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A Brief Overview of Trichotillomania Trick- oh – till – oh – main – ee - ah PowerPoint PPT Presentation


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A Brief Overview of Trichotillomania Trick- oh – till – oh – main – ee - ah compulsive hair pulling. Scalp Pulling Damage. Lash and Brow Pulling Damage. Who Gets Trichotillomania?. Prevalence Hair Pulling. DSM-III-R TTM prevalence estimates of 0.6 - 3.4%

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A Brief Overview of Trichotillomania Trick- oh – till – oh – main – ee - ah

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A brief overview of trichotillomania trick oh till oh main ee ah

A Brief Overview

of

Trichotillomania

Trick- oh – till – oh – main – ee- ah

compulsive hair pulling


Scalp pulling damage

Scalp Pulling Damage


Lash and brow pulling damage

Lash and Brow Pulling Damage


Who gets trichotillomania

Who Gets Trichotillomania?


Prevalence hair pulling

PrevalenceHair Pulling

  • DSM-III-R TTM prevalence estimates of 0.6 - 3.4%

    Christenson GA, Pyle RL, Mitchell JE. Estimated Lifetime prevalence of trichotillomania in college students. J Clin Psychiatry 1991; 52:415-417

  • 10% prevalence estimates of “non-clinical hair pulling” in student populations when criteria are relaxed. (B & C are dropped.)

    Stanley MA, Borden JW, Bell GE, & Wagner GE. Non-Clinical Hair Pulling: Phenomenology and Related Psychopathology. 1994; 8:119-130


A brief overview of trichotillomania trick oh till oh main ee ah

DSM IV-R Definition of Trichotillomania (TTM)

  • A. Recurrent hairpulling with noticeable hair loss

  • B. Tension before pulling or when attempting to resist

  • C. Pleasure, gratification, or relief when pulling

  • D. Not better accounted for by another disorder and not due to a general medical condition

  • E. Clinically significant distress/functional impairment


How should it be classified

How Should it be Classified?

  • It is NOT Obsessive Compulsive Disorder (OCD)!

  • Is it an OC-Spectrum Disorder?

  • A Stereotypy Disorder?

  • A Body Focused Repetitive Behavior? (BFRB)

  • How SHOULD it be classified?

  • DSM-V Workgroup is pondering this very question


The dsm and current icd classification impulse control disorders

The DSM and Current ICD Classification: Impulse Control Disorders

Intermittent Explosive Disorder

Kleptomania

Pyromania

Pathological Gambling

Trichotillomania


Impulse control disorders not otherwise specified

Impulse-Control Disorders Not Otherwise Specified

ICD-NOS

This category is for disorders involving impulsive behaviors not mentioned in the main category. For example, compulsive sexual behavior, compulsive shopping, or skin picking, to the extent that this behavior damages the person's relationships and causes significant distress and trouble to the person.


Recommended classification body focused repetitive behaviors

Recommended Classification:Body Focused Repetitive Behaviors

  • Compulsive Hair Pulling (TTM)

  • Compulsive Skin Picking (CSP)

  • Excessive Nail Biting (Onychophagia)

  • Excessive Nose Picking

  • Excessive Lip Picking

  • Excessive Cheek biting

  • Common traits:

    repetitive, self-soothing, body-focused, grooming / pseudo-grooming related


A brief overview of trichotillomania trick oh till oh main ee ah

The Trichotillomania Impact Project:Exploring Phenomenology,Functional Impairment, & Treatment Utilization

Woods DW, Flessner CA, Franklin ME, Keuthen NJ, Goodwin R, Stein DJ, Walther M,

&

The TLC Scientific Advisory Board

Published December 2006: Journal of Clinical Psychiatry


A brief overview of trichotillomania trick oh till oh main ee ah

Most Common Pulling Sites

Adults

  • Scalp79%

  • Eyebrows65%

  • Eyelashes59%

  • Pubic59%

  • Legs 30%

  • Arm17%

  • Other25%

  • The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment Utilization J Clin Psychiatry 67:12, December 2006


A brief overview of trichotillomania trick oh till oh main ee ah

Most Common Pulling Sites

Children

  • Scalp85%

  • Eyebrows52%

  • Eyelashes38%

  • Pubic27%

  • Legs 18%

  • Arm 9%

  • More than one58%

  • The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment Utilization J Clin Psychiatry 67:12, December 2006


