04 - 10.4 Hair Pulling Disorder (Trichotillomania)

10.4 Hair-Pulling Disorder (Trichotillomania)

study, only 18 percent of patients responded to medication and CBT. The challenges posed by hoarding patients to typical CBT treatment include poor insight to the behavior and low motivation and resistance to treatment. The most effective treatment for the disorder is a cognitive behavioral model that includes training in decision making and categorizing; exposure and habituation to discarding; and cognitive restructuring. This includes both office and in-home sessions. The role of the therapist in this model is to assist in the development of decision-making skills, to provide feedback about normal saving behavior, and to identify and challenge the patient’s erroneous beliefs about possessions. The goal in treatment is to get rid of a significant amount of possessions, thereby making the living space livable, and to provide the patient with the skills to maintain a positive balance between the amount of possessions and livable space. Studies have shown a 25 to 34 percent reduction in hoarding behaviors using this method. Restructuring of this method for group and webbased interventions are currently under study and show promise. Pharmacological treatment studies using SSRIs have shown mixed results. Some studies have shown a negative response to SSRI treatment in hoarding patients compared with nonhoarders, while others have found no significant difference between the two groups. REFERENCES DiMauro J, Genova M, Tolin DF, Kurtz MM. Cognitive remediation for neuropsychological impairment in hoarding disorder: A pilot study. J Obsessive-Compulsive and Related Disorders. 2014;3(2), 132–138. Frost RO, Steketee G, Tolin DF. Comorbidity in hoarding disorder. Depress Anxiety. 2011;28:876. Frost RO, Tolin DF, Steketee G, Fitch KE, Selbo-Bruns A. Excessive acquisition in hoarding. J Anxiety Disord. 2009;23:632. Grisham JR, Norberg MM, Williams AD, Certoma SP, Kadib R. Categorization and cognitive deficits in compulsive hoarding. Behav Res Ther. 2010;48:886. Hall BJ, Tolin DF, Frost RO, Steketee G. An exploration of comorbid symptoms and clinical correlates of clinically significant hoarding symptoms. Depress Anxiety. 2013;30(1):67–76. Hoarding disorder. In: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013:247. Iervolino AC, Perroud N, Fullana MA, Guipponi M, Cherkas L, Collier DA, Mataix-Cols D. Prevalence and heritability of compulsive hoarding: A twin study. Am J Psychiatry. 2009;116:1156. Mataix-Cols D, Billotti D, de la Cruz L, Nordsletten A. The London field trial for hoarding disorder. Psychol Med. 2013;43(4):837–847. Timpano KR, Rasmussen J, Exner C, Rief W, Schmidt NB, Wilhelm S. Hoarding and the multi-faceted construct of impulsivity: A cross-cultural investigation. J Psychiatr Res. 2013;47(3):363–370. Tolin DF, Villavicencio A. Inattention, but not obsessive-compulsive disorder, predicts the core features of hoarding disorder. Behav Res Ther. 2011;49:120. 10.4 Hair-Pulling Disorder (Trichotillomania) Hair-pulling disorder is a chronic disorder characterized by repetitive hair pulling,

leading to variable hair loss that may be visible to others. It is also known as trichotillomania, a term coined by a French dermatologist Francois Hallopeau in 1889. The disorder was once deemed rare and little about it was described beyond phenomenology. It is now regarded as more common. The disorder is similar to obsessive-compulsive disorder and impulse control in that there is increased tension prior to the hair pulling and a relief of tension or gratification after the hair pulling. EPIDEMIOLOGY The prevalence of hair-pulling disorder may be underestimated because of accompanying shame and secretiveness. The diagnosis encompasses at least two categories of hair pulling that differ in incidence, severity, age of presentation, and gender ratio. Other subsets may exist. The most serious, chronic form of the disorder usually begins in early to midadolescence, with a lifetime prevalence ranging from 0.6 percent to as high as 3.4 percent in general populations and with female to male ratio as high as 10 to 1. The number of men may actually be higher, because men are even more likely than women to conceal hair pulling. A patient with chronic hair-pulling disorder is likely to be the only or oldest child in the family. A childhood type of hair-pulling disorder occurs approximately equally in girls and boys. It is said to be more common than the adolescent or young adult syndrome and is generally far less serious dermatologically and psychologically. An estimated 35 to 40 percent of patients with hair-pulling disorder chew or swallow the hair that they pull out at one time or another. Of this group, approximately onethird develop potentially hazardous bezoars—hairballs accumulating in the alimentary tract. COMORBIDITY Significant comorbidity is found between hair-pulling disorder and obsessive-compulsive disorder (OCD); anxiety disorders; Tourette’s disorder; depressive disorders; eating disorders; and various personality disorders—particularly obsessive-compulsive, borderline, and narcissistic personality disorders. Comorbid substance abuse disorder is not encountered as frequently as it is in pathological gambling, kleptomania, and other impulse disorders. ETIOLOGY Although hair-pulling disorder is regarded as multidetermined, its onset has been linked to stressful situations in more than one-fourth of all cases. Disturbances in mother–child relationships, fear of being left alone, and recent object loss are often cited as critical factors contributing to the condition. Substance abuse may encourage development of the disorder. Depressive dynamics are often cited as predisposing factors, but no particular personality trait or disorder characterizes patients. Some see self-stimulation

