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Hanna GL, Liu Y, Rentschler LG, Hanna BS, Arnold PD, Gehring WJ. Altered Error Monitoring and Decreased Flanker Task Accuracy in Pediatric Obsessive-Compulsive Disorder. Child Psychiatry Hum Dev 2024:10.1007/s10578-024-01711-4. [PMID: 38795241 DOI: 10.1007/s10578-024-01711-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2024] [Indexed: 05/27/2024]
Abstract
The error-related negativity (ERN) and error positivity (Pe) are components of the event-related potential following an error that are potential mechanistic biomarkers of obsessive-compulsive disorder (OCD). The study examined the ERN, Pe, flanker task accuracy, and clinical measures in 105 OCD cases and 105 matched healthy controls (HC) ages 8-18 years. Higher flanker task accuracy in all participants was associated with an increased ERN amplitude and increased difference between Pe and correct positivity amplitudes (ΔPe). Compared to HC, OCD cases had an increased ERN but decreased ΔPe and flanker task accuracy. Those differences were also significant in tic-related and non-tic-related OCD cases compared to HC. A lower ΔPe was associated in cases with an earlier age at OCD symptom onset. The results support the hypothesis that OCD involves defects in an error monitoring system and suggest a reduced ΔPe may compromise error signaling and cause uncertainty about the correctness of a response.
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Affiliation(s)
- Gregory L Hanna
- Department of Psychiatry, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI, 48109-5766, USA.
| | - Yanni Liu
- Department of Psychiatry, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI, 48109-5766, USA
| | - Lauren G Rentschler
- Department of Psychiatry, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI, 48109-5766, USA
| | - Barbara S Hanna
- Department of Psychiatry, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI, 48109-5766, USA
| | - Paul D Arnold
- Mathison Centre for Mental Health Research and Education, University of Calgary, Calgary, AB, T2N 4N1, Canada
| | - William J Gehring
- Department of Psychology, University of Michigan, Ann Arbor, MI, 48109, USA
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Doolan BJ, Ali R, Baron SE. Optimizing treatment of compulsive hair pulling in children and young people: A case series from a pediatric psychodermatology service. J Dermatol 2024; 51:612-613. [PMID: 38445800 DOI: 10.1111/1346-8138.17136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 12/29/2023] [Accepted: 01/20/2024] [Indexed: 03/07/2024]
Affiliation(s)
- Brent J Doolan
- Guy's and St. Thomas' NHS Foundation Trust, London, UK
- St. John's Institute of Dermatology, School of Basic and Medical Biosciences, King's College London, London, UK
| | - Rukshana Ali
- Guy's and St. Thomas' NHS Foundation Trust, London, UK
- St. John's Institute of Dermatology, School of Basic and Medical Biosciences, King's College London, London, UK
| | - Susannah E Baron
- Guy's and St. Thomas' NHS Foundation Trust, London, UK
- St. John's Institute of Dermatology, School of Basic and Medical Biosciences, King's College London, London, UK
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3
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Comertoglu Arslan S, Uzun Cicek A, Ucuz I, Dogru H. Sociodemographic variables, clinical characteristics, and treatments in children with trichotillomania in terms of age and gender: a multicenter study. Nord J Psychiatry 2023; 77:36-45. [PMID: 35352628 DOI: 10.1080/08039488.2022.2052179] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Although trichotillomania (TTM) is a common, typically pediatric-onset disorder, data on the phenomenology of TTM in children, accompanying comorbid psychiatric disorders, and treatment options are extremely limited. In our study, it was aimed to investigate these variables and related factors in patients undergoing psychiatric evaluation and follow-up. METHOD The study included 79 children and adolescents between the ages of 4 and 17 who were diagnosed with TTM and followed up in four different Child and Adolescent Psychiatry outpatient clinics between 2015 and 2020. The sociodemographic characteristics of these patients, clinical features of the disease, comorbid psychiatric disorders, and treatment approaches have been studied. RESULTS Our results showed that TTM was more common in girls, hair and eyebrow plucking was the most common, and symptoms and features accompanying TTM changed with age, but not with gender. Again, 79.7% of these children had at least one psychiatric comorbid disorder (most common being anxiety disorders and Attention Deficit/Hyperactivity Disorder), comorbidity was closely related to TTM severity, 93.7% used at least one pharmacotherapeutic agent, and positive response rates to treatment were found to be low. Moreover, TTM severity was found to increase with age and disease duration. CONCLUSION Study findings support that clinical presentation, disease severity and comorbidity rates may change with age in children and adolescents with TTM, and early intervention is important to prevent clinical progression/worsening and mental health sequela.