A brief overview of trichotillomania trick oh till oh main ee ah

Pulling Characteristics - Adult

CharacteristicResponse

  • Unpleasant urges prior to pulling71-89% of time

  • Pull to achieve a certain bodily sensation30-70% of time

  • Pulling preceded by bodily sensation71-89% of time

  • Pulling preceded by physical and

    mental anxiety0-10% of time

  • Urge increases when resisting71-89% of time

  • Post pulling anxiety90-100% of time

  • Awareness of pulling71-89% of time

    The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment Utilization J Clin Psychiatry 67:12, December 2006


A brief overview of trichotillomania trick oh till oh main ee ah

Pulling Phenomenology

Children

  • Pulling severity similar to Adult TTM

  • 29% never/almost never experienced tension prior to pulling

  • 13% never/almost never experienced “pleasure, gratification, or relief” after pulling

  • 4% said they were “Never” or “Almost Never” aware of pulling

  • The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment Utilization J Clin Psychiatry 67:12, December 2006


Trichobezoars hair balls

Trichobezoars: Hair Balls

  • Approximately ¼ of the TTM population does something oral with the hair – from rubbing it on a lip to ingesting part or all of the hair: causing the potential for a trichobezoar, or “hair ball” to develop because hair is not digestible. If a trichobezoar does form, it can become life threatening and must be removed surgically.


Other medical problems

Other Medical Problems

  • Other complications can arise as a result of pulling and picking behavior, such as:

  • Neuromuscular Problems

  • Carpal Tunnel Syndrome

  • Infections

  • Avoidance of Medical Care


Anxiety and bfrbs

Anxiety and BFRBs

On average, adults with a BFRB were more anxious than persons without a BFRB

The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment Utilization J Clin Psychiatry 67:12, December 2006


Depression and bfrbs

Depression and BFRBs

On average, adults with a BFRB were more depressed than persons without a BFRB

The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment Utilization J Clin Psychiatry 67:12, December 2006


A brief overview of trichotillomania trick oh till oh main ee ah

Occupational/Academic Impact

Occupational:

  • 23% report daily interference w/ job duties

  • 15% reported failing to pursue job advancement

  • 4% reported having quit a job b/c of pulling

    Academic:

  • 76% report difficulty w/ studying b/c of pulling

  • 5% reported having dropped out b/c of pulling

  • Mean of 9 missed school days/yr. due to pulling

  • The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment Utilization J Clin Psychiatry 67:12, December 2006


Functional impairment in children

Functional Impairment in Children

  • 55.6% of parents reported their children avoided social or recreational activities.

  • 54.9% of children reported TTM interfered with studying.

  • 36.1% of children reported TTM impaired academic performance.

    The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment Utilization J Clin Psychiatry 67:12, December 2006


Recommended treatment

Recommended Treatment


Challenges in treatment

Challenges in Treatment

  • Limited Public and Professional Awareness

  • Sufferers fail to initiate treatment due to limited awareness

  • Many mental health providers still diagnose it as OCD and minimize its severity/impact

  • Lack of trained professionals often results in poor treatment outcomes


Cognitive behavioral model

Cognitive-Behavioral Model

  • Behavior is a function of:

    antecedents and consequences

  • Antecedents: (things before…)

    • Visual, kinesthetic, tactile, affective, cognitive, environmental

  • Consequences: (things after…)

    • Positive emotional state, tension reduction, pleasurable sensation


Behavioral treatment

Behavioral Treatment

  • Cognitive Behavioral Treatment

    • Habit Reversal Training

    • Stimulus Control

    • Comprehensive Behavioral Approach (ComB)

    • Acceptance and Commitment Therapy

    • Dialectical Behavior Therapy


Pharmacotherapy

Pharmacotherapy

The literature includes case reports, a few case series, open trials and a few control studies.

No drug has received FDA approval for TTM.

Results across studies have been contradictory with only some showing modest improvement on meds.

Medications Used in the Treatment of TTM

Selective Serotonin Reuptake Inhibitors

Other Antidepressants

Opiate Antagonists

Mood Stabilizers

Anxiolytics

Neuroleptics

Topical Agents

Other Agents (ie, Methylphenidate)


Non prescription

Non-Prescription

Inositol (B-vitamin family)

N-acetyl-cysteine “NAC” (amino acid)

NAC - Recent Double Blind Study completed with promising results.

