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Trichotillomania, also known as Hair-Pulling Disorder, is characterized by recurrent pulling out of one's hair over brief episodes or sustained periods of time and results in hair loss. ACT-enhanced behavior therapy (A-EBT) has been shown to be an effective approach in the treatment of trichotillomania by promoting psychological flexibility around hair pulling urges and teaching stimulus control and habit reversal training. However, there is limited support of A-EBT for clients with an ethnic minority identity. This case report focuses on an adult, Hispanic female client, Luna (pseudonym), who received eight sessions of A-EBT for the treatment of trichotillomania. At post-treatment, Luna showed significant improvements in number of hairs pulled, trichotillomania specific psychological flexibility, depression and anxiety. Luna's case highlights barriers to care such as potential resistance in seeking mental health services, the influence of family members' beliefs on receiving mental health services, and the limited access to specialized treatment of trichotillomania. [ABSTRACT FROM AUTHOR]

Background: Body-focused repetitive behaviors (BFRBs) are common but under-recognized mental disorders. The present study aimed to examine the efficacy of a video presentation of self-help techniques for BFRBs compared to a web-based intervention containing psychoeducation and comprehensive self-help treatment information on BFRBs to reduce symptomatology as well as the same videos as in the first condition. Methods: A total of 217 participants with BFRBs were randomly assigned to (1) a video condition conveying the established self-help techniques habit reversal training (HRT), decoupling (DC), and decoupling in sensu (DC-is) to reduce BFRBs, (2) a website condition that offered psychoeducational information and treatment material, including the videos from the first treatment condition, or (3) a waitlist control (WLC) condition. A six-week post assessment was conducted. The Generic Body-Focused Repetitive Behavior Scale 45 (GBS-45) served as the primary outcome. Results: The self-help video condition showed greater improvement in GBS-45 subscales for nail biting in comparison to the self-help website and WLC conditions. For other BFRBs (e.g., joint cracking, trichophagia), the impairment subscale showed significant results in post hoc analyses in favor of the two treatment conditions. Subjective ratings of the techniques were satisfactory and comparable across treatment groups, with slightly higher ratings in favor of the video condition. Conclusions: The video condition showed better improvement than the control condition on nail biting and other BFRBs. Superior results in the self-help website condition compared to the WLC were shown only for the group of "other" BFRBs (i.e., not trichotillomania, nail biting, dermatillomania, lip/cheek biting). We speculate this might be because users were overwhelmed by the many different approaches described without clear guidelines for how to implement them in daily life. In light of a prior study, we assume that a manualized version of the self-help techniques is superior to the video delivery and recommend that the self-help videos should be used as a complement to a manualized version. Future research should address long-term effects of self-help interventions for BFRBs. [ABSTRACT FROM AUTHOR]

Background: Self-help habit reversal training and decoupling are effective in improving body-focused repetitive behaviors (BFRBs). However, most studies to date on self-help techniques have assessed short-term effects only. The present study aimed to elucidate whether treatment effects would be sustained over a longer period of time. Methods: We conducted a 2-year follow-up study of a cohort of 391 participants with mixed BFRBs who were initially randomized to four conditions (wait list control, habit reversal training, decoupling, decoupling in sensu). At post assessment, participants were allowed to use other treatment techniques, enabling us to explore treatment effects in those who continued to use the initial method only versus those who used additional techniques. The Generic Body-Focused Repetitive Behavior Scale (GBS-36) served as the primary outcome. Results: Improvements achieved at post assessment were maintained at follow-up for all experimental conditions, with decoupling showing significantly greater treatment gains at follow-up relative to the wait list control group (last observation carried forward: p =.004, complete cases: p =.015). Depression at follow-up slightly improved compared to baseline and post assessment similarly across all conditions, arguing against "symptom displacement" to other psychopathological syndromes. Retention rates were similarly low across the four conditions (48.5–54.6%), making bias unlikely (but not firmly excluding it). Participants who adhered to the initial protocol until follow-up showed a pattern of improvement similar to those using additional techniques. Discussion: Our study speaks for the long-term effectiveness of behavioral self-help techniques to reduce BFRBs, particularly decoupling. Of note, participants were allowed to use other self-help manuals after completing the post assessment; thus, randomization was removed. However, a minority of the participants chose this option. [ABSTRACT FROM AUTHOR]

Background: Little research has examined telehealth delivery of habit reversal training (HRT) for body focused repetitive behaviors (BFRBs; i.e., trichotillomania and excoriation disorder) and no known studies have directly compared these two modalities relative to one another. The present study examines providers and their perceptions of in-person and telehealth delivery of HRT for BFRBs. Methods: HRT providers (n = 172) completed an online survey assessing experiences with in-person and telehealth HRT. Feasibility ratings were recorded for telehealth relative to in-person delivery of HRT for different patient ages, and BFRB symptom severity. Additionally, perceived ability to identify and address factors that may interfere with delivery of HRT, individual differences that may interfere with HRT, and overall ability to implement different aspects of HRT over both mediums were also recorded. Results: Providers reported high feasibility for both in-person and telehealth HRT. Providers also reported greater ability to identify and address factors that can adversely impact HRT, and better ability to address patient individual differences that may influence treatment in an in-person environment relative to telehealth. Greater feasibility was reported for telehealth relative to in-person for ages greater than 13 years and lower feasibility for less than 13 years relative to the mean of all other groups, and greater feasibility for telehealth HRT for less severe BFRB presentations. Conclusion: Findings suggest that providers perceive delivery of the various components of HRT are feasible in-person and via telehealth; however, various factors may differentially impact these perceptions and create contexts in which one modality is perceived to be more feasible. [ABSTRACT FROM AUTHOR]