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Affiliation(s)
- Semiha Comertoglu Arslan
- Department of Child and Adolescent Psychiatry, Kahramanmaras Sutcuımam University, Kahramanmaras, Turkey
| | - Ayla Uzun Cicek
- Department of Child and Adolescent Psychiatry, Cumhuriyet University, Sivas, Turkey
| | - Ilknur Ucuz
- Department of Child and Adolescent Psychiatry, Inonu University, Malatya, Turkey
| | - Hicran Dogru
- Department of Child and Adolescent Psychiatry, Ataturk University, Erzurum, Turkey
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Rangu S, Castelo-Soccio L. Trichotillomania in Children and the Different Approaches between Dermatological and Behavioral Health Professionals at an Urban Tertiary Care Center. Skin Appendage Disord 2021; 7:1-7. [PMID: 33614710 DOI: 10.1159/000510524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 07/27/2020] [Indexed: 11/19/2022] Open
Abstract
Background Trichotillomania (TTM) is a complex disease with varying clinical characteristics, and psychosocial impairment is noted in many TTM patients. Despite its prevalence in childhood, there is limited research on pediatric TTM. Objective To analyze the clinical and epidemiologic features of TTM in children evaluated by dermatologists and behavioral health specialists. Method We performed a retrospective chart review of 137 pediatric patients seen at the Children's Hospital of Philadelphia with initial presentation of TTM at age 17 or younger. Patients were treated by dermatology or behavioral health. Results The majority of the patients were females, with an average diagnosis age around 8 years. Over half had a psychiatric comorbidity, and over a quarter had a skin disorder. Skin disorders were more commonly present in those evaluated by dermatology, and psychiatric comorbidities were more commonly present in those evaluated by behavioral health. The most common form of treatment was behavioral therapy, with medications prescribed more often by dermatologists. Conclusions TTM patients choose to present to behavioral health or dermatology; however, there are distinctive differences between the two cohorts. With behavioral and pharmacologic treatment options, a relationship between dermatologists and behavioral health specialists is necessary for multifactorial management of TTM.
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Affiliation(s)
- Sneha Rangu
- Section of Dermatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Leslie Castelo-Soccio
- Section of Dermatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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5
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Peris TS, Rozenman M, Gonzalez A, Vreeland A, Piacentini J, Tan PZ, Ricketts EJ. Family functioning in pediatric trichotillomania, obsessive compulsive disorder, and healthy comparison youth. Psychiatry Res 2019; 281:112578. [PMID: 31586836 DOI: 10.1016/j.psychres.2019.112578] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 09/18/2019] [Accepted: 09/22/2019] [Indexed: 10/25/2022]
Abstract
Pediatric trichotillomania (TTM) is an understudied condition that can be highly impairing; little is known about family environmental features that shape its development and course. We examined family functioning among age and gender-matched groups of youth with primary TTM (n = 30; mean age = 12.87), obsessive compulsive disorder (OCD; n = 30; mean age = 12.70), and no psychiatric history (healthy controls; HC; n = 30; mean age = 12.46). An additional group of n = 25 TTM cases was employed to examine relationships between TTM severity and family functioning. All youth completed standardized diagnostic assessment, including the Family Environment Scale (FES) and Children's Report of Parenting Behavior Inventory (CRPBI). Family functioning was more impaired among both TTM and OCD cases relative to controls, as evidenced by higher levels of child-reported FES conflict and lower cohesion, expressiveness, and organization. Less consistent findings emerged on parent report, with cohesion, but not conflict, distinguishing the HC and clinical groups. In keeping with prior research, parents of TTM-affected youth also reported lower expressiveness and cohesion than parents in the OCD group. There was limited evidence for links between hair-pulling severity and family impairment and no links to parenting behavior. Findings are discussed in terms of implications for family focused treatment.
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Affiliation(s)
- Tara S Peris
- UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA 90095, United States.
| | | | - Araceli Gonzalez
- California State University Long Beach, Long Beach, CA 90840, United States
| | | | - John Piacentini
- UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA 90095, United States
| | - Patricia Z Tan
- UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA 90095, United States
| | - Emily J Ricketts
- UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA 90095, United States
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Abstract
Trichotillomania can present in childhood, with many families seeking initial evaluation by a dermatologist for hair loss. Prompt and accurate diagnosis by dermatologists is crucial, as children can suffer from academic or social impairments as well as mental health sequelae. Children are especially vulnerable to lasting psychological distress from appearance-related bullying. This article reviews the psychosocial impacts of pediatric trichotillomania and the current interventions studied in this population. Included are studies evaluating behavioral therapies as well as pharmacologic options. This review highlights the importance of early and appropriate identification, intervention, and the need for more treatment studies in the pediatric population.
