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A Preliminary Investigation of Metacognitive Therapy and Habit Reversal as a Treatment for Trichotillomania

  • Hossein Shareh (a1)
Abstract

Background: Not all patients suffering from trichotillomania (TTM) recover completely using CBT and of those that do, only a few maintain their recovery over time. Aims: The purpose of the present study was to investigate the effectiveness of metacognitive methods combined with habit reversal (MCT/HRT) in trichotillomania with a relatively long-term follow-up. Method: A case series (n = 8) and a randomized wait-list controlled trial (n = 34) design were conducted in this study. In the case series, three of the eight patients dropped out of the study. Therefore, TTM-related symptoms were evaluated in five patients suffering from TTM before and after brief metacognitive plus habit reversal therapy during 1-month, 6-month, and 12-month follow-ups. The treatment consisted of detached mindfulness (DM) techniques, ritual postponement and habit reversal training (HRT) in eight sessions. Results: All patients were responders at post-treatment in case series. After the 12-month follow-up, the results were associated with higher pre-treatment levels of self-esteem and global functioning and lower pre-treatment levels of depression and anxiety with nearly complete abstinence from hair pulling immediately after treatment. A randomized wait-list controlled trial with experimental (n = 17) and waiting list group (n = 17) was then conducted to confirm the case series results. There were significant differences between the two groups regarding changes in MGH-HPS, Y-BOCS-TM, RSES, GAF, BDI, BAI and self-monitoring. Therefore, the MCT/HRT treatment was found to be more effective than the waiting list group. Conclusions: A combined treatment including metacognitive and habit reversal techniques is remarkably effective in patients with TTM.

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Corresponding author
Correspondence to Hossein Shareh, Associate Professor of Clinical Psychology, Hakim Sabzevari University, Sabzevar, Iran. E-mail: hsharreh@yahoo.com.au, h.shareh@hsu.ac.ir
References
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Adams, A. N., Adams, M. A. and Miltenberger, R. G. (2008). Habit reversal training. In O'Donohue, W. and Fisher, J. E. (eds), Cognitive Behavior Therapy: Applying Empirically Supported Techniques in your Practice. Hoboken, NJ: Wiley.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th edn). Arlington, VA: American Psychiatric Publishing.
Attkisson, C. C. and Greenfield, T. K. (1999). The UCSF client satisfaction scales: I. The client satisfaction questionnaire-8. In Maruish, M. E. (ed), The Use of Psychological Testing for Treatment Planning and Outcomes Assessment (2nd edn). Mahwah, NJ: Lawrence Erlbaum Associates.
Attkisson, C. C. and Zwick, R. (1982). The Client Satisfaction Questionnaire: Psychometric properties and correlations with service utilization and psychotherapy outcome. Evaluation and Program Planning, 6, 299314.
Barlow, D. H. and Hersen, M. (1984). Single Case Experimental Designs: Strategies for Studying Behavior Change (2nd edn). Newton, MA: Allyn and Bacon.
Beck, A. T., Epstein, N., Brown, G. and Steer, R. A. (1988a). An inventory for measuring clinical anxiety: psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893897.
Beck, A. T. and Steer, R. A. (1991). Relationship between Beck Anxiety Inventory and the Hamilton Anxiety Rating Scale with anxious patients. Journal of Anxiety Disorders, 5, 213223.
Beck, A. T., Steer, R. A. and Brown, G. (1996). Beck Depression Inventory Manual (2nd edn). San Antonio, TX: Psychological Corporation.
Beck, A. T., Steer, R. A. and Garbin, M. G. (1988b). Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clinical Psychology Review, 8, 77100.
Bienvenu, O. J., Wang, Y., Shygart, Y. Y., Welch, J. M., Grados, M. A., Fyer, A. J. et al. (2008). Sapap3 and pathological grooming in humans: results from the OCD collaborative genetics study. American Journal of Medical Genetics, 150, 710720.