Diet

Sugar

Caffeine

Food Allergies

Missing Nutrients - i.e. DHA


Other non pharmacological approaches

Other Non-Pharmacological Approaches

Psychotherapy

Hypnotherapy

Support groups

Meditation

Prayer

Diet / Exercise

Stoppulling.com / Stoppicking.com


Current research overview tlc s role in promoting

Current research Overview:TLC’s Role in Promoting…

More research has taken place in the last two decades on TTM than in the previous 100 years.

This dates from the inception of the Trichotillomania Learning Center.


A brief overview of trichotillomania trick oh till oh main ee ah

TLC Funded Research

  • 8 Pilot Studies have been funded by the TLC Research Fund

    • 2003 Investigating the Efficacy of Combined Habit Reversal and Acceptance and Commitment Therapies as a treatment for TTM

    • 2003 A Comparison of Phenomenological Factors in TTM and TS (Tourette’s Syndrome)

    • 2004TTM: Investigating Clinical & Genetic Variants in the Genetically Homogeneous Afrikaner Population

    • 2005Investigating the Efficacy of Combined Habit Reversal and Acceptance and Commitment Therapies as a treatment for Chronic Skin Picking

    • 2008Two Icelandic Research Studies on Pathological Skin Picking

    • 2008The Comprehensive Survey on Trichotillomania: Analysis of a Large Data Set from 1,154 Hair Pullers

    • 2008Proposed Functional fMRI Study in TTM (neuroimaging)

    • 2009Double-Blind, Placebo-ControlledTrial of N-acetylcysteine for Childhood TTM


A brief overview of trichotillomania trick oh till oh main ee ah

Larger Research Projects

Assisted by TLC

  • Pediatric Manual NIMH grant 2003

  • NIMH RO1 Grant – Pediatrics 2008

  • NIMH RO1 Grant – Adult 2008

  • Impact Validation / Genetics Project

  • MGH Family Nature/Nurture Study

  • Addiction modeling studies (needed)

  • Medication studies (needed)


Why are genetics important

Why are Genetics Important?

  • To identify rational treatment, understanding the underlying biological processes that create the pathology (illness) allows the development of effective intervention at an appropriate point.

  • Several genes have now been implicated in some cases of TTM. (Research is still in early stages.)

  • These genes are Hoxb8, SLITRIK1, and SAPAP3


Barbering in mice an animal model

Barbering in Mice: an Animal Model?

  • “Barbering” (fur and whisker trimming in laboratory mice) can be a spontaneous animal model for TTM

  • Similarities to TTM: Barbering mice pluck focused areas of hair, a female bias exists, onset is normally during puberty, and post-pulling tactile and oral behaviors are noted.

Usually one unmarked barber

Barber is usually dominant


Morphometric neuroimaging findings

Morphometric Neuroimaging Findings

  • Decreased size of the left putamen in TTM vs control subjects

  • Decreased size of cerebellar cortex in TTM vs control subjects

  • TTM severity scores were inversely correlated with L primary sensorimotor cerebellar cluster volumes, with smaller volumes associated with more severe TTM.


Srt in ttm serial reactiontime

SRT in TTM(Serial ReactionTime)

The SRT is a neuroimaging test given to subjects while their brains are being scanned. It involves measuring reaction times in response to signals given.

  • No activation in either the striatum or hippocampus evident with the SRT in TTM

  • This suggests different brain circuitry involved in TTM and OCD


Current and future research

Current and Future Research

  • TLC has begun to establish a data repository for both phenotypic and genetic materials.

  • One goal is to learn more about TTM.

    Symptoms / Course / Outcome

  • Another goal is to find genes that increase the risk for TTM.

  • Eventually, this information should lead to better treatments for people who suffer from this disorder.


Summary of recent research advances in treatment

Summary of Recent Research & Advances in Treatment

  • TLC-sponsored research has led to significant advances in the understanding of both child and adult TTM over the past few years

  • These scientific gains have led to significant advances in treatment (primarily cognitive-behavioral treatments)

  • Combined intervention addressing multiple aspects of TTM may be the most effective approach

  • Ongoing work in behavioral, genetic, animal, and neuroscientific aspects of TTM should lead to more effective treatments over the next few years


A brief overview of trichotillomania trick oh till oh main ee ah

207 McPherson Street, Suite H  Santa Cruz, CA 95060  831-457-1004

www.trich.org


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