Research Article DEPRESSION AND ANXIETY 0 : 1–4 (2010) DBT-ENHANCED HABIT REVERSAL TREATMENT FOR TRICHOTILLOMANIA: 3- AND 6-MONTH FOLLOW-UP RESULTS Nancy J. Keuthen, Ph.D., 1Ã Barbara O. Rothbaum, Ph.D., 2 Martha J. Falkenstein, B.S., 1 Suzanne Meunier, Ph.D., 1 Kiara R. Timpano, Ph.D., 1 Michael A. Jenike, M.D., 1 and Stacy Shaw Welch, Ph.D. 3 Background: Maintenance of gains with cognitive-behavioral treatment for trichotillomania (TTM) has historically been problematic. Methods: We conducted follow-up assessments 3 and 6 months after completion of a 3-month maintenance phase on 10 individuals with DSM-IV-TR TTM who participated in an open trial of a dialectical behavior therapy (DBT)-enhanced habit reversal treatment (HRT). Results: Significant improvement from baseline was reported at 3- and 6-month follow-up on all measures of hair pulling severity and emotion regulation, although some worsening was reported on some measures from earlier study time points. At 6-month follow-up, five and four participants were full and partial responders, respectively. Significant correla- tions were reported at both follow-up time points between changes in hair pulling severity and emotion regulation capacity. Conclusions: DBT-enhanced HRT offers promise for improved long-term treatment results in TTM. Changes in TTM severity from baseline to 3- and 6-month follow-up is correlated with changes in emotion regulation capacity. Depression and Anxiety 0:1–4, 2010. r r 2010 Wiley-Liss, Inc. Key words: trichotillomania; hair pulling; habit reversal; dialectical behavior therapy INTRODUCTION Failure to maintain treatment gains has been the norm for psychosocial treatment trials in trichotillo- mania (TTM). [1,2] Maintenance of improvement with cognitive-behavioral treatment (CBT) has been re- ported in only one study of adult TTM individuals with psychometrically-acceptable follow-up mea- sures. [3] In their acceptance and commitment therapy (ACT)-enhanced habit reversal treatment (HRT) for TTM, Woods et al. reported maintenance of reduc- tions in hair pulling severity at 3-month follow-up with improvement in pulling severity correlated with reduction in experiential avoidance. We developed a novel treatment for TTM encom- passing elements of traditional HRT [4,5] and dialectical behavior therapy (DBT), [6,7] coupled with an enhanced emphasis on relapse prevention training. Our treatment protocol not only includes strategies that are effective for the ‘‘automatic’’ or habit-like pulling but also addresses the ‘‘focused’’ pulling related to uncomfortable emo- tional and sensory experiences. In our own research, [8] we reported a correlation between problematic hair pulling and affective regulation with predicted relation- ships between affective pulling triggers, problematic emotion regulation, and pulling severity. Published online in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/da.20778 Received for publication 18 September 2010; Revised 10 November 2010; Accepted 11 November 2010 The authors disclose the following financial relationships within the past 3 years: Contract grant sponsor: David Judah Fund. Ã Correspondence to: Nancy J. Keuthen, Ph.D., Trichotillomania Clinic and Research Unit, Massachusetts General Hospital, Simches 2, 185 Cambridge Street, Boston, MA 02114. E-mail: nkeuthen@partners.org 1 Massachusetts General Hospital/Harvard Medical School, Massachusetts 2 Emory University School of Medicine, Atlanta, Georgia 3 Anxiety and Stress Reduction Center (Seattle, WA), University of Washington, Washington r r 2010 Wiley-Liss, Inc.