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Affiliation(s)
- Emily D Henkel
- Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Sasha D Jaquez
- Department of Psychiatry, Dell Medical School, University of Texas at Austin, Austin, Texas.,Texas Child Study Center, Austin, Texas.,Dell Children's Medical Center, Austin, Texas
| | - Lucia Z Diaz
- Dell Children's Medical Center, Austin, Texas.,Division of Dermatology, Dell Medical School, University of Texas at Austin, Austin, Texas.,Department of Pediatrics, Dell Medical School, University of Texas at Austin, Austin, Texas
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Lee HJ, Espil FM, Bauer CC, Siwiec SG, Woods DW. Computerized response inhibition training for children with trichotillomania. Psychiatry Res 2018; 262:20-27. [PMID: 29407564 DOI: 10.1016/j.psychres.2017.12.070] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 09/29/2017] [Accepted: 12/30/2017] [Indexed: 12/14/2022]
Abstract
Evidence suggests that trichotillomania is characterized by impairment in response inhibition, which is the ability to suppress pre-potent/dominant but inappropriate responses. This study sought to test the feasibility of computerized response inhibition training for children with trichotillomania. Twenty-two children were randomized to the 8-session response inhibition training (RIT; n = 12) or a waitlisted control (WLT; n = 10). Primary outcomes were assessed by an independent evaluator, using the Clinical Global Impression-Improvement (CGI-I), and the NIMH Trichotillomania Severity (NIMH-TSS) and Impairment scales (NIMH-TIS) at pre, post-training/waiting, and 1-month follow-up. Relative to the WLT group, the RIT group showed a higher response rate (55% vs. 11%) on the CGI-I and a lower level of impairment on the NIMH-TIS, at post-training. Overall symptom reductions rates on the NIMH-TSS were 34% (RIT) vs. 21% (WLT) at post-training. The RIT's therapeutic gains were maintained at 1-month follow-up, as indicated by the CGI-I responder status (= 66%), and a continuing reduction in symptom on the NIMH-TSS. This pattern of findings was also replicated by the 6 waitlisted children who received the same RIT intervention after post-waiting assessment. Results suggest that computerized RIT may be a potentially useful intervention for trichotillomania.
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Affiliation(s)
- Han-Joo Lee
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, WI, USA.
| | - Flint M Espil
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Stephan G Siwiec
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Douglas W Woods
- Department of Psychology, Marquette University, Milwaukee, WI, USA
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Abstract
Adolescents who struggle with trichotillomania (TTM; hairpulling disorder) are not alone, their parents also struggle. The focus of this qualitative study was to identify what parents (N = 30) perceive as stressful about parenting an adolescent with TTM and how they cope with these stressors. Parents described uncertainty about the course of the disorder and powerlessness in the ability to protect their adolescent from the reactions of others or assist them in curtailing the hairpulling as very distressing. Data analysis revealed eight coping strategies used to manage these stressors and the accompanying grief: (a) information gathering, (b) anticipatory guidance, (c) crying, (d) hypervigilance, (e) gaining emotional support from others, (f) acceptance, (g) goal revision, and (h) guiding rather than protecting their adolescent. The study findings can be used by school nurses to gain a deeper understanding of this disorder and to provide family-centered care in the school setting.
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Affiliation(s)
- Marcia S Stevens
- School of Nursing, College of Allied Health and Nursing, Minnesota State University, Mankato, Mankato, MN, USA
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Alexander JR, Houghton DC, Twohig MP, Franklin ME, Saunders SM, Neal-Barnett AM, Compton SN, Woods DW. Factor analysis of the Milwaukee Inventory for Subtypes of Trichotillomania-Adult Version. J Obsessive Compuls Relat Disord 2016; 11:31-38. [PMID: 27668153 PMCID: PMC5033380 DOI: 10.1016/j.jocrd.2016.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The Milwaukee Inventory for Subtypes of Trichotillomania-Adult Version (MIST-A; Flessner et al., 2008) measures the degree to which hair pulling in Trichotillomania (TTM) can be described as "automatic" (i.e., done without awareness and unrelated to affective states) and/or "focused" (i.e., done with awareness and to regulate affective states). Despite preliminary evidence in support of the psychometric properties of the MIST-A, emerging research suggests the original factor structure may not optimally capture TTM phenomenology. Using data from a treatment-seeking TTM sample, the current study examined the factor structure of the MIST-A via exploratory factor analysis. The resulting two factor solution suggested the MIST-A consists of a 5-item "awareness of pulling" factor that measures the degree to which pulling is done with awareness and an 8-item "internal-regulated pulling" factor that measures the degree to which pulling is done to regulate internal stimuli (e.g., emotions, cognitions, and urges). Correlational analyses provided preliminary evidence for the validity of these derived factors. Findings from this study challenge the notions of "automatic" and "focused" pulling styles and suggest that researchers should continue to explore TTM subtypes.
