3 sources checked
    • cites Cederberg et al., 2016 source

      The Introduction reports that earlier ACT trials found psychological flexibility mediated changes in depression, pain-related functioning, and life satisfaction. The Results report that this study found acceptance mediated change in physical functioning at six months, but it did not test valued action or mindfulness facets as mediators. (LLM, conf=0.83)

      Experimental — accuracy not yet measured
    • cites Hayes et al., 2010 source

      The Results (Predicting responder status; page unavailable) report that changes in acceptance and valued action predicted treatment response, and the Discussion reports that change in acceptance predicted quality of life. This was a study of acceptance-based behavioral therapy for generalized anxiety disorder, not an ACT study; it did not establish mediation or report mindfulness facets as mediators. The authors describe their findings as preliminary. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites Pots et al., 2016 source

      The Results (Mediation analyses; page unavailable) report that psychological flexibility and several mindfulness facets mediated the effect of web-based ACT on depressive symptoms compared with a waiting-list control. The Methods (Measures; page unavailable) identify those processes as the measured mediators; the paper does not establish valued action as a separate mediator or report mediation of functioning or quality-of-life outcomes. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
  • Premisecitation

    Acceptance-enhanced behavior therapy has empirical support as a treatment for trichotillomania.

    “In particular, acceptance-enhanced behavior therapy (AEBT) is an empirically supported intervention for trichotillomania (Woods et al., 2022), which combines habit reversal training with elements from ACT to increase effective responding to urges to pull (trichotillomaniaspecific psychological flexibility) and behavioral changes guided by personal values.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Woods et al., 2022 source
  • Premisecitation

    Two clinical trials found that lower baseline self-reported psychological flexibility forecast better long-term anxiety outcomes with cognitive-behavioral therapy than with acceptance and commitment therapy.

    “In two clinical trials, lower self-rated baseline psychological flexibility predicted better long-term outcomes in cognitive-behavioral therapy (CBT) relative to ACT for anxiety (Craske et al., 2014; Wolitzky-Taylor et al., 2012).”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites Craske et al., 2014 source
    • cites Wolitzky-Taylor et al., 2012 source
  • Premisecitation

    In McGuire et al. (2014), therapeutic contact hours and combining habit reversal training with emotional components were correlated, confounding independent moderating effects.

    “However, both variables were correlated, confounding independent moderating effects.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites McGuire et al., 2014 source
  • Interpretationcitation

    Psychological flexibility as an overall skill appears to be helpful in the treatment of trichotillomania.

    “Moreover, given that psychological flexibility as an overall skill appears to be helpful in the treatment of trichotillomania, it may be instructive to identify specific processes within this model that contribute to improved outcomes (Villatte et al., 2016).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Villatte et al., 2016 source

      The Discussion (page unavailable) reports that ACT components targeting psychological-flexibility processes improved symptoms and quality of life in adults with mixed anxiety and depression. It does not report treatment outcomes for trichotillomania, so the disorder-specific part of the claim is unsupported. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
  • May combine two claims. 25
  • Classified as probably not a substantial claim. 26

  • May combine two claims.

    Premisecitation

    McGuire et al. (2014) reported that age and comorbid anxiety or depressive disorders were not significantly related to treatment effect size.

    “No significant associations were found between age or comorbid anxiety and depressive disorders and treatment effect size (McGuire et al., 2014).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites McGuire et al., 2014 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Meta-analytic evidence supports habit reversal training as the usual first-line intervention for trichotillomania.

    “Generally, habit reversal training is considered the first line treatment for trichotillomania, with meta-analytic evidence supporting its efficacy (Bate et al., 2011; McGuire et al., 2014).”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites Bate et al., 2011 source
    • cites McGuire et al., 2014 source

  • May combine two claims.

    Premisecitation

    McGuire et al. (2014) found larger effects when more therapeutic contact hours were provided and when habit reversal training included emotional components rather than being delivered alone.

