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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
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