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