DEPRESSION AND ANXIETY 27 : 953–959 (2010)

Research Article
PILOT TRIAL OF DIALECTICAL BEHAVIOR
THERAPY-ENHANCED HABIT REVERSAL
FOR TRICHOTILLOMANIA
Nancy J. Keuthen, Ph.D.,1 Barbara O. Rothbaum, Ph.D.,2 Stacy Shaw Welch, Ph.D.,3 Caitlin Taylor, B.A.,1
Martha Falkenstein, B.S.,1 Mary Heekin, L.M.S.W.,2 Cathrine Arndt Jordan, M.S.,2 Kiara Timpano, Ph.D.,1
Suzanne Meunier, Ph.D.,1 Jeanne Fama, Ph.D.,1 and Michael A. Jenike, M.D.1

Background: Not all hair pullers improve acutely with cognitive–behavioral

treatment (CBT) and few maintain their gains over time. Methods: We conducted
an open clinical trial of a new treatment that addresses affectively triggered pulling
and emphasizes relapse prevention in addition to standard CBT approaches. Ten
female participants satisfying DSM-IV criteria for trichotillomania (TTM) at two
study sites received Dialectical Behavior Therapy (DBT)-enhanced CBT consisting
of 11 weekly sessions and 4 maintenance sessions over the following 3 months.
Independent assessors rated hair pulling impairment and global improvement at
several study time points. Participants completed self-report measures of hair
pulling severity and emotion regulation. Results: Significant improvement in
hair pulling severity and emotion regulation, as well as hair pulling impairment
and anxiety and depressive symptoms, occurred during acute treatment and were
maintained during the subsequent 3 months. Significant correlations were
reported between changes in emotion regulation and hair pulling severity during
both the acute treatment and maintenance phases. Conclusions: This study offers
preliminary evidence for the efficacy of DBT-enhanced CBT for TTM and suggests
the importance of addressing emotion regulation during TTM treatment.
Depression and Anxiety 27:953–959, 2010. r 2010 Wiley-Liss, Inc.

Key words: trichotillomania; hair pulling; habit reversal; dialectical behavior

therapy

INTRODUCTION
E mpirical research has recently documented the
phenomenology and psychosocial impairment asso-
ciated with trichotillomania (TTM).[1,2] Unfortunately,
though, treatment options are limited, with clinical
outcomes modest at best, even with first-line interven-
tions such as cognitive–behavioral treatment (CBT).
Not all individuals with TTM benefit from CBT and,
of those that do, few achieve complete abstinence from
hair pulling. In addition, failure to maintain treatment
gains has plagued the field,[3,4] with maintenance of
improvement with CBT reported in only one study of
adult TTM individuals utilizing rigorous follow-up
assessments.[5] Not surprisingly, the perception of
TTM as a treatment refractory disorder has persisted.
1
Massachusetts General Hospital/Harvard Medical School,
Boston, Massachusetts
2
Emory University School of Medicine, Atlanta, Georgia
3
Anxiety and Stress Reduction Center, University of Washington,
Seattle, Washington
The authors disclose the following financial relationship within the
past 3 years: Contract grant sponsor: David Judah Fund.
Correspondence to: Nancy J. Keuthen, Trichotillomania Clinic and
Research Unit, Massachusetts General Hospital, Simches 2, 185
Cambridge St, Boston, MA 02114. E-mail: nkeuthen@partners.org
Received for publication 20 April 2010; Revised 29 June 2010;
Accepted 1 July 2010
DOI 10.1002/da.20732
Published online 18 August 2010 in Wiley Online Library (wiley
onlinelibrary.com).

r 2010 Wiley-Liss, Inc.