Bloch, M. H., Landeros-Weisenberger, A., Dombrowski, P., Kelmendi, B., Wegner, R., Nudel, J., Pittenberger, C., Leckman, J. F. and Coric, V. (2007). Systematic review: pharmacological and behavioral treatment for trichotillomania. Biological Psychiatry, 62, 839846.
Bohne, A., Savage, C. R., Deckersbach, T., Keuthen, N. J. and Wilhelm, S. (2008). Motor inhibition in trichotillomania and obsessive–compulsive disorder. Journal of Psychiatric Research, 42, 141150.
Busseri, M. A. and Tyler, J. D. (2003). Interchangeability of the working alliance inventory and working alliance inventory, short form. Psychological Assessment, 15, 193197.
Christenson, G. A., Mackenzie, T. B. and Mitchell, J. E. (1994). Adult men and women with trichotillomania: a comparison of male and female characteristics. Psychosomatics, 35, 142149.
Cohen, J. (1960). A coefficient of agreement for nominal scales. Educational and Psychological Measurement, 20, 3746.
Diefenbach, G. J., Reitman, D. and Williamson, D. A. (2000). Trichotillomania: a challenge to research and practice. Clinical Psychology Review, 20, 289309.
Diefenbach, G. J., Tolin, D. F., Crocetto, J. S., Maltby, N. and Hannan, S. E. (2005). Assessment of trichotillomania: a psychometric evaluation of hair-pulling scales. Journal of Psychopathology and Behavioral Assessment, 27, 169–78.
Diefenbach, G. J., Tolin, D. F., Hannan, S., Maltby, N. and Crocetto, J. (2006). Group treatment for trichotillomania: behavior therapy versus supportive therapy. Behavior Therapy, 37, 353363.
Duke, C. D., Keely, M. L., Geffken, G. R. and Storch, E. A. (2010). Trichotillomania: a current review. Clinical Psychology Review, 30, 181193.
Dunkle, J. and Friedlander, M. L. (1996). Contribution of therapist experience and personal characteristics to the working alliance. Journal of Counseling Psychology, 43, 456460.
Falkenstein, M. J., Mouton-Odum, S., Mansueto, C. S., Golomb, R. G. and Haaga, D. A. (2016). Comprehensive behavioral treatment of trichotillomania: a treatment development study. Behavior Modification, 40, 414438.
Fata, L., Birashk, B., Atef-Vahid, M. K. and Dabson, K. S. (2005). Meaning assignment structures/schema, emotional states and cognitive processing of emotional information: comparing two conceptual frameworks. IEEE Transl Iranian Journal of Psychiatry and Clinical Psychology, 11, 312−26.
Ferrão, Y. A., Miguel, E. and Stein, D. J. (2009). Tourette's syndrome, trichotillomania and obsessive–compulsive disorder: how closely are they related? Psychiatry Research, 170, 3242.
Fine, K. M., Walther, M. R., Joseph, J. M., Robinson, J., Ricketts, E. J., Bowe, W. E. and Woods, D. W. (2012) Acceptance-enhanced behavior therapy for trichotillomania in adolescents. Cognitive and Behavioral Practice, 19, 463471.
First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B. W. and Benjamin, L. (1997). Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II0). Washington, DC: American Psychiatric Association.
First, M. B., Spitzer, R. L., Gibbon, M. and Williams, J. B. W. (1996). Structured Clinical Interview for DSM-IV Axis I Disorders-Patient edition (SCID-I/P, version 2.0). New York: New York Psychiatric Institute, Biometrics Research Department.
Fisher, P. L. and Wells, A. (2008). Metacognitive therapy for obsessive-compulsive disorder: a case series. Journal of Behavior Therapy and Experimental Psychiatry, 39, 117132.
Flessner, C. A., Penzel, F., Trichotillomania Learning Center–Scientific Advisory Board and Keuthen, N. J. (2010).Current treatment practices for children and adults with trichotillomania: consensus among experts. Cognitive and Behavioral Practice, 17, 290300.
