Psychotherapy
It is believed that the most effective form of TTM treatment is psychotherapy, usually behavioral therapy (BT) (Table
1). This form of treatment is the most commonly used and also the best-known method of TTM treatment. In a randomized study comparing BT and cognitive therapy (CT), 48 patients with TTM diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV and being older than 15 years completed treatment consisting of six therapeutic sessions of CT (
n = 26) or BT (
n = 22) [
18]. Each participant was informed about methods of monitoring the progress of treatment, and patients were also aware that CT had not been used before in treatment of TTM. Patients were followed for the 3-month treatment-free period. Additional follow-up measurements took place after 12 and 24 months. The effect of both treatment regimens was comparable. Both CT and BT resulted in reduction of TTM symptoms (severity, urge, inability to resist, and negative beliefs) immediately after treatment. Patients in both treatment conditions showed a relapse in TTM symptoms at 3 months follow-up, but the effect sizes for CT after the 3-month treatment-free period were larger than those found for BT in four of five outcome measurements. Nevertheless, at 12 and 24 months follow-ups, the severity of TTM symptoms was very similar in both groups [
18].
Recent studies indicate that cognitive behavioral therapy is the most empirically validated treatment for TTM. The effectiveness of behavioral and cognitive therapy has been described in a study on 22 children (mean age 12.6 ± 3.0 years) with primary diagnosis of TTM and with symptoms persisting for more than 6 months. Participants were given eight therapeutic sessions. As many as 77.3% of patients responded positively to treatment, and 63.6% maintained improvement 6 months after end of therapy [
19]. Behavioral and cognitive therapy was also tested in Falkenstein et al.’s study [
20]. A total of 16 patients aged between 17 and 59 years underwent a 12-week therapy led by trained specialists. Measurements using different scales (Massachusetts General Hospital Hairpulling Scale—MGH-HPS, Psychiatric Institute Trichotillomania Scale—PITS) clearly indicated a significant positive therapeutic effect. Despite good results, the study was conducted on a small group, which reduces their credibility [
20].
Another study included 60 adults with a significant predominance of women (
n = 57) [
21]. In the first stage of this study, all participants started therapy by using the dedicated program’s website. For 10 weeks, patients learned self-monitoring of behavior, emotions, and rituals associated with the desire to pull their hair. On this basis, a list of behaviors was established, which patients used to combat hair loss. After 10 weeks, significant improvement was seen in eight patients, four of whom reported complete recovery of normal functioning. It is worth emphasizing that these people used the internet more often than the rest of the participants. At the end of the first step, all participants in the project were asked to join the next part of the study, in which 8 weeks of habit-reversal training (HRT) was given. HRT is a type of BT based on awareness training (self-monitoring), stimulus control, and competing response practice (practicing a motor response). In total, 76% of the patients were treated in step 2; 50% of patients improved reliably during step 2 on MGH-HPS, and 46% recovered normal functioning [
21].
According to Azrin’s study [
22], a single session of HRT (
n = 18) reduced self-reported hair pulling behavior by 99%, compared with a reduction of 58% following 1 day of self-directed negative practice (
n = 15). Another study evaluated the effectiveness of HRT in comparison with usual treatment which was given to patients prior to an intervention by their healthcare providers. All participants (
n = 40, 85 % females) meeting diagnostic criteria for TTM were randomized to either 8 weekly sessions of HRT by trained therapists or to 8 weeks of treatment “as usual.” Patients evaluated therapy effectiveness directly after treatment, and 1 and 3 months later. All assessments were conducted by a trained rater who was blinded to treatment conditions. The results showed that 16/21 participants (76%) were rated as treatment responders in the HRT group versus 4/19 (21%) in the usual treatment group (
p < 0.001) [
23]. In addition, Shareh compared the effectiveness of metacognitive methods combined with HRT (MCT/HRT) in TTM versus waiting list (i.e., no treatment) and documented significant and durable improvement in the treatment group and no improvement in the waiting list [
24].
It is believed that TTM is related to higher risk of co-occurring depression and anxiety disorders. In a large study in 2017, 530 adults with TTM were examined using a variety of clinical measures (including symptom severity, psychosocial measures of functioning, and psychiatric comorbidity) [
25]. Among all participants, 58 (10.9%) had major depressive disorders (MDD), 97 (18.3%) an anxiety disorder, and 58 (10.9%) both MDD and an anxiety disorder. Patients with MDD and patients with anxiety and MDD reported the worst level of symptom severity regarding all clinical measures. These results suggest that adults with TTM and co-occurring MDD and anxiety disorders exhibit unique clinical features, which may also have treatment implications [
25].