The Trichotillomania Impact Project (TIP): Exploring Phenomenology, Functional Impairment, and Treatment Utilization
Abstract
Background Trichotillomania (TTM) occurs in 0.6% to 3.4% of adults. Questions remain about phenomenological features of the disorder, its impact on functioning, and treatment utilization. The current study (i.e., The Trichotillomania Impact Project) was designed to provide initial information regarding these issues. Method An Internet-based survey was completed by 1697 individuals who self-reported symptoms consistent with a diagnosis of TTM (DSM-IV-TR). The survey assessed phenomenological experiences; social, occupational, academic, and psychological impact; as well as treatment-seeking experiences. The survey link operated from April 2005 through May 2005. Results Survey results suggest considerable variability in TTM phenomenology. Individuals with more severe TTM symptoms endorsed more frequent phenomenological experiences of physical or mental anxiety prior to pulling and relief, pleasure, or gratification after pulling. Mild to moderate life impairment in social, occupational, academic, and psychological functioning was reported for the entire study sample. These impairments were more pronounced as TTM symptoms became more severe. A summary of treatment seeking in the sample suggests that pharmacotherapy was the most commonly received treatment, followed by behavior therapy. Unfortunately, treatment in general was perceived as relatively ineffective. Conclusion This study underscores the clinical significance of severe hair pulling and highlights the need for research…
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Cues to pulling may include stress, boredom, or "downtime."
“Cues to pulling may include stress, boredom, or “downtime.””
From Trichotillomania (hair pulling disorder) (2019) · cites this paper as [2]
Many people with trichotillomania are not fully aware of their pulling behaviors, referred to as "automatic" pulling, which comprises a more habitual form of the disorder.
“In addition, many people not being fully aware of their pulling behaviors also referred to as “automatic” pulling and comprise a more habitual form of the disorder.[2]”
From Trichotillomania (hair pulling disorder) (2019) · cites this paper as [2]
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BackgroundTrichotillomania and its clinical relationship to depression and anxiety
Grant, J., Redden, S., Medeiros, G. C., Odlaug, B., Curley, E. E., Tavares, H., & Keuthen, N. (2017) · International journal of psychiatry in clinical practice · doi:10.1080/13651501.2017.1314509 · Cited by 49 · see citing works
“1991) and frequently associated with clinically significant psychosocial impairment (Woods et al. 2006).”
BackgroundSelf-citationAcceptance and Commitment Therapy and Habit Reversal Training for the Treatment of Trichotillomania
Crosby, J. M., Dehlin, J. P., Mitchell, P. R., & Twohig, M. (2012) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2012.02.002 · Cited by 48 · see citing works
Bradley, B. (2021) · Anthropology & Medicine · doi:10.1080/13648470.2020.1864807 · Cited by 48 · see citing works
“usually display limited knowledge of the conditions (Woods et al. 2006; Tucker et al. 2011).”
BackgroundHabit reversal training in trichotillomania: guide for the clinician
Morris Sarah, H., Zickgraf Hana, F., Dingfelder Hilary, E., & Franklin Martin, E. (2013) · Expert Review of Neurotherapeutics · doi:10.1586/14737175.2013.827477 · Cited by 47 · see citing works
Clinical features of olfactory reference syndrome: An internet-based study.
Greenberg, J., Shaw, A. M., Reuman, L., Schwartz, R. A., & Wilhelm, S. (2016) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2015.11.001 · Cited by 46 · see citing works
“Internet studies offer many benefits, including providing anonymity and access to a severely ill populationwhomay lack nearby clinical care or who may avoid seeking treatment due to embarrassment about the condition [41]; however, the medium may be prone to selection bias by including only those individualswhohave com…”
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
“Recent adult TTM research suggests that CBT is superior to wait-list (Van Minnen et al., 2003; Woods et al., 2006), pharmacotherapy (Ninan et al., 2000; Van Minnen et al., 2003), pill placebo (Ninan et al.)”
BackgroundResultSelf-citationCharacteristics of trichotillomania and excoriation disorder across the lifespan
Lin, A., Farhat, L. C., Flores, J. M., Levine, J. L. S., Fernandez, T. V., Bloch, M. H., & Olfson, E. (2023) · Psychiatry Research · doi:10.1016/j.psychres.2023.115120 · Cited by 47 · see citing works
Trichotillomania across the life span.
