Trichotillomania: Trichotillomania:

An OverviewAn OverviewDavid Dia, PhD, LCSW, CCBTDavid Dia, PhD, LCSW, CCBT

University of TennesseeUniversity of Tennessee

DisclosuresDisclosures

No financial disclosures or conflicts No financial disclosures or conflicts of interest to reportof interest to report

Information is presented as Information is presented as educational. It is not intended to educational. It is not intended to diagnosis, treat, or be a substitute diagnosis, treat, or be a substitute for expert medical or mental health for expert medical or mental health care.care.

OverviewOverview

General informationGeneral information MedicationMedication Psychosocial TreatmentsPsychosocial Treatments

What is in a name?What is in a name?

Trich = hairTrich = hair Tillo = pullingTillo = pulling Mania = impulseMania = impulse

Diagnosis – DSM IV-TRDiagnosis – DSM IV-TR

Impulse Control DisorderImpulse Control Disorder May be related to Obsessive May be related to Obsessive

compulsive disorder (anxiety) or tic compulsive disorder (anxiety) or tic disorderdisorder

Pathological GamblingPathological Gambling

Diagnosis – DSM IV-TRDiagnosis – DSM IV-TR

CriteriaCriteria Recurrent pulling out of one’s hair with Recurrent pulling out of one’s hair with

noticeable hair lossnoticeable hair loss Sense of tension before pulling or when Sense of tension before pulling or when

attempting to resistattempting to resist Pleasure, gratification, or relief when Pleasure, gratification, or relief when

pulling out hairpulling out hair Causes clinically significant impairmentCauses clinically significant impairment

Other terms to knowOther terms to know

Trichophagia – eating the hairsTrichophagia – eating the hairs Bezoars – hair ballsBezoars – hair balls Alopecia – hair lossAlopecia – hair loss

General FactsGeneral Facts

Estimated 2.5 million people (.6% Estimated 2.5 million people (.6% lifetime)lifetime)

Average age of onset = 13 years oldAverage age of onset = 13 years old 3.4% Females vs. 1.5% of Males hair 3.4% Females vs. 1.5% of Males hair

lossloss Tends to have a waxing and waning Tends to have a waxing and waning

coursecourse

General FactsGeneral Facts

Can be triggered and exacerbated Can be triggered and exacerbated by anxietyby anxiety

Two types, not mutually exclusiveTwo types, not mutually exclusive Focused vs. automaticFocused vs. automatic

General FactsGeneral Facts

Only 15% of adults experience Only 15% of adults experience significant improvement with significant improvement with community treatment!community treatment!

Most (55%) believed their clinicianMost (55%) believed their clinician Did not have significant knowledge of Did not have significant knowledge of

the disorderthe disorder Did not have knowledge of evidenced Did not have knowledge of evidenced

based treatmentbased treatment

ComorbidityComorbidity

Adult SampleAdult Sample MoodMood AnxietyAnxiety Substance abuseSubstance abuse Personality D/OPersonality D/O

Pediatric SamplePediatric Sample AnxietyAnxiety DepressionDepression Disruptive Disruptive

BehavioralBehavioral TicsTics

ConsequencesConsequences

Lower life satisfactionLower life satisfaction Higher levels of stressHigher levels of stress Lower self-esteemLower self-esteem

Suspected CausesSuspected Causes

Genetic ComponentGenetic Component 5HT2A, hoxB8, and SLITRT15HT2A, hoxB8, and SLITRT1

NeurotransmittersNeurotransmitters DopamineDopamine Monoamine system (MAOI)Monoamine system (MAOI) Gultamate (precursor to GABA)Gultamate (precursor to GABA) Neuroadrenaline systemNeuroadrenaline system Serotonin?Serotonin?