• Negative effects of self-help interventions are largely ignored. • We developed a novel questionnaire to tap adverse events on online interventions. • Malpractice was most frequently reported. • Format and usage frequency predicted the occurrence of negative effects. Despite the proven effectiveness of psychotherapy for psychiatric disorders, adverse events or unwanted effects may occur. Unwanted effects, however, are rarely assessed. In self-help interventions, which usually are not supported by a therapist, such effects have received even less attention even though special caution is needed regarding unwanted effects such as those related to misapplication. For the present study, we present the newly developed Positive and Negative Effects of Psychotherapy Scale for Internet-Based Intervention (PANEPS-I) and examine possible unwanted effects of an internet-based self-help intervention in individuals with body-focused repetitive behaviors (BFRBs), aggregating three different techniques: habit reversal training (HRT), decoupling (DC), and decoupling in sensu (DC-is). Some HRT users have expressed concern that the suppression of the problematic behavior could lead to rebound effects, but this has not been examined rigorously. Following baseline assessment, 141 participants with at least one BFRB were randomly assigned to two intervention groups that differed only with respect to the delivery mode (video, manual); the content was the same. After 6 weeks, a post-assessment was conducted. Unwanted effects were assessed using the PANEPS-I. A total of 70% of the participants (both treatment groups combined) reported at least one positive effect of the intervention. Negative effects were reported by 14–92% of participants, depending on the effect. The highest agreement rates were found for "no positive goal orientation" (52.5%), "did not address personal problems" (48.8%), "time/performance pressure" (20.9%), shame (16.3%), and concerns about data privacy (14.3%). Participants in the manual intervention group reported unethical procedures (e.g., data privacy concerns) more often (Cohen's d =.44) than those in the video intervention group. Responders reported more positive effects and nonresponders more malpractice (| d | =.80,.54, respectively). HRT users (self-report) showed no significant differences compared to nonusers regarding negative effects. Stepwise hierarchical regression analyses indicated a dose-response relationship for reported positive effects and malpractice. Side effects may occur in any kind of intervention. Usage of HRT did not lead to more reported negative effects compared to nonusage. To improve the quality and effectiveness and ensure the safety of the user, especially those using digital self-help interventions, it is important to regularly assess unintended effects since there is no supervision of the patient in unguided self-help interventions. [ABSTRACT FROM AUTHOR]

Background: Behavioral interventions hold promise in improving body-focused repetitive behaviors (BFRBs), such as hair pulling and skin picking. The effect of combining different treatment techniques is currently unknown. Methods: In the framework of a randomized controlled crossover trial, 334 individuals with at least one BFRB were allocated either to a waitlist control or to three experimental conditions (1:1:1:1). Participants in the experimental condition received self-help manuals teaching habit reversal training (HRT), decoupling (DC) and decoupling in sensu (DC-is) during a six-week period. Treatment conditions differed only in the order of manual presentation. We examined whether applying more than one technique would lead either to add-on or interference effects. Results: The three treatment conditions were significantly superior to the waitlist control group in the improvement of BFRBs according to intention-to-treat analyses at a medium effect size (all p ≤ 0.002, d = 0.52 – 0.54). The condition displaying DC first significantly reduced depressive symptoms (p = 0.003, d = 0.47) and improved quality of life (p = 0.011, d = 0.39) compared to the waitlist control. Those using more techniques concurrently showed the strongest decline in BFRB symptoms, even after controlling for days practiced. Participants rated all manuals favorably, with standard DC and HRT yielding greatest acceptability. Discussion: Results tentatively suggest the concurrent application of different behavioral treatments for BFRBs leads to add-on effects. Results were superior when DC was practiced first, with positive effects extending to depressive symptoms and quality of life. Integrating the three techniques into one self-help manual or video along with other treatment procedures (e.g., stimulus control techniques) is recommended. [ABSTRACT FROM AUTHOR]

This study piloted the use of ACT-informed exposure as an adjunct to habit reversal training (HRT) for excoriation disorder (ExD). Using a nonconcurrent multiple baseline single case design, four participants completed sessions of exposure and HRT. Repeated measures and self-report data were collected on skin picking and psychological flexibility. Two participants completed HRT followed by exposure, and two participants completed exposure followed by HRT. Results support the effectiveness of HRT in reducing picking. Results suggest exposure may have some impact in reducing picking, but effects were weaker compared to HRT. Contrary to predictions, repeated measures and self-report data did not indicate consistent improvement in psychological flexibility during exposure phases. As any reduction in picking may be clinically meaningful and all participants maintained gains at follow-up, there is some indication that exposure may be a second-line treatment worth further study. Limitations and future areas of research are discussed. [ABSTRACT FROM AUTHOR]

Compulsive joint cracking is a body-focused repetitive behavior (BFRB), which often results in negative social feedback due to its characteristic sound. While behavioral techniques are recommended in BFRBs, no published studies or case reports exist specifically for compulsive joint cracking. The authors report the case of DZ, who engaged in severe joint cracking of his knuckles and, at times, his back. The individual was assessed with an adapted version of the Generic BFRB Scale (GBS). DZ was instructed on how to perform decoupling, a technique that has shown efficacy in other BFRBs. He was also advised to use "fidget devices" that mimic aspects of the dysfunctional behavior in a less conspicuous way. Scores on the GBS were reduced by almost 50%, which corresponded with DZ's subjective appraisal of feeling more in control. Randomized controlled trials are needed to assess the (differential) efficacy these techniques to ameliorate compulsive joint cracking. [ABSTRACT FROM AUTHOR]

The Habit Reversal Training (HRT) is a behavioral procedure for treating the so-called nervous habits, such as nail biting, hair pulling and thumb sucking. In addition to being an established clinical procedure, HRT is also a strategy for behavioral change that can serve the entire community. For this reason, this review aims to explore the studies proposing the use of HRT for the reduction of hand-to-face habits in the context of COVID-19 pandemic. Touching one's nose, mouth and eyes, indeed, is one of the means of virus transmission that many awareness campaigns seek to highlight. After an overview of how HRT works and of the current epidemiological situation, studies supporting Habit Reversal Training for the reduction of risky hand-to-face habits are presented. The possible strategies are then exposed and critically discussed to identify their limitations and propose a new version according to the Relational Frame Theory. [ABSTRACT FROM AUTHOR]

