"StopPulling.com: An Interactive, Self-Help Program for Trichotillomania" Research Study

StopPulling.com is “an internet-based treatment programs for both trichotillomania and skin picking by Dr. Keuthen, Dr. Suzanne Mouton-Odum, and Dr. Melinda Stanley.” (TLC website). Dr. Keuthen is the author of the popular book Help for Hair Pullers which is available on Amazon. “StopPulling.com was developed by leading experts in the field of trichotillomania. The program is based upon years of clinical practice and empirical research”.

The research article I am reviewing “StopPulling.com: An Interactive, Self-Help Program for Trichotillomania” is a study done by some of the people who made it. It sounds interesting to me!

Reasons for an internet based treatment program; “Despite the widespread nature of this disorder, relatively few mental health professionals are educated about cognitive behavioral treatment for TTM, leaving sufferers frustrated and oftentimes misinformed. Further, when treatment is available, it is sometimes cost prohibitive.”

True dat! I never actually met a specialist in TTM so the few therapist I saw gave helpful tips but were not experts. Even if one was in my area, not sure I could have afforded it so I definitely see an online program being able to close this gap. My laptop is rarely farther than a few feet from me at any moment.

Also, other disorders have utilized this tool as well. With the shame associated with TTM, it’s likely to be helpful stepping stone for a lot of people.

Author writes “A computer-based strategy also minimizes cost and provides a more interactive, individualized self-help strategy than bibliotherapy. More immediate feedback and reinforcement are available with a computer-based approach, and there is the possibility of greater maintenance of improvements. However, no such strategy has been developed heretofore for trichotillomania. This paper describes the development and two phases of program evaluation for StopPulling.com, an on-line, interactive, self-help approach for TTM based on empirically supported cognitive behavioral treatment for this disorder. The ultimate goal of this work is to enhance dissemination of empirically supported approaches to manage repetitive hair pulling for people who otherwise would not have access and to provide expert and nonexpert clinicians with a potentially useful adjunct to in-person treatment. However, it is important to note that StopPulling.com is not meant to serve as a substitute for more comprehensive care that allows for attention to a broader array of symptoms and coexistent problems in the context of an ongoing interpersonal therapeutic relationship.”

Method

Program Development

“The primary goals in developing StopPulling.com were to create a program for adults and adolescents with TTM that was affordable, accessible, and confidential.1 Key components include interactive behavioral programs that: (a) assess and increase awareness of precipitating and maintaining factors associated with hair pulling; (b) teach a range of coping skills to reduce the frequency and severity of symptoms; and (c) provide an avenue for maintaining treatment gains.

At program start-up, participants are queried about associated symptoms (e.g., major depression, psychotic processes, suicidality, obsessive-compulsive disorder, severe anxiety, and substance abuse). If any of these symptoms are endorsed, participants are encouraged to seek alternate help before initiating the program. Referral sources are offered at this time.

The program includes three modules: assessment, intervention, and maintenance. The assessment module focuses on gathering information about behavioral sequences surrounding hair pulling and identifying unique cues and reinforcers for each person. Following the empirical literature about common precipitating cues and consequences (e.g., Diefenbach et al., 2002Mansueto et al., 1999), participants are asked to record situations, precipitating behaviors, and thoughts and feelings experienced before, during, and after pulling. Participants are asked to enter information on a daily record every time they pull or have an urge to pull a hair (see Figure 1). “

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And my question, is sometimes hairpulling has nothing to do with my emotions. Sometimes I just feel nothing and pull. This is a whole other aspect to trich/TTM that seems to get neglected in research articles. For example, on a normal day, how do you know exactly how you feel? I feel ok. Nothing bad, nothing good. Why am I pulling? No one seems to be able to understand this outside of the pullers mind.

At any rate logging the number of hairs, where, how often is very good technique. Keeping bags of the hair after you pulled really gets you motivated to stop.

“The number of hairs pulled each day is presented to the user in graphic form to facilitate visual tracking of progress.” That sounds pretty cool. Probably helps motivate you to keep up the good work!

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“Five subsections of the assessment module ask for progressively more detailed information, including preceding motor behaviors (e.g., stroking the hair or searching for a certain hair); physical sensations associated with pulling (e.g., itching, burning); feelings experienced before, during, and after hair pulling; thoughts associated with pulling; and postpulling behaviors (e.g., biting the root off of the hair or simply discarding the hair). The assessment module takes approximately 2 to 5 weeks to complete, depending on the frequency of data entry. At the end of the assessment module, each user is presented with an individualized behavioral Personal Analysis, which is a summary of all relevant data previously entered (see Figure 2). This analysis provides the foundation for the selection of coping skills to be presented during the intervention phase. All data are recorded for the user and summarized in graphic form on My Page (see Figure 3). In addition to the graph, subscribers may view their entries, edit past entries, and navigate through the program via My Page.”

“The goal of the maintenance module is to maintain gains made during active treatment. TTM has a high relapse rate, and continued monitoring of behavior and reminders to use coping skills may serve to prevent relapse and promote recovery. During the maintenance module, participants continue to record all urges/episodes on the daily record. If situational correlates change and new high-risk situations are noted, the program incorporates the changes into the Personal Analysis and additional coping strategies may be offered. Users continue to rate the strength of their urges before and after use of coping strategies, and they continue to set weekly goals. If goals are not met for 4 consecutive weeks, the program considers this a relapse and the user is directed to return to the intervention module to review coping strategies and reevaluate high-risk situations. During the maintenance module, users are presented with weekly activities intended to assist with recovery and relapse prevention. These activities include specific exercises to aid users in defining for themselves what recovery means, how to accept urges without responding to them, and long-term approaches to affective and sensory regulation (e.g., how to reinforce oneself for positive changes; how to continue to remind oneself to use coping strategies, etc.).”

