Update on Trichotillomania

Despite its occurrence in up to 3.4% of adults, hair-pulling disorder or trichotillomania (TTM) is often under-diagnosed and inappropriately treated, according to a panel of experts presenting at the recent APA meeting in Philadelphia. 
   
The experts described the phenomenology, epidemiology, symptoms and diagnosis of trichotillomania; discussed psychopharmacological and behavioral treatment modalities for the disorder, along with recent trials in children and adults; highlighted research advances; and summarized proposed changes for the disorder in the DSM-5. 

Presenters were Douglas Woods, PhD, Professor of Psychology at the University of Wisconsin-Milwaukee, who has an NIH grant to study Acceptance-Enhanced Behavior Therapy for Trichotillomania; Jon E Grant, MD, MPH, JD, Professor of Psychiatry and Co-Director of the Impulse Control Disorders Clinic at the University of Minnesota-Milwaukee; and Martin Franklin, PhD, Associate Professor of Clinical Psychology in Psychiatry at the University of Pennsylvania and Director of the Child and Adolescent OCD, Tic, Trich and Anxiety Group (COTTAGe). Others were Michael Bloch, MD, Assistant Professor in the Yale Child Study Center and Assistant Director of the Yale OCD Clinic, and Eric Hollander, MD, Clinical Professor in the Department of Psychiatry and Behavioral Sciences and Director of the Autism and Obsessive Compulsive Spectrum Program at the Albert Einstein College of Medicine, Montefiore Medical Center, in New York. Melissa Rooney, MD, served as Chair.

In his overview of trichotillomania, Woods described TTM as a “poorly understood disorder” that affects “lots of people,” primarily females. The estimated lifetime prevalence in adults ranges between 0.6% and 3.4%. TTM seems to have a bimodal age of onset, he said. The typical onset of TTM is between ages 9 and 13. This group usually has a more chronic form of the disorder and a “more difficult response to treatment,” Woods added. “Baby trich,” with onset between 18 months and 4 years, Woods said, is believed to be short-term, related to attachment issues and related to covarying oral habits.

TTM frequently exists with other disorders, according to several presenters. In one study, Flessner and colleagues¹ found that up to 60% of individuals with TTM had another current psychiatric disorder. Disorders often comorbid with TTM include major depression, generalized anxiety disorder, social phobia, obsessive-compulsive disorder, other impulse control disorders and substance use disorder.

While some clinicians have speculated that the hair pulling may be a response to trauma, Woods said that only 5% of patients have comorbid TTM and post-traumatic stress disorder (PTSD). 

Impact
Common pulling sites, Woods said, include the scalp, eyelashes, eyebrows, and pubic area. Pulling can be both automatic (ie, outside awareness) and focused (ie,in response to identifiable affective triggers) within each individual, rather than exclusively one form or the other, although automatic pulling seems more prevalent in children.

TTM sufferers can experience medical complications such as skin irritations at the pulling site, dental problems from biting or chewing their hair, infections, and repetitive-use hand injuries. A subset of individuals with TTM who ingest the hairs after pulling are at risk for GI complications stemming from trichobezoars, which have been documented in children as young as 4 years.

In the Trichotillomania Impact Project for Adults (TIP-A), an Internet-based survey of individuals with TTM, those surveyed (1697 respondents) reported mild to moderate life impairment in social, occupational, academic, and psychological functioning, Woods said. For example, more than 20% said they avoided vacations, 23% said TTM interfered with their job duties, and 24% said they missed school.²  In the Child and Adolescent Trichotillomania Impact Project (CA-TIP), most of the surveyed 133 youths (ages 10 to 17) reported some impairment in social and academic functioning.³ Some children with TTM have experienced significant impairment due to peer teasing, avoidance of activities such as swimming and socializing and difficulty in concentrating on schoolwork. 

Grant, in his presentation, discussed the heterogeneity of TTM and the likely genetic and familial links. “There is probably involvement of multiple genes conferring biological vulnerability,” he said. A twin study, he added, showed significant differences. Among 34 identified twin pairs, 24 were monozygotic (MZ) and 10 were dizygotic (DZ). Respective concordance rates for MZ and DZ twin pairs were significantly different at 38.1% and 0% for DSM-IV TTM criteria.⁴

Grant also explored the neurobiological underpinning of TTM as identified using neuroimaging, neurocognitive assessment and animal models. The stop-signal reaction-time (SSRT) task, which measures inhibition of a response that has already been initiated (ie, the ability to stop), was administered to individuals with TTM and individuals with OCD, Grant said. Chamberlain and coworkers⁵ found that both OCD and TTM individuals showed impaired inhibition of motor responses, but for those with TTM, the deficit was worse than for those with OCD. 