954 Keuthen et al.
Several years ago, the meta-analysis of Bloch et al.[6]
demonstrated the superiority of habit reversal training
(HRT),[7,8] the hallmark CBT approach for TTM, over
pharmacotherapy with either clomipramine or selective
serotonergic reuptake inhibitors. These data, coupled
with a consensus amongst practitioners,[9] have sup-
ported the choice of HRT as the first-line treatment for
TTM. More recently, Grant et al.[10] reported success-
ful outcomes using N-acetylcysteine, an amino acid
known to modulate glutamate function, in a double-
blind, placebo-controlled study of TTM. Despite the
groundbreaking nature of this study, only 56% of their
participants were much or very much improved after 12
weeks of treatment, thus highlighting the need for
additional treatment choices and outcome research.
It has been hypothesized that truncated CBT outcomes
can be attributed to a ‘‘one size fits all’’ approach with
the use of HRT, despite knowledge that different TTM
subtypes or styles exist. In the early 1990s, Christenson
et al.[11] proposed two types of hair pulling: automatic or
habit-like pulling occurring out of conscious awareness
and focused pulling occurring volitionally in response to
uncomfortable inner experiences (e.g. emotions, urges,
sensations, or thoughts). Subsequent analysis of cue
profiles[12] provided corroborative evidence for two
TTM components characterized by negative affect with
awareness of pulling and sedentary activities with ‘‘con-
templative attitudes.’’ More recent work documents differ-
ences in TTM phenomenology and severity, comorbid
affective symptoms and repetitive behaviors as a function
of the predominance of different pulling styles.[13–15]
The occurrence of significant comorbid affective
symptoms in TTM, and the potential role of affective
variables as cues, reinforcers, and maintaining variables
for TTM, has been repeatedly noted. In a large sample
survey of college students, Hajcak et al.[16] reported
increased levels of affective distress in students endorsing
frequent hair pulling. In an early study with subclinical
hair pullers, Stanley et al.[17] documented pre- to
postpulling reductions in tension, boredom, sadness,
and anger. Diefenbach et al.[18] had 44 DSM-III-R TTM
individuals rate the intensity of emotional states before,
during, and after hair pulling. Significant decreases in
boredom, anxiety, and tension occurred across time as
well as significant increases in relief, guilt, sadness, and
anger. Postpulling reductions in anxiety and tension, as
well as the experience of relief, were posited to function
as negative and positive reinforcers for hair pulling.
Diefenbach et al. further hypothesized that the negative
emotional sequelae of TTM may facilitate subsequent
pulling through ‘‘tension–reduction–tension’’ cycles or
associated dysfunctional cognitions. A subsequent study
comparing pullers and normal controls revealed signi-
ficant group differences in self-reported emotional
experiences secondary to hair pulling with greater affective
changes upon pulling in those with TTM.[19] Research
with pediatric pullers indicates pleasure secondary to
pulling, thus suggesting a positive reinforcement mecha-
nism for TTM maintenance in youth.[20]
Depression and Anxiety
More recently, Shusterman et al.[21] conducted a
large-scale Internet survey of self-identified hair pullers
to examine the potential contribution of affective
regulation in TTM. These authors reported a small-
to-moderate correlation between problematic hair
pulling and affective regulation. Furthermore, pre-
dicted relationships between affective pulling triggers,
problematic emotion regulation, and pulling severity
were found.
In addition to clinical evidence, neuroimaging work
provides preliminary support for the relevance of
emotion regulation to TTM. A recent structural
magnetic resonance imaging study of TTM conducted
by Chamberlain et al.[22] documented increased density
of grey matter in the left amygdalo–hippocampal
formation, a region in the limbic system known for
its involvement in arousal and emotional learning.
These collective findings have led several researchers
to suggest the need for TTM treatments that flexibly
address the occurrence of different pulling patterns in
persons with TTM. It has been hypothesized that
HRT may be more effective in addressing the habit-
like, ‘‘sedentary contemplative’’ style of TTM more
than the focused style (often accompanied by uncom-
fortable affective states) though empirical corrobora-
tion for this is lacking. Accordingly, it has been
suggested that techniques addressing dysregulated
affect may be necessary to improve TTM outcomes.
