Depression, anxiety, and functional impairment in children with trichotillomania

Statistical predictors of psychosocial impairment in body-focused repetitive behaviors

BACKGROUND

Skin picking disorder and trichotillomania, also characterized as body-focused repetitive behaviors (BFRBs), often lead to functional impairment. Some people with BFRBs, however, report little if any psychosocial dysfunction. There has been limited research as to which clinical aspects of BFRBs are associated with varying degrees of functional impairment.

METHODS

Adults (n = 98), ages 18 to 65 with a current diagnosis of trichotillomania (n = 37), skin picking disorder (n = 32), trichotillomania plus skin picking disorder (n = 10), and controls (n = 19) were enrolled. Partial least squares regression (PLS) was used to identify variables associated with impairment on the Sheehan Disability Scale.

RESULTS

PLS identified an optimal model accounting for 45.8% of variation in disability. Disability was significantly related to (in order of descending coefficient size): severity of picking, perceived stress, comorbid disorders (specifically, anxiety disorders / obsessive-compulsive disorder), trait impulsivity, family history of alcohol use disorder, atypical pulling/picking sites, and older age.

CONCLUSIONS

At present mental disorders are viewed as unitary entities; however, the extent of impairment varies markedly across patients with BFRBs. These data suggest that whereas symptom nature/severity is important in determining impairment, so too are other variables commonly unmeasured in clinical practice. Outcomes for patients may thus be maximized by rigorously addressing comorbid disorders; as well as integrating components designed to enhance top-down control and stress management. Interestingly, focused picking and emotional pulling were linked to worse disability, hinting at some differences between the two types of BFRBs, in terms of determinants of impairment.

Trichotillomania and Skin-Picking Disorder: An Update

Trichotillomania (hair pulling disorder) and skin-picking (excoriation) disorder are common neuropsychiatric disorders (each with a point prevalence of around 2%) but are underrecognized by professionals. Affected individuals repeatedly pull out their own hair or pick at their skin, and these symptoms not only have a negative impact on these individuals because of the time they occupy but can also lead to considerable physical disfigurement, with concomitant loss of self-esteem and avoidance of social activities and intimate relationships. The behaviors may also have serious physical consequences. Trichotillomania and skin picking frequently co-occur, and both disorders commonly present with co-occurring depression, anxiety, impulsive, and obsessive-compulsive disorders. Behavioral therapy currently appears to be the most effective treatment for both. Pharmacotherapy, in the form of N-acetylcysteine or olanzapine, may also play a role in treatment.

Measuring Treatment Response in Pediatric Trichotillomania: A Meta-Analysis of Clinical Trials

Objectives: In clinical trials of pediatric trichotillomania (TTM), three instruments are typically employed to rate TTM severity: (1) the Massachusetts General Hospital Hair Pulling Scale (MGH-HPS), (2) the National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS), and (3) the Trichotillomania Scale for Children (TSC). These instruments lack standardized definitions of treatment response, which lead researchers to determine their own definitions of response post hoc and potentially inflate results. We performed a meta-analysis to provide empirically determined accuracy measures for percentage reduction cut points in these three instruments. Methods: MEDLINE was searched for TTM clinical trials. A total of 67 studies were initially identified, but only 5 were clinical trials focused on TTM in pediatric populations and therefore were included in this meta-analysis (n = 180). A Clinical Global Impressions Improvement score ≤2 was used to define clinical response. Receiver operating characteristic principles were employed to determine accuracy measures for percentage reduction cut points on each one of the instruments. Meta-DiSc software was employed to provide pooled accuracy measures for each cut point for each instrument. The Youden Index and the distance to corner methods were used to determine the optimal cut point. Results: The optimal cut points to determine treatment response were a 45% reduction on the MGH-HPS (Youden Index 0.40, distance to corner 0.20), a 35% reduction on the NIMH-TSS (Youden Index 0.42, distance to corner 0.17), a 25% reduction on the TSC child version (TSC-C; Youden Index 0.40, distance to corner 0.18), and a 45% (distance to corner 0.30) or 50% reduction (Youden Index 0.33) on the TSC parent version (TSC-P). The TSC-C had less discriminative ability at determining response in younger children in comparison to older children; no age-related differences were observed on the TSC-P. Conclusions: This study provides empirically determined cut points of treatment response on three instruments that rate TTM severity. These data-driven cut points will benefit future research on pediatric TTM.