    “For example, McGuire et al. (2014) reported significantly larger effect sizes with more therapeutic contact hours and when habit reversal training was combined with emotional components (compared to “pure” habit reversal training).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites McGuire et al., 2014 source

  • May combine two claims.

    Premisecitation

    Psychological flexibility is associated with mental health and distress and seems to function as a transdiagnostic mechanism of change in treatment.

    “It is correlated with psychological problems and health and appears to be a transdiagnostic process of change in treatment (Bond et al., 2011; Hayes et al., 2022; Kashdan & Rottenberg, 2010).”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites Bond et al., 2011 source
    • cites Hayes et al., 2022 source
    • cites Kashdan & Rottenberg, 2010 source

  • Classified as probably not a substantial claim.

    Premisecitation

    Acceptance-enhanced behavior therapy combines habit reversal training with acceptance and commitment therapy elements to increase effective responding to urges and values-guided behavior.

    “In particular, acceptance-enhanced behavior therapy (AEBT) is an empirically supported intervention for trichotillomania (Woods et al., 2022), which combines habit reversal training with elements from ACT to increase effective responding to urges to pull (trichotillomaniaspecific psychological flexibility) and behavioral changes guided by personal values.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Woods et al., 2022 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The AAQ-TTM is negatively correlated with depression, with a correlation of −.61 with the BDI.

    “The AAQ-TTM has been found to be negative correlated with trichotillomania severity (r = −.37 with NIMH-TSS and −.49 with MGH-HPS), anxiety (r = −.36 with BAI), and depression (r = −.61 with BDI; Houghton et al., 2014).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Houghton et al., 2014 source

      Results §3.3 (page unavailable) reports that the AAQ-TTM was significantly correlated with the BDI, supporting the claimed association with depression. The passages in our copy do not give the correlation’s direction or the specific value of −.61, so those details are not verified. (LLM, conf=0.84)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The Acceptance and Action Questionnaire - Trichotillomania has shown good internal consistency, concurrent validity, and incremental validity over the AAQ-II.

    “It has shown good internal consistency, concurrent validity, as well as incremental validity over the AAQ-II (Houghton et al., 2014).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Houghton et al., 2014 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The AAQ-TTM is negatively correlated with anxiety, with a correlation of −.36 with the BAI.

    “The AAQ-TTM has been found to be negative correlated with trichotillomania severity (r = −.37 with NIMH-TSS and −.49 with MGH-HPS), anxiety (r = −.36 with BAI), and depression (r = −.61 with BDI; Houghton et al., 2014).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Houghton et al., 2014 source

      The Results (§3.3 Validity; page unavailable) state that the AAQ-TTM was significantly correlated with BAI anxiety scores. The passages in our copy do not give the correlation’s direction or the claimed coefficient of −.36, so those details cannot be verified. (LLM, conf=0.83)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The AAQ-TTM is negatively correlated with trichotillomania severity, with correlations of −.37 with the NIMH-TSS and −.49 with the MGH-HPS.

    “The AAQ-TTM has been found to be negative correlated with trichotillomania severity (r = −.37 with NIMH-TSS and −.49 with MGH-HPS), anxiety (r = −.36 with BAI), and depression (r = −.61 with BDI; Houghton et al., 2014).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Houghton et al., 2014 source

      The Results (§3.3 Validity; page unavailable) report significant correlations between AAQ-TTM scores and both the NIMH-TSS and MGH-HPS. The Methods (§2.2.1; page unavailable) say higher AAQ-TTM scores indicate greater psychological flexibility, consistent with an inverse relationship to severity. The passages in our copy do not give the claimed coefficients of −.37 and −.49, so those exact values are not verified. (LLM, conf=0.79)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Forman et al. (2012) reported that cognitive therapy worked through cognitive and affective strategies, while acceptance and commitment therapy worked through acceptance-oriented strategies.

    “For instance, Forman et al. (2012) found that outcomes for cognitive therapy were facilitated by cognitive and affective change strategies, such as cognitive challenging and distraction, whereas ACT outcomes were facilitated by psychological acceptance strategies, such as willingness to experience internal experiences as they are—consistent with the respective theories of change.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Forman et al., 2012 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    For anxiety-disorder patients with greater behavioral avoidance, acceptance and commitment therapy produced larger symptom decreases than cognitive-behavioral therapy.