Kratochvil, C., & Bloch, M. (2009) · Journal of the American Academy of Child and Adolescent Psychiatry · doi:10.1097/chi.0b013e3181ae09f3 · Cited by 42 · see citing works
Disgust, shame and the psychosocial impact of skin picking: Evidence from an online support forum
Anderson, S., & Clarke, V. (2019) · Journal of Health Psychology · doi:10.1177/1359105317700254 · Cited by 40 · see citing works
“Shame has previously been shown to inhibit direct disclosure within the phenomenologically similar condition of trichotillomania (Woods et al., 2006), so it is not surprising that some of the more painful details of skin picking’s emotional experience are revealed by a more anonymous and…”
BackgroundThe Phenomenology of Hairpulling in College Students
Duke, D., Keeley, M. L., Ricketts, E., Geffken, G., & Storch, E. (2010) · Journal of Psychopathology and Behavioral Assessment · doi:10.1007/s10862-009-9150-4 · Cited by 38 · see citing works
Striatal abnormalities in trichotillomania: a multi-site MRI analysis
Isobe, M., Redden, S. A., Keuthen, N. J., Stein, D. J., Lochner, C., Grant, J. E., & Chamberlain, S. R. (2018) · NeuroImage: Clinical · doi:10.1016/j.nicl.2017.12.031 · Cited by 37 · see citing works
“The condition has lifetime prevalence of 0.5–1% based on surveys, yet is often hidden, undiagnosed and untreated (Grant et al., 2016; Woods et al., 2006).”
BackgroundInfluentialSelf-citationLee, E. B., Haeger, J., Levin, M. E., Ong, C. W., & Twohig, M. P. (2018) · Journal of Obsessive-Compulsive and Related Disorders · doi:10.1016/j.jocrd.2018.04.003 · Cited by 45 · see citing works
Nutritional up-regulation of serotonin paradoxically induces compulsive behavior.
Dufour, B., Adeola, O., Cheng, H.-W., Donkin, S., Klein, J. D., Pajor, E., & Garner, J. (2010) · Nutritional neuroscience · doi:10.1179/147683010x12611460764688 · Cited by 36 · see citing works
Trichotillomania (hair pulling disorder)
Grant, J. (2019) · Indian Journal of Psychiatry · doi:10.4103/psychiatry.indianjpsychiatry_529_18 · Cited by 35 · see citing works
“” In addition, many people not being fully aware of their pulling behaviors also referred to as “automatic” pulling and comprise a more habitual form of the disorder.[2] Approximately 10%–20% of people with trichotillomania eat their hair after pulling it (“trichophagia”), which can result in gastrointestinal obstruct…”
Abnormal perceptual sensitivity in body-focused repetitive behaviors
Houghton, D. C., Alexander, J. R., Bauer, C. C., & Woods, D. W. (2017) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2017.12.005 · Cited by 54 · see citing works
Self-citationRahman, 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.”
InfluentialPsychosocial dysfunction associated with skin picking disorder and trichotillomania.
Grant, J., Redden, S., Leppink, E. W., Odlaug, B., & Chamberlain, S. (2016) · Psychiatry Research · doi:10.1016/j.psychres.2016.03.004 · Cited by 34 · see citing works
“Skin picking disorder (SPD) and trichotillomania (TTM) and are often debilitating conditions (Christenson et al., 1991; Woods et al., 2006; Grant et al., 2012).”
BackgroundResultLong-Term Outcome in Pediatric Trichotillomania
Schumer, M. C., Panza, K. E., Mulqueen, J. M., Jakubovski, E., & Bloch, M. (2015) · Depression and Anxiety · doi:10.1002/da.22390 · Cited by 34 · see citing works
“[1] Individuals afflicted with trichotillomania suffer hair loss and irritation from repetitively pulling hair from parts of their body such as the scalp, eyelashes, eyebrows, pubic, etc.[2] Psychological and physical effects of trichotillomania severely interfere with individuals’ social, occupational, and/or academi…”
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
“TTM predominantly occurs in women by a ratio of approximately 8:1 (Christenson, Mackenzie, & Mitchell, 1991; Cohen et al., 1995; Woods et al., 2006), although this gender discrepancy may be less pronounced in children (Chang, Lee, Chiang, & Lü, 1991; Muller, 1987).”
