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Mandarino MJ, Stummer L, Trueba AF, Vahia I, Freedberg A. Review of Management Considerations for Excoriation Disorder in Older Adults. Am J Geriatr Psychiatry 2024; 32:879-894. [PMID: 38538517 DOI: 10.1016/j.jagp.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 02/25/2024] [Accepted: 02/27/2024] [Indexed: 06/11/2024]
Abstract
Excoriation disorder (ED) is defined as compulsive skin picking that results in skin damage and emotional distress. Optimal management of ED includes individualized treatment plans consisting of psychotherapies, behavioral and pharmacologic interventions. Compared with younger populations, older adults are at increased risk for poor outcomes, such as infection and hospitalization, and require unique management considerations. Risk factors that contribute to disease burden include age-related changes to the skin and underlying medical and psychiatric comorbidities. A literature review was conducted on ED yielding limited evidence exclusive to older adults. The authors suggest a therapeutic approach to ED in older adults based on available evidence and experience from inpatient and outpatient psychiatric settings. Finally, opportunities for future research are highlighted.
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Affiliation(s)
| | | | - Ana F Trueba
- McLean Hospital (MJM, LS, AFT, IV, AF), Belmont, MA; Harvard Medical School (AFT, IV, AF), Boston, MA; Universidad San Francisco de Quito (AFT), Quito, Ecuador
| | - Ipsit Vahia
- McLean Hospital (MJM, LS, AFT, IV, AF), Belmont, MA; Harvard Medical School (AFT, IV, AF), Boston, MA
| | - Alexis Freedberg
- McLean Hospital (MJM, LS, AFT, IV, AF), Belmont, MA; Harvard Medical School (AFT, IV, AF), Boston, MA; ConcertoCare (AF), New York, NY
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2
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Riordan CP, Owusu-Adjei B, Daci R, Phelan A, Mietus CJ, Kosarchuk J, Lambert W, Qureshi HM, Lim JC, Mihalek O, Li D, Sorour O, Homsy C, Kryzanski J, Aulet R, Johnson MD. Self-Trephination in Cranial Excoriation Disorder. Neurosurgery 2024:00006123-990000000-01204. [PMID: 38856202 DOI: 10.1227/neu.0000000000003004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 03/29/2024] [Indexed: 06/11/2024] Open
Abstract
BACKGROUND AND IMPORTANCE Trephination is a procedure in which a small hole is made in the skull. Rare cases of self-trephination by individuals seeking medical benefit have been reported. Excoriation disorder is a compulsive skin-picking condition in which an individual self-inflicts cutaneous lesions. Left untreated, severe excoriation disorder can pose significant health risks. CLINICAL PRESENTATION Here, we describe 5 patients who presented with self-trephination due to a severe form of compulsive cranial excoriation at 2 neighboring academic medical centers over a 4-year period. We review the clinical presentation of self-trephination in cranial excoriation disorder and associated risk factors, surgical and nonsurgical interventions, complications of the disease, treatments, and mortality. Defining clinical characteristics include repetitive self-induced destruction of the scalp and skull with entry into the intracranial compartment, frequent psychiatric comorbidities, infection or injury of the brain with consequent neurological morbidity or mortality, and frequent treatment failures because of poor adherence. CONCLUSION Self-trephination in cranial excoriation disorder is a severe neuropsychological disorder and neurosurgical emergency that exposes the brain and is often life-threatening. Appropriate therapy requires antibiotics, surgical debridement and repair of the wound, and concomitant effective psychiatric management of the underlying compulsion, including the use of antidepressants and behavioral therapy.
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Affiliation(s)
- Coleman P Riordan
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Brittany Owusu-Adjei
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
- UMass Memorial Health, Worcester, Massachusetts, USA
| | - Rrita Daci
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
- UMass Memorial Health, Worcester, Massachusetts, USA
| | - Alannah Phelan
- Division of Plastic Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Constance J Mietus
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
- UMass Memorial Health, Worcester, Massachusetts, USA
| | - Jacob Kosarchuk
- Department of Neurosurgery, Tufts University Medical Center, Boston, Massachusetts, USA
| | - William Lambert
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
- UMass Memorial Health, Worcester, Massachusetts, USA
| | - Hanya M Qureshi
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
- UMass Memorial Health, Worcester, Massachusetts, USA
| | - Jeewoo Chelsea Lim
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Olivia Mihalek
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Danielle Li
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Omar Sorour
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Christopher Homsy
- Department of Plastic Surgery, Tufts University Medical Center, Boston, Massachusetts, USA
| | - James Kryzanski
- Department of Neurosurgery, Tufts University Medical Center, Boston, Massachusetts, USA
| | - Ricardo Aulet
- UMass Memorial Health, Worcester, Massachusetts, USA
- Department of Otolaryngology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Mark D Johnson
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
- UMass Memorial Health, Worcester, Massachusetts, USA
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Khan S, Hughes S, Hill O. N-acetyl Cysteine Supplementation to Alleviate Skin Picking Disorder: A Case Report. Cureus 2024; 16:e53440. [PMID: 38435146 PMCID: PMC10909310 DOI: 10.7759/cureus.53440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2024] [Indexed: 03/05/2024] Open
Abstract
There are body-focused repetitive behaviors, such as skin picking, trichotillomania, or nail biting, for which therapeutic interventions are available and can be tried, but unfortunately, there are no FDA-approved medications specifically for them. These disorders can cause functional impairment, disrupt activities of daily living, and be burdensome for both the patients and their loved ones. This case report will discuss an over-the-counter vitamin supplement, N-acetyl cysteine (NAC), that can be used safely but is often overlooked.
