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Treating trichotillomania: A meta-analysis of treatment effects and moderators for behavior therapy and serotonin reuptake inhibitors
Open accessAbstract
Few randomized controlled trials (RCTs) exist examining the efficacy of behavior therapy (BT) or serotonin reuptake inhibitors (SRIs) for the treatment of trichotillomania (TTM), with no examination of treatment moderators. The present meta-analysis synthesized the treatment effect sizes (ES) of BT and SRI relative to comparison conditions, and examined moderators of treatment. A comprehensive literature search identified 11 RCTs that met inclusion criteria. Clinical characteristics (e.g., age, comorbidity, therapeutic contact hours), outcome measures, treatment subtypes (e.g., SRI subtype, BT subtype), and ES data were extracted. The standardized mean difference of change in hair pulling severity was the outcome measure. A random effects meta-analysis found a large pooled ES for BT (ES = 1.41, p < 0.001). BT trials with greater therapeutic contact hours exhibited larger ES (p = 0.009). Additionally, BT trials that used mood enhanced therapeutic techniques exhibited greater ES relative to trials including only traditional BT components (p = 0.004). For SRI trials, a random effects meta-analysis identified a moderate pooled ES (ES = 0.41, p = 0.02). Although clomipramine exhibited larger ES relative to selective serotonin reuptake inhibitors, the difference was not statistically significant. Publication bias was not identified for either treatment. BT yields large treatment effects for TTM, with further examination needed to disentangle confounded treatment moderators. SRI trials exhibited a moderate pooled ES, with no treatment moderators identified. Sensitivity analyses highlighted the need for further RCTs of SRIs, especially among youth with TTM.
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“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).”
From The role of psychological flexibility in acceptance-enhanced behavior therapy for trichotillomania: Moderation and mediation findings (2023) · cites this paper as McGuire et al., 2014
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“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).”
From The role of psychological flexibility in acceptance-enhanced behavior therapy for trichotillomania: Moderation and mediation findings (2023) · cites this paper as McGuire et al., 2014
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“No significant associations were found between age or comorbid anxiety and depressive disorders and treatment effect size (McGuire et al., 2014).”
From The role of psychological flexibility in acceptance-enhanced behavior therapy for trichotillomania: Moderation and mediation findings (2023) · cites this paper as McGuire et al., 2014
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“However, both variables were correlated, confounding independent moderating effects.”
From The role of psychological flexibility in acceptance-enhanced behavior therapy for trichotillomania: Moderation and mediation findings (2023) · cites this paper as McGuire et al., 2014
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Citations
Cites
Diagnostic and Statistical Manual of Mental Disorders
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A Fail-Safe N for Effect Size in Meta-Analysis
Orwin, R. G. (1983) · Journal of Educational Statistics · doi:10.2307/1164923 · Cited by 2,064 · cited 1×
“Finally, sensitivity analyses included Rosenthal's Fail-safe N (Rosenthal, 1991), Orwin's Fail-safe N (Orwin, 1983), and a comparison of ES across control conditions.”
MethodEspinosa, J. C. (2004) · Cited by 939
Swedo, S. E., Leonard, H. L., Rapoport, J. L., Lenane, M. C., Goldberger, E. L., & Cheslow, D. L. (1989) · New England Journal of Medicine · doi:10.1056/nejm198908243210803 · Cited by 601 · cited 22×
“Table 1 displays the 11 RCTs that met inclusion criteria that allowed for comparisons of seven BT trials (n= 182 participants) and six SRI trials (n= 118 participants).”
BackgroundMethodInfluentialThe Massachusetts General Hospital (MGH) Hairpulling Scale: 1. Development and Factor Analyses
Keuthen, N. J., O’Sullivan, R. L., Ricciardi, J. N., Shera, D., Savage, C. R., Borgmann, A. S., Jenike, M. A., & Baer, L. (2010) · Psychotherapy and Psychosomatics · doi:10.1159/000289003 · Cited by 444 · cited 3×
“In the absence of clinician ratings, selfreport measures of hair pulling severity were preferred, which included the MGH-HPS (Keuthen et al., 1995; O'Sullivan et al., 1995) and the Trichotillomania Scale for Children and Parents (Tolin et al.”
Method
Cited by
Sorted by citations
McGuire, J., Piacentini, J., Lewin, A., Brennan, E. A., Murphy, T., & Storch, E. A. (2015) · Depression and Anxiety · doi:10.1002/da.22389 · Cited by 262
“The relationship between a greater number of CBT contact hours and larger treatment effects is consistent with psychosocial interventions for related disorders.[64, 65] Similarly, CBT trials that had higher treatment dropout rates were associated with lower therapeutic benefit.”
Self-citationContemporary cognitive behavior therapy: A review of theory, history, and evidence
Thoma, N., Pilecki, B., & McKay, D. (2015) · Psychodynamic Psychiatry · doi:10.1521/pdps.2015.43.3.423 · Cited by 197
Fineberg, N. A., Apergis-Schoute, A. M., Vaghi, M. M. S., Banca, P., Gillan, C. M., Voon, V., Chamberlain, S. R., Cinosi, E., Reid, J. E., Shahper, S., et al. (2017) · The International Journal of Neuropsychopharmacology · doi:10.1093/ijnp/pyx088 · Cited by 195
“Habit reversal therapy, rather than ERP, has emerged as the psychological therapy of choice (McGuire et al., 2014).”
Farhat, L. C., Olfson, E., Nasir, M., Levine, J. L. S., Li, F., Miguel, E. C., & Bloch, M. H. (2020) · Depression and Anxiety · doi:10.1002/da.23028 · Cited by 133
Comorbidity and quality of life in adults with hair pulling disorder
Houghton, D. C., Maas, J., Twohig, M. P., Saunders, S. M., Compton, S. N., Neal-Barnett, A. M., Franklin, M. E., & Woods, D. W. (2016) · Psychiatry Research · doi:10.1016/j.psychres.2016.02.063 · Cited by 97
Metadata
- Authors
- McGuire, J. F., Ung, D., Selles, R. R., Rahman, O., Lewin, A. B., Murphy, T. K., & Storch, E. A.
- Affiliations
- University of South Florida (US)
- Johns Hopkins University (US)
- Corresponding author
- McGuire, Joseph F.
- Venue
- Journal of Psychiatric Research
- Publisher
- Elsevier BV
- Published
- 2014-11
- Volume
- 58
- Pages
- 76-83
- ISSN
- 0022-3956 (ISSN-L)
- PMC
- PMC4163503
- OpenAlex
- W2160932918
- Cited by
- 142
- References
- 63
- Citations by year
- 2026: 3 · 2025: 6 · 2024: 11 · 2023: 18 · 2022: 7 · 2021: 8 · 2020: 7 · 2019: 14 · 2018: 14 · 2017: 18 · 2016: 17 · 2015: 17 · 2014: 1
- FWCI
- 2.67
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Journal of Psychiatric Research (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Mental Health (MH093381, R01MH093381)
- 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 › Personality Disorders and Psychopathology
- Keywords
- trichotillomania, hair pulling, behavior therapy, serotonin reuptake inhibitors, clomipramine, selective serotonin reuptake inhibitors, treatment moderators, treatment effect size, youth
- MeSH terms
- Adolescent, Adult, Analysis of Variance, Behavior Therapy, Clomipramine, Female, Humans, Male, Trichotillomania, Reproducibility of Results, Randomized Controlled Trials as Topic, Treatment Outcome, Selective Serotonin Reuptake Inhibitors, Young Adult
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