Although several conceptual models have identified
affective symptoms as behavioral triggers (e.g.[23]), and
affect regulation as one of the mechanisms that
underlies the disorder (e.g.[24]), little has been done to
address dysregulated affect in treatment protocols.
To date, Woods et al.[5] are the only researchers who
have addressed both styles of TTM in their treatment
protocol by utilizing Acceptance and Commitment
Therapy (ACT) in combination with HRT. The
treatment focus in ACT is to promote the acceptance
of uncomfortable internal events with an enhanced
commitment to one’s valued life goals. In their wait-list
controlled study, significant reductions in TTM
severity and impairment, as well as comorbid anxiety
and depressive symptoms plus experiential avoidance,
were reported for those in the active treatment
condition in comparison with control participants.
Furthermore, improvement was maintained at 3-month
follow-up and reductions in TTM severity were
correlated with decreases in experiential avoidance.
Another treatment approach that has been success-
fully utilized with a range of psychological conditions
characterized by affective dysregulation and impulsivity
is Dialectical Behavior Therapy (DBT).[25,26] DBT has
been noted for its concrete, step-by-step methods of
instruction in specific skills. Although it shares some
conceptual overlap with ACT, our extensive clinical
experience with hair pullers has led us to believe that
DBT may have unique strengths as a treatment
package to augment traditional CBT approaches for
the TTM population. Most importantly, DBT offers a
 Research Article: Pilot Trial of Dialectical Behavior
skills package that is explicit and easily understood. It
breaks down difficult abstract concepts into brief,
structured skill sets using a format that is easily
disseminated to therapists and clients. DBT can also
be readily utilized by therapists with a working
knowledge of CBT without learning additional theory.
Although both ACT and DBTemphasize acceptance of
difficult internal experiences as well as life change,
DBT provides more focused emphasis and instruction
on change strategies for internal experiences, such as
specific instruction on how to regulate emotions or
change unhelpful cognitions.
In this pilot study we sought to investigate the
efficacy of combined DBT and traditional cognitive
behavioral interventions in the acute treatment of 10
individuals with TTM. We also assessed maintenance
of treatment benefit 3 months after completion of acute
treatment and the relationship between changes in both
emotion regulation and TTM severity with treatment.
METHOD
PARTICIPANTS
Ten female participants were enrolled across two study sites
(MGH/Harvard, n 5 5; Emory University School of Medicine,
n 5 5). Mean age and illness onset were 30.50 (SD 5 8.30) and
11.25 (SD 5 3.88) years, respectively. Three participants had current
comorbid psychiatric diagnoses (hypochondriasis, n 5 1; generalized
anxiety disorder, n 5 1; and major depressive disorder, n 5 1). Three
participants were currently taking psychotropic medications (citalo-
pram, n 5 1; buproprion, n 5 1; escitalopram, n 5 2; and lamotrigine,
n 5 1). None of these medications were prescribed specifically for
TTM. All participants were Caucasian. Three participants were
married and seven were single. None of the participants dropped out
during the duration of the study.
Interested individuals were initially phone screened to assess for
preliminary satisfaction of study criteria. Study inclusion criteria
consisted of a primary DSM-IV diagnosis of TTM; Z18 years of age;
a minimum MGH-HPS total scale score of 10; and a minimum TTM
symptom duration of 1 year with no significant remissions (as defined
by complete abstinence of hair extraction for a 2-week period during
the prior 6 months). All participants could provide informed consent
and had sufficient intellectual capacity to accurately complete
assessment measures. Exclusion criteria included the presence of a
serious psychiatric condition including mental retardation, psychosis,
pervasive developmental disorder, organic mental disorders, manic
episode, ADHD, suicidality, lifetime alcohol or substance depen-
dence, or alcohol or substance abuse within the past 3 months; the
presence of a serious medical condition that would limit ability to
routinely attend sessions and complete homework assignments;
involvement in other psychiatric treatment for TTM; prior CBT
for TTM; prior DBT; and psychotropic medications for TTM within
2 months of baseline assessment. Individuals were enrolled if on
stable psychotropic medication for a comorbid psychiatric illness as
long as they had no plans to change medication during the study.