BackgroundSelf-citationOpen-Label Trial of Aripiprazole in the Treatment of Trichotillomania
White, M. P., & Koran, L. (2011) · Journal of Clinical Psychopharmacology · doi:10.1097/jcp.0b013e318221b1ba · Cited by 34 · see citing works
Trichotillomania and Co-occurring Anxiety
Grant, J., Redden, S., Leppink, E. W., & Chamberlain, S. (2016) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2016.09.005 · Cited by 33 · see citing works
“In fact, one study of 894 individuals with trichotillomania found that 83% reported anxiety associated with pulling (Woods et al., 2006).”
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
Self-citationWeidt, S., Klaghofer, R., Kuenburg, A., Bruehl, A. B., Delsignore, A., Moritz, S., & Rufer, M. (2015) · Psychotherapy and Psychosomatics · doi:10.1159/000431290 · Cited by 32 · see citing works
Evidence-Based Psychosocial Treatments for Pediatric Body-Focused Repetitive Behavior Disorders
Woods, D. W., & Houghton, D. (2016) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374416.2015.1055860 · Cited by 32 · see citing works
“Psychosocial difficulties due to TTM might increase in severity over the course of development (Franklin et al., 2008; Walther et al., 2014; Woods et al., 2006), possibly because hair pulling and its affects might become less socially acceptable as one matures.”
BackgroundSelf-citationThe Role of Sex and Gender in Dermatology - From Pathogenesis to Clinical Implications
Lagacé, F., D’Aguanno, K., Prosty, C. J., Laverde‐Saad, A., Cattelan, L., Ouchene, L., Oliel, S., Genest, G., Doiron, P., Richer, V., et al. (2023) · Journal of Cutaneous Medicine and Surgery · doi:10.1177/12034754231177582 · Cited by 38 · see citing works
Age of Onset of Trichotillomania Symptoms: Investigating Clinical Correlates
Flessner, C., Lochner, C., Stein, D., Woods, D. W., Franklin, M., & Keuthen, N. (2010) · Journal of Nervous and Mental Disease · doi:10.1097/nmd.0b013e3181fe7423 · Cited by 31 · see citing works
“We used data obtained with the internet-based Trichotillomania Impact Project (TIP; Woods et al., 2006).”
BackgroundMethodInfluentialSelf-citationBehavior therapy for pediatric trichotillomania: Exploring the effects of age on treatment outcome
Franklin, M., Edson, A. L., & Freeman, J. (2010) · Child and Adolescent Psychiatry and Mental Health · doi:10.1186/1753-2000-4-18 · Cited by 31 · see citing works
“The concept of urge plays an important role, as most participants in TTM studies to date have reported tension or some other unpleasant sensation that precedes pulling [12].”
BackgroundSelf-citationKeuthen, N., Tung, E. S., Woods, D. W., Franklin, M., Altenburger, E. M., Pauls, D., & Flessner, C. (2015) · Behavior Modification · doi:10.1177/0145445515580533 · Cited by 30 · see citing works
Self-citationTrichotillomania, stereotypic movement disorder, and related disorders
Stein, D., Garner, J., Keuthen, N., Franklin, M., Walkup, J., Woods, D. W., & the Board (2007) · Current Psychiatry Reports · doi:10.1007/s11920-007-0036-4 · Cited by 30 · see citing works
Self-citationDSM‐5 FIELD SURVEY: HAIR‐PULLING DISORDER (TRICHOTILLOMANIA)
Lochner, C., Grant, J., Odlaug, B., Woods, D. W., Keuthen, N., & Stein, D. J. (2012) · Depression and Anxiety · doi:10.1002/da.22011 · Cited by 29 · see citing works
“This is consistent with previous data.[7, 8] That said, it is notable that participants who do endorse an urge to pull may have more severe hair-pulling symptoms than those without.”
