Trichotillomania: An Overview

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Trichotillomania An Overview

• David Dia, PhD, LCSW, CCBT
• University of Tennessee

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Disclosures

• No financial disclosures or conflicts of interest
  to report
• Information is presented as educational. It is
  not intended to diagnosis, treat, or be a
  substitute for expert medical or mental health
  care.

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Overview

• General information
• Medication
• Psychosocial Treatments

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What is in a name?

• Trich hair
• Tillo pulling
• Mania impulse

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Diagnosis DSM IV-TR

• Impulse Control Disorder
• May be related to Obsessive compulsive disorder
  (anxiety) or tic disorder
• Pathological Gambling

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Diagnosis DSM IV-TR

• Criteria
• Recurrent pulling out of ones hair with
  noticeable hair loss
• Sense of tension before pulling or when
  attempting to resist
• Pleasure, gratification, or relief when pulling
  out hair
• Causes clinically significant impairment

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Other terms to know

• Trichophagia eating the hairs
• Bezoars hair balls
• Alopecia hair loss

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General Facts

• Estimated 2.5 million people (.6 lifetime)
• Average age of onset 13 years old
• 3.4 Females vs. 1.5 of Males hair loss
• Tends to have a waxing and waning course

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General Facts

• Can be triggered and exacerbated by anxiety
• Two types, not mutually exclusive
• Focused vs. automatic

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General Facts

• Only 15 of adults experience significant
  improvement with community treatment!
• Most (55) believed their clinician
• Did not have significant knowledge of the
  disorder
• Did not have knowledge of evidenced based
  treatment

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Comorbidity

• Adult Sample
• Mood
• Anxiety
• Substance abuse
• Personality D/O

• Pediatric Sample
• Anxiety
• Depression
• Disruptive Behavioral
• Tics

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Consequences

• Lower life satisfaction
• Higher levels of stress
• Lower self-esteem

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Suspected Causes

• Genetic Component
• 5HT2A, hoxB8, and SLITRT1
• Neurotransmitters
• Dopamine
• Monoamine system (MAOI)
• Gultamate (precursor to GABA)
• Neuroadrenaline system
• Serotonin?

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Suspected Causes

• Inferior frontal cortex cognition
• Amygdala-hippocampal formation affect
  regulation
• Putamen habit learning
• VTA and Nucleus accumbens
• Mediates reward process

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Compulsive Skin Picking

• General Information
• 2 to 4 of the population
• More common in females
• Bimodal onset --
• Late childhood to early adolescents
• 30 to 45 years old
• Causes
• Genetic (hoxb8)

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Overview of Treatment

• No randomized control studies with pediatric
• Behavioral treatments with adults demonstrate
  efficacy
• Uncontrolled studies with pediatric show similar
  results as adults
• SSRIs (double blind, placebo controlled) have no
  efficacy

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Overview of Treatment

• Supportive or psychodynamic therapy no or minimal
  affect

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Treatment -- Medications

• Mancini et al. (2009) -- pediatric
• Retrospective chart review (N 11)
• 10 tried on SRI and 1 on antipsychotic
• 2 on SRI and 9 on antipsychotic
• 2 remitted
• Results favored antipsychotics
• Risperidone (Risperdol)
• Quetiapine (Seroquel)

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Medications - Adults

• SSRI vs. control condition
• 3 studies
• Tricyclic vs. control
• Clomipramine (Anafranil) 2 studies
• HRT vs. SSRI
• HRT vs. Clomipramine
• Clomipramine vs. SSRI
• (SSRIs fluvoxamine, fluoxetine, , sertraline,
  citalopram)

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Medications Experimental -- Adults

• Opioid antagonist Naltrexone and Nalmefene
• Mood Stabilizers lithium and Valproic acid
  (Depakote)
• Dopamine reuptakers inhibitors Focalin,
  Ritalin, Wellburtrin)
• Norepinephrine inhibitor clomipramine
• Glutamatergic N-acetylcysteine

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Medical

• Neurosurgery, Transcranial Magnetic Stimulation
  (TMS), ECT
• No evidence

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Psychosocial Treatments

• HRT/CBT vs. control
• 5 studies pediatric
• 77 to 61 clinically significant changes
• For example, 16 to 5 of the MBHHPS
• 5 controlled studies with adults
• 91 to 61 reduction
• Hypnotherapy
• Two uncontrolled, small studies with adults

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Treatment Guidelines Pediatric

• Psychoeducation
• 0 to 7 years
• Response prevention implemented with parents
• Older than 7 years
• Habit reversal therapy

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Treatment Guidelines Pediatric

• If there continues to be significant impairment
  from trich despite prolonged behavioral treatment
  with experienced clinician consider
• N-acetylcysteine
• Initial dose 600mg, titrated to a max does of
  1200mg BID
• Clomipramine
• (Medications, including OTR, needs to be
  dispensed/recommended by physician)

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Treatment - CSP

• One Double Blind Study
• Fluoxetine improvement in 2 or 3 outcome
  measures
• Open label
• Fluvoxamine, Fluoxetine, Lamotrigine,
  Escitalopram, N-acetylcysteine

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Treatment - CSP

• 3 Psychosocial studies
• HRT with 3 month F/U
• HRT ACT
• Internet based treatment 62 responders
• 115 participants
• 15 completed all three phases

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Comprehensive ModelMansueto et al. (1999)

• Phase I
• Assessment and functional analysis
• Phase 2
• Identify and target modalities
• Phase 3
• Identify and implement strategies
• Phase 4
• Evaluation and modification

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Phase I

• Two types of antecedents to pulling
• Cues that trigger the urge to pull
• Discriminative stimuli that facilitates pulling
• Actually pulling
• Consequences of pulling
• Maintains pulling
• Terminate pulling

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Phase I

• Cues
• External settings and implements associated
• Internal affective states, visual or tactile
  sensations, cognitive cues
• Discrimitive stimuli (set the stage)
• External environment free of potential
  observers, presences of pull instruments
• Internal urge, posture cues, cognitive

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Phase I

• Preparation
• Specific Hair selected
• Disposition of hair
• Discarded
• Retrain
• Inspect
• Bite/swallow
• Wrapping hair / tickle

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Intervention Phase I

• Self-monitoring

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Phase 2

• Cognitive modality
• Cognitive restructuring, guided self dialogue
• Affective modality
• Relaxation exercises, exposure, positive imagery,
  stress management
• Motoric modality
• Finger tip bandages, gloves, bracelets, eye
  glasses, scarf's, etc.
• Silly putty, worry beads, soft brush

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Phase 2

• Sensory modality
• Numbing cream, brushing hair, washing hair
  vigorously, shampoo
• Gummy bears, sunflower seeds, dental floss, koosh
  balls, frayed blankets
• Dying hair, cutting finger nails
• Environmental
• Removing tweezers, covering mirrors
• Behavioral plans, stimulus control

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Phase 2

• Habit reversal
• Self-monitoring
• Awareness training
• Hair pulling and high risk situations
• Stimulus control
• Decrease opportunities or interfere
• Competing response intervention

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Phase 3

• Identify and choose treatment strategies
• Client to use strategy for at least one week
• Primary issue getting the client to use
  strategy consistently

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Phase 4

• Evaluation and Modification

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Questions