Suspected CausesSuspected Causes

Inferior frontal cortex – cognitionInferior frontal cortex – cognition Amygdala-hippocampal formation – Amygdala-hippocampal formation –

affect regulationaffect regulation Putamen – habit learningPutamen – habit learning VTA and Nucleus accumbensVTA and Nucleus accumbens

Mediates reward processMediates reward process

Compulsive Skin PickingCompulsive Skin Picking

General InformationGeneral Information 2 to 4% of the population2 to 4% of the population More common in femalesMore common in females Bimodal onset --Bimodal onset --

Late childhood to early adolescentsLate childhood to early adolescents 30 to 45 years old30 to 45 years old

CausesCauses Genetic (hoxb8)Genetic (hoxb8)

Overview of TreatmentOverview of Treatment

No randomized control studies with No randomized control studies with pediatricpediatric

Behavioral treatments with adults Behavioral treatments with adults demonstrate efficacydemonstrate efficacy

Uncontrolled studies with pediatric Uncontrolled studies with pediatric show similar results as adultsshow similar results as adults

SSRIs (double blind, placebo SSRIs (double blind, placebo controlled) have no efficacycontrolled) have no efficacy

Overview of TreatmentOverview of Treatment

Supportive or psychodynamic Supportive or psychodynamic therapy no or minimal affecttherapy no or minimal affect

Treatment -- MedicationsTreatment -- Medications

Mancini et al. (2009) -- pediatricMancini et al. (2009) -- pediatric Retrospective chart review (N = 11)Retrospective chart review (N = 11) 10 tried on SRI and 1 on antipsychotic10 tried on SRI and 1 on antipsychotic 2 on SRI and 9 on antipsychotic2 on SRI and 9 on antipsychotic

2 remitted2 remitted Results favored antipsychoticsResults favored antipsychotics

Risperidone (Risperdol)Risperidone (Risperdol) Quetiapine (Seroquel)Quetiapine (Seroquel)

Medications - AdultsMedications - Adults

SSRI vs. control conditionSSRI vs. control condition 3 studies 3 studies

Tricyclic vs. controlTricyclic vs. control Clomipramine (Anafranil) 2 studiesClomipramine (Anafranil) 2 studies

HRT vs. SSRIHRT vs. SSRI HRT vs. ClomipramineHRT vs. Clomipramine Clomipramine vs. SSRIClomipramine vs. SSRI

(SSRIs – fluvoxamine, fluoxetine, , sertraline, citalopram)(SSRIs – fluvoxamine, fluoxetine, , sertraline, citalopram)

Medications – Experimental -- AdultsMedications – Experimental -- Adults

Opioid antagonist = Naltrexone and Opioid antagonist = Naltrexone and NalmefeneNalmefene

Mood Stabilizers = lithium and Mood Stabilizers = lithium and Valproic acid (Depakote)Valproic acid (Depakote)

Dopamine reuptakers inhibitors = Dopamine reuptakers inhibitors = Focalin, Ritalin, Wellburtrin)Focalin, Ritalin, Wellburtrin)

Norepinephrine inhibitor – Norepinephrine inhibitor – clomipramineclomipramine

Glutamatergic – N-acetylcysteine Glutamatergic – N-acetylcysteine

MedicalMedical

Neurosurgery, Transcranial Neurosurgery, Transcranial Magnetic Stimulation (TMS), ECTMagnetic Stimulation (TMS), ECT No evidenceNo evidence

Psychosocial TreatmentsPsychosocial Treatments

HRT/CBT vs. controlHRT/CBT vs. control 5 studies pediatric5 studies pediatric

77% to 61 % “clinically significant changes”77% to 61 % “clinically significant changes” For example, 16 to 5 of the MBHHPSFor example, 16 to 5 of the MBHHPS

5 controlled studies with adults 5 controlled studies with adults 91% to 61% reduction91% to 61% reduction

HypnotherapyHypnotherapy Two uncontrolled, small studies with Two uncontrolled, small studies with

adultsadults

Treatment Guidelines Treatment Guidelines PediatricPediatric

PsychoeducationPsychoeducation 0 to 7 years0 to 7 years

Response prevention implemented with Response prevention implemented with parentsparents

Older than 7 yearsOlder than 7 years Habit reversal therapyHabit reversal therapy

Treatment Guidelines Treatment Guidelines PediatricPediatric

““If there continues to be significant If there continues to be significant impairment from trich despite impairment from trich despite prolonged behavioral treatment with prolonged behavioral treatment with experienced clinician consider”experienced clinician consider” N-acetylcysteine N-acetylcysteine

Initial dose 600mg, titrated to a max does of Initial dose 600mg, titrated to a max does of 1200mg BID1200mg BID

ClomipramineClomipramine

(Medications, including OTR, needs to be dispensed/recommended by (Medications, including OTR, needs to be dispensed/recommended by physician)physician)