    “Furthermore, another study found that, among individuals with anxiety disorders who exhibited more behavioral avoidance (less flexibility), ACT resulted in greater symptom reduction than CBT (Davies et al., 2015).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Davies et al., 2015 source

  • May combine two claims.

    Interpretationown data

    Trichotillomania-specific psychological flexibility, anxiety, or depression did not explain the link between condition and quality of life, suggesting the presence of unmeasured mediators.

    “At the same time, that trichotillomania-specific psychological flexibility, anxiety, or depression did not explain the link between condition and quality of life suggests the presence of unmeasured mediators.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The mediation models are assumed to be correctly specified with no unmeasured confounding of the mediator-outcome relationship.

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    Psychoeducation about trichotillomania was the sole shared element of AEBT and PST.

    “The only overlapping component between both interventions was psychoeducation about trichotillomania.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Higher baseline trichotillomania-specific psychological flexibility was associated with similar symptom reduction over time in treatment and active control conditions, suggesting AEBT may be less incrementally beneficial to individuals who already have the skill.

    “Higher baseline trichotillomania-specific psychological flexibility was associated with similar symptom reduction over time in the treatment and active control conditions, which suggests that AEBT may be less incrementally beneficial to individuals who already have the skill of responding flexibly to unpleasant private experiences.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The treatment conditions are assumed to have been delivered as intended.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    The CGI was administered by blinded independent evaluators who received weekly supervision from the principal investigator.

    “Independent evaluators receiving weekly supervision from the Principal Investigator (DWW) who were unaware of the study condition administered the CGI.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    Initial evidence points to psychological flexibility as a possible key treatment target in trichotillomania, though no large clinical trial has yet tested this hypothesis.

    “Thus, preliminary evidence suggests that psychological flexibility may be a key process of change to target in trichotillomania, but this hypothesis has not been examined in a large-scale clinical trial for trichotillomania.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    Psychometric quality for the NIMH-TSS has been inconsistent, and adding supplementary measures has been advised.

    “The NIMH-TSS has shown inconsistent psychometric quality, and use of supplementary measures (e.g., self-report) has been recommended (Diefenbach et al., 2005).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Diefenbach et al., 2005 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The QLI has demonstrated predictive validity and sensitivity to treatment.

    “The QLI has shown predictive validity and treatment sensitivity (Frisch et al., 2005).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Frisch et al., 2005 source

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Clinician-rated measures were administered by master's- or doctoral-level evaluators blinded to treatment assignment.

    “All clinician-rated measures were completed by master’s- and doctoral-level independent evaluators who were unaware of the treatment condition.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The CGI has been used before to measure outcomes in trichotillomania trials.

    “The CGI has been found to be reliable and valid (Berk et al., 2008) and has been previously used to assess outcomes in trichotillomania clinical trials (e.g., Farhat et al., 2019).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Farhat et al., 2019 source

  • May combine two claims.

    Interpretationown data

    Psychological flexibility did not mediate the effect of treatment condition on quality of life, indicating that the process of change related to better quality of life was not captured in these analyses.

    “Nevertheless, psychological flexibility did not mediate the effect of treatment condition on quality of life, indicating that the process of change related to better quality of life was not captured in these analyses.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The mediation models are assumed to be correctly specified with no unmeasured confounding of the mediator-outcome relationship.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The CGI has demonstrated reliability and validity.

    “The CGI has been found to be reliable and valid (Berk et al., 2008) and has been previously used to assess outcomes in trichotillomania clinical trials (e.g., Farhat et al., 2019).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Berk et al., 2008 source
    • cites Farhat et al., 2019 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Sixteen people left the study before completion, so 69 participants finished treatment.

    “Sixteen participants dropped out over the course of the study, leaving a total of 69 treatment completers.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    PST was structured like AEBT and lasted the same amount of time.

