Reversal of trichotillomania with aripiprazole

Sensory symptoms in body-focused repetitive behaviors, restless legs syndrome, and Tourette syndrome: An overlap?

Tourette syndrome (TS) is a neurodevelopmental condition characterized by multiple tics. Sensory symptoms play a key role in the clinical phenomenology and pathophysiology of TS, as most patients report premonitory urges driving tic expression. Interestingly, sensory symptoms have also been reported in other conditions characterized by repeated behaviors. This review explores the nature of sensory symptoms reported by patients with body focused repetitive behaviors (BFRBs, especially trichotillomania and skin picking disorder) and restless legs syndrome (RLS) in comparison to TS. A sense of mounting inner tension and reinforcement mechanisms driven by gratification and relief on expression of the tic or repetitive behavior appear to be implicated across all conditions. Subjective urges can be temporarily suppressed by patients with TS and selected BFRBs, whereas patients with RLS tend to report dysesthesia more frequently than a suppressible urge to move. The observed similarities in the phenomenology of sensory symptoms across these conditions raise the possibility of a comparable underlying pathophysiology. Preliminary findings suggest an overlap of neural pathways encompassing the insula, basal ganglia (putamen), and posterior cingulate cortex.

Trichotillomania is more related to Tourette disorder than to obsessive-compulsive disorder

OBJECTIVE

Trichotillomania (TTM) is characterized by the pulling out of one's hair. TTM was classified as an impulse control disorder in DSM-IV, but is now classified in the obsessive-compulsive related disorders section of DSM-5. Classification for TTM remains an open question, especially considering its impact on treatment of the disorder. In this review, we questioned the relation of TTM to tic disorder and obsessive-compulsive disorder (OCD).

METHOD

We reviewed relevant MEDLINE-indexed articles on clinical, neuropsychological, neurobiological, and therapeutic aspects of trichotillomania, OCD, and tic disorders.

RESULTS

Our review found a closer relationship between TTM and tic disorder from neurobiological (especially imaging) and therapeutic standpoints.

CONCLUSION

We sought to challenge the DSM-5 classification of TTM and to compare TTM with both OCD and tic disorder. Some discrepancies between TTM and tic disorders notwithstanding, several arguments are in favor of a closer relationship between these two disorders than between TTM and OCD, especially when considering implications for therapy. This consideration is essential for patients.

Critical Review of the Use of Second-Generation Antipsychotics in Obsessive-Compulsive and Related Disorders

Currently, all second-generation antipsychotics are approved for schizophrenia. Many are also approved for bipolar disorder, with some also approved as adjunctive treatment for depression and autism-related irritability. Second-generation antipsychotics are increasingly being prescribed for indications other than those approved by the Food and Drug Administration, such as in dementia, anxiety, and post-traumatic stress disorder to name a few. Obsessive-compulsive and related disorders are a group of disorders characterized by preoccupation and repetitive behaviors. According to the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, obsessive-compulsive disorder, body dysmorphic disorder, trichotillomania, hoarding disorder, and excoriation, the latter two being newly designated disorders, fall under obsessive-compulsive and related disorders. Due to a lack of well designed clinical studies specifically addressing the use of second-generation antipsychotics in obsessive-compulsive and related disorders, it is unknown whether these agents are clinically beneficial. Current research describing the pathophysiology of these disorders shows the involvement of similar brain regions and neurotransmitters across the five obsessive-compulsive and related disorders. Despite differences in the receptor binding profiles, second-generation antipsychotics share many common pharmacodynamics properties. This review sought to examine all the published reports of second-generation antipsychotics being used in the management of symptoms of the aforementioned diseases and compile evidence for clinicians who encounter patients who are unresponsive to standard treatment.

Review of available studies of the neurobiology and pharmacotherapeutic management of trichotillomania

Trichotillomania (TTM) is a psychiatric disorder characterized by an irresistible urge to pull out one's hair. Currently there are no FDA approved treatments for TTM, which makes it difficult for clinicians to select an appropriate therapeutic plan. The clinical studies that have been performed do not provide sufficient or consistent evidence regarding which drug classes should be administered. Unfortunately, most of the available data consist of case reports and clinical trials with limited sample size. This review provides an overview of currently available clinical literature that targets TTM. A summary of clinical trials as well as case reports is provided. The most common rating scales used for clinical assessment are also reviewed. The etiology of TTM remains unclear. Studies that examine various neuroanatomical, neurobiologic, as well as genetic factors associated with TTM are thoroughly discussed in this review. It is evident that clear understanding of TTM is crucial to provide better recognition, assessment, and treatment to patients of this disorder. Finally, despite research efforts for establishing pharmacological options for treatment, it is clear that new targets are warranted in order to ensure a clinically supported effective pharmacological approach to treat TTM.

Treatment of puberty trichotillomania with low-dose aripiprazole

The present case is of a 14-year-old female with trichotillomania (TTM) that was treated with a low dose of aripiprazole (ARP) 1.5 mg/day. To our knowledge, this is the first published report to show an improvement of pubertal TTM using an ultra-low dose of ARP. In this case, a 50-mg fluvoxamine monotherapy for 2 years and a subsequent 4-month comprehensive cognitive behavioral therapy (CBT) monotherapy did not improve her hair-pulling symptoms. However, the treatment with a low-dose ARP of 1.5 mg/day dramatically improved her TTM symptoms without extrapyramidal symptoms. In this regard, low-dose ARP treatment for TTM might be a safe alternative to antidepressants, which carry the risk of agitation with suicidal ideation in adolescents.

Aripiprazole augmentation in 13 patients with refractory obsessive-compulsive disorder: a case series

OBJECTIVES

The primary treatment for obsessive-compulsive disorder (OCD) is selective serotonin reuptake inhibitors (SSRI). However, approximately a third of patients do not respond to SSRIs and remain chronically affected.

METHODS

Therefore, we added aripiprazole to SSRI therapy for 13 patients with treatment-refractory OCD (subjects who failed to respond to SSRI therapy for at least 2 months, and for an average of 508 days). Participants underwent at least 7 weeks of treatment with aripiprazole augmentation.

RESULTS

Patients were evaluated using the Y-BOCS and GAF scales. Aripiprazole (3-12 mg)/SSRI co-therapy significantly improved Y-BOCS and GAF scores. However, many patients needed to take antiparkinsonian drugs to control extrapyramidal symptoms.

CONCLUSIONS

These results suggest that aripiprazole augmentation of SSRI therapy may be effective for treatment-refractory OCD.

Aripiprazole: Trichotillomania

This Hospital Pharmacy feature is extracted from Off-Label Drug Facts, a quarterly publication available from Wolters Kluwer Health. Off-Label Drug Facts is a practitioner-oriented resource for information about specific drug uses that are unapproved by the US Food and Drug Administration. This new guide to the literature enables the health care professional or clinician to quickly identify published studies on off-label uses and determine if a specific use is rational in a patient care scenario. References direct the reader to the full literature for more comprehensive information before patient care decisions are made. Direct questions or comments regarding Off-Label Drug Uses to jgeneral@kumc.edu .

The efficacy of low-dose aripiprazole treatment for trichotillomania

This case report describes a 20-year-old man with trichotillomania (TTM). The patient was first treated with paroxetine and carbocisteine without response. Following the addition of aripiprazole (3 mg/d) to the other medications, the TTM was fully alleviated. After stopping treatment, 1.5 to 3.0 mg/d of aripiprazole alone improved TMM symptoms upon recurrence. These findings indicate that further investigation of low-dose aripiprazole for the treatment of TTM is warranted.