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Affiliation(s)
- Samira Khan
- Behavioral Health, West Virginia University (WVU) - Berkeley Medical Center, Martinsburg, USA
| | - Sarah Hughes
- Behavioral Medicine and Psychiatry, West Virginia University School of Medicine, Martinsburg, USA
| | - Olivia Hill
- Behavioral Medicine and Psychiatry, West Virginia University School of Medicine, Martinsburg, USA
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Rahman SM, Jafferany M, Barkauskaite R. Habit-reversal training: a psychotherapeutic approach in treating body-focused repetitive behaviour disorders. Clin Exp Dermatol 2023; 48:1310-1316. [PMID: 37470438 DOI: 10.1093/ced/llad247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 06/29/2023] [Accepted: 07/17/2023] [Indexed: 07/21/2023]
Abstract
Body-focused repetitive behaviours (BFRBs) are recurrent, compulsive, destructive behaviours directed towards the body. Although studies have demonstrated a 12-14% prevalence rate, researchers found that dermatologists and psychiatrists show a lack of knowledge regarding psychodermatology resources and information about BFRB disorders (BFRBDs) such as trichotillomania (TTM). There is limited research about treatments including ones investigating the clinical applications of various self-help training such as decoupling (DC) and DC in sensu (DC-is) as well as about habit-reversal training (HRT). HRT is a five-component behavioural intervention that aims to develop a competing response to a specific unwanted behaviour. Studies have found substantial support for HRT's efficacy in treating a variety of maladaptive repetitive behaviours including onychotillomania, TTM, skin-picking disorder and chronic cheek biting. Additionally, many psychotherapies can augmented HRT. Psychotherapies include acceptance and commitment therapy, dialectical behaviour therapy, psychodynamic psychotherapy, mindfulness mediation and the cognitive psychophysiological model. A recently investigated variant of HRT, DC-is, resulted in consistently satisfactory objective and subjective improvement for treating BFRBDs, and HRT showed good subjective but poor objective improvement compared with standard DC. HRT and HRT variants are effective therapeutic treatments for BFRBDs; however, further randomized double-blinded and placebo-controlled trials are required to examine HRT's therapeutic profile.
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Affiliation(s)
- Syed Minhaj Rahman
- Department of Dermatology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Mohammad Jafferany
- Department of Psychiatry, Central Michigan University/CMU Medical Education Partners, Saginaw, MI, USA
| | - Ruta Barkauskaite
- Institute of Psychology, Mykoles Romeris University, Vilnius, Lithuania
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Flannery MK, Falkenstein MJ, Boyd M, Haaga DAF. Untroubled Pullers: An Examination of Nonclinical Hair-Pulling. J Obsessive Compuls Relat Disord 2023; 38:100821. [PMID: 37485310 PMCID: PMC10358351 DOI: 10.1016/j.jocrd.2023.100821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
Nonclinical hair-pulling is much more prevalent than hair pulling associated with a diagnosis of trichotillomania (TTM). However, little is known about nonclinical pulling. The purpose of this exploratory research was to begin characterizing a subset of nonclinical hair pullers we refer to as "untroubled pullers," people who engage in recurrent, noncosmetic hair-pulling without associated distress or impairment. In a secondary analysis of two studies conducted online, untroubled pullers reported significantly lower symptom severity than did those diagnosed with TTM. The Big Five personality dimensions did not differentiate the groups in Study 1, but untroubled pullers endorsed significantly less disability, focused and automatic pulling, social anxiety, perceived risk in intimacy, and perfectionism in Study 2. These findings remained significant after controlling for symptom severity. Age and race resulted in mixed findings between the two studies, but no differences arose in other demographics. These findings suggest that symptom severity may not sufficiently explain differences in associated distress and impairment. Future studies are needed on how other constructs related to distress and impairment interact with hair-pulling behavior to provide insight into when pulling is associated with clinically significant distress or impairment.
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Affiliation(s)
- Meghan K Flannery
- