Behavioural treatment of trichotillomania: Two-year follow-up results
Introduction
Brief behaviour therapy (BT) and serotonin re-uptake inhibitors (SRIs) have both been reported to be effective in the treatment of trichotillomania (TTM). However, better post-treatment outcomes were found for brief BT in the two randomized controlled studies that directly compared the effects of the two treatments (Minnen, Van Hoogduin, Keijsers, Hendriks, & Hellenbrand, 2003; Ninan, Rothbaum, Marsteller, Knight, & Eccard, 1993). Brief BT, therefore, seems to be the treatment of choice for TTM. Nevertheless, the findings of studies that investigated whether the positive treatment responses of BT are maintained in the long run have been inconsistent. Azrin, Nunn, and Frantz (1980) reported an excellent gain maintenance at 4 and 22 months for 19 TTM patients treated with habit reversal training. Rosenbaum and Ayllon (1981) found similar positive effects for their follow-up assessments at 6 and 12 months in 4 patients treated with the same procedure. In contrast, Mouton and Stanley (1996) obtained considerable relapses after 4 weeks and 6-months in 5 patients treated with habit reversal, as did Lerner, Franklin, Meadows, Hembree, and Foa (1998) in their 3.7-year follow-up assessment of 13 patients. These findings suggest that in TTM initial positive responses may be difficult to maintain after treatment (Diefenbach, Reitman, & Williamson, 2000; Keuthen, Aronowitz, Badenoch, & Wilhelm, 1999).
Adequate insight into the factors that foster or impede treatment gain maintenance is lacking. So research is aimed at identifying relapse-prone patients prior to treatment which would allow therapists to tailor treatments to the patient's needs in such a way as to reduce the risk of relapse. Based on the literature and clinical observations, the present study focuses on three pre-treatment symptom characteristics and two treatment process issues in relation to long-term treatment outcome.
TTM symptom duration and age at onset were previously found to be unrelated to long-term treatment outcome (Keuthen et al. (1998), Keuthen, O’Sullivan, & Sprich-Buckminster (1998); Lerner et al., 1998) and they were currently not investigated. Lerner et al. reported that pre-treatment levels of TTM symptom severity and depression were positively related to higher levels of TTM symptoms at their long-term follow-up. In contrast, Keuthen et al. (1998), Keuthen, O’Sullivan, & Sprich-Buckminster (1998) and Keuthen, Fraim, Deckersbach et al. (2001) reported higher levels of pre-treatment depression in treatment responders than non-responders 6 years after BT and/or SRI treatment. Neuroticism has frequently been related to poorer gain maintenance in relapse-prone disorders such as pathological gambling (e.g., Echeburua, Fernandez-Montalvo, & Beaz, 2001), substance abuse (e.g., Fisher, Elias, & Ritz, 1998; McCormick, Dowd, Quirk, & Zegarra, 1998) and recurrent depression (e.g., Angst, 1999; Gormley, O’Leary, & Costello, 1999; Scott, 1988; Surtees, & Wainwright, 1996). Since negative affectivity triggers hairpulling in TTM patients (Christenson, Ristveldt, & Mackenzie, 1993), neuroticism may also be a predictor of relapse after initial successful treatment of TTM.
In our investigation, we addressed the potential role of two-treatment process issues in long-term BT treatment outcome. Lerner et al. (1998) reported on two patients who had achieved total abstinence from hairpulling at treatment completion. Both patients showed little recurrence of symptoms at the long-term follow-up. Complete abstinence following treatment may thus be associated with better long-term effects than partial symptom reduction.
The second issue concerns the change processes during BT. BT applications aimed at nervous habits are rooted in learning theory (see e.g., Azrin & Nunn, 1973; Keuthen et al., 1999; Mansueto, Stemberger, Thomas, & Golomb, 1997). By interrupting the chain of conditioned and discriminant stimuli, urge, hairpulling behaviour, and gratification following hairpulling, classical and operant conditioning of hairpulling behaviour weakens over time. In a previous study (Minnen et al., 2003) session-to-session outcome measurements had revealed marked reductions of hairpulling even after the first few treatment sessions in many of the TTM patients. Based on this observation, we pondered whether brief BT results in the patient's increased effort to resist the urge to pull hair from the start of treatment, but not in a timely reduction of the urge to pull hair. Patients remain prone to relapse as long as the urge to give in to the habit remains unchanged (see e.g., Muraven & Baumeister, 2000).
In the present study, TTM patients were treated with a brief, manual-based BT. Follow-up data were collected 3 months and 2 years after treatment. We sought to answer the following 4 questions: (1) How well are TTM patients able to maintain their post-treatment results in the long term? (2) Do higher levels of pre-treatment TTM symptoms, depression, and neuroticism predict more severe TTM symptoms in long-term follow-up? (3) Does complete abstinence from hairpulling at treatment conclusion predict better long-term results than partial symptom reduction? (4) Does BT change the patient's ability to resist pulling hair right from the start of the treatment while their urge to do so reduces only slowly over the course of treatment?
Section snippets
Patients
All patients participating in the present study were sufferers from TTM who had contacted a university outpatient clinic of their own accord after seeing a Dutch television show in which the BT program for TTM was mentioned and who had subsequently joined a randomized, waiting-list controlled study into the effects of BT versus fluoxetine (FL, Van Minnen et al., 2003). Inclusion criteria were as follows: primary diagnosis of trichotillomania according to DSM-IV (American Psychiatric
Results
With respect to the first research question, Table 1 presents the mean pre- and post-treatment assessment ratings and the 3-month and 2-year follow-up scores for the primary and secondary outcome measures. Pre-treatment-to-post-treatment and pre-treatment-to-follow-up effect sizes for each of the outcome measures are also listed. We used Cohen's d for one-sample repeated measures (Cohen, 1988) to calculate the effect sizes.
MGHHS pre-treatment assessment scores, post-treatment assessment scores
Discussion
In line with previous studies (Azrin et al., 1980; Lerner et al., 1998; Mouton & Stanley, 1996; Rosenbaum & Ayllon, 1981) TTM symptoms had reduced considerably immediately after brief BT. The effect size obtained for the MGHHS was excellent. In addition, depressive symptoms and general psychopathology had also decreased.
The 3-month and 2-year follow-up evaluations, as based on the MGHHS scores, were available for 19 and 24 of the 28 patients, respectively. Compared to the post-treatment
Acknowledgements
We would like to thank Inge Hellenbrand, Marion Verheul, Mayke de Jonge, Nicole Heerbaart and Monique Voogd for their help in collecting the data.
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