Groth-Marnat, G. (2003). Handbook of Psychological Assessment (5th edn). Chichester, UK: Wiley.
Guy, W. (1976) ECDEU Assessment Manual for Psychopharmacology. US Department of Health, Education, and Welfare publication (ADM) 76338. Rockville, MD: National Institute of Mental Health, pp. 218222.
Himle, M. B., Flessner, C. A. and Woods, D. W. (2004). Advances in the behavior analytic treatment of trichotillomania and Tourette's syndrome. Journal of Early and Intenstive Behaviour Intervention, 1, 5865.
Huynh, M., Gavino, A. C. and Magid, M. (2013). Trichotillomania. Seminars in Cutaneous Medicine and Surgery, 32, 8894.
Keijsers, G. P. J, van Minnen, A., Hoogduin, C. A. L., Klaassen, B. N. W., Hendriks, M. J. and Tanis-Jacobs, J. (2006). Behavioural treatment of trichotillomania: two-year follow-up results. Behaviour Research and Therapy, 44, 359370.
Keuthen, N. J., Flessner, C. A., Woods, D. W., Franklin, M. E., Stein, D. J., Cashin, S. E. et al. (2007). Factor analysis of the Massachusetts General Hospital Hairpulling Scale. Journal of Psychosomatic Research, 62, 707709.
Keuthen, N. J., O'Sullivan, R. L., Ricciardi, J. N., Shera, D., Savage, C. A., Borgmann, A. S., Jenike, M. A. and Baer, L. (1995). The Massachusetts General Hospital (MGH) hair pulling scale: development and factor analysis. Psychotherapy and Psychosomatics, 64, 141145.
Keuthen, N. J., Rothbaum, B. O., Fama, J., Altenburger, E., Falkenstein, M. J., Sprich, S. E. and Welch, S. S. (2012). DBT-enhanced cognitive-behavioral treatment for trichotillomania: a randomized controlled trial. Journal of Behavioral Addictions, 1, 106114.
Keuthen, N. J., Rothbaum, B. O., Welch, S. S., Taylor, C., Falkenstein, M., Heekin, M., Jordan, C. A., Timpano, K., Meunier, S., Fama, J. and Jenike, M. A. (2010). Pilot trial of dialectical behavior therapy-enhanced habit reversal for trichotillomania. Depression and Anxiety, 27, 953959.
Keuthen, N. J. and Sprich, S. E. (2012). Utilizing DBT skills to augment traditional CBT for trichotillomania: an adult case study. Cognitive and Behavioral Practice, 19, 372380. doi:10.1016/j.cbpra.2011.02.004
Larsen, D. L., Attkisson, C. C., Hargreaves, W. A. and Nguyen, T. D. (1979). Assessment of client/patient satisfaction: development of a general scale. Evaluation and Program Planning, 2, 197207.
Lerner, J., Franklin, M. E., Meadows, E. A., Hembree, E. and Foa, E. B. (1998). Effectiveness of a cognitive behavioral treatment program for trichotillomania: an uncontrolled evaluation. Behavior Therapy, 29, 157171.
Leon, A. C., Shear, M. K., Klerman, G. L. et al. (1993). A comparison of symptom determinants of patient and clinician global ratings in patients with panic disorder and depression. Journal of Clinical Psychopharmacology, 13, 327331.
Ligiero, D. P. and Gelso, C. J. (2002). Countertransference, attachment, and the working alliance: the therapist's contributions. Psychotherapy: Theory, Research, Practice, Training, 39, 311.
Martin, D. J., Garske, J. P. and Davis, K. D. (2000). Relation of therapeutic alliance with outcome and other variables: a meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 428450.
Mouton, S. G. and Stanley, M. A. (1996). Habit reversal training for trichotillomania: a group approach. Cognitive and Behavioral Practice, 3, 159182.