Electroconvulsive therapy for trichotillomania in a bipolar patient

A recent review on the use of electroconvulsive therapy (ECT) in obsessive-compulsive-related disorders (OCRDs) identified reports of trichotillomania (TTM) in only three patients, but it did not describe the specific effect of ECT on hair-pulling behaviors. The authors present a case report of Mrs. A, a 77-year-old widowed housewife with a lifelong history of episodic TTM and bipolar disorder who was effectively treated with ECT. However, on each attempt to withdraw ECT, her condition deteriorated. Eventually, a decision was made to maintain ECT (one session every week), which resulted in no further relapse over the followup period. ECT shows some potential promise for reducing hair-pulling behaviors in the context of severe depression.

Trichotillomania (hair pulling disorder)

Trichotillomania is characterized by the repetitive pulling out of one's own hair leading to hair loss and possibly functional impairment. Trichotillomania has been documented in the medical literature since the 19^th century. Prevalence studies suggest that trichotillomania is a common disorder (point prevalence estimates of 0.5%-2.0%). Although grouped with the obsessive-compulsive disorder (OCD) in the diagnostic and statistical manual of mental disorders-5, trichotillomania is distinct from OCD in many respects. For example, the treatment of trichotillomania generally employs habit reversal therapy and medication (n-acetylcysteine or olanzapine), both of which are quite different from those used to treat OCD. Conversely, some first-line treatments used for OCD (e.g., selective serotonin reuptake inhibitors) appear ineffective for trichotillomania. This article presents what is known about trichotillomania and the evidence for a variety of treatment interventions.

Awareness Enhancing and Monitoring Device plus Habit Reversal in the Treatment of Trichotillomania: An Open Feasibility Trial

Habit Reversal Therapy (HRT) is helpful for many persons suffering from trichotillomania. However successful habit reversal therapy requires awareness of hair pulling behaviors. Available methods to monitor hair pulling behaviors are less than ideal, particularly when sufferers are unaware of their pulling-related behaviors. This open feasibility trial included 20 persons with trichotillomania who were treated with nine weeks of HRT with experienced clinicians following a well-established HRT protocol. HRT was augmented with an electronic Awareness Enhancing and Monitoring Device (AEMD) designed to alert users of hand to head contact and to monitor the frequency of pulling-related behaviors. The AEMD included a neck unit and two wrist units, each equipped with vibrating alert functions. The results of the open trial revealed significant improvements in trichotillomania symptoms as measured by clinician and self-report rating scales. Most participants met study criteria for HRT completion and treatment effects were large. Participants reported that the AEMD, when operational, was effective in alerting participants to TTM-related behaviors. The monitoring function of the AEMD did not operate as designed. Subjective feedback focused on the AEMD concept was positive but AEMD reliability problems and complaints about the wearability the units were common. Recommendations for AEMD design modifications were included.

Trichotillomania in celiac disease patient refractory to iron replacement

Trichotillomania is characterized by recurring hair pulling behavior and repeated attempts to decrease or stop the behavior. This behavior can cause a trichobezoar, which is a mass of hair found in the stomach. Patients with diagnosed celiac disease may have an urge to swallow their hair due to iron or folat deficiency, which is called pica. We report a case of an 11-year old girl with celiac disease who has had trichotillomania for a duration of 2 years, and required an operation due to residual gastric hair mass. In this case trichotillomania was more likely caused by behavioral disorders secondary to celiac disease, rather than the iron deficiency due to malabsorption.