Treatment approaches
The FDA has not approved any pharmacological treatment for TTM. Several of the presenters emphasized that SSRIs-the most commonly prescribed pharmacological treatment for trichotillomania-have little or no efficacy in treating hair-pulling, although they may be helpful for patients with comorbid TTM and depression or anxiety. Clomipramine (Anafranil), a tricyclic antidepressant with serotonergic and other properties, appears to be more efficacious than placebo, but its unfavorable adverse-effect profile renders it a second-line treatment.

New data have emerged that support the efficacy of N-acetylcysteine (NAC), a glutamate modulator, and olanzapine (Zyprexa), an atypical antipsychotic, for TTM. In a 12-week, double-blind, placebo-controlled trial involving 50 adults with TTM, Grant and associates⁶ found that those assigned to receive NAC experienced a mean reduction (improvement) of 40.9% on the primary outcome measure (ie, Massachusetts General Hospital Hair Pulling Scale [MGH-HPS], and a responder rate of 56% (ie, "much" or "very much" improved on the Clinical Global Impressions (CGI) scale by the study endpoint).

Bloch presented results of a randomized placebo-controlled trial of NAC in children with TTM, in which NAC was not found to be more effective than placebo in treating symptoms of pediatric TTM.  He recommended using behavioral therapy for children with TTM before attempting any pharmacological interventions.

Regarding olanzapine, Van Ameringen and colleagues⁷ conducted a randomized, double-blind, placebo-controlled trial to determine whether a dopaminergic treatment such as that used in tics and Tourette syndrome would be effective against trichotillomania. The researchers reported that 85% of olanzapine-treated patients (11 of 13) and 17% of placebo-treated patients (2 of 12) were considered responders according to the primary outcome measure, the Clinical Global Impressions-Improvement (CGI-I) scale (P = .001).

Franklin noted that efficacious, nonpharmacological treatments have been used for TTM, in particular, cognitive-behavioral interventions involving procedures collectively known as habit reversal training.

Core TTM treatment elements, according to Franklin, include psychoeducation; self-monitoring/awareness training, wherein techniques are implemented to improve the patient’s awareness of pulling and the patient’s awareness of the urge that precedes pulling; stimulus control, which includes a variety of methods that serve as “speed bumps” to reduce the likelihood that pulling behavior begins; competing response training, in which patients are taught at the earliest sign of pulling or of the urge to pull, to engage in a behavior that is physically incompatible with pulling for a brief period until the urge subsides; and addressing internal antecedents and affect regulation functions (eg relaxation techniques for stress management). 

He emphasized that parents of children with TTM should avoid using guilt to try and control their child’s hair-pulling behaviors and that clinicians should use positive reinforcement. Further discussion of pediatric trichotillomania is contained in a recent article by Harrison and Franklin.⁸

Some resources for patients mentioned by the presenters include the Trichotillomania Learning Center (http://www.trich.org) and StopPulling.com, an online behavioral program designed to help individuals reduce their hair pulling.

Hollander ended the symposium by discussing the rationale for the proposed change in name from trichotillomania to hair-pulling disorder (trichotillomania). In the DSM-IV-TR, TTM is classified as one of five impulse control disorders, he said. In DSM-5, experts are recommending it be listed as an obsessive-compulsive spectrum disorder.


References1. Flessner CA, Knopik VS, McGeary J. Hair pulling disorder (trichotillomania): genes, neurobiology, and a model for understanding impulsivity and compulsivity. Psychiatry Res. 2012 Apr 24; [Epub ahead of print].
2. Woods DW, Flessner CA, Franklin ME, et al; Trichotillomania Learning Center-Scientific Advisory Board. The Trichotillomania Impact Project (TIP): exploring phenomenology, functional impairment, and treatment utilization. J Clin Psychiatry. 2006;67:1877-1888.
3. Franklin ME, Flessner CA, Woods DW, et al; Trichotillomania Learning Center-Scientific Advisory Board. The Child and Adolescent Trichotillomania Impact Project: descriptive psychopathology, comorbidity, functional impairment, and treatment utilization. J Dev Behav Pediatr. 2008;29:493-500.
4. Novak CE, Keuthen NJ, Stewart SE, Pauls DL. A twin concordance study of trichotillomania. Am J Med Genet B Neuropsychiatr Genet. 2009;150B:944-949.
5. Chamberlain SR, Fineberg NA, Blackwell AD, et al. Motor inhibition and cognitive flexibility in obsessive-compulsive disorder and trichotillomania. Am J Psychiatry. 2006;163:1282-1284.
6. Grant JE, Odlaug BL, Kim SW. N-acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: a double-blind, placebo-controlled study. Arch Gen Psychiatry. 2009;66:756-763.
7. Van Ameringen M, Mancini C, Patterson B, et al.  A randomized, double-blind, placebo-controlled trial of olanzapine in the treatment of trichotillomania. J Clin Psychiatry. 2010;71:1336-1343.
8. Harrison JP, Franklin ME.  Pediatric trichotillomania. Curr Psychiatry Rep. 2012;14:188-196.