Reliability and Validity of a Photo Rating Measure of Alopecia

  • David A. F. Haaga
  • Martha J. Falkenstein
  • Maria Banis
  • Elizabeth J. Malloy
  • Lauren McDonough
  • Kate Rogers


Numerous studies of trichotillomania (TTM) incorporate measures of the extent of alopecia (hair loss) resulting from hair pulling. This study used data from a clinical trial of stepped care for TTM to provide further evidence pertaining to a 1–7 alopecia rating scale (Tolin et al. 2002). Ratings were based on photographs of participants’ (N = 60) most severely affected pulling site. Alopecia rating proved highly acceptable (88 % completed the assessment), stable (10-week retest reliability r for wait-listed participants = 0.63), and convergently valid (r = 0.51 with an interviewer’s rating of hair loss based on live observation). Alopecia ratings were not significantly related to self-rated social impairment resulting from TTM, nor with total symptom severity. Hair regrowth rate varies by sex, age, and pulling site, so alopecia rating cannot serve as a direct marker of TTM treatment progress. Nonetheless, it appears to be a reliable and valid measure of a consequence of pulling that is of great concern to people with TTM. Future research should examine its potential treatment utility as a means of giving patients feedback on the side effects of progress they are making in therapy.


Alopecia Trichotillomania Measurement Hair pulling 



This research was supported by National Institute of Mental Health Grant 1R15MH086852-01.

We are grateful to Charley Mansueto for consultation on the project and to Sam Nelson and Natalie Rusch for assistance in conducting the research.

Conflict of Interest

The authors declare that they have no conflicts of interest to report.

Experiment Participants

Study procedures were approved by the American University Institutional Review Board, and participants were treated in accordance with the APA ethical code. All participants provided informed consent to the research procedures.


