Trichotillomania

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Michael H. Bloch Yale Child Study Center, New Haven, CT, USA

Synonyms

Methyl chloroform; TCE; 1,1,1-trichloroethane

Synonyms

Chronic hairpulling

Definition

Trichotillomania is classified as an ► impulse-control disorder in ► DSM-I . Trichotillomania is characterized by recurrent hairpulling that causes noticeable hair loss and significant distress or impairment. Additionally, according to DSM-IV, trichotillomania requires that an individual should sometimes experience urges prior to pulling, and a sense of pleasure, gratification, or relief after the act.

Role of Pharmacotherapy

Trichotillomania has an estimated lifetime prevalence of roughly 0.6%. However, the estimated lifetime prevalence increases to roughly 3% when preceding urges and pleasure/ relief afterward are removed from the diagnostic criteria. Trichotillomania patients have a high rate of ► comor-bid illnesses, with approximately 82% of adults presenting for treatment experiencing at least one other Axis I psychiatric disorder (Woods et al. 2006a). Common comorbidities include depression, anxiety disorders, obsessive-compulsive disorder, substance use disorders, posttraumatic stress disorder, and other body-focused impulse control disorders. Trichotillomania in adults has a strong female predominance and a chronic, waxing and waning course. Longitudinal studies of adults with tri-chotillomania have demonstrated little improvement in symptoms over time (Keuthen et al. 2001). Trichotillo-mania has an average onset age of around 13 years. It should be distinguished from chronic hairpulling in young children. Hairpulling in young children is considered a behavior consistent with developmentally appropriate environmental exploration and is usually self-limited.

A proper assessment in a patient with trichotillomania involves getting a detailed history of their hairpulling. When discussing hair-pulling behaviors it is important to address (1) antecedent cognitions, behaviors, and feelings prior to pulling, (2) the settings in which pulling occurs, (3) body locations from which pulling occurs, and (4) post-pulling behavior. Trichotillomania patients commonly experience emotions such as boredom, tension, and anxiety prior to hair-pulling episodes and/or a physical urge to pull. Commonly experienced cognitions prior to hairpulling include beliefs about the inappropriate appearance of certain hairs (gray, coarse, etc.), that hairlines or lengths of hair need to be symmetrical or that the patient is unattractive or unlovable because of his or her appearance. Common post-pulling behaviors involve biting, rubbing, or eating the hair. Also, discarding of the hairs in fairly stereotyped ways is the norm. In patients who ingest their own hair, trichobezoars (conglomerations of hair and food that form in the gastrointestinal tract) are of particular concern as they can lead to weight loss, iron deficiency anemia, malabsorption, and even gastrointestinal tract obstruction.

Trichotillomania patients also usually have specific places where they engage in the behavior, i.e., the bedroom or the bathroom. The most common sites ofhairpulling are the scalp (73%), eyebrows (56%), eyelashes (53%), pubic region (46%), and legs (15%) (Woods et al. 2006a). A physical examination of areas of hairpulling can uncover areas of irritation, follicle damage, and atypical regrowth of hair, all of which are common in patients with tri-chotillomania. Rating scales, such as the self-report Massachusetts General Hospital Hair-pulling Scale and the clinician-rated National Institute of Mental Health Trichotillomania Severity Scale, are useful in measuring the severity of trichotillomania symptoms and tracking changes in symptom severity over time.