    “The PST condition was structured similarly to AEBT with matching duration, and the protocol used was based on Pinsker (1997).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The study did not include specific process measures that might have clarified how different aspects of psychological flexibility influenced outcomes.

    “Second, we did not include specific process measures that might have clarified how different aspects of psychological flexibility influenced outcomes.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The MGH-HPS has shown good internal and test-retest reliability, acceptable convergent and divergent validity, and sensitivity to change in hair pulling.

    “It has demonstrated strong internal and test-retest reliability, acceptable convergent and divergent validity, as well as sensitivity to changes in hair pulling (Diefenbach et al., 2005; Keuthen et al., 1995; O’Sullivan et al., 1995).”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites Diefenbach et al., 2005 source
    • cites Keuthen et al., 1995 source
    • cites O’Sullivan et al., 1995 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The study was registered with clinicaltrials.gov (NCT00872742).

    “This study was funded by the National Institute of Mental Health (R01MH080966; Woods, PI), registered with www.clinicaltrials.gov (NCT00872742), and approved by the Institutional Review Boards (IRBs) at the University of Wisconsin-Milwaukee and Texas A&M University.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The Beck Anxiety Inventory has demonstrated excellent internal consistency and convergent and divergent validity.

    “The BAI has demonstrated excellent internal consistency as well as convergent and divergent validity (Fydrich et al., 1992).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Fydrich et al., 1992 source

  • May combine two claims.

    Premisecitation

    Norberg et al. (2007) reported that psychological flexibility mediated the associations of both fear of negative evaluation and shame with hair-pulling severity.

    “Norberg et al. (2007) also found that psychological flexibility mediated the link between fear of negative evaluation and hair-pulling severity, as well as between shame and hair-pulling severity.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Norberg et al., 2007 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The study did not examine other potential moderators, such as age and co-occurring presentations.

    “Finally, we did not examine other potential moderators, such as age and co-occurring presentations (McGuire et al., 2014).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    Acceptance and commitment therapy appears to improve diverse outcomes and clinical presentations through change processes that match its theory.

    “Thus, it appears that ACT improves outcomes via processes of change congruent with its underlying theory across a range of outcomes as well as across clinical presentations.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    The current findings emphasize the relevance of trichotillomania-specific psychological flexibility in predicting who will benefit from AEBT versus PST, as well as explaining one possible mechanism by which AEBT reduces trichotillomania severity.

    “In summary, current findings emphasize the relevance of trichotillomania-specific psychological flexibility in terms of predicting who will benefit from AEBT versus PST, as well as explaining one possible mechanism by which AEBT reduces trichotillomania severity.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The mediation models are assumed to be correctly specified with no unmeasured confounding of the mediator-outcome relationship.
    • Rests on an assumption: The treatment conditions are assumed to have been delivered as intended.

  • May combine two claims.

    Interpretationown data

    The evidence indicates trichotillomania-specific flexibility as a process of change specific to AEBT, providing support for the precision of AEBT.

    “The evidence from current findings indicating trichotillomania-specific flexibility as a process of change specific to AEBT provides support for the precision of AEBT as a means of improving symptoms through increasing trichotillomania-specific flexibility.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The mediation models are assumed to be correctly specified with no unmeasured confounding of the mediator-outcome relationship.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The Beck Depression Inventory has shown good internal consistency reliability and convergent validity.

    “It has shown good internal consistency reliability and convergent validity (A. T. Beck et al., 1988).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites A. T. Beck et al., 1988

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Study design and conductcitation

    The sample was relatively homogeneous, primarily female-identifying and White, which undermines generalizability of the findings to more diverse populations.

    “First, the sample was relatively homogeneous (primarily female-identifying and White), undermining generalizability of findings to more diverse populations and perpetuating an endemic problem in clinical research (Polo et al., 2019).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    The trial is registered on clinicaltrials.gov and followed the Declaration of Helsinki.

    “The study is listed on clinicaltrials.gov and was conducted in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    This finding contradicts the hypothesized role of psychological flexibility in AEBT, as the authors would also expect it to mediate quality of life.

