{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,22]],"date-time":"2026-10-22T22:38:09Z","timestamp":1792708689807,"version":"4.5.0"},"reference-count":28,"publisher":"Wiley","issue":"12","license":[{"start":{"date-parts":[[2019,11,6]],"date-time":"2019-11-06T00:00:00Z","timestamp":1572998400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100001322","name":"South African Medical Research Council","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100001322","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Brain and Behavior"],"published-print":{"date-parts":[[2019,12]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Background<\/jats:title><jats:p>A promising approach to reducing the\u00a0phenotypic heterogeneity of psychiatric disorders involves the identification of homogeneous subtypes. Careful study of comorbidity in obsessive\u2010compulsive disorder (OCD) contributed to the identification of the\u00a0DSM\u20105 subtype of OCD with tics. Here we investigated one of the largest available cohorts of clinically diagnosed trichotillomania (TTM) to determine whether subtyping TTM based on comorbidity would help delineate clinically meaningful subgroups.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>As part of an ongoing international collaboration, lifetime comorbidity data were collated from 304 adults with pathological hair\u2010pulling who fulfilled criteria for <jats:italic>DSM\u2010IV\u2010TR<\/jats:italic> or <jats:italic>DSM\u20105<\/jats:italic> TTM. Cluster analysis (Ward's method) based on comorbidities was undertaken.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Three clusters were identified, namely Cluster 1: cases without any comorbidities (<jats:italic>n<\/jats:italic>\u00a0=\u00a063, 20.7%) labeled \u201csimple TTM,\u201d Cluster 2: cases with comorbid\u00a0major depressive disorder only (<jats:italic>N<\/jats:italic>\u00a0=\u00a049, 16.12%) labeled \u201cdepressive TTM,\u201d and Cluster 3: cases presenting with combinations of the investigated comorbidities (<jats:italic>N<\/jats:italic>\u00a0=\u00a0192, 63.16%) labeled \u201ccomplex TTM.\u201d The clusters differed in terms of hair\u2010pulling severity (<jats:italic>F<\/jats:italic>\u00a0=\u00a03.75, <jats:italic>p<\/jats:italic>\u00a0=\u00a0.02; Kruskal\u2013Wallis [KW] <jats:italic>p<\/jats:italic>\u00a0&lt;\u00a0.01) and depression symptom severity (<jats:italic>F<\/jats:italic>\u00a0=\u00a05.07, <jats:italic>p\u00a0<\/jats:italic>=\u00a0&lt;.01; KW <jats:italic>p<\/jats:italic>\u00a0&lt;\u00a0.01), with cases with any comorbidity presenting with increased severity. Analysis of the temporal nature of these conditions in a subset suggested that TTM onset generally preceded major depressive disorder in (subsets of) Clusters 2 and 3.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>The findings here are useful in emphasizing that while many TTM patients present without comorbidity, depression is present in a substantial proportion of cases. In clinical practice, it is crucial to assess comorbidity, given the links demonstrated here between comorbidity and symptom severity. Additional research is needed to replicate these findings and to determine whether cluster membership based on comorbidity predicts response to treatment.<\/jats:p><\/jats:sec>","DOI":"10.1002\/brb3.1456","type":"journal-article","created":{"date-parts":[[2019,11,6]],"date-time":"2019-11-06T11:43:59Z","timestamp":1573040639000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":41,"title":["Comorbidity in trichotillomania (hair\u2010pulling disorder): A cluster analytical approach"],"prefix":"10.1002","volume":"9","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4766-3704","authenticated-orcid":false,"given":"Christine","family":"Lochner","sequence":"first","affiliation":[{"name":"SA MRC Unit on Risk and Resilience in Mental Disorders Department of Psychiatry Stellenbosch University Cape Town South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nancy J.","family":"Keuthen","sequence":"additional","affiliation":[{"name":"Department of Psychiatry Massachusetts General Hospital and Harvard Medical School Boston MA USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erin E.","family":"Curley","sequence":"additional","affiliation":[{"name":"Department of Psychology Temple University Philadelphia PA USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Esther S.","family":"Tung","sequence":"additional","affiliation":[{"name":"Department of Psychiatry Massachusetts General Hospital and Harvard Medical School Boston MA USA"},{"name":"Department of Psychological and Brain Sciences Boston University Boston MA USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah A.","family":"Redden","sequence":"additional","affiliation":[{"name":"Department of Psychiatry and Behavioral Neuroscience University of Chicago Chicago IL USA"},{"name":"Department of Psychology Florida State University Tallahassee FL USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emily J.","family":"Ricketts","sequence":"additional","affiliation":[{"name":"Department of Psychiatry and Biobehavioral Sciences University of California Los Angeles CA USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher C.","family":"Bauer","sequence":"additional","affiliation":[{"name":"Department of Psychology Marquette University Milwaukee WI USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Douglas W.","family":"Woods","sequence":"additional","affiliation":[{"name":"Department of Psychology Marquette University Milwaukee WI USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jon E.","family":"Grant","sequence":"additional","affiliation":[{"name":"Department of Psychiatry and Behavioral Neuroscience University of Chicago Chicago IL USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dan J.","family":"Stein","sequence":"additional","affiliation":[{"name":"SA MRC Unit on Risk &amp; Resilience in Mental Disorders Department of Psychiatry and Neuroscience Institute University of Cape Town Cape Town South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2019,11,6]]},"reference":[{"key":"e_1_2_9_2_1","volume-title":"American Psychiatric Association diagnostic and statistical manual of mental disorders 4th edition \u2013 Text revision (DSM\u2010IV\u2010TR)","author":"American Psychiatric Association","year":"2000"},{"key":"e_1_2_9_3_1","doi-asserted-by":"publisher","DOI":"10.1176\/appi.books.9780890425596"},{"key":"e_1_2_9_4_1","doi-asserted-by":"publisher","DOI":"10.1016\/0272-7358(88)90050-5"},{"key":"e_1_2_9_5_1","doi-asserted-by":"publisher","DOI":"10.1001\/archpsyc.1961.01710120031004"},{"key":"e_1_2_9_6_1","doi-asserted-by":"publisher","DOI":"10.1007\/s10862-005-0633-7"},{"key":"e_1_2_9_7_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.janxdis.2009.07.015"},{"key":"e_1_2_9_8_1","volume-title":"Structured clinical interview for DSM\u2010IV Axis I disorders \u2013 Patient edition (SCID\u2010I\/P, Version 2.0, 8\/98 revision)","author":"First M. 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