► Selective serotonin reuptake inhibitors (SSRIs) are the most commonly utilized pharmacological intervention to treat trichotillomania (Woods et al. 2006a) (► SSRIs and related compounds). Initial open-label trials showed improvement over time in trichotillomania patients taking SSRIs. However, in four randomized, blinded, ► placebo-controlled trials, SSRIs have failed to show benefit compared to placebo (Christenson et al. 1991; Dougherty et al. 2006; Streichenwein and Thornby 1995; van Minnen et al. 2003). A ► meta-analysis that combined the results of the four previously conducted trials similarly failed to show any evidence of an improvement compared to placebo treatment (Bloch et al. 2007). Although there is substantial evidence that pharmacological treatment with SSRI is no more effective than placebo in the treatment of primary hairpulling in trichotilloma-nia patients, these medications may still be quite effective in treating comorbid illness in these patients. ► Depression, ► anxiety disorders, and ► post traumatic stress disorder are all common comorbidities in trichotilloma-nia patients, and there is substantial evidence demonstrating improvements in these conditions with SSRI pharmacotherapy. When SSRI pharmacotherapy is initiated in a trichotillomania patient, the goal of therapy should be to specifically target comorbid illness that is impairing to the patient, as SSRI pharmacotherapy for primary trichotil-lomania has little evidence of efficacy.

Clomipramine is a ► tricyclic antidepressant (TCA) that has been extensively studied in the treatment of trichotillomania (► antidepressants). Initial results from a 10-week, randomized, double-blind, crossover study of 13 women that compared ► clomipramine, a serotoner-gically potent TCA, to desipramine, a noradrenergically potent TCA, demonstrated substantial improvement in trichotillomania patients treated with clomipramine (Swedo et al. 1989). However, most of the patients in this trial experienced a relapse in their symptoms after longer-term treatment with clomipramine. Another small, 9-week, randomized, placebo-controlled parallel-group study showed some increased improvement of trichotillo-mania symptoms with clomipramine compared to ► placebo, but not to the level of statistical significance (Ninan et al. 2000). Clomipramine was very poorly tolerated in this study, with 40% of subjects dropping out early due to side effects. Common side effects associated with clomip-ramine include weight gain, anticholinergic symptoms, and sedation. The meta-analysis of randomized trials with clomipramine suggests modest short-term benefits when compared to control conditions. However, evidence suggests that benefits from clomipramine are short-lived.

A substantial number of case reports and uncontrolled trials have suggested the possible efficacy of both typical and atypical antipsychotics in trichotillomania (► antipsychotic drugs). Additionally, case reports suggest the possible efficacy of glutamate-modulating agents such as riluzole, ► «-acetylcysteine, and ► topiramate. ► Naltrex-one, a opioid antagonist used to treat urge-related disorders such as alcoholism and ► pathological gambling, has shown some evidence of efficacy in uncontrolled trials. Skepticism is warranted when viewing the likely efficacy of any treatment of trichotillomania studied in an unblinded, uncontrolled fashion. Many patients with trichotillomania improve over the short-term regardless of treatment after presenting for initial treatment. Greater familiarity and psychoeducation about the disorder, meeting other individuals with the disorder, supportive clinicians, and engaging in any active intervention against the disorder are all powerful forces toward patient improvement. These aspects of treatment, along with the waxing and waning course of the disorder, make it difficult to assess efficacy in uncontrolled trials.

Role of Non-Pharmacological Therapies

► Habit reversal therapy (HRT) is a behavioral therapy designed for the treatment of trichotillomania and tics. HRT is a manualized, behavioral technique that is administered over a period of 2-3 months with a maintenance period for relapse prevention. HRT involves several different components - self-monitoring, awareness training, stimulus control, and competing response training. The self-monitoring component of HRT requires patients to keep records of their hairpulling. Awareness training works to increase patient awareness of hair-pulling behaviors and of high-risk situations that increase the risk of hairpulling. Stimulus control employs interventions designed to decrease the opportunities to pull and to intervene or prevent pulling behaviors. Competing response training involves teaching a patient to engage in a behavior that is physically incompatible with pulling for a set period of time when they feel the urge to pull. In HRT, patients are only permitted to pull after they have engaged in the competing response behaviors.

Trichotillomania. Fig. 1. Relative efficacy of treatments in trichotillomania: effect sizes of habit reversal therapy (HRT), clomipramine, and SSRI. Circles represent the point estimate and lines the 95% confidence intervals for effect sizes for each intervention. (Adapted with permission from Bloch et al. 2007.)

