A Brief Overview ofTrichotillomania 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 % Christenson GA, Pyle RL, Mitchell JE. Estimated Lifetime prevalence of trichotillomania in college students. J Clin Psychiatry 1991; 52: % 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:

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 DSM IV-R Definition of Trichotillomania (TTM)

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 Intermittent Explosive Disorder Kleptomania Pyromania Pathological Gambling Trichotillomania

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 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

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

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 Most Common Pulling Sites Adults

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 Most Common Pulling Sites Children

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 Pulling Characteristics - Adult

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 Pulling Phenomenology Children

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 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 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 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

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 Occupational/Academic Impact

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

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 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 Cognitive Behavioral Treatment –Habit Reversal Training –Stimulus Control –Comprehensive Behavioral Approach (ComB) –Acceptance and Commitment Therapy –Dialectical Behavior Therapy

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 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 Psychotherapy Hypnotherapy Support groups Meditation Prayer Diet / Exercise Stoppulling.com / Stoppicking.com

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.

TLC Funded Research TLC Funded Research 8 Pilot Studies have been funded by the TLC Research Fund 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-ControlledT rial of N-acetylcysteine for Childhood TTM

 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) Larger Research Projects Assisted by TLC

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

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