تجزیه حرکتی: مداخله خودیاری برای درمان تریکوتیلومانیا

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.

Trichotillomania (TTM) is presently classified in DSM-IV-TR and ICD-10 as an impulse control disorder, characterized by the recurrent and irresistible urge to pull out one’s own hair resulting in noticeable hair loss. The hair pulling is often preceded by an increase of tension and a relief when pulling out the hair. The prevalence rate for TTM is estimated at 0.6% if all diagnostic criteria are met (Christenson et al., 1991 and Duke et al., 2009). However, a substantial subgroup of patients with hair pulling behavior neither reports a build up of tension nor a subsequent relief (Franklin et al., 2008). If this subgroup is included, the prevalence rises to an estimated rate of 1.2% (Duke et al., 2009). Three subtypes of TTM have been identified across several studies: TTM with early onset hair-pulling, automatic hair-pulling and focused hair-pulling (Christenson et al., 1993, Swedo et al., 1992 and Walsh and McDougle, 2001), whereby the latter types are often mixed (Shusterman, Feld, Baer, & Keuthen, 2009). Shusterman et al. (2009) assume that “automatic pulling” is primarily driven by boredom and “focused pulling” by anxiety and tension. Whereas most studies of community samples reported a similar prevalence of TTM in men and women (Duke et al., 2009 and Graber and Arndt, 1993), in clinical settings TTM is more frequent in women (Christenson and Crow, 1996, Cohen et al., 1995 and Shusterman et al., 2009). Cognitive-behavioral therapy (CBT), including Habit Reversal Training (HRT; Azrin & Nunn, 1973) is regarded as the first line treatment for TTM (Duke, Keeley, Geffken, & Storch, 2010). HRT involves different components with the focus on motor habits, in particular awareness training and competing response training (Azrin & Nunn, 1973). As the name expresses, competing response training teaches patients to substitute the malbehavior with an (freezing) alternative behavior (e.g. clenching one’s fist for some time). Various studies have confirmed the effectiveness of HRT in the treatment of TTM (overview in Duke et al., 2010). A systematic review reported that HRT was even superior to pharmacological approaches (SSRI and clomipramine) for TTM (Bloch et al., 2007). Many individuals with TTM fear that their areas of hair loss due to hair pulling could be discovered by others. Wigs and special hair-cuts often successfully cover the hair loss to the public. Patients often avoid social activities and do not disclose their problem to others (Neudecker & Rufer, 2004). Feelings of embarrassment and shame can also result in avoidance of professional treatment such as CBT (Diefenbach et al., 2005 and Shusterman et al., 2009). Hence, functional impairment and decreased quality of life associated with TTM receive increased recognition in current research (Diefenbach et al., 2000, Duke et al., 2010, Franklin et al., 2008 and Woods et al., 2006). To help people with TTM and other auto-aggressive impulse control disorders such as nail biting at a low threshold, we have developed a novel self-help technique, entitled decoupling (DC). Parts of DC may be considered a variant of HRT. HRT and DC both aim to stop the dysfunctional movements by actively interfering at the motor level. Whereas HRT typically teaches the subject to perform a “freezing” behavior (e.g. clenching a fist) instead of hair-pulling or other habits, the aim of DC is to mimic the initial motor phase of the malbehavior but then to shift its behavioral target: The new behavior at first resembles the hair-pulling movement but, close to its usual target (hair, nails), it is deviated onto another one (e.g. nose instead of hair). The final motor phase should be executed with an accelerated movement which intends to override strong future impulses to execute hair pulling and to make the movement become more aware and salient by means of the irritation resulting from two strong competing motor programs. Since many patients describe an almost sensory urge in their fingers and scalp to perform hair pulling, these body parts are included in further motor sequences: (1) The fingers of one hand should perform the individual pulling procedure on the fingers of the other hand so that the motor program is acted out to some degree but its target is again shifted, (2) The hairy part of the head should be massaged making sure at the same time that the hair is not pulled out or is otherwise compromised. DC is perhaps most beneficial for those who have problems detecting cues for hair-pulling. It may serve as an alternative to HRT for those who experience difficulties to initiate the alternative competing response in time. Since it is easy to learn and available via self-help it is a treatment option for those not (yet) seeking or even avoiding professional help. TTM, like OCD (Moritz, 2008), is a hidden disorder as many sufferers do not seek professional help (Cohen et al., 1995 and Woods et al., 2006). Our study was therefore deliberately conducted over the Internet. As will be outlined in greater detail in the discussion, internet studies are an important complementary approach to clinical studies and psychometric properties, completion rates and fidelity are at least satisfactory (Chinman et al., 2004, Moritz et al., 2010, Ritter et al., 2004 and Riva et al., 2003) if certain precautions are met (e.g. “cookies” to prevent multiple log-ons from the same computer, control questions, incentive at the end of the study to ensure completion, careful choice of specialized Internet networks). For the present study, we hypothesized that the application of DC would decrease hair pulling to a greater degree than progressive muscle relaxation (PMR), an intervention commonly recommended in the treatment of TTM and one component of HRT. No group differences were expected for scales tapping depression and OCD.