    “This finding contradicts the hypothesized role of psychological flexibility in AEBT, as we would also expect it to mediate quality of life, given the emphasis in AEBT on valued action.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The mediation models are assumed to be correctly specified with no unmeasured confounding of the mediator-outcome relationship.

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Participants were randomized to a treatment condition.

    “Ninety-one individuals were enrolled in the study, of whom 85 were randomized to a treatment condition (35 in AEBT, 34 in PST).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Ethics approval for the study came from the institutional review boards of the University of Wisconsin-Milwaukee and Texas A&M University.

    “This study was funded by the National Institute of Mental Health (R01MH080966; Woods, PI), registered with www.clinicaltrials.gov (NCT00872742), and approved by the Institutional Review Boards (IRBs) at the University of Wisconsin-Milwaukee and Texas A&M University.”
    Quote in the paperNot a substantial claim
39 of 39

  • The paper relies on this without support.

    Psychological flexibility is the primary hypothesized process of change in acceptance and commitment therapy.

    “Psychological flexibility—the primary hypothesized process of change in ACT—may be another moderator to consider.”

  • The paper relies on this without support.

    Missing data are assumed to be missing at random.

    “Maximum likelihood estimation was used to handle missing data (Newman, 2016; Wothke, 2000).”

  • The paper relies on this without support.

    The mediation models are assumed to be correctly specified with no unmeasured confounding of the mediator-outcome relationship.

    “In each model, treatment condition was the independent variable (X), and AAQ-TTM, BAI, and BDI-II at midtreatment (T2) were mediators (M).”

  • The paper relies on this without support.

    The treatment conditions are assumed to have been delivered as intended.

    “Using data from a randomized controlled trial comparing AEBT and PST for trichotillomania, we found that the effect of condition on treatment trajectories was moderated by baseline trichotillomania-specific psychological flexibility.”
4 of 4

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Treatment-group counts do not total the randomized sample

    Major

    The stated allocation is 35 participants in AEBT and 34 in PST, totaling 69 rather than the reported 85 randomized participants. The same paragraph identifies 69 as the number of treatment completers.

    Reported 85 · recomputed 69

  • Disorder-recovery coefficient falls outside its confidence interval

    Minor

    The reported interaction coefficient of −4.11 is not within its stated 95% confidence interval of −0.19 to −0.07.

2 of 2

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Authors
Ong, C. W., Woods, D. W., Franklin, M. E., Saunders, S. M., Neal-Barnett, A. M., Compton, S. N., & Twohig, M. P.
Affiliations
  • University of Toledo (US)
  • Marquette University (US)
  • Rogers Behavioral Health (US)
  • Kent State University (US)
  • Duke University (US)
  • Utah State University (US)
Corresponding author
Ong, Clarissa W.
ORCID
Venue
Behaviour Research and Therapy
Publisher
Elsevier BV
Published
2023-05
Volume
164
Pages
104302
ISSN
0005-7967 (ISSN-L)
DOI
10.1016/j.brat.2023.104302
PMC
PMC10115155
OpenAlex
W4360609737
Cited by
15
References
50
Citations by year
2026: 2 · 2025: 4 · 2024: 6 · 2023: 3
FWCI
4.01
Type
journal article
Language
en
Open access
Licence
Locations
  • Behaviour Research and Therapy (acceptedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (submittedVersion)
  • Digital Commons - USU (Utah State University) (submittedVersion, cc-by-nc-nd)
Funders
  • National Institute of Mental Health (R01MH080966)
  • National Institutes of Health
Topics
  • Social Sciences › Psychology › Clinical Psychology › Obsessive-Compulsive Spectrum Disorders
  • Social Sciences › Psychology › Clinical Psychology › Sexuality, Behavior, and Technology
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Keywords
trichotillomania, psychological flexibility, change processes, treatment moderators, symptom relief, quality of life, anxiety, depression
MeSH terms
Adult, Anxiety, Anxiety Disorders, Behavior Therapy, Humans, Quality of Life

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