Body-focused repetitive behaviors (BFRBs) include skin picking, trichotillomania, nail biting and cavitadaxia/lip-cheek biting, among other behaviors. For the first time, we compared three different self-help techniques aimed at reducing BFRBs. We explored the acceptance and preliminary efficacy of the approaches and whether the techniques exerted differential effects depending on BFRB-type. A total of 113 participants with at least one BFRB were randomly allocated to either habit reversal training (HRT; active elements: awareness and competing response training), decoupling (DC) or decoupling in sensu (DC-is). Reassessment was conducted 4 weeks later. The Generic Body-Focused Repetitive Behavior Scale (GBS) served as the primary outcome. The completion rate was best for DC-is (68.6%) as compared to HRT (57.1%) and DC (53.5%). A total of 34.8% of completers in the DC group showed an improvement of at least 35% on the GBS compared to 10.0% in the HRT and 23.3% in the DC-is group. In accordance with previous work, moderator analyses showed that improvement under DC is best for non-skin-pickers. A dose-effect relationship emerged, particularly for HRT. Subjective appraisal ratings were more favorable for DC-is and HRT than for DC. With respect to completion rate, subjective appraisal and symptom improvement, DC-is yielded consistently satisfactory results, whereas HRT showed good subjective but rather poor objective improvement. Those who performed DC, especially non-skin-pickers, showed good improvement but overall completion and subjective efficacy were low. Future studies should investigate whether the three techniques exert add-on effects when combined and whether demonstration via new media (e.g., video) will augment comprehensibility and thus efficacy of the techniques. [ABSTRACT FROM AUTHOR]

Part II of the European clinical guidelines for Tourette syndrome and other tic disorders (ECAP journal, 2011) provides updated information and recommendations for psychological interventions for individuals with tic disorders, created by a working group of the European Society for the Study of Tourette Syndrome (ESSTS). A systematic literature search was conducted to obtain original studies of psychological interventions for tic disorders, published since the initial European clinical guidelines were issued. Relevant studies were identified using computerized searches of the MEDLINE and PsycINFO databases for the years 2011–2019 and a manual search for the years 2019–2021. Based on clinical consensus, psychoeducation is recommended as an initial intervention regardless of symptom severity. According to a systematic literature search, most evidence was found for Habit Reversal Training (HRT), primarily the expanded package Comprehensive Behavioral Intervention for Tics (CBIT). Evidence was also found for Exposure and Response Prevention (ERP), but to a lesser degree of certainty than HRT/CBIT due to fewer studies. Currently, cognitive interventions and third-wave interventions are not recommended as stand-alone treatments for tic disorders. Several novel treatment delivery formats are currently being evaluated, of which videoconference delivery of HRT/CBIT has the most evidence to date. To summarize, when psychoeducation alone is insufficient, both HRT/CBIT and ERP are recommended as first-line interventions for tic disorders. As part of the development of the clinical guidelines, a survey is reported from ESSTS members and other tic disorder experts on preference, use and availability of psychological interventions for tic disorders. [ABSTRACT FROM AUTHOR]

It is unclear if the results of randomised controlled trials (RCTs) of behaviour therapy (BT) for Tourette syndrome (TS) and chronic tic disorder (CTD) can be generalised to naturalistic clinical settings and are durable long-term. In this naturalistic study, 74 young people with TS/CTD received BT at a specialist clinic. Data were collected at baseline, post-treatment, and at 3-, 6-, and 12-month follow-ups. Measures included the Yale Global Tic Severity Scale (YGTSS) and the Clinical Global Impression-Improvement scale (CGI-I), amongst others. Tic severity and tic-related impairment improved after treatment, with large within-group effect sizes. At post-treatment, 57% of the participants were classified as treatment responders according to the CGI-I. Tic severity and tic-related impairment improved further through the follow-up, with 75% treatment responders at the 12-month follow-up. BT is an effective and durable treatment for young people with TS/CTD in a naturalistic specialist clinical setting, with comparable effects to RCTs. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the feasibility and efficacy of ACT‐enhanced Group Behavior Therapy (AEGBT) for mixed diagnosis groups including patients with trichotillomania (TTM) and skin‐picking disorder (SPD) in routine psychiatric care. Method: Adult patients (N = 40) with TTM and/or SPD received 10 weeks of AEGBT followed by five booster sessions. The primary outcome measure for TTM was the Massachusetts General Hospital Hairpulling Scale (MGH‐HPS) and for SPD the Skin Picking Scale‐Revised (SPS‐R), assessed at posttreatment and at booster sessions. Results: Results showed significant reductions in hair pulling and skin‐picking severity from baseline to posttreatment and large effect sizes at posttreatment. Improvements remained significant at the 12‐month follow‐up for patients with SPD, but not for patients with TTM. Group attendance was high and few patients dropped out from treatment. The group format enabled therapists to see 25% more patients compared with an individual format. Conclusion: The results provide initial support for the feasibility and efficacy of an adapted treatment approach for TTM and SPD. [ABSTRACT FROM AUTHOR]

• Six-month outcomes from an RCT of acceptance-enhanced behavior therapy (AEBT) for TTM. • AEBT was compared to psychoeducation and supportive therapy (PST). • AEBT treatment gains were maintained from post-treatment to six-month follow-up. • At follow-up, symptom severity did not differ between AEBT and PST. • Higher TTM severity at baseline predicted higher TTM severity at follow-up for PST Acceptance-enhanced behavior therapy for trichotillomania (AEBT-TTM) is effective in reducing trichotillomania (TTM) symptoms, but the durability of treatment effects remains in question. This study analyzed 6-month follow-up data from a large randomized clinical trial comparing AEBT-TTM to an active psychoeducation and supportive therapy control (PST). Adults with TTM (N =85; 92% women) received 10 sessions of AEBT-TTM or PST across 12 weeks. Independent evaluators assessed participants at baseline, post-treatment, and 6 months follow-up. For both AEBT-TTM and PST, self-reported and evaluator-rated TTM symptom severity decreased from baseline to follow-up. TTM symptoms did not worsen from post-treatment to follow-up. At follow-up, AEBT-TTM and PST did not differ in rates of treatment response, TTM diagnosis, or symptom severity. High baseline TTM symptom severity was a stronger predictor of high follow-up severity for PST than for AEBT-TTM, suggesting AEBT-TTM may be a better option for more severe TTM. Results support the efficacy of AEBT-TTM and show that treatment gains were maintained over time. Although AEBT-TTM yielded lower symptoms at post-treatment, 6-month follow-up outcomes suggest AEBT-TTM and PST may lead to similar symptom levels in the longer term. Future research should examine mechanisms that contribute to long-term gain maintenance. [ABSTRACT FROM AUTHOR]