  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington: American Psychiatric Association.Google Scholar
  2. Azrin, N. H., Nunn, R. G., & Frantz, S. E. (1980). Treatment of hair pulling (trichotillomania): a comparative study of habit reversal and negative practice training. Journal of Behavior Therapy and Experimental Psychiatry, 11, 13–20. doi: 10.1016/0005-7916(80)90045-2.CrossRefGoogle Scholar
  3. Beck, A. T., Steer, R. A., & Rainieri, W. F. (1988). Scale for suicide ideation: psychometric properties of a self-report version. Journal of Clinical Psychology, 44, 499–505.CrossRefPubMedGoogle Scholar
  4. Diefenbach, G. J., Tolin, D. F., Crocetto, J., Maltby, N., & Hannan, S. (2005a). Assessment of trichotillomania: a psychometric evaluation of hair-pulling scales. Journal of Psychopathology and Behavioral Assessment, 27, 169–178. doi: 10.1007/s10862-005-0633-7.CrossRefGoogle Scholar
  5. Diefenbach, G. J., Tolin, D. F., Hannan, S., Crocetto, J., & Worhunsky, P. (2005b). Trichotillomania: impact on psychosocial functioning and quality of life. Behaviour Research and Therapy, 43, 869–884. doi: 10.1016/j.brat.2004.06.010.CrossRefPubMedGoogle Scholar
  6. Diefenbach, G. J., Tolin, D. F., Hannan, S., Maltby, N., & Crocetto, J. (2006). Group treatment for trichotillomania: behavior therapy versus supportive therapy. Behavior Therapy, 37, 353–363. doi: 10.1016/j.beth.2006.01.006.CrossRefPubMedGoogle Scholar
  7. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (2002). Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Patient Edition With Psychotic Screen. New York: Biometrics Research, New York State Psychiatric Institute.Google Scholar
  8. Frost, R. O., Steketee, G., Tolin, D. F., & Renaud, S. (2008). Development and validation of the clutter image rating. Journal of Psychopathology and Behavioral Assessment, 30, 193–203. doi: 10.1007/s10862-007-9068-7.CrossRefGoogle Scholar
  9. Keuthen, N. J., O’Sullivan, R. L., Ricciardi, J. N., Shera, D., Savage, C. R., Borgman, A. S., & Baer, L. (1995). The Massachusetts general hospital (MGH) hairpulling scale: I. Development and factor analysis. Psychotherapy and Psychosomatics, 64, 141–145. doi: 10.1159/ 000289003.CrossRefPubMedGoogle Scholar
  10. Myers, R. J., & Hamilton, J. B. (1951). Regeneration and rate of growth of hairs in man. Annals of the New York Academy of Sciences, 53, 562–568. doi: 10.1111/j.1749-6632.1951.tb31957.x.CrossRefPubMedGoogle Scholar
  11. Nelson-Gray, R. O. (2003). Treatment utility of psychological assessment. Psychological Assessment, 15, 521–531. doi: 10.1037/1040-3590.15.4.521.CrossRefPubMedGoogle Scholar
  12. O’Sullivan, R. L., Keuthen, N. J., Hayday, C. F., Ricciardi, J. N., Buttolph, M. L., Jenike, M. A., & Baer, L. (1995). The Massachusetts General Hospital (MGH) hairpulling scale: 2. Reliability and validity. Psychotherapy and Psychosomatics, 64, 146–148. doi: 10.1159/000289004.CrossRefPubMedGoogle Scholar
  13. Olsen, E. A., Whiting, D., Bergfeld, W., Miller, J., Hordinsky, M., Wanser, R., Zhang, P., & Kohut, B. (2007). A multicenter, randomized, placebo-controlled, double-blind clinical trial of a novel formulation of 5 % minoxidil topical foam versus placebo in the treatment of androgenetic alopecia in men. Journal of the American Academy of Dermatology, 57, 767–774. doi: 10.1016/j.jaad.2007.04.012.CrossRefPubMedGoogle Scholar
  14. Ricketts, E. J., Brandt, B. C., & Woods, D. W. (2012). The effects of severity and causal explanation on social perceptions of hair loss. Journal of Obsessive Compulsive and Related Disorders, 1, 336–343. doi: 10.1016/j.jocrd.2012.07.007.CrossRefGoogle Scholar
  15. Rogers, K., Banis, M., Falkenstein, M. J., Malloy, E. J., McDonough, L., Nelson, S. O., Rusch, N., & Haaga, D. A. F. (2014). Stepped care in the treatment of trichotillomania. Journal of Consulting and Clinical Psychology, 82, 361–367. doi: 10.1037/a0035744.PubMedCentralCrossRefPubMedGoogle Scholar
  16. Rothbaum, B. O., & Ninan, P. T. (1994). The assessment of trichotillomania. Behaviour Research and Therapy, 32, 651–662. doi: 10.1016/0005-7967(94)90022-1.CrossRefPubMedGoogle Scholar
  17. Sheehan, D. V. (1983). The Anxiety Disease. New York: Scribner’s.Google Scholar
  18. Stanley, M. A., & Mouton, S. G. (1996). Trichotillomania treatment manual. In V. B. Van Hasselt & M. Hersen (Eds.), Sourcebook of psychological treatment manuals for adult disorders (pp. 657–687). New York: Plenum Press.CrossRefGoogle Scholar
  19. Swedo, S. E., Leonard, H. L., Rapoport, J. L., Lenane, M. C., Goldberger, B. A., & Cheslow, B. A. (1989). A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling). New England Journal of Medicine, 321, 497–501. doi: 10.1056/NEJM198908243210803.CrossRefPubMedGoogle Scholar
  20. Tolin, D. F., Franklin, M. E., Diefenbach, G. J., & Gross, A. (2002). Cognitive-behavioral therapy for pediatric trichotillomania: an open trial. Presented to the Association for Advancement of Behavior Therapy, Reno.Google Scholar
  21. Winchel, R. M., Jones, J. S., Molcho, A., Parsons, B., Stanley, B., & Stanley, M. (1992). The psychiatric institute trichotillomania scale (PITS). Psychopharmacology Bulletin, 28, 463–476.PubMedGoogle Scholar
  22. Woods, D. W., Flessner, C. A., Franklin, M. E., Keuthen, N. J., Goodwin, R. D., Stein, D. J., & Trichotillomania Learning Center-Scientific Advisory Board. (2006). The trichotillomania impact project (TIP): exploring phenomenology, functional impairment, and treatment utilization. Journal of Clinical Psychiatry, 67, 1877–1888.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • David A. F. Haaga
    • 1
  • Martha J. Falkenstein
    • 1
  • Maria Banis
    • 1
  • Elizabeth J. Malloy
    • 1
  • Lauren McDonough
    • 1
  • Kate Rogers
    • 1
  1. 1.Department of Psychology, Asbury BuildingAmerican UniversityWashingtonUSA

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