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Affiliation(s)
- Jennifer R. Alexander
- Department of Psychology, Texas A&M University, 4235 TAMU, College Station, TX 77840, USA
| | - David C. Houghton
- Department of Psychology, Texas A&M University, 4235 TAMU, College Station, TX 77840, USA
| | - Michael P. Twohig
- Department of Psychology, Utah State University, 2810 Old Main Hill, Logan, UT 84322, USA
| | - Martin E. Franklin
- Department of Psychiatry, University of Pennsylvania School of Medicine, 3535 Market St., Philadelphia, PA 19104, USA
| | - Stephen M. Saunders
- Department of Psychology, Marquette University, 604 N. 16th St., Milwaukee, WI 53233, USA
| | | | - Scott N. Compton
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, 2213 Elba St., Durham, NC 27705, USA
| | - Douglas W. Woods
- Department of Psychology, Texas A&M University, 4235 TAMU, College Station, TX 77840, USA
- Department of Psychology, Marquette University, 604 N. 16th St., Milwaukee, WI 53233, USA
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Brennan E, Francazio S, Gunstad J, Flessner C. Inhibitory Control in Pediatric Trichotillomania (Hair Pulling Disorder): The Importance of Controlling for Age and Symptoms of Inattention and Hyperactivity. Child Psychiatry Hum Dev 2016; 47:173-82. [PMID: 26001984 DOI: 10.1007/s10578-015-0554-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Trichotillomania (hair pulling disorder, HPD) is characterized by significant psychological distress, childhood-onset, and, in adults, certain cognitive deficits such as inhibitory control. A total absence of such literature exists within pediatric HPD samples, including research investigating neurocognitive aspects of disparate pulling-styles. The present study aims to address these gaps in the literature. Youth with HPD and healthy controls (N = 45) were compared on an automated neurocognitive task--stop-signal task (SST)--assessing inhibitory control. Youth with HPD (n = 17), controlling for age and attention issues, were found to perform better on the stop-signal reaction time compared to controls (n = 28). No significant relationships between performance on the SST and HPD severity, distress/impairment, or pulling-styles were noted. Findings from the current study suggest that children with HPD may not exhibit deficits in motor inhibition as compared to controls when the effects of age and attentional problems are controlled.
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Affiliation(s)
- Elle Brennan
- Department of Psychological Sciences, Kent State University, 600 Hilltop Drive, Kent, OH, USA
| | - Sarah Francazio
- Department of Psychological Sciences, Kent State University, 600 Hilltop Drive, Kent, OH, USA
| | - John Gunstad
- Department of Psychological Sciences, Kent State University, 600 Hilltop Drive, Kent, OH, USA
| | - Christopher Flessner
- Department of Psychological Sciences, Kent State University, 600 Hilltop Drive, Kent, OH, USA.
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Flessner CA, Brennan E, Murphy YE, Francazio S. IMPAIRED EXECUTIVE FUNCTIONING IN PEDIATRIC TRICHOTILLOMANIA (HAIR PULLING DISORDER). Depress Anxiety 2016; 33:219-28. [PMID: 26580849 DOI: 10.1002/da.22450] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 09/27/2015] [Accepted: 10/09/2015] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND No neurocognitive examinations of pediatric trichotillomania (hair pulling disorder; HPD) have taken place. As a result, science's understanding of the underlying pathophysiology associated with HPD in youths is greatly lacking. The present study seeks to begin to address this gap in the literature via examination of executive functioning in a stimulant-free sample of children with HPD. METHODS Sixteen and 23 children between 9 and 17 years of age meeting DSM-5 diagnostic criteria for HPD or classified as a healthy control, respectively, were recruited (N = 39) to complete structured interviews, self-reports, and a subset of tests from the Cambridge Automatic Neurocognitive Test Assessment Battery (CANTAB) assessing cognitive flexibility/reversal learning (intradimensional/extradimensional; IED), working memory (spatial span; SSP), and planning and organization (Stocking of Cambridge; SOC). RESULTS Hierarchical regression analyses indicated that, after controlling for appropriate covariates, diagnostic status predicted impaired performance on both the IED (reversal learning only) and SOC (planning and organization) but failed to predict cognitive flexibility or working memory capacity. Correlational analyses revealed that pulling severity was strongly related to working memory capacity, while disparate relationships between pulling styles (automatic, focused pulling) were evident with respect to working memory and planning and organization. CONCLUSIONS Children with HPD performed more poorly on tasks of executive functioning as compared to controls. Correlational analyses suggest potentially distinct pathophysiology underlying automatic and focused pulling warranting further research. Limitations and future areas of inquiry are discussed.