This report investigated the improvement in Automatic and Focused styles of hair pulling among youth with trichotillomania (TTM). Youth with TTM (N = 40) participated in a clinical trial that compared habit reversal training (HRT) to treatment-as-usual (TAU). Participants completed a baseline assessment to characterize hair pulling severity, self-reported hair pulling styles, and co-occurring psychiatric conditions. Youth were randomly assigned to receive eight weekly sessions of HRT or eight weeks of TAU. Afterward, youth completed a post-treatment assessment of hair pulling severity and hair pulling styles. Youth in the TAU condition then received eight weekly sessions of HRT and completed another post-treatment assessment. Analyses revealed that the Focused pulling style largely improved with HRT (d = 0.73) compared to TAU (d = 0.11). However, there was limited improvement for the Automatic pulling style following either HRT (d = 0.10) or TAU (d = -0.31). This same pattern of effects was also found during open-label treatment with HRT. Although behavior therapies such as HRT are the principle treatment for youth with TTM, the Automatic pulling style exhibited limited improvement to this therapeutic approach. Therefore, therapeutic strategies that enhance awareness to pulling behaviors may produce more robust outcomes to behavior therapy for youth with TTM. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the effectiveness of a modified four‐session Comprehensive Behavioral Intervention for Tics programme for decreasing tics in children and adolescents with Tourette's syndrome. Background: Comprehensive Behavioral Intervention for Tics programme has been shown to decrease tic severity. However, the lack of behaviour therapists in countries, such as in Taiwan, may preclude application of the standard eight‐session, 10‐week programme. Design: Randomized controlled study. Methods: Participants aged 6–18 years diagnosed with Tourette's syndrome or chronic tic disorder were recruited from February 2015 through September 2016. Participants in the control and intervention groups (N = 23 each) received the routine care (daily pyridoxine [50 mg] and psychoeducation). The intervention group received additional four behavioural intervention sessions over a 3‐month period that included psychoeducation, habit reversal training, relaxation training, and education on tic relapse prevention. The outcome measures, Yale Global Tic Severity Scale scores, were assessed at before and after the completion of programme for both groups and again at 3 months follow‐up for the intervention group. The effect of the intervention on severity scores was assessed using a generalized estimated equation. Results: Comparison of scores before and after intervention showed that the intervention significantly decreased the severity of total motor tics (B = −3.28, p <.01) and total tics (B = −5.86, p <.01) as compared with control treatment. YGTSS scores for the intervention group were lower at 3‐month follow‐up as compared with before treatment or immediately after treatment completion (total tics, p <.001). Conclusion: The modified four‐session Comprehensive Behavioral Intervention for Tics programme was more effective than routine care for decreasing tic severity in our cohort of 6‐ to 18‐year olds. This improvement was maintained 3 months after intervention. Impact: Healthcare providers, including nurses, in countries currently not adopting Comprehensive Behavioral Intervention for Tics programme should be made aware of the positive effects of this modified intervention for Tourette's syndrome. [ABSTRACT FROM AUTHOR]

The aim of this study is to evaluate a cognitive-behavioral treatment for children and adolescents with tic disorder including habit reversal training (HRT) in a sample of children and adolescents (n = 27). Multiple outcome measures were used to assess the effects of the treatment on tic symptoms. In addition, impairment/subjective burden ratings and the self-efficacy to control tics were assessed. A within-subject design with two phases (8 weeks diagnostic; 16 sessions treatment) was analyzed using multilevel modeling (MLM). During the treatment phase, significant improvements in tic symptoms, impairment, and self-efficacy to control tics were found on most outcome measures. Treatment effects were found on the clinical rating of tic symptoms (Yale Global Tic Severity Scale [YGTSS]), the self-efficacy to control tics, and the video-observed motor tic frequency by comparing the improvements during treatment with the course of the outcome measures during the preceding diagnostic phase. [ABSTRACT FROM AUTHOR]

Chronic tic disorders may have a huge influence on quality of life. Habit reversal training (HRT) and exposure response prevention (ERP) are effective treatments. In a blinded assessed, open trial, this study evaluates the effectiveness of a newly developed Scandinavian tic treating manual designed to treat adolescents with a chronic tic disorder, combining HRT and ERP. The study compared the efficacy of treatment based on the same manual delivered either individually or in groups. The study was an open randomized controlled clinical trial in which adolescents were randomized to either individual or group therapy. Both therapies included nine sessions. The parents were offered group-based psycho-education. The exclusion criteria were chosen to design a study that would be close to clinical practice. This is the first Scandinavian study that examines the effectiveness of a treatment manual combining HRT and ERP delivered in an individual and group setting. The study showed a significant reduction of the Total Tic score on the Yale Global Tic Severity Scale both in the individual (effect size 1.21) and group setting (effect size 1.38). A total of 66.7% of participants were considered responders. There was no statistical significant difference between the individual and group setting apart from the functional impairment score. The reductions were comparable with those shown in other studies. The participants applied both HRT and ERP, and the majority (36/59) reported an increased post-treatment experience of control. The newly designed Scandinavian manual was equally effective in the individual and group setting with effect sizes comparable with those shown in other studies. [ABSTRACT FROM AUTHOR]

This randomized controlled trial examined the long-term effects of group-based psychological interventions on measures of tic severity, self-reported quality of life (QOL), and school attendance. Children (n = 28) with Tourette syndrome (TS) were assessed 12 months after completing a course of either group-based Habit Reversal Training (HRT) or Education. Both groups demonstrated long-term improvement in tic severity and QOL, which included significant continued improvement during the follow-up (FU) period. Both groups also showed significant posttreatment improvement in school attendance. Further research is required to explore potential therapeutic mechanisms, independent or mutual, which may underlie long-term symptom improvements. [ABSTRACT FROM AUTHOR]