Nedeljkovic, M. and Kyrios, M. (2007). Confidence in memory and other cognitive processes in obsessive-compulsive disorder. Behavior Research and Therapy, 45, 28992914.
Nguyen, T. D., Attkisson, C. C. and Stegner, B. L. (1983). Assessment of patient satisfaction: development and refinement of a service evaluation questionnaire. Evaluation and Program Planning, 6, 299313.
Ninan, E. T., Rothbaum, B. O., Marsteller, E A., Knight, B. T. and Eccard, M. B. (2000). A placebocontrolled trial of cognitive-behavioral therapy and clomipramine in trichotillomania. Journal of Clinical Psychiatry, 61, 4750.
O'Sullivan, R. L., Keuthen, N. J., Hayday, C. F., Ricciardi, J. N., Buttolph, M. L., Jenike, M. A. and Baer, L. (1995). Massachusetts General Hospital (MGH) Hairpulling Scale: 2. Reliability and validity. Psychotherapy and Psychosomatics, 64, 146148.
Rees, C. S. and van Koesveld, K. E. (2008). An open trial of group metacognitive therapy for obsessive-compulsive disorder. Journal of Behavior Therapy and Experimental Psychiatry, 39, 451458.
Rosenberg, M. (1965). Society and the Adolescent Self-Image. Princeton, NJ: Princeton University Press.
Sadock, B. J. and Sadock, V. A. (2007). Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (10th edn). Philadelphia, USA: Lippincott Williams and Wilkins.
Shareh, H., Gharraee, B., Atef-Vahid, M. K. and Eftekhar, M. (2010). Metacognitive therapy (MCT), fluvoxamine, and combined treatment in improving obsessive-compulsive, depressive and anxiety symptoms in patients with obsessive-compulsive disorder (OCD). Iranian Journal of Psychiatry and Behavioral Sciences, 4, 1725.
Sidman, M. (1960). Tactics of Scientific Research Evaluating Experimental Data in Psychology. New York: Basic Books.
Spitzer, R. L., Gibbon, M., Williams, J. B. W. and Endicott, J. (1996). Global assessment of functioning (GAF) scale. In Sederer, L. I., and Dickey, B. (eds), Outcomes Assessment in Clinical Practice, pp. 7678. Baltimore, MD: Williams and Wilkins.
Stanley, M. A., Breckenridge, J. K., Snyder, A. G. and Novy, D. M. (1999). Clinician rated measure of hairpulling: a preliminary psychometric evaluation. Journal of Psychopathology and Behavioral Assessment, 21, 157–82.
Stanley, M. A., Prather, R. C., Wagner, A. L., Davis, M. L. and Swann, A. C. (1993). Can the Yale-Brown Obsessive-Compulsive Scale be used to assess trichotillomania? A preliminary report. Behaviour Research and Therapy, 31, 171177.
Stanley, M. A., Swann, A. C., Bowers, T. C., Davis, M. L. and Taylor, D. J. (1992). A comparison of clinical features in trichotillomania and obsessive-compulsive disorder. Behaviour Research and Therapy, 30, 3944.
Stein, D. J., Christenson, G. A. and Hollander, E. H. (1999). Trichotillomania. Washington DC: American Psychiatric Press.
Stein, D. J., Grant, J. E., Franklin, M. E., Keuthen, N., Lochner, C., Singer, H. S., Woods, D.W., Hercogova, J. and Lotti, T. (2010). Trichotillomania (hair pulling disorder), skin picking disorder, and stereotypic movement disorder: towaed DSM-V. Depression and Anxiety, 27, 611626.
Tolin, D. F., Franklin, M. E., Diefenbach, G. J. and Gross, A. (2002, November). Cognitive-behavioral therapy for pediatric trichotillomania: an open trial. Paper presented at the the Association for Advancement of Behavior Therapy, Reno, NV.
Tracey, T. J. and Kokotovic, A. M. (1989). Factor structure of the working alliance inventory. Journal of Consulting and Clinical Psychology, 57, 207210.