Fifty-six phone screens were conducted across both sites. Reasons
for excluding individuals from enrollment included: exclusionary
comorbid psychiatric or medical diagnoses or TTM not being the
primary diagnosis (n 5 19), scheduling issues or geographic distance
(n 5 8), unstable medication regimens (n 5 8), failure to meet TTM
diagnostic criteria or MGH-HPS hair pulling severity score Z10
(n 5 5), inability to commit to study timeline or treatment (n 5 2),
955
current or past CBT for TTM or DBT (n 5 2), and callers lost to
contact (n 5 2).
Eligible individuals were scheduled for an in-person interview with
an independent assessor (IA). All IAs had a minimum of masters-level
training in psychology or social work. IAs received training in
structured assessment interviews by their respective site PI (NJK or
BOR). Reliability was established by review of taped assessments by
the PI at the alternate site. The baseline evaluation included
administration of several semi-structured interviews for diagnosis,
TTM history, and TTM symptom profile, as well as completion of
patient self-report scales.
The study was registered with ClinicalTrials.gov and IRB approval
was obtained at each study site before subject enrollment. All subjects
completed informed consent before study participation.
ASSESSMENT OF OUTCOMES
Our assessment battery consisted of clinician-administered semi-
structured interviews for psychiatric diagnosis (SCID-P, TDI-R,
KSADS-E), TTM history (PITS), and TTM symptom impairment
(NIMH-TIS). Global improvement ratings (CGI) were completed
both by study IAs and therapists. Self-report scales were utilized to
assess TTM severity (MGH-HPS), mood and anxiety symptoms
(BDI, BAI), and emotion regulation (DERS, ARR, NMR). Comple-
tion of all baseline study assessment measures required only 1.5–2 hrs
for most participants
Our battery of study instruments included the following:
Clinician-administered instruments
Structured clinical interview for DSM-IV axis I
disorders—patient edition (SCID-P). The SCID-P[27]
was used to assess comorbid psychiatric diagnoses and exclusionary
disorders.
Trichotillomania diagnostic interview—revised
(TDI-R). The TDI[28] is a clinician-based, semi-structured
interview modeled after the SCID and consisting of 3-point ratings
of responses assessing the DSM-III-R diagnostic criteria for TTM.
We revised the TDI to ensure conformity with DSM-IV criteria for
TTM and used it to establish TTM diagnosis.
ADHD Module of the schedule for affective disorders
and schizophrenia for school age children—epidemio-
logic version (KSADS-E). The ADHD module of the
KSADS-E[29] is a clinician-based structured interview used to
diagnose ADHD. For our study, all items were worded in both
the present and past tense. Adult ADHD was diagnosed if: (1) full
DSM-IV criteria were met by the age of 7, (2) a chronic symptom
course occurred from childhood to adulthood, and (3) a moderate or
severe level of impairment from ADHD symptoms is currently
endorsed (i.e. ADHD CGIZ4). The K-SADS was used to diagnose
adult and childhood history of ADHD.
Psychiatric institute trichotillomania scale (PITS). The
PITS[30] is a semi-structured assessment tool with a guided interview
format that provides data on TTM disorder onset, course, and pulling
sites.
Clinical global improvement scale (CGI). The
CGI[31] is a 7-point Likert scale frequently utilized to measure
improvement in clinical trials. Scores range from 1 (very much
improved) to 7 (very much worse). CGI ratings by the IAs were used
to determine treatment responder status.
NIMH trichotillomania impairment scale (NIMH-
TIS). The NIMH-TIS[32] is a clinican-rated scale with a possible
score from 0 (absent) to 10 (severe). Ratings are based on severity of
alopecia, time spent pulling or hiding damage, ability to control
pulling, interference, and incapacitation.