Trichotillomania

Trichotillomania, characterized by the repetitive pulling out of one’s own hair leading to hair loss and functional impairment, has been documented in the medical literature since the 19^th century, but has received scant research attention. Community prevalence studies suggest that trichotillomania is a common disorder with point prevalence estimate of 0.5% to 2.0%. Although recently grouped with OCD in the DSM-5, clinicians need to be aware that trichotillomania and OCD may have less in common than originally thought. In fact, approaches to treating trichotillomania, which include habit reversal therapy and medication (n-acetyl cysteine or olanzapine), are quite different from those used to treat OCD; and some first-line treatments used for OCD appear ineffective for trichotillomania. Based on our clinical experience and research findings, the article recommends several management approaches to trichotillomania.

Clinical Characteristics of Pediatric Trichotillomania: Comparisons with Obsessive-Compulsive and Tic Disorders

This study compared youth ages 5-17 years with a primary diagnosis of trichotillomania (TTM, n = 30) to those with primary OCD (n = 30) and tic disorder (n = 29) on demographic characteristics, internalizing, and externalizing symptoms. Findings suggest that youth with primary TTM score more comparably to youth with tics than those with OCD on internalizing and externalizing symptom measures. Compared to the OCD group, youth in the TTM group reported lower levels of anxiety and depression. Parents of youth in the TTM group also reported fewer internalizing, externalizing, attention, and thought problems than those in the OCD group. Youth with TTM did not significantly differ from those with primary Tic disorders on any measure. Findings suggest that pediatric TTM may be more similar to pediatric tic disorders than pediatric OCD on anxiety, depression, and global internalizing and externalizing problems.

The relationship of psychological trauma with trichotillomania and skin picking

OBJECTIVE

Interactions between psychological, biological and environmental factors are important in development of trichotillomania and skin picking. The aim of this study is to determine the relationship of traumatic life events, symptoms of post-traumatic stress disorder and dissociation in patients with diagnoses of trichotillomania and skin picking disorder.

METHODS

The study included patients who was diagnosed with trichotillomania (n=23) or skin picking disorder (n=44), and healthy controls (n=37). Beck Depression Inventory, Traumatic Stress Symptoms Scale and Dissociative Experiences Scale were administered. All groups checked a list of traumatic life events to determine the exposed traumatic events.

RESULTS

There was no statistical significance between three groups in terms of Dissociative Experiences Scale scores (P=0.07). But Beck Depression Inventory and Traumatic Stress Symptoms Scale scores of trichotillomania and skin picking groups were significantly higher than the control group. Subjects with a diagnosis of trichotillomania and skin picking reported statistically significantly higher numbers of traumatic and negative events in childhood compared to healthy subjects.

CONCLUSION

We can conclude that trauma may play a role in development of both trichotillomania and skin picking. Increased duration of trichotillomania or skin picking was correlated with decreased presence of post-traumatic stress symptoms. The reason for the negatively correlation of severity of post-traumatic stress symptoms and self-harming behavior may be speculated as developing trichotillomania or skin picking symptoms helps the patient to cope with intrusive thoughts related to trauma. Future longitudinal research must focus on whether trauma and post-traumatic stress or trichotillomania and skin picking precede the development of mental disorder.

Age and gender correlates of pulling in pediatric trichotillomania

OBJECTIVE

Our goals were to examine clinical characteristics and age and gender correlates in pediatric trichotillomania.

METHOD

A total of 62 children (8-17 years of age) were recruited for a pediatric trichotillomania treatment trial and characterized using structured rating scales of symptoms of hairpulling and common comorbid conditions. We analyzed the association between qualitative and quantitative characteristics of pulling, comorbidities, and age and gender. We also examined the type of treatments these children previously received in the community.