Twohig, M. P. and Woods, D. W. (2004). A preliminary investigation of acceptance and commitment therapy as a treatment for trichotillomania. Behavior Therapy, 35, 803820.
van Minnen A, Hoogduin, K. A, Keijsers, G. P, Hellenbrand, I. and Hendriks, G. J. (2003). Treatment of trichotillomania with behavioral therapy or fluoxetine: A randomized, waiting-list controlled study. Archives of General Psychiatry, 60, 517522.
Walther, M. R., Ricketts, E. J., Conelea, C. A. and Woods, D. W. (2010). Recent advances in the understanding and treatment of trichotillomania. Journal of Cognitive Psychotherapy: An International Quarterly, 24, 4664.
Wechsler, D. A. (1999). Wechsler Abbreviated Scale of Intelligence. San Antonio, TX: The Psychological Corporation.
Wells, A. (1997). Cognitive Therapy of Anxiety Disorders: A Practice Manual and Conceptual Guide. Chichester, UK: Wiley.
Wells, A. (2000). Emotional Disorders and Metacognition: Innovative Cognitive Therapy. Chichester, UK: Wiley.
Wells, A. (2005). Detached mindfulness in cognitive therapy: a metacognitive analysis and ten techniques. Journal of Rational-Emotive and Cognitive-Behavior Therapy, 23, 337355.
Wells, A. (2009). Metacognitive Therapy for Anxiety and Depression. New York: Guilford Press.
Welch, S. S. and Kim, J. (2012). DBT-enhanced cognitive behavioral therapy for adolescent trichotillomania: an adolescent case study. Cognitive and Behavioral Practice, 19, 483493.
Winchel, R. M., Jones, J. S., Molcho, A., Parsons, B., Stanley, B. and Stanley, M. (1992a). The psychiatric institute trichotillomania scale (PITS). Psychopharmacology Bulletin, 28, 463476.
Winchel, R. M., Jones, J. S., Stanley, B., Molcho, A. and Stanley, M. (1992b). Clinical characteristics of trichotillomania and its response to fluoxetine. Journal of Clinical Psychiatry, 53, 304308.
Wongpakaran, T. and Wongpakaran, N. (2012). A comparison of reliability and construct validity between the original and revised versions of the Rosenberg Self-Esteem Scale. Psychiatry Investigation, 9, 5458.
Woods, D. W. (2006). Habit reversal treatmentmanual for tic disorders. In Woods, D. W. and Miltenberger, R. G. (eds), Tic Disorders, Trichotillomania, and Other Repetitive Behavior Disorders, pp. 97132. US: Springer.
Woods, D. W., Flessner, C. A., Franklin, M. E., Keuthen, N. J., Goodwin, R. D., Stein, D. J. and Walther, M. R. (2006a). The Trichotillomania Impact Project (TIP): exploring phenomenology, functional impairment and treatment utilization. Journal of Clinical Psychology, 67, 18771878.
Woods, D. W., Wetterneck, C. T. and Flessner, C. A. (2006b). A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania. Behaviour Research and Therapy, 44, 639656.
Yeh, A. H., Taylor, S., Thordarson, D. S. and Corcoran, K. M. (2003). Efficacy of telephone-administered cognitive behavior therapy for obsessive-compulsive spectrum disorders: case studies. Cognitive Behavior Therapy, 32, 7581.
Zanarini, M. C., Skodol, A. E., Bender, D., Dolan, R., Sanislow, C., Schaefer, E. et al. (2000). The Collaborative Longitudinal Personality Disorders Study: reliability of axis I and II diagnoses. Journal of Personality Disorders, 14, 291299.
Zuchner, S., Wendland, J. R., Ashley-Koch, A. E., Collins, A. L., Tran-Vet, K. N., Quinn, K. et al. (2009). Multiple rare sapap3 missense variants in trichotillomania and OCD. Molecular Psychiatry, 14, 69.
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