Depression and Anxiety
956 Keuthen et al.
Self-report instruments
Massachusetts general hospital hair pulling scale
(MGH-HPS). The MGH-HPS[33] is a self-report instrument
for the assessment of severity of hair pulling behavior, urges, and
distress.
Beck depression inventory II (BDI-II). The BDI-II[34]
is a 21-item self-report inventory that assesses the severity of
depression.
Beck anxiety inventory (BAI). The BAI[35] is a 21-item
self-report inventory designed to assess anxiety severity.
Difficulty in emotion regulation scale (DERS). The
DERS[36] is a 36-item self-report instrument based on a multi-
dimensional conceptualization of emotion regulation. It has six
subscales measuring awareness, clarity, and nonacceptance of emo-
tional responses, limited strategies for emotion regulation with
perceived efficacy, and difficulties with impulse control and goal-
directed behavior when experiencing negative emotions. Preliminary
data indicate high internal consistency, good test–retest reliability,
and adequate construct and predictive validity. Lower scores reflect
greater emotion regulation capacity.
Affective regulation rating (ARR). The ARR is a
5-point Likert scale designed for this study by the first author to
measure perceived ability to modulate TTM-related mood states.
Individuals are instructed to select the three moods most likely to
have triggered their TTM during the prior week and then rate their
ability to modulate those moods from 1 (‘‘not at all able’’) to 5
(‘‘completely able’’).
Generalized expectancy for negative mood regula-
tion scale (NMR). The NMR[37] is a 30-item self-report scale
used to assess expectations that specific behaviors or cognitions will
alleviate a negative mood state. Items are rated on a 5-point scale
ranging from 1 (‘‘strong disagreement’’) to 5 (‘‘strong agreement’’).
High internal consistency coefficients, discriminant validity from
social desirability, and temporal stability have been reported. Higher
scores reflect greater expectations for the capacity to regulate
emotions.
PROCEDURES
Study participation consisted of 11 weekly 50-minute acute treat-
ment sessions followed by 4 booster sessions during a maintenance
phase over the subsequent 3 months (at 2, 4, 8, and 12 weeks post-
treatment). The initial treatment session was scheduled within 1 week
of the baseline assessment. The study therapists at each site (NJK,
BOR) treated five subjects. All therapy sessions were videotaped for
peer supervision and treatment integrity ratings by the alternate site.
Site therapists administered a manualized treatment protocol
developed by several of the study authors (NJK, BOR, and SSW).
The treatment protocol included elements of both HRT and DBT
assessed to be relevant to the treatment of TTM. We included
mindfulness, emotion regulation, and distress tolerance DBT skills,
but not interpersonal effectiveness skills, as the latter were deemed
less relevant to TTM. All skills were tailored specifically to address
TTM. Mindfulness skills were employed to increase focused
attention to the moment for early detection of pulling behavior and
urges (that can occur out of awareness) as well as affective, sensory,
motor, and cognitive experiences likely to trigger pulling. Emotion
regulation was taught in a similar fashion to the original treatment,
with participants both reducing vulnerability to negative emotion as
well as learning skills they could use to regulate emotion without
pulling. Distress tolerance skills were tailored to the issues common
to TTM, such as tolerating urges or difficult experiences without
pulling. The acute treatment phase consisted of psychoeducation,
HRT and stimulus control procedures, DBT skills training, and
Depression and Anxiety
TABLE 1. Treatment outline by session
Session 1: Psychoeducation, motivational interviewing, chain
analysis, and self-monitoring
Session 2: Competing response, stimulus control procedures, and
prevention training
Sessions 3–5: Mindfulness training
Sessions 6–8: Emotion regulation training
Sessions 9–10: Distress tolerance training
Session 11: Relapse prevention training
Sessions 12–15: Maintenance sessions with emphasis on relapse
prevention and review of prior techniques
relapse prevention techniques. An emphasis on careful behavioral
assessment, often using behavioral ‘‘chain analyses,’’ was utilized
throughout the treatment and guided the emphasis on treatment
strategies. The session-by-session acute treatment protocol is
presented in Table 1.