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Affiliation(s)
| | - Elle Brennan
- Department of Psychological Sciences, Kent State University, Kent, Ohio
| | - Yolanda E Murphy
- Department of Psychological Sciences, Kent State University, Kent, Ohio
| | - Sarah Francazio
- Department of Psychological Sciences, Kent State University, Kent, Ohio
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Abstract
Trichotillomania (TTM) is a type of impulse control disorder, characterized by recurrent pulling of hair. The etiology of TTM is complex, but a genetic contribution to this condition was advocated based on a limited number of reports on familial TTM. We report a 13-year-old male with history of focal hair loss in the scalp. Examination showed a patchy area of hair loss, with several short broken hairs of varying lengths. Dermoscopy and pathology examinations were consistent with TTM. Upon further questioning, his father admitted repeated pulling of his beard. The paternal grandfather also suffers from severe hair pulling of his beard since puberty. To our knowledge, this is the first report of TTM in a 3 generation family. This report strengthens the possibility that TTM is a genetic disease, probably with a complex inheritance pattern. It also highlights the importance of appropriate family history taking when examining a TTM patient.
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Affiliation(s)
- Yuval Ramot
- Department of Dermatology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Alexander Maly
- Department of Pathology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Liran Horev
- Department of Dermatology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Abraham Zlotogorski
- Department of Dermatology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
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Emer J, Luber A, Gropper J, Sidhu H, Phelps R. A patch of hair loss on the scalp. THE JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY 2013; 6:45-49. [PMID: 23882315 PMCID: PMC3718756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Jason Emer
- The authors are from Mount Sinai School of Medicine, Departments of Dermatology and Dermatopathology, New York, New York
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N-Acetylcysteine in the treatment of pediatric trichotillomania: a randomized, double-blind, placebo-controlled add-on trial. J Am Acad Child Adolesc Psychiatry 2013; 52:231-40. [PMID: 23452680 PMCID: PMC3745012 DOI: 10.1016/j.jaac.2012.12.020] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 12/18/2012] [Accepted: 12/26/2012] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To examine the efficacy of N-acetylcysteine (NAC) for the treatment of pediatric trichotillomania (TTM) in a double-blind, placebo-controlled, add-on study. METHOD A total of 39 children and adolescents aged 8 to 17 years with pediatric trichotillomania were randomly assigned to receive NAC or matching placebo for 12 weeks. Our primary outcome was change in severity of hairpulling as measured by the Massachusetts General Hospital-Hairpulling Scale (MGH-HPS). Secondary measures assessed hairpulling severity, automatic versus focused pulling, clinician-rated improvement, and comorbid anxiety and depression. Outcomes were examined using linear mixed models to test the treatment×time interaction in an intention-to-treat population. RESULTS No significant difference between N-acetylcysteine and placebo was found on any of the primary or secondary outcome measures. On several measures of hairpulling, subjects significantly improved with time regardless of treatment assignment. In the NAC group, 25% of subjects were judged as treatment responders, compared to 21% in the placebo group. CONCLUSIONS We observed no benefit of NAC for the treatment of children with trichotillomania. Our findings stand in contrast to a previous, similarly designed trial in adults with TTM, which demonstrated a very large, statistically significant benefit of NAC. Based on the differing results of NAC in pediatric and adult TTM populations, the assumption that pharmacological interventions demonstrated to be effective in adults with TTM will be as effective in children, may be inaccurate. This trial highlights the importance of referring children with TTM to appropriate behavioral therapy before initiating pharmacological interventions, as behavioral therapy has demonstrated efficacy in both children and adults with trichotillomania.
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