Trichotillomania is characterized by recurrent pulling out of one's hair, leading to significant hair loss and accompanied by clinically significant distress and/or functional impairment. The current study used data from a randomized controlled trial comparing the effectiveness of acceptance-enhanced behavior therapy (AEBT) to psychoeducation plus supportive therapy (PST; active control) for trichotillomania in an adult sample. The objectives were to examine the moderating and mediating influence of trichotillomania-specific psychological flexibility in treatment for trichotillomania. Participants with lower baseline flexibility performed better in AEBT than PST in terms of greater symptom reduction and quality of life. Lower baseline flexibility also predicted higher likelihood of disorder recovery in AEBT relative to PST. In addition, relative to PST, symptom reduction in AEBT was mediated by psychological flexibility, controlling for anxiety and depression. These findings suggest that psychological flexibility is a relevant process of change in the treatment of trichotillomania. Clinical implications and directions for future research are discussed. • Examined moderating and mediating role of psychological flexibility in AEBT for TTM. • Lower baseline flexibility predicted better outcomes in AEBT relative to control. • Psychological flexibility mediated symptom reduction in AEBT relative to control. [ABSTRACT FROM AUTHOR]

Objectives: This study evaluated the treatment efficacy of habit reversal training (HRT) relative to treatment as usual (TAU) for children and adolescents aged 7-17 years with a primary diagnosis of trichotillomania (TTM).Method: An initial assessment consisting of semistructured interviews and rating scales was conducted. Participants (N = 40, 85% female) meeting diagnostic criteria for TTM were randomized to either 8 weekly sessions of HRT by trained therapists or 8 weeks of TAU. One week after the final HRT session or final TAU week, patients completed a posttreatment assessment, followed by 1- and 3-month follow-up assessments. All assessments were conducted by a trained rater who was blinded to treatment condition.Results: The group by time analysis of variance yielded a significant interaction on the National Institute of Mental Health-Trichotillomania Severity Scale Total Score (F1,38 = 16.47, p < 0.001, η2p = 0.30). The mean score decreased from 12.67 ± 4.60 at baseline to 5.62 ± 4.38 at posttreatment in the HRT group (t20 = 5.99, p < 0.001, d = 1.31), whereas the TAU group changed from 10.42 ± 4.35 to 9.32 ± 4.11 (t18 = 1.34, p = 0.20, d = 0.31). The Massachusetts General Hospital-Hair Pulling Scale Total Score decreased from 15.14 ± 3.86 at baseline to 7.14 ± 5.54 at posttreatment in the HRT group (t20 = 6.16, p < 0.001, d = 1.34); the TAU group changed from 14.16 ± 4.51 to 12.26 ± 4.34 (t18 = 1.50, p = 0.15, d = 0.34). On the Clinical Global Impressions-Improvement, 16/21 participants (76%) were rated as treatment responders in the HRT group versus 4/19 (21%) in the TAU group (χ2 = 12.13, p < 0.001, V = 0.55). At 1-month follow-up, 10-12 treatment responders who completed the assessment maintained improvement. At 3-month follow-up, six of eight maintained improvement.Conclusions: HRT can be an effective treatment for TTM in youth. [ABSTRACT FROM AUTHOR]

Background Primary tic disorders, notably Tourette syndrome, are very common movement disorders in childhood. However, the management of such patients still poses great therapeutic challenges to medical professionals. Methods Based on a synthesis of the available guidelines published in Europe, Canada, and the United States, coupled with more recent therapeutic developments, the authors provide a pragmatic guide to aid clinicians in deciding when and how to treat patients who have primary tic disorders. Results After a systematic assessment of tics and common neuropsychiatric comorbidities (primarily attention-deficit hyperactivity disorder [ ADHD] and obsessive-compulsive disorder [ OCD]), the first step in treatment is a comprehensive psychoeducation of patients and families that addresses the protean phenomenology of tics and associated behaviors, coping mechanisms, prognosis, and treatment options. When more active intervention beyond watchful monitoring is indicated, hierarchical evaluation of treatment targets (i.e., tics vs. comorbid behavioral symptoms) is crucial. Behavioral treatments for tics are restricted to older children and are not readily available to all centers, mainly due to the paucity of well-trained therapists. Pharmacological treatments, such as antipsychotics for tics, stimulants and atomoxetine for ADHD, and α2A-agonists for children with tics plus ADHD, represent widely available and effective treatment options, but safety monitoring must be provided. Combined polypharmacological and behavioral/pharmacological approaches, as well as neuromodulation strategies, remain under-investigated in this population of patients. Conclusions The treatment of children with tics and Tourette syndrome is multifaceted. Multidisciplinary teams with expertise in neurology, psychiatry, psychology, and pediatrics may be helpful to address the complex needs of these children. [ABSTRACT FROM AUTHOR]

Persistent tic disorders and Tourette disorder (TD) are neuropsychiatric conditions that commonly co-occur among youth with obsessive-compulsive disorder. Although historically managed with pharmacological agents such as antipsychotics and alpha-2 agonists, behavioral interventions like habit reversal training (HRT) and the comprehensive behavioral intervention for tics have demonstrated considerable efficacy in reducing tic symptom severity. This case study illustrates the implementation of behavior therapy in reducing tic symptom severity of an adolescent with TD. Arlene was a 14-year-old girl with TD who presented with moderate tic symptom severity that caused her physical, academic, and social impairment. In addition to concurrent pharmacotherapy, Arlene completed a 20-session weekly course of HRT, and experienced a clinically meaningful reduction in tic symptom severity and tic-related impairment. This example provides further evidence of the benefit of behavior therapy in reducing tic symptom severity and highlights key considerations for treatment of youth with TD. [ABSTRACT FROM AUTHOR]

Trichotillomania (TTM) involves the compulsive pulling of one’s bodily hair and is often associated with significant distress or impairment. The present case study concerns a college-aged woman, whose history of TTM extended over 5 years and had been unsuccessfully treated by psychotherapy and medication management. Although TTM can be a challenging disorder to treat, the literature indicates that cognitive-behavioral therapy (CBT) has been successful in this regard. Therefore, we implemented CBT based on the manual developed by Keuthen, Stein, and Christenson; specific elements of therapy used included relaxation, self-monitoring, habit reversal training (HRT), reinforcement/punishment contingencies, thought monitoring, and cognitive restructuring. This approach was successful, as the client evidenced a 72% decrease in hair-pulling after using HRT alone, and complete elimination of hair-pulling after introducing the cognitive-restructuring element. Impressively, the gains lasted not only in the short term, but also had been reportedly maintained at a 5-year follow-up. [ABSTRACT FROM AUTHOR]