DATA ANALYSES
Nonparametric statistics were utilized as inspection of study
variable distributions indicated that assumptions for the use of
parametric statistics were violated. The Wilcoxon signed ranks test
was used to compare scale scores for TTM severity, TTM
impairment, mood severity, and emotion regulation across three
study time points (baseline, posttreatment, 3-month maintenance).
Spearman’s rank correlation was used to assess relationships between
changes in both TTM severity and emotion regulation at the same
time points. Treatment responder status could be either ‘‘full’’
(CGIr2 and Z35% decrease in MGH-HPS total scores) or ‘‘partial’’
(CGIr2 or Z35% decrease in MGH-HPS total scores). Given the
pilot nature of this study, we did not control for the number of
statistical analyses performed.
RESULTS
ACUTE TREATMENT OUTCOMES
TTM severity. At posttreatment, eight partici-
pants were full responders (CGIr2 and Z35%
decrease in MGH-HPS total scores) and two partici-
pants were nonresponders. Responder status ratings
were identical using IA and therapist CGI scores. See
Table 2 for median scale scores for all measures at
baseline, posttreatment, and 3-month maintenance.
(Median scale scores are reported given use of
nonparametric statistics.) Total scale scores improved
significantly from pre- to posttreatment for the MGH-
HPS (Z 5 2.55, P 5.011, n 5 10).
TTM impairment. Total scale scores improved
significantly from pre- to posttreatment for the
NIMH-TIS (Z 5 2.02, P 5.043, n 5 5). (TIS scores
were not available for one study site.)
Mood severity. Significant pre- to posttreatment
improvement was reported for total BDI (Z 5 2.53,
P 5.011, n 5 10) and BAI (Z 5 2.54, P 5.011, n 5 10)
scores.
Emotion regulation. Significant pre- to posttreat-
ment improvement was reported for ARR (Z 5 2.81,
P 5.005, n 5 10), DERS (Z 5 2.71, P 5.007), and
NMR total scores (Z 5 2.31, P 5.021, n 5 10).
 Research Article: Pilot Trial of Dialectical Behavior
TABLE 2. Median total scale scores at baseline,
posttreatment, and 3-month maintenance
Instrument Baseline Posttreatment 3-Month maintenance
CGI N/A 2.00 1.00
MGH-HPS 18.50 7.00 5.50
NIMH-TIS 6.50 1.00 1.00
BDI 7.00 0.50 0.50
BAI 5.50 2.50 1.00
ARR 7.00 12.50 14.00
DERS 75.50 60.50 66.00
NMR 106.00 119.00 117.50
Regarding subscale scores, significant pre- to post-
treatment improvement was reported for DERS aware-
ness (Z 5 1.95, P 5.051), goals (Z 5 2.20, P 5.028),
strategies (Z 5 2.51, P 5.012), and clarity (Z 5 2.21,
P 5.027) subscale scores. Significant pre- to posttreat-
ment improvement was reported for the NMR general
(Z 5 2.25, P 5.024) and behavioral (Z 5 2.25,
P 5.024) subscale scores.
3-MONTH MAINTENANCE OUTCOMES
TTM symptom severity. At the end of the
3-month maintenance phase, eight participants were
full responders. The two participants who were
nonresponders at posttreatment converted to partial
responders. Responder status ratings were again iden-
tical using IA and therapist CGI scores. CGI ratings
from posttreatment to 3-month maintenance were
significantly improved (Z 5 2.53, P 5.011, n 5 10).
MGH-HPS total scores from pre-treatment to
3-month maintenance were significantly different
(Z 5 2.81, P 5.005, n 5 10). Total scale scores for
neither scale were significantly different from post-
treatment to 3-month maintenance (P4.05), indicating
maintenance of treatment gains.