In three randomized, parallel-group studies, HRT demonstrated superior efficacy compared to wait-list or placebo controls (Ninan et al. 2000; van Minnen et al. 2003; Woods et al. 2006b). HRT also demonstrated superiority to pharmacotherapy with fluoxetine and clomip-ramine in two of these randomized trials (Ninan et al. 2000; van Minnen et al. 2003). A recent meta-analysis demonstrated that, in randomized, controlled trials, HRT shows superior ► effect sizes compared to pharmacological agents for trichotillomania (Bloch et al. 2007). Figure 1 depicts the relative effect sizes of HRT compared to pharmacotherapies for the treatment of trichotilloma-nia. Further trials are needed to demonstrate that HRT will maintain efficacy when compared to control conditions that account for the nonspecific aspects of therapy (i.e., emotional support and psychoeducation).

Support groups (e.g., the Trichotillomania Learning Center in Santa Cruz, California, www.trich.org) can also be very helpful in treating trichotillomania. Such groups can provide treatment referrals and support to individuals experiencing the condition. Often times, hearing other individuals' stories, coping mechanisms and strategies can help the individual develop more effective personal approaches for adjusting to and managing the disorder.

Conclusion

Trichotillomania can cause substantial impairment for individuals who suffer from it. Individuals may have significant dermatological and medical problems as a direct result of hairpulling. Substantial psychosocial impairment may occur due to the resulting hair loss. Effective behavioral treatments for trichotillomania, such as HRT, have been developed over recent years. Access to skilled therapists practicing HRT remains a major challenge for trichotillomania treatment. Currently, expert HRT treatment for trichotillomania is available at only a few academic centers. No pharmacological agents have convincingly demonstrated long-term efficacy in the treatment of trichotillomania. Novel pharmacological treatments are urgently needed given the problem of access to effective behavioral treatments for most patients and given the substantial proportion of patients for whom this behavioral technique is not tolerable or who still do not experience adequate symptom relief.

Cross-References

► Antidepressants

► Antipsychotic Drugs

► Impulse Control Disorders

► SSRIs and Related Compounds Selective

References

Bloch MH, Landeros-Weisenberger A et al (2007) Systematic review: pharmacological and behavioral treatment for trichotillomania. Biol Psychiatry 62(8):839-846 Christenson GA, Mackenzie TB et al (1991) A placebo-controlled, double-blind crossover study of fluoxetine in trichotillomania. Am J Psychiatry 148(11):1566-1571 Dougherty DD, Loh R et al (2006) Single modality versus dual modality treatment for trichotillomania: sertraline, behavioral therapy, or both? J Clin Psychiatry 67(7):1086-1092 Keuthen NJ, Fraim C et al (2001) Longitudinal follow-up of naturalistic treatment outcome in patients with trichotillomania. J Clin Psychiatry 62(2):101-107 Ninan PT, Rothbaum BO et al (2000) A placebo-controlled trial of cognitive-behavioral therapy and clomipramine in trichotillomania. J Clin Psychiatry 61(1):47-50 Streichenwein SM, Thornby JI (1995) A long-term, double-blind, placebo-controlled crossover trial of the efficacy of fluoxetine for trichotillomania. Am J Psychiatry 152(8):1192-1196 Swedo SE, Leonard HL et al (1989) A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling). N Engl J Med 321(8):497-501 van Minnen A, Hoogduin KA et al (2003) Treatment of trichotillomania with behavioral therapy or fluoxetine: a randomized, waiting-list controlled study. Arch Gen Psychiatry 60(5):517-522 Woods DW, Flessner CA et al (2006a) The trichotillomania impact project (TIP): exploring phenomenology, functional impairment, and treatment utilization. J Clin Psychiatry 67(12): 1877-1888

Woods DW, Wetterneck CT et al (2006b) A controlled evaluation of acceptance and commitment therapy plus habit reversal for tricho-tillomania. Behav Res Ther 44:639-656

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