Quality of life of children with Tourette Syndrome (TS) is impacted greatly by its symptoms and their social consequences. Habit Reversal Training (HRT) is effective but has not, until now, been empirically evaluated in groups. This randomised controlled trial evaluated feasibility and preliminary efficacy of eight HRT group sessions compared to eight Education group sessions. Thirty-three children aged 9–13 years with TS or Chronic Tic Disorder took part. Outcomes evaluated were tic severity and quality of life (QoL). Tic severity improvements were found in both groups. Motor tic severity (Yale Global Tic Severity Scale) showed greatest improvements in the HRT group. Both groups showed a strong tendency toward improvements in patient reported QoL. In conclusion, group-based treatments for TS are feasible and exposure to other children with tics did not increase tic expression. HRT led to greater reductions in tic severity than Education. Implications, such as cost-effectiveness of treatment delivery, are discussed. [ABSTRACT FROM AUTHOR]

Acceptance and commitment therapy (ACT) is a function-based treatment that can be applied to multiple clinical concerns where psychological inflexibility is a mediating issue. This case study describes the use of ACT in combination with habit reversal training for a man with a primary concern of Tourette’s disorder and a secondary concern of chewing tobacco use. Large reductions were seen in the primary outcomes of motor and vocal tics (measured by behavioral tracking and a semi-structured assessment) and chewing tobacco use after 19 individual sessions. Furthermore, increases in psychological flexibility and quality of life and decreases in overall symptomatology were seen at posttreatment. This article conceptualizes this case from a cohesive theory, describes the details of the presenting concerns, and explains the treatment used and treatment outcomes. A description of barriers and suggestions for further treatment and research are also presented. [ABSTRACT FROM AUTHOR]

Patients with chronic itch suffer from higher levels of depression and anxiety than their healthy counterparts. Furthermore, psychological factors, such as stress, are known to aggravate itch. The mere act of thinking about itching can induce the sensation. Interventions like habit reversal training and arousal reduction have been shown to have positive effects on itch relief. Yet, there is still limited data on the psychological management to control the itch scratch cycle and a description of methods suitable to address itch. In this review, we describe different psychological interventions shown to be effective in the treatment of chronic itch. We also provide suggestions based on our experience of suitable interventions for patients with different types of itch. [ABSTRACT FROM AUTHOR]

Background and Objectives: Trichotillomania disorder is a repetitive pulling of hair to the point of noticeable loss. TTM has been tied to a number of negative effects and avoidance of important activities. The purpose of this study was to investigate the effectiveness of combination of Acceptance and Commitment Therapy (ACT) with Habit Reversal Training (HRT) on reduction of trichotillomania symptoms. Subjects and Methods: In this study single-case experiment with A-B design with follow up was used. Two patients were selected by purposeful sampling. In order to gather information and data, in addition to the diagnostic interview based on DSM-5, Milwaukee Inventory for subtypes of trichotillomania–Adult Version: MIST-A and The Massachusetts General Hospital (MGH) Hair-pulling Scale were used. Seven-session ACT plus HRT protocol was delivered for each participant individually. Data drawn in three phases of baseline, intervention and follow-up, for participants separately. Result: Data were interpreted by visual analysis and result showed that the combination of ACT and HRT was effective in reducing TTM symptoms in both patients, and the treatment out come was maintained in follow-up phase. Conclusion: The results showed a traditional behavioral approach (HRT) combined with an approach that addresses the cognitive and emotional components of the behaviour (ACT), significantly reduce TTM symptoms. Combined ACT with HRT is more treatment of TTM. [ABSTRACT FROM AUTHOR]

This report examined the most frequently reported bothersome tics among individuals with chronic tic disorders and evaluated the improvement and remission of tics and their associated characteristics. Youths and adults ( N = 240) were randomly assigned to receive the comprehensive behavioral intervention for tics (CBIT) or psychoeducation and supportive therapy (PST). At baseline, motor tics and tics with an urge were rated as more bothersome relative to vocal tics and tics without premonitory urges. The five most common bothersome tics included eye blinking, head jerks, sniffing, throat clearing, and other complex motor tics. While CBIT outperformed PST across tic type and urge presence, tics preceded by premonitory urges at baseline had higher severity at posttreatment across treatment condition. Six individual tic types had lower severity at posttreatment following CBIT relative to PST. Baseline urge presence was associated with tic remission for CBIT but not PST. Specific bothersome tics were more likely to remit with CBIT relative to PST. Findings suggest that individual tics respond and remit differently to CBIT relative to PST, with implications highlighting the negative reinforcement hypothesis in tic symptom maintenance. Clinicaltrials.gov identifiers NCT00218777; NCT00231985. [ABSTRACT FROM AUTHOR]

Most research on neurodevelopmental disorders has focused on their abnormalities. However, what remains intact may also be important. Increasing evidence suggests that declarative memory, a critical learning and memory system in the brain, remains largely functional in a number of neurodevelopmental disorders. Because declarative memory remains functional in these disorders, and because it can learn and retain numerous types of information, functions, and tasks, this system should be able to play compensatory roles for multiple types of impairments across the disorders. Here, we examine this hypothesis for specific language impairment, dyslexia, autism spectrum disorder, Tourette syndrome, and obsessive–compulsive disorder. We lay out specific predictions for the hypothesis and review existing behavioral, electrophysiological, and neuroimaging evidence. Overall, the evidence suggests that declarative memory indeed plays compensatory roles for a range of impairments across all five disorders. Finally, we discuss diagnostic, therapeutic and other implications. [ABSTRACT FROM AUTHOR]

Few randomized controlled trials (RCTs) exist examining the efficacy of behavior therapy (BT) or serotonin reuptake inhibitors (SRIs) for the treatment of trichotillomania (TTM), with no examination of treatment moderators. The present meta-analysis synthesized the treatment effect sizes (ES) of BT and SRI relative to comparison conditions, and examined moderators of treatment. A comprehensive literature search identified 11 RCTs that met inclusion criteria. Clinical characteristics (e.g., age, comorbidity, therapeutic contact hours), outcome measures, treatment subtypes (e.g., SRI subtype, BT subtype), and ES data were extracted. The standardized mean difference of change in hair pulling severity was the outcome measure. A random effects meta-analysis found a large pooled ES for BT (ES = 1.41, p < 0.001). BT trials with greater therapeutic contact hours exhibited larger ES (p = 0.009). Additionally, BT trials that used mood enhanced therapeutic techniques exhibited greater ES relative to trials including only traditional BT components (p = 0.004). For SRI trials, a random effects meta-analysis identified a moderate pooled ES (ES = 0.41, p = 0.02). Although clomipramine exhibited larger ES relative to selective serotonin reuptake inhibitors, the difference was not statistically significant. Publication bias was not identified for either treatment. BT yields large treatment effects for TTM, with further examination needed to disentangle confounded treatment moderators. SRI trials exhibited a moderate pooled ES, with no treatment moderators identified. Sensitivity analyses highlighted the need for further RCTs of SRIs, especially among youth with TTM. [ABSTRACT FROM AUTHOR]