ResultSelf-citationMoattari, C. R., & Jafferany, M. (2021) · Skin Appendage Disorders · doi:10.1159/000519817 · Cited by 28 · see citing works
Twohig, M. P., Petersen, J. M., Fruge, J. E., Ong, C. W., Barney, J. L., Krafft, J., Lee, E. B., & Levin, M. E. (2021) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2021.01.004 · Cited by 46 · see citing works
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
“…in both adults and children with significant avoidance and distress related to public activities, sexual intimacy, and athletic endeavors reported (Diefenbach, Tolin, Hannan, Crocetto, & Worhunsky, 2005; Franklin et al., 2007; Stemberger, Thomas, Mansueto, & Carter, 2000; Woods et al., 2006).”
BackgroundSelf-citationPredictors 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
“It is associated with significant distress and impaired psychosocial functioning in many domains (Diefenbach, Reitman, & Williamson, 2000; Woods et al., 2006a).”
Diagnostic Accuracy of Trichoscopy in Trichotillomania: A Systematic Review
Kaczorowska, A., Rudnicka, L., Stefanato, C., Waśkiel-Burnat, A., Warszawik-Hendzel, O., Olszewska, M., & Rakowska, A. (2021) · Acta Dermato-Venereologica · doi:10.2340/00015555-3859 · Cited by 26 · see citing works
“It consists of round haemorrhages around hair shafts and, according to the authors, can be very suggestive of trichotillomania (4, 36).”
BackgroundSlikboer, R., Nedeljkovic, M., Bowe, S., & Moulding, R. (2017) · Clinical Psychologist · doi:10.1111/cp.12074 · Cited by 26 · see citing works
Asplund, M., Lenhard, F., Andersson, E., & Ivanov, V. Z. (2022) · Internet Interventions · doi:10.1016/j.invent.2022.100573 · Cited by 25 · see citing works
“In addition, occupational interference was experienced by almost 80 % of the participants with TTM and 35 % of individuals with SPD (Diefenbach et al., 2005; Flessner and Woods, 2006).”
BackgroundResultCapel, L., Petersen, J. M., Woods, D. W., Marcks, B. A., & Twohig, M. (2023) · Cognitive Therapy and Research · doi:10.1007/s10608-023-10381-w · Cited by 25 · see citing works
“Social impairment can include difficulties in close relationships, declining to pursue occupational or educational advancements, and interference in schooling (Grant et al., 2017; Woods et al., 2006a, b, c).”
Self-citation
- Authors
- Woods, D. W., Flessner, C. A., Franklin, M. E., Keuthen, N. J., Goodwin, R. D., Stein, D. J., Walther, M. R., & Trichotillomania Learning Center-Scientific Advisory Board
- Affiliations
- University of Wisconsin–Milwaukee (US)
- ORCID
- Venue
- The Journal of Clinical Psychiatry
- Publisher
- Physicians Postgraduate Press, Inc
- Published
- 2006-12-15
- Volume
- 67
- Issue
- 12
- Pages
- 1877-1888
- ISSN
- 0160-6689 (ISSN-L)
- OpenAlex
- W2042276786
- Cited by
- 317
- References
- 0
- Citations by year
- 2026: 8 · 2025: 18 · 2024: 15 · 2023: 25 · 2022: 16 · 2021: 19 · 2020: 10 · 2019: 9 · 2018: 16 · 2017: 25 · 2016: 20 · 2015: 29 · 2014: 11 · 2013: 9 · 2012: 14
- FWCI
- 13.28
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Journal of Clinical Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Obsessive-Compulsive Spectrum Disorders
- Social Sciences › Psychology › Clinical Psychology › Body Image and Dysmorphia Studies
- Health Sciences › Medicine › Urology › Hair Growth and Disorders
- Keywords
- trichotillomania, hair pulling, phenomenology, symptom severity, functional disability, social functioning, occupational functioning, academic functioning, psychological functioning, treatment seeking, pharmacotherapy, behavior therapy, treatment effectiveness, perceived treatment effectiveness
- MeSH terms
- Activities of Daily Living, Adolescent, Adult, Aged, Behavior Therapy, Drug Therapy, Female, Health Surveys, Humans, Male, Mental Health, Mental Health Services, Middle Aged, Severity of Illness Index, Trichotillomania
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