Treatment - CSPTreatment - CSP

One Double Blind StudyOne Double Blind Study Fluoxetine – improvement in 2 or 3 Fluoxetine – improvement in 2 or 3

outcome measuresoutcome measures Open labelOpen label

Fluvoxamine, Fluoxetine, Lamotrigine, Fluvoxamine, Fluoxetine, Lamotrigine, Escitalopram, N-acetylcysteineEscitalopram, N-acetylcysteine

Treatment - CSPTreatment - CSP

3 Psychosocial studies3 Psychosocial studies HRT with 3 month F/UHRT with 3 month F/U HRT + ACTHRT + ACT Internet based treatment – 62% Internet based treatment – 62%

“responders”“responders” 115 participants115 participants 15% completed all three phases15% completed all three phases

Comprehensive ModelComprehensive ModelMansueto et al. (1999)Mansueto et al. (1999)

Phase I Phase I Assessment and functional analysisAssessment and functional analysis

Phase 2 Phase 2 Identify and target modalitiesIdentify and target modalities

Phase 3 Phase 3 Identify and implement strategiesIdentify and implement strategies

Phase 4 Phase 4 Evaluation and modificationEvaluation and modification

Phase IPhase I

Two types of antecedents to pullingTwo types of antecedents to pulling Cues that trigger the urge to pullCues that trigger the urge to pull Discriminative stimuli that facilitates Discriminative stimuli that facilitates

pullingpulling Actually pullingActually pulling Consequences of pullingConsequences of pulling

Maintains pullingMaintains pulling Terminate pullingTerminate pulling

Phase IPhase I

CuesCues External – settings and implements External – settings and implements

associatedassociated Internal – affective states, visual or Internal – affective states, visual or

tactile sensations, cognitive cuestactile sensations, cognitive cues Discrimitive stimuli (set the stage)Discrimitive stimuli (set the stage)

External – environment free of potential External – environment free of potential observers, presences of pull instrumentsobservers, presences of pull instruments

Internal – urge, posture cues, cognitiveInternal – urge, posture cues, cognitive

Phase IPhase I

PreparationPreparation Specific Hair selectedSpecific Hair selected Disposition of hairDisposition of hair

DiscardedDiscarded RetrainRetrain

InspectInspect Bite/swallowBite/swallow Wrapping hair / tickleWrapping hair / tickle

Intervention Phase IIntervention Phase I

Self-monitoringSelf-monitoring

Phase 2Phase 2

Cognitive modalityCognitive modality Cognitive restructuring, guided self Cognitive restructuring, guided self

dialoguedialogue Affective modalityAffective modality

Relaxation exercises, exposure, positive Relaxation exercises, exposure, positive imagery, stress managementimagery, stress management

Motoric modalityMotoric modality Finger tip bandages, gloves, bracelets, Finger tip bandages, gloves, bracelets,

eye glasses, scarf's, etc. eye glasses, scarf's, etc. Silly putty, worry beads, soft brushSilly putty, worry beads, soft brush

Phase 2Phase 2

Sensory modalitySensory modality Numbing cream, brushing hair, washing Numbing cream, brushing hair, washing

hair vigorously, shampoohair vigorously, shampoo Gummy bears, sunflower seeds, dental Gummy bears, sunflower seeds, dental

floss, koosh balls, frayed blanketsfloss, koosh balls, frayed blankets Dying hair, cutting finger nailsDying hair, cutting finger nails

EnvironmentalEnvironmental Removing tweezers, covering mirrorsRemoving tweezers, covering mirrors Behavioral plans, stimulus controlBehavioral plans, stimulus control

Phase 2Phase 2

Habit reversalHabit reversal Self-monitoringSelf-monitoring Awareness trainingAwareness training

Hair pulling and high risk situationsHair pulling and high risk situations Stimulus controlStimulus control

Decrease opportunities or interfereDecrease opportunities or interfere Competing response interventionCompeting response intervention

Phase 3Phase 3

Identify and choose treatment Identify and choose treatment strategiesstrategies

Client to use strategy for at least one Client to use strategy for at least one weekweek

Primary issue – getting the client to Primary issue – getting the client to use strategy consistentlyuse strategy consistently

Phase 4Phase 4

Evaluation and ModificationEvaluation and Modification

QuestionsQuestions