RESULTS

We found lower rates of comorbid depression and anxiety disorders than have been reported in adult trichotillomania samples. Focused hairpulling significantly increased with age, whereas automatic pulling remained constant. Older children with hairpulling experienced more frequent urges and a decreased ability to refrain from pulling. Female participants reported greater distress and impairment associated with hairpulling, even though the severity of pulling did not differ from that of male participants.

CONCLUSION

These results confirm several findings from the Children and Adolescent Trichotillomania Impact Project (CA-TIP). Our cross-sectional findings suggest there may be a developmental progress of symptoms in trichotillomania. Children appeared to develop more focused pulling, to become more aware of their urges, and to experience more frequent urges to pull, as they get older. Although these are important findings, they need to be confirmed in prospective longitudinal studies.

Evidence-based assessment of compulsive skin picking, chronic tic disorders and trichotillomania in children

Body-focused repetitive behavior (BFRB) is an umbrella term for debilitating, repetitive behaviors that target one or more body regions. Despite regularly occurring in youth, there has been limited investigation of BFRBs in pediatric populations. One reason for this may be that there are few reliable and valid assessments available to evaluate the presence, severity and impairment of BFRBs in youth. Given the shift toward evidence-based assessment in mental health, the development and utilization of evidence-based measures of BFRBs warrants increasing attention. This paper examines the available evidence-base for assessments in youth across three BFRB-related disorders: compulsive skin picking, chronic tic disorders and trichotillomania. Based upon present empirical support in samples of youth, recommendations are made for an evidence-based assessment of each condition.

Pharmacotherapy for anxiety disorders in children and adolescents

Anxiety disorders are the most common mental health diagnoses in youth, and carry risks for ongoing impairments and subsequent development of other psychiatric comorbidities into adulthood. This article discusses considerations for assessment and treatment of anxiety disorders in youth, with a focus on the evidence base of pharmacologic treatment and important clinical considerations to optimize care. We then briefly describe the impact of anxiety on neuronal elements of fear circuitry to highlight how treatments may ameliorate impairments through enhanced plasticity Overall, pharmacotherapy for anxiety disorders is effective in improving clinical symptoms, particularly in combination with psychotherapy. Response is typically seen within several weeks, yet longitudinal studies are limited. Selective serotonin reuptake inhibitors are thought to be relatively safe and effective for acute treatment of several classes of anxiety disorders in youth, with increasing evidence supporting the role of neuronal plasticity in recovery.

Pharmacotherapy for anxiety disorders in children and adolescents

Anxiety disorders comprise the most prevalent mental health disorders among children and adults. Psychotherapy and pharmacotherapy are effective in improving clinical impairments from anxiety disorders and maintaining these improvements. This article discusses how to obtain a suitable diagnosis for anxiety disorders in youth for implementing appropriate treatments, focusing on the evidence base for pharmacologic treatment. Clinical guidelines are discussed, including Food and Drug Administration indications and off-label use of medications, and considerations for special populations and youth with comorbidities are highlighted. Findings suggest moderate effectiveness of medication, particularly selective serotonin reuptake inhibitors, in the treatment of anxiety disorders in youth.

A preliminary analysis of the phenomenology of skin-picking in Prader-Willi syndrome

To examine the nature and psychosocial correlates of skin-picking behavior in youth with Prader-Willi Syndrome (PWS). Parents of 67 youth (aged 5-19 years) with PWS were recruited to complete an internet-based survey that included measures of: skin-picking behaviors, the automatic and/or focused nature of skin-picking, severity of skin-picking symptoms, anxiety symptoms, developmental functioning, symptoms of inattention, impulsivity, and oppositionality, and quality of life. Results indicated that skin-picking was endorsed in 95.5% of youth. Direct associations of moderate strength were found between skin-picking severity and symptoms of anxiety, inattention, oppositionality, developmental functioning, and quality of life. Other descriptive data, such as areas picked, cutaneous factors, antecedents, and consequences related to skin-picking are reported. The prevalence and consequences associated with skin-picking in PWS indicate a greater need for clinician awareness of the behavior and interventions tailored to meet the needs of this population.