Objective There are effective treatments of trichotillomania (TTM), but access to expert providers is limited. This study tested a stepped care model aimed at improving access. Method Participants were 60 (95% women, 75% Caucasian, 2% Hispanic) adults (M = 33.18 years) with TTM. They were randomly assigned to Immediate vs. Waitlist (WL) conditions for Step 1 (10 weeks of web-based self-help via StopPulling.com). After Step 1, participants chose whether to engage in Step 2 (8 sessions of in-person Habit Reversal Training). Results In Step 1 the Immediate condition had a small (d = .21) but significant advantage, relative to WL, in reducing TTM symptom ratings by interviewers (masked to experimental condition but not to assessment point); there were no differences in self-reported TTM symptoms, alopecia, functional impairment, or quality of life. Step 1 was more effective for those who used the site more often. Stepped care was highly acceptable: motivation did not decrease during Step 1; treatment satisfaction was high, and 76% enrolled in Step 2. More symptomatic patients self-selected into HRT, and on average they improved significantly. Over one-third (36%) made clinically significant improvement in self-reported TTM symptoms. Considering the entire stepped care program, participants significantly reduced symptoms, alopecia, and impairment, and increased quality of life. For quality of life and symptom severity, there was some relapse by 3-month follow-up. Conclusions Stepped care is acceptable, and HRT was associated with improvement. Further work is needed to determine which patients with TTM can benefit from self-help and how to reduce relapse.

Objective This study sought to identify predictors of relapse in a behavior therapy trial for trichotillomania (TTM), or hair-pulling disorder. Relapse is common after treatment for TTM, and only a few studies have examined what might predict relapse. Method Data was examined from a TTM treatment study with a stepped-care approach (step 1. web-based self-help; step 2. individual behavior therapy) (N = 60). Implications of significant predictive relations were illustrated by constructing Probability of Treatment Benefit (PTB) charts (Lindhiem, Kolko, & Cheng, 2012), which quantify the probability of maintaining gains according to predictors of maintenance. Results Abstinence at the conclusion of treatment and lower TTM severity during initial response significantly predicted maintenance. Abstinence periods prior to treatment, residual urges after achieving abstinence, pre-treatment TTM severity, intrinsic motivation, and treatment compliance did not predict maintenance. Conclusions Post-treatment abstinence and lower TTM severity during initial response predicted maintenance. Replications of this research are needed to determine the usefulness of these possible predictors in identifying relapse-prone patients, with the aim of improving clinical decision-making and developing strategies to help these patients better maintain gains. This is the first TTM study to use PTB charts, which can help clarify the meaning of prognostic analyses.

Different studies of the treatment of trichotillomania (TTM) use varying standards to determine the proportion of patients who obtain clinically meaningful benefits, but there is little information on the similarity of results yielded by these methods or on their comparative validity. Data from a stepped care (1. Web-based self-help; 2. Individual behavior therapy) (N = 60) treatment study of TTM were used to evaluate seven potential standards: complete abstinence, >=25% symptom reduction, recovery of normal functioning, and clinical significance (recovery + statistically reliable change), each of the last three being measured by self-report (Mass. General Hospital Hair Pulling Scale; MGH-HPS) or interview (Psychiatric Institute Trichotillomania Scale; PITS). Depending on the metric, response rates ranged from 25 to 68%. All standards were significantly associated with one another, though less strongly for the 25% symptom reduction metrics. Concurrent (with deciding to enter Step 2 treatment) and predictive (with 3-month follow-up treatment satisfaction, TTM-related impairment, quality of life, and diagnosis) validity results were variable but generally strongest for clinical significance as measured via self-report. Routine reporting of the proportion of patients who make clinically significant improvement on the MGH-HPS, supplemented by data on complete abstinence, would bolster the interpretability of TTM treatment outcome findings.

Numerous studies of trichotillomania (TTM) incorporate measures of the extent of alopecia (hair loss) resulting from hair pulling. This study used data from a clinical trial of stepped care for TTM to provide further evidence pertaining to a 1-7 alopecia rating scale (Tolin et al. 2002). Ratings were based on photographs of participants' (N=60) most severely affected pulling site. Alopecia rating proved highly acceptable (88 % completed the assessment), stable (10-week retest reliability r for wait-listed participants=0.63), and convergently valid (r=0.51 with an interviewer's rating of hair loss based on live observation). Alopecia ratings were not significantly related to self-rated social impairment resulting from TTM, nor with total symptom severity. Hair regrowth rate varies by sex, age, and pulling site, so alopecia rating cannot serve as a direct marker of TTM treatment progress. Nonetheless, it appears to be a reliable and valid measure of a consequence of pulling that is of great concern to people with TTM. Future research should examine its potential treatment utility as a means of giving patients feedback on the side effects of progress they are making in therapy.

Future studies should focus on the investigation of factors that may enable or hinder racial and ethnic minority participants to benefit from online and/or self-help behavior therapy for TTM.