TTM impairment. TIS total scale scores from
pre-treatment to 3-month maintenance were signifi-
cantly different (Z 5 2.03, P 5.042, n 5 10), but not
from posttreatment to 3-month maintenance.
Mood severity. BDI total scores from pre-
treatment to 3-month maintenance were significantly
different (Z 5 2.67, P 5.008, n 5 10) as were BAI total
scores (Z 5 2.53, P 5.012, n 5 10), but not from
posttreatment to 3-month maintenance.
Emotion regulation. Significant improvement
from pre-treatment to 3-month maintenance was
reported for ARR (Z 5 2.81, P 5.005, n 5 10), DERS
(Z 5 2.60, P 5.009, n 5 10), and NMR total scores
(Z 5 2.65, P 5.008, n 5 10). Significant improvement
from pre-treatment to 3-month maintenance was
reported for the DERS impulse (Z 5 2.68, P 5.007,
n 5 10), awareness (Z 5 1.96, P 5.049, n 5 10), non-
acceptance (Z 5 2.02, P 5.043, n 5 10), goals (Z 5 1.96,
P 5.050, n 5 10), and clarity (Z 5 2.26, P 5.024,
n 5 10) subscale scores. Significant improvement from
pretreatment to 3-month maintenance was reported for
957
the NMR general (Z 5 2.38, P 5.017, n 5 10) and
behavioral (Z 5 2.11, P 5.035, n 5 10) subscale
scores. Pretreatment to 3-month maintenance scores
for the NMR cognitive subscale approached signifi-
cance (Z 5 1.84, P 5.066, n 5 10).
DERS and NMR total and subscale scores did not
change significantly from posttreatment to 3-month
maintenance. Changes in ARR scale scores from
posttreatment to 3-month maintenance approached
significance (Z 5 1.89, P 5.059, n 5 10).
RELATIONSHIP BETWEEN TTM SEVERITY
AND EMOTION REGULATION
At baseline, MGH-HPS total scale scores were signi-
ficantly correlated with DERS goals subscale scores
(rS 5 .643, n 5 10, P 5.045, n 5 10) and approached
significance with DERS impulse subscale scores
(rS 5 .572, n 5 10, P 5.084, n 5 10). No other correla-
tions were significant between the MGH-HPS total
scale scores and the total and subscale scores of the
three emotion regulation measures.
Pre- to posttreatment changes in MGH-HPS total
scores were, however, significantly correlated with
changes in DERS (rS 5 .691, n 5 10, P 5.027, n 5 10)
and ARR (rS 5 .849, n 5 10, P 5.002, n 5 10) total
scale scores. Pre- to posttreatment changes in MGH-
HPS total scores were also significantly correlated with
changes in DERS impulse subscale scores (rS 5 .630,
n 5 10, P 5.051, n 5 10). The correlation between pre-
to posttreatment changes in MGH-HPS total scores
and the DERS goals subscale scores neared significance
(rS 5 .610, n 5 10, P 5.061, n 5 10).
Pretreatment to 3-month maintenance changes in
MGH-HPS total scores were significantly correlated
with changes in DERS total scores (rS 5 .667, n 5 10,
P 5.035, n 5 10) and ARR (rS 5 .689, n 5 10, P 5.027,
n 5 10) total scale scores. Pretreatment to 3-month
maintenance changes in MGH-HPS total scores were
also correlated with changes in DERS goals (rS 5 .820,
n 5 10, P 5.004, n 5 10) and impulse (rS 5 .654, n 5 10,
P 5.040, n 5 10) subscale scores. The correlation
between changes in the MGH-HPS total scores and
DERS awareness subscale scores approached significance
(rS 5 .603, n 5 10, P 5.065, n 5 10). None of the
correlations between hair pulling severity and emotion
regulation total or subscale scores between posttreatment
and 3-month maintenance were significant.
