Trichotillomania an overview
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Trichotillomania: An Overview. David Dia, PhD, LCSW, CCBT University of Tennessee. Disclosures. No financial disclosures or conflicts of interest to report

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Trichotillomania an overview

Trichotillomania: An Overview

David Dia, PhD, LCSW, CCBT

University of Tennessee


Disclosures

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.


Overview

Overview

  • General information

  • Medication

  • Psychosocial Treatments


What is in a name

What is in a name?

  • Trich = hair

  • Tillo = pulling

  • Mania = impulse


Diagnosis dsm iv tr

Diagnosis – DSM IV-TR

  • Impulse Control Disorder

  • May be related to Obsessive compulsive disorder (anxiety) or tic disorder

  • Pathological Gambling


Diagnosis dsm iv tr1

Diagnosis – DSM IV-TR

  • Criteria

    • Recurrent pulling out of one’s 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


Other terms to know

Other terms to know

  • Trichophagia – eating the hairs

  • Bezoars – hair balls

  • Alopecia – hair loss


General facts

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


General facts1

General Facts

  • Can be triggered and exacerbated by anxiety

  • Two types, not mutually exclusive

    • Focused vs. automatic


General facts2

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


Comorbidity

Adult Sample

Mood

Anxiety

Substance abuse

Personality D/O

Pediatric Sample

Anxiety

Depression

Disruptive Behavioral

Tics

Comorbidity


Consequences

Consequences

  • Lower life satisfaction

  • Higher levels of stress

  • Lower self-esteem


Suspected causes

Suspected Causes

  • Genetic Component

    • 5HT2A, hoxB8, and SLITRT1

  • Neurotransmitters

    • Dopamine

    • Monoamine system (MAOI)

    • Gultamate (precursor to GABA)

    • Neuroadrenaline system

    • Serotonin?


Suspected causes1

Suspected Causes

  • Inferior frontal cortex – cognition

  • Amygdala-hippocampal formation – affect regulation

  • Putamen – habit learning

  • VTA and Nucleus accumbens

    • Mediates reward process


Compulsive skin picking

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)


Overview of treatment

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


Overview of treatment1

Overview of Treatment

  • Supportive or psychodynamic therapy no or minimal affect


Treatment medications

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)


Medications adults

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)


Medications experimental adults

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


Medical

Medical

  • Neurosurgery, Transcranial Magnetic Stimulation (TMS), ECT

    • No evidence


Psychosocial treatments

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


Treatment guidelines pediatric

Treatment Guidelines Pediatric

  • Psychoeducation

    • 0 to 7 years

      • Response prevention implemented with parents

    • Older than 7 years

      • Habit reversal therapy


Treatment guidelines pediatric1

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)


Treatment csp

Treatment - CSP

  • One Double Blind Study

    • Fluoxetine – improvement in 2 or 3 outcome measures

  • Open label

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


Treatment csp1

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


Comprehensive model mansueto et al 1999

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


Phase i

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


Phase i1

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


Phase i2

Phase I

  • Preparation

  • Specific Hair selected

  • Disposition of hair

    • Discarded

    • Retrain

      • Inspect

      • Bite/swallow

      • Wrapping hair / tickle


Intervention phase i

Intervention Phase I

  • Self-monitoring


Phase 2

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


Phase 21

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


Phase 22

Phase 2

  • Habit reversal

    • Self-monitoring

    • Awareness training

      • Hair pulling and high risk situations

    • Stimulus control

      • Decrease opportunities or interfere

    • Competing response intervention


Phase 3

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


Phase 4

Phase 4

  • Evaluation and Modification


Questions

Questions


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