as the primary goal of hair pulling. Family members of hair-pulling disorder patients often have a history of tics, impulsecontrol disorders, and obsessive-compulsive symptoms, further supporting a possible genetic predisposition. One study looked at the neurobiology of hair-pulling disorder and found a smaller volume of the left putamen and left lenticulate areas. More recently, a study of the genetics of trichotillomania reported a relationship between a serotonin 2A (5-HT2A) receptor gene polymorphism (T102C) and trichotillomania. However, because these studies examined relatively few subjects, these findings need to be replicated in a larger sample to be able to determine the role of basal ganglia abnormalities and serotonin in the etiology of trichotillomania. DIAGNOSIS AND CLINICAL FEATURES The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes diagnostic criteria from hair-pulling disorder. Before engaging in the behavior, patients with hair-pulling disorder may experience an increasing sense of tension and achieve a sense of release or gratification from pulling out their hair. All areas of the body may be affected, most commonly the scalp (Fig. 10.4-1). Other areas involved are eyebrows, eyelashes, and beard; trunk, armpits, and pubic area are less commonly involved (Fig. 10.4-2). FIGURE 10.4-1 Hair-pulling disorder (trichotillomania). Note the typical findings of an area of incomplete alopecia involving the frontal and vertex scalp. (From Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2009, with permission.)

FIGURE 10.4-2 Example of plucking of the pubic hair because of hair-pulling disorder. Two types of hair pulling have been described. Focused pulling is the use of an intentional act to control unpleasant personal experiences, such as an urge, bodily sensation (e.g., itching or burning), or thought. In contrast, automatic pulling occurs outside the person’s awareness and most often during sedentary activities. Most patients have a combination of these types of hair pulling. Hair loss is characterized by short, broken strands appearing together with long, normal hairs in the affected areas. No abnormalities of the skin or scalp are present. Hair pulling is not reported as being painful, although pruritus and tingling may occur in the involved area. Trichophagy, mouthing of the hair, may follow the hair plucking. Complications of trichophagy include trichobezoars, malnutrition, and intestinal obstruction. Patients usually deny the behavior and often try to hide the resultant alopecia. Head banging, nail biting, scratching, gnawing, excoriation, and other acts of self-mutilation may be present. Ms. C, a 27-year-old single woman, came to a local clinic complaining of persistent hair pulling. She first started at age 11, when she began to pick the hairs at the nape of her neck. She would persistently pick at the hair until there was almost none left. Fortunately, her hair was long, so no one noticed the lack of hair at the back of her neck. Over the years, her hair picking progressed until she began picking hair from her entire head, leaving noticeable small bald patches. She strategically hid the bald patches by brushing over the remainder of her hair or with carefully placed scarves and hats. Despite her habit, Ms. C was pretty normal. She got good grades in school and was a year away from getting her master’s degree. Ms. C’s habit was constant, occurring every day, often without her noticing it. She could simply be reading an assignment for school and eventually her hand would find

its way into her hair to find a hair to pull. Soon she would notice a small pile of hairs in her book or on her lap, indicating that she had been pulling her hair out for a while. Whenever she tried to stop herself from pulling her hair, she would become increasingly nervous and anxious until she resumed the hair pulling. Her hair pulling sessions lasted anywhere from 10 minutes to an hour. PATHOLOGY AND LABORATORY EXAMINATION If necessary, the clinical diagnosis of hair-pulling disorder can be confirmed by punch biopsy of the scalp. In patients with a trichobezoar, blood count may reveal a mild leukocytosis and hypochromic anemia due to blood loss. Appropriate chemistries and radiological studies should also be performed, depending on the bezoar’s suspected location and impact on the gastrointestinal (GI) tract. DIFFERENTIAL DIAGNOSIS Hair pulling may be a wholly benign condition or it may occur in the context of several mental disorders. The phenomenology of hair-pulling disorder and OCD overlap. As with OCD, hair-pulling disorder is often chronic and recognized by patients as undesirable. Unlike those with OCD, patients with hair-pulling disorder do not experience obsessive thoughts, and the compulsive activity is limited to one act, hair pulling. Patients with factitious disorder actively seek medical attention and the patient role and deliberately simulate illness toward these ends. Patients who malinger or who have factitious disorder may mutilate themselves to get medical attention, but they do not acknowledge the self-inflicted nature of the lesions. Patients with stereotypic movement disorder have stereotypical and rhythmic movements, and they usually do not seem distressed by their behavior. A biopsy may be necessary to distinguish hair-pulling disorder from alopecia areata and tine capitis. COURSE AND PROGNOSIS The mean age at onset of hair-pulling disorder is in the early teens, most frequently before age 17, but onset has been reported much later in life. The course of the disorder is not well known; both chronic and remitting forms occur. An early onset (before age 6) tends to remit more readily and responds to suggestions, support, and behavioral strategies. Late onset (after age 13) is associated with an increased likelihood of chronicity and poorer prognosis than the early-onset form. About a third of persons presenting for treatment report a duration of 1 year or less, whereas in some cases, the disorder has persisted for more than two decades. TREATMENT No consensus exists on the best treatment modality for hair-pulling disorder. Treatment usually involves psychiatrists and dermatologists in a joint endeavor.