Trichotillomania is a poorly understood complex disorder of multifaceted pathology which often requires an interdisciplinary approach for management A case of trichotillomania is presented who showed poor response to pharmacotherapy but responded well to behaviour therapy in the form of habit reversal training. Treatment lasted 16 sessions. The patient recovered fully by the end of 12th session. The condition is briefly discussed. [ABSTRACT FROM AUTHOR]

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 versus waitlist (WL) conditions for Step I (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 [HRT]). 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. [ABSTRACT FROM AUTHOR]

Abstract: Individual randomized controlled trials (RCTs) of habit reversal training and a Comprehensive Behavioral Intervention for Tics (collectively referred to as behavior therapy, BT) have demonstrated efficacy in reducing tic severity for individuals with Tourette Syndrome and Chronic Tic Disorders (collectively referred to as TS), with no examination of treatment moderators. The present meta-analysis synthesized the treatment effect sizes (ES) of BT relative to comparison conditions, and examined moderators of treatment. A comprehensive literature search identified eight RCTs that met inclusion criteria, and produced a total sample of 438 participants. A random effects meta-analysis found a medium to large ES for BT relative to comparison conditions. Participant mean age, average number of therapy sessions, and the percentage of participants with co-occurring attention deficit hyperactivity disorder (ADHD) were found to moderate treatment effects. Participants receiving BT were more likely to exhibit a treatment response compared to control interventions, and identified a number needed to treat (NNT) of three. Sensitivity analyses failed to identify publication bias. Overall, BT trials yield medium to large effects for TS that are comparable to treatment effects identified by meta-analyses of antipsychotic medication RCTs. Larger treatment effects may be observed among BT trials with older participants, more therapeutic contact, and less co-occurring ADHD. [Copyright &y& Elsevier]

Abstract: Cluster analytic methods have examined the symptom presentation of chronic tic disorders (CTDs), with limited agreement across studies. The present study investigated patterns, clinical correlates, and treatment outcome of tic symptoms. 239 youth and adults with CTDs completed a battery of assessments at baseline to determine diagnoses, tic severity, and clinical characteristics. Participants were randomly assigned to receive either a comprehensive behavioral intervention for tics (CBIT) or psychoeducation and supportive therapy (PST). A cluster analysis was conducted on the baseline Yale Global Tic Severity Scale (YGTSS) symptom checklist to identify the constellations of tic symptoms. Four tic clusters were identified: Impulse Control and Complex Phonic Tics; Complex Motor Tics; Simple Head Motor/Vocal Tics; and Primarily Simple Motor Tics. Frequencies of tic symptoms showed few differences across youth and adults. Tic clusters had small associations with clinical characteristics and showed no associations to the presence of coexisting psychiatric conditions. Cluster membership scores did not predict treatment response to CBIT or tic severity reductions. Tic symptoms distinctly cluster with little difference across youth and adults, or coexisting conditions. This study, which is the first to examine tic clusters and response to treatment, suggested that tic symptom profiles respond equally well to CBIT. Clinical trials.gov. identifiers: NCT00218777; NCT00231985. [Copyright &y& Elsevier]

Tourette syndrome (TS) is a disorder characterised by multiple motor and vocal tics and is frequently associated with behavioural problems. Tics are known to be affected by internal factors such as inner tension and external factors such as the surrounding environment. A number of behavioural treatments have been suggested to treat the symptoms of TS, in addition to pharmacotherapy and surgery for the most severe cases. This review compiled all the studies investigating behavioural therapies for TS, briefly describing each technique and assessing the evidence in order to determine which of these appear to be effective. Different behavioural therapies that were used included habit reversal training (HRT), massed negative practice, supportive psychotherapy, exposure with response prevention, self-monitoring, cognitive-behavioural therapy, relaxation therapy, assertiveness training, contingency management, a tension-reduction technique and biofeedback training. Overall, HRT is the best-studied and most widely-used technique and there is sufficient experimental evidence to suggest that it is an effective treatment. Most of the other treatments, however, require further investigation to evaluate their efficacy. Specifically, evidence suggests that exposure with response prevention and self-monitoring are effective, and more research is needed to determine the therapeutic value of the other treatments. As most of the studies investigating behavioural treatments for TS are small-sample or single-case studies, larger randomised controlled trials are advocated. [ABSTRACT FROM AUTHOR]

Tics are sudden, rapid and repetitive stereotyped movements or vocalizations. Once thought to be a rare disorder, many children and adults are now known to suffer from tic disorders, including Tourette syndrome. Pharmacological treatments have been the most commonly used treatment modality for tic disorders. More to the point behavioral psychotherapies have been shown to be effective. The present article aims to introduce one of the behavioral techniques, namely Habit Reversal Training (HRT) for the treatment of tic disorders including Tourette syndrome and evaluate the results of randomized-controlled studies. Results of the studies with large groups of children and adults demonstrated that HRT are effective compared to the control groups. Future studies are needed to develop new behavioral treatments for those patients who do not respond to HRT and also to examine the effects of combining behavioral treatments for tics with pharmacotherapy. [ABSTRACT FROM AUTHOR]

Available treatment for chronic tic disorders (CTD) focuses on the reduction of tics but often does not directly address the psychosocial impairment associated with tics. There is empirical support for a new psychosocial intervention to reduce tics and their related impairment, but this treatment has not yet been applied to adults with CTD. With this in mind, the authors report on the case of “Jim,” a 22-year-old male with significantly impairing tic symptoms. Following 10 sessions of weekly cognitive-behaviorally oriented therapy combining habit reversal training, distress tolerance, cognitive restructuring, and problem solving, Jim exhibited marked improvement in tic severity as illustrated by a decrease in his score on the total tic score of the Yale Global Tic Severity Scale from 16 at baseline to 8 at posttreatment. Therapeutic gains were maintained at 4-month follow-up. This case study provides preliminary support for the use of a psychosocial intervention for addressing coping with CTD in young adults. [ABSTRACT FROM AUTHOR]

