Quality of life and clinical severity in pathological skin picking and trichotillomania

Age at onset in trichotillomania:clinical variables and neurocognitive performance

OBJECTIVE

Trichotillomania (TTM), or compulsive hair pulling, is a common psychiatric disorder characterized by psychosocial impairment and reduced quality of life. The aim of this retrospective study was to characterize the impact of age at TTM onset on clinical variables and neuropsychological function using a variety of clinical and neurocognitive measures.

METHOD

The study sample included 98 adult treatment-seeking individuals with a DSM-IV diagnosis of TTM. Correlates were explored by grouping participants into childhood-onset (onset at ≤ 11 years old, n = 42) or later-onset (≥ 12 years old, n = 56) TTM and via linear regression. All subjects underwent a semistructured clinical interview with a psychiatrist and completed a variety of paper-pencil tests regarding TTM severity and quality of life. A subset (n = 44) of subjects underwent neurocognitive testing assessing motor inhibition and set-shifting compared to a sample (n = 27) of age- and gender-matched healthy controls. Data were collected from September 2006 through July 2011.

RESULTS

Postpubertal age at onset was significantly associated with greater TTM symptom severity. Clinically, the later-onset group pulled their hair for a significantly greater amount of time daily (P = .008), had higher clinician-rated TTM severity on the Clinical Global Impressions-Severity of Illness scale (P = .042), and had higher patient-rated severity on the Massachusetts General Hospital Hairpulling Scale (P = .022) compared to healthy controls. On the neurocognitive tasks, later-onset TTM was characterized by stop-signal impairments (P = .020) and relatively spared set-shifting, consistent with previous studies in the literature. In contrast, the childhood-onset manifestation was associated with set-shifting deficits in stages of the task completed and total errors adjusted (both P < .001) but relatively spared stop-signal performance compared to healthy controls.

CONCLUSION

Results indicate that childhood-onset of TTM is common, as confirmed by the fact that 42.9% of our sample met childhood-onset criteria, and may differ neurobiologically from the prototypical later-onset form. Future neurobiological and treatment studies should measure age at onset and explore further these putative differences.Trial Registration ClinicalTrials.gov identifiers: NCT00354770 and NCT00775229.

Dronabinol, a cannabinoid agonist, reduces hair pulling in trichotillomania: a pilot study

RATIONALE

Trichotillomania is characterized by repetitive pulling causing noticeable hair loss. Pharmacological treatment data for trichotillomania are limited.

OBJECTIVE

Dronabinol appears to reduce the exocitotoxic damage caused by glutamate release in the striatum and offers promise in reducing compulsive behavior.

METHODS

Fourteen female subjects (mean age = 33.3  ±  8.9) with DSM-IV trichotillomania were enrolled in a 12-week open-label treatment study of dronabinol (dose ranging from 2.5-15 mg/day). The primary outcome measure was change from baseline to study endpoint on the Massachusetts General Hospital Hair Pulling Scale (MGH-HPS). In order to evaluate effects on cognition, subjects underwent pre- and post-treatment assessments using objective computerized neurocognitive tests. Data were collected from November 2009 to December 2010.

RESULTS

Twelve of the 14 subjects (85.7%) completed the 12-week study. MGH-HPS scores decreased from a mean of 16.5  ±  4.4 at baseline to 8.7  ±  5.5 at study endpoint (p = 0.001). Nine (64.3%) subjects were "responders" (i.e., ≥ 35% reduction on the MGH-HPS and "much or very much improved" Clinical Global Impression scale). The mean effective dose was 11.6  ±  4.1 mg/day. The medication was well-tolerated, with no significant deleterious effects on cognition.

CONCLUSIONS

This study, the first to examine a cannabinoid agonist in the treatment of trichotillomania, found that dronabinol demonstrated statistically significant reductions in trichotillomania symptoms, in the absence of negative cognitive effects. Pharmacological modulation of the cannabinoid system may prove useful in controlling a range of compulsive behaviors. Given the small sample and open-label design, however larger placebo-controlled studies incorporating cognitive measures are warranted.