Psychopharmalogical methods that have been used to treat psychodermatological disorders include topical steroids and hydroxyzine hydrochloride (Vistaril), an anxiolytic with antihistamine properties; antidepressants; and antipsychotics. Initial case reports showed efficacy of selective serotonin reuptake inhibitors (SSRIs) for hair-pulling disorder. Patients who respond poorly to SSRIs may improve with augmentation with pimozide (Orap), a dopamine receptor antagonist. Other medications that have been reported to have some efficacy for hair-pulling disorder include fluvoxamine (Luvox), citalopram (Celexa), venlafaxine (Effexor), naltrexone (ReVia), and lithium (Eskalith). A report of successful lithium treatment cited the possible effect of the drug on aggression, impulsivity, and mood instability as an explanation. In one study, patients taking naltrexone had a reduction in symptom severity. Case reports also indicate successful treatment with buspirone (BuSpar), clonazepam (Klonopin), and trazodone (Desyrel). Successful behavioral treatments, such as biofeedback, self-monitoring, desensitization, and habit reversal, have been reported, but most studies have been based on individual cases or a small series of cases with relatively short follow-up periods. Chronic hair-pulling disorder has been treated successfully with insight-oriented psychotherapy. Hypnotherapy has been mentioned as potentially effective in the treatment of dermatological disorders in which psychological factors may be involved; the skin has been shown to be susceptible to hypnotic suggestion. REFERENCES Bloch MH. Trichotillomania and other impulsive-control disorders. In: Hudak R, Dougherty DD, eds. Clinical ObsessiveCompulsive Disorders in Adults and Children. New York: Cambridge University Press; 2011:207. Grant JE, Stein DJ, Woods DW, Keuthen NJ, eds. Trichotillomania, Skin Picking, and Other Body-Focused Repetitive Behaviors. Arlington, VA: American Psychiatric Publishing; 2011. Keuthen NJ, Rothbaum BO, Falkenstein MJ, Meunier S, Timpano KR, Jenike MA, Welch SS. DBT-enhanced habit reversal treatment for trichotillomania: 3-and 6-month follow-up results. Depress Anxiety. 2011;28:310. Klipstein KG, Berman L. Bupropion XL for the sustained treatment of trichotillomania. J Clin Psychopharm. 2012;32:298. Kumar B. The mind-body connection: An integrated approach to the diagnosis of colonic trichobezoar. Int J Psychiatry Med. 2011;41:263. Lee HJ, Franklin SA, Turkel JE, Goetz AR, Woods DW. Facilitated attentional disengagement from hair-related cues among individuals diagnosed with trichotillomania: An investigation based on the exogenous cueing paradigm. J Obsess Compul Relat Disord. 2012;1:8. Leombruni P, Gastaldi F. Oxcarbazepine for the treatment of trichotillomania. Clin Neuropharm. 2010:33:107. Lochner C, Seedat S, Stein DJ. Chronic hair-pulling: Phenomenology-based subtypes. J Anxiety Disord. 2010;24:196. McDonald KE. Trichotillomania: Identification and treatment. J Counsel Dev. 2012;90:421. Moeller FG. Impulse-control disorders not elsewhere classified. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Baltimore: Lippincott Williams & Wilkins; 2009:2178. Panza KE, Pittenger C, Bloch MH. Age and gender correlates of pulling in pediatric trichotillomania. J Am Acad Child Adolesc Psychiatry. 2013;52(3):241–249. Roos A, Fouche J-P, Stein DJ, Lochner C. White matter integrity in hair-pulling disorder (trichotillomania). Psychiatry Res. 2013;211(3):246–250.