This article describes the course of treatment for a 55-year-old woman presenting with a particularly challenging case of skin picking disorder. Treatment consisted of five phases (psychoeducation, habit-reversal training, cognitive training, exposure, and relapse prevention), over an 11-month period, in which each new phase built on to the previous phase. Digital photos of wounds resulting from skin picking were also taken during treatment. Several sources of information (continuous self-monitoring, rating scales, self-report, photos) indicated significant treatment gains, especially following Phases 3 and 4. Several challenges were encountered, most notably designing exposure-based techniques that were tailored to match the client’s needs and content of symptoms. Several treatment implications are discussed, including tailoring manualized treatments, managed care concerns, and suggestions for clinicians and supervisors. Taken together, this study adds to the scant literature on treatment of skin picking in older, typically developing adults. [ABSTRACT FROM PUBLISHER]

Abstract: Trichotillomania (TTM) is classified as an impulse control disorder characterized by the recurrent urge to pull out one’s own hair resulting in noticeable hair loss. Cognitive-behavioral therapy, involving habit reversal training, currently represents the treatment of choice. The present study assessed the feasibility and effectiveness of a novel self-help technique, entitled decoupling (DC). DC aims at attenuating TTM by performing movements that decouple the behavioral elements involved in hair pulling. A total of 42 subjects with TTM were recruited via self-help forums for TTM and were randomized either to DC or progressive muscle relaxation (PMR). After four weeks, participants were asked to fill out the same questionnaires as before and rate the effectiveness of the intervention. The completion rate was high and the reliability of the assessments at least satisfactory. The DC group showed a significantly greater decline on the Massachusetts General Hospital – Hair-Pulling Scale, which served as the primary outcome, relative to PMR indicating a medium to strong effect size. Declines on scales tapping depression and obsessive–compulsive disorder were comparable between the two groups. Despite some methodological limitations and the need for replication including follow-up and expert ratings, the present study suggests that DC may prove beneficial to a substantial number of individuals affected with TTM. [ABSTRACT FROM AUTHOR]

Chronic tic disorders (CTDs), including Tourette Syndrome, affect approximately 1 in 100 individuals, and pediatric onset is the norm. Pharmacotherapy has traditionally been the first line of treatment for CTD. However, given that partial response to pharmacotherapy is typical and that the side effect profile for efficacious medications warrants consideration before initiating treatment, there is a clear need to develop and disseminate psychosocial treatments to enhance outcomes among individuals with CTDs. The current report describes findings from a pilot project designed to: (a) train two sites in behavior therapy involving Habit Reversal Training (HRT) for CTDs; (b) pilot test the HRT protocol in adolescents and young adults with CTDs; (c) develop and refine a combined Habit Reversal Training plus Acceptance and Commitment Therapy (HRT+ACT) protocol for CTDs; and (d) pilot test the combined protocol in adolescents and young adults with CTDs. Results indicated that, on average, both the HRT alone and the HRT+ACT groups experienced substantial, clinically relevant, durable, and comparable reductions in tic symptoms through the 1 month follow-up, as well as improvements in participant and parent-rated global functioning over this same period. [ABSTRACT FROM AUTHOR]

This study examined 88 hairstylists' awareness, exposure, and perceptions about treatment for people with trichotillomania (TTM). We investigated the influence of hairstylists' obtained educational level, years of experience, and understanding of TTM in relation to their willingness to refer clients for mental health treatment. Results indicate that hairstylists notice hair loss and discussed this with their clients. Hairstylists generally reported a favorable opinion of psychotherapy and a willingness to refer clients to mental health professionals. No measured variables (e.g. experience, education, or awareness of TTM) predicted willingness to refer clients for treatment. Overall, the results from this study suggest that hairstylists may aid in the early identification of TTM symptoms, particularly for females because a greater proportion of clients seen by hairstylists are females and females more commonly present with symptoms of TTM. [ABSTRACT FROM AUTHOR]

Objective: This annotation reviews recent evidence that points to the likely role of aberrant neural oscillations in the pathogenesis of Tourette syndrome (TS). Methods: The available anatomic and electrophysiological findings in TS are reviewed in the context of an emerging picture of the crucial role that neural oscillations play in maintaining normal central nervous system (CNS) function. Results: Neurons form behavior-dependent oscillating networks of various sizes and frequencies that bias input selection and facilitate synaptic plasticity, mechanisms that cooperatively support temporal representation as well as the transfer and long-term consolidation of information. Coherent network activity is likely to modulate sensorimotor gating as well as focused motor actions. When these networks are dysrhythmic, there may be a loss of control of sensory information and motor action. The known electrophysiological effects of medications and surgical interventions used to treat TS likely have an ameliorative effect on these aberrant oscillations. Similarly, a strong case can be made that successful behavioral treatments involve the willful training regions of the prefrontal cortex to engage in tic suppression and the performance of competing motor responses to unwanted sensory urges such that these prefrontal regions become effective modulators of aberrant thalamocortical rhythms. Conclusions: A deeper understanding of neural oscillations may illuminate the complex, challenging, enigmatic, internal world that is TS. [ABSTRACT FROM AUTHOR]

Trichotillomania is characterized by the repeated urge to pull out hair, leading to noticeable hair loss, distress, and social or functional impairment. Most of the cases present initially to dermatologists with complaints of loss of hair and is often confused with other dermatological conditions like alopecia areata, tinea capitis, traction alopecia, and loose anagen syndrome. It is a chronic condition and difficult to treat. No formal treatment algorithm is present for trichotillomania and no drug has been found to be universally effective. We present a case report of a 22-year-old single female diagnosed with trichotillomania, with complaints of recurrent hair pulling resulting in noticeable hair loss since the age of 8 years. She was treated with Habit Reversal Training with Stimulus Control over a period of 12 weeks and attained complete remission. The effectiveness of HRT plus for the treatment of Trichotillomania is ascertained. [ABSTRACT FROM AUTHOR]