Participants who tried it out

“Participants were 265 users of StopPulling.com, who signed on between January 1, 2003, and December 31, 2003, and had at least 2 weeks of data available for outcome analyses.2 Demographic data were available for 190 to 192 of the 265 participants. The majority of these individuals were women (95.3%; n = 181). Age distribution was as follows: 2.1% under 12 years (n = 4); 19.3% 12–18 years (n = 37); 9.9% 19–24 years (n = 19); 22.4% 25–30 years (n = 43); 27.6% 31–40 years (n = 53); 14.6% 41–50 years (n = 28); 3.6% 51–60 years (n = 7); 0.5% 61–70 years (n = 1). Most participants were Caucasian.”

Duration of program use

“On average, participants used StopPulling.com for 11.7 weeks (SD = 11.36; n = 265). Duration of program use correlated significantly and positively with hair-pulling frequency at baseline (r = .25, p < .001), suggesting that participants who reported more hairs pulled per week at program initiation were more likely to use StopPulling.com for a longer period of time.”

Active versus inactive users

“At the time of data analyses, 126 users were actively using StopPulling.com and 139 users had discontinued program use. “ So 53% people stopped using it. Who knows why though. Maybe it didn’t work for their subtype. Maybe it was hard to keep up with. It costs $30 a month so maybe some people just didn’t feel like spending more money on it.

Outcome Analyses

Baseline versus final ratings

“Mean scores at baseline and final rating on each outcome for participants with at least two data points are reported in Table 2. Analyses of covariance demonstrated a main effect of time on MGH scores, F(1, 266) = 7.01, p < .009, eta2 = .03, with means indicating a significant (although modest) reduction in symptoms from baseline to final rating. The Time × Weeks interaction was not significant, F(1, 266) = 1.88, p > .17, suggesting that improvement on this measure occurred independently of program duration. Hair-pulling frequency also demonstrated improvement over time, but in this case, only the Time × Weeks interaction was significant, F(1, 262) = 22.96, p < .001, eta2 = .08, indicating that duration of program use accounted for the moderate changes from baseline to final ratings. Unexpectedly, urge severity increased somewhat from baseline to final rating, F(1, 262) = 4.49, p < .04, eta2 = .02.”

So essentially, some things did improve and then shockingly, urge intensity increased but not my too much. Maybe it makes sense that your urge intensity would “seem” to increase since you aren’t pulling your hair as much? But the frequency (hair loss) went down so that’s the most important part for some of us.

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“Data from 265 users with at least 2 weeks of outcomes suggested significant, albeit modest, reductions in overall severity and frequency of hair pulling. Ratings of overall severity improved regardless of duration of program use, although there was some evidence that significant improvement on this global measure occurred only during the assessment phase, with maintenance of gains during intervention. Reductions in frequency of hair pulling, on the other hand, appeared related to duration of program use, suggesting that longer use of StopPulling.com resulted in greater reductions in the numbers of hairs pulled. On this outcome measure, the majority of improvement occurred during the intervention phase, although significant variability in reported hair-pulling frequency likely precluded identification of statistically significant findings. Unexpectedly, self-reported urges to pull increased over time. It is possible that stronger urges resulted from decreases in actual pulling behavior, but it is important to note that the size of this effect was quite small and therefore not clinically meaningful.”

How does this stack up against traditional methods?

“Although response rates (defined according to MGH scores) were lower than those reported on comparable measures at posttreatment following more intensive CBT for TTM in academic clinical trials (86%, Lerner et al., 1998; 64%, van Minnen et al., 2003), rates were comparable to those reported at long-term follow-up after more intense CBT (31%; Lerner et al., 1998). Because rates of relapse are high across all treatment for TTM (Keuthen et al., 2001Lerner et al., 1998), the rate of improvement here is particularly notable given the self-help nature of the approach. “

Conclusion

“StopPulling.com is an easily accessible and private self-help option that may produce improvement comparable to long-term outcomes following intensive CBT. As such, StopPulling.com may be useful as a stand-alone approach to be used by patients without access to treatment providers or as an adjunctive approach to be used by patients currently in treatment with an expert or nonexpert provider. 

It is unlikely that StopPulling.com will be of optimal value to all individuals who suffer from repetitive hair pulling. However, the data overall suggest that StopPulling.com may provide a potentially useful self-help alternative or adjunctive approach for reducing repetitive hair pulling. Nevertheless, it is important to note that StopPulling.com is not an Internet-based therapy that allows for interactive work with a treatment provider. Rather, it is an entirely self-help format, and users receive feedback derived via a computer algorithm that summarizes data input by the user him- or herself.”

So, it’s self-driven and affordable and convenient. If you can’t make it to an TTM expert, or your therapist isn’t one, this could be helpful.

If you can’t afford a therapist, I’d look into DBT workbook and doing this online program. At the end of the day, only you know how to help yourself.

Emily Kight