DISCUSSION
Our acute treatment results indicate that DBT-
enhanced CBT for TTM is effective in reducing hair
pulling severity and impairment when evaluated with
independent assessor, clinician, and self-report mea-
sures. Importantly, functioning at 3-month mainte-
nance was either not significantly different than at
posttreatment or showed improvement (both IA and
clinician CGI ratings showed improvement for two
Depression and Anxiety
958 Keuthen et al.
participants from posttreatment to 3-month mainte-
nance). CGI ratings were significantly improved
from posttreatment to 3-month maintenance. These
findings are noteworthy given that symptom relapse
posttreatment has historically been the norm in the
TTM treatment literature with the exception of
one study.[5]
Our data documented significant posttreatment
improvement in emotion regulation capacity, as well
as in the severity of anxiety and depressive symptoma-
tology, even though the median scale scores for the
latter were subclinical at baseline. Again, these gains
were preserved during the 3-month maintenance
period, indicating that emotion regulation skills in
TTM individuals are maintained for 3 months after
acute treatment with minimal clinician involvement.
As hypothesized, improvement in emotion regulation
capacity was correlated with reductions in hair pulling
severity with treatment. Although we are unable to
determine directionality of the relationship from our
data, this finding is consistent with our conceptualiza-
tion of hair pulling as a dysfunctional mechanism for
the reduction of uncomfortable affect. These findings
extend earlier results[21] documenting relationships
between pulling severity and both problematic emotion
regulation and identified affective triggers. Of note,
investigation of the relationship between pulling
severity and emotion regulation capacity at baseline
yielded minimal results. This is in contrast to our
report of a small-to-medium relationship between
difficulty with affective regulation and hair pulling
severity in our prior large sample Internet-based survey
of pullers referenced above. It is unclear why we
failed to document a relationship between emotion
regulation capacity and pulling severity at baseline in
this study.
Consistent with the work of Woods et al.[5] our
treatment outcome data underscore the need for
treatment techniques that address uncomfortable inter-
nal experiences that can co-occur with hair pulling
behavior. Our DBT-enhanced CBT protocol offers an
alternative treatment approach to ACT-enhanced CBT
that, arguably, may be more easily disseminated given
its focus on instruction in concrete skills for emotion
regulation and distress tolerance.
It is important to recognize the limitations inherent
in any study. As this was an open clinical trial, our IAs
were aware that study patients had received treatment
and, thus, were not blind. It is noteworthy that our
sample had lowered psychiatric comorbidity rates than
comparable clinic samples of TTM individuals. Next
steps would entail investigation of treatment efficacy in
pullers with greater comorbidity. It is possible that our
treatment would require modification to specifically
target the comorbid symptoms, in pullers with
co-occurring psychiatric illness. It is also possible that
in a pilot study of this nature, robust correlations as we
reported, as well as the lack of significant findings,
could be attributable to small sample sizes.
Depression and Anxiety
Although our preliminary results are promising, they
await future investigation with adequately powered,
double-blind, controlled studies comparing the efficacy
of our protocol with appropriate control conditions
(e.g. placebo, minimal attention, alternative psychoso-
cial treatment, and psychopharmacological interven-
tion). It is noteworthy that, to date, behavioral
treatments for TTM have yet to be rigorously
examined in comparison with credible control condi-
tions. Additionally, longer term follow-up of treatment
outcome is necessary to ascertain whether our acute
treatment gains endure past the 3-month maintenance
period and, accordingly, if modifications in our
treatment protocol for TTM are warranted.
Acknowledgments. We acknowledge the David
Judah Fund for its financial support of this research.
We also express our heartfelt thanks to all study
participants and to Christina Pearson, Jennifer Raikes,
and the Trichotillomania Learning Center staff who
assisted with study recruitment. We also wish to
recognize Susan Sprich Ph.D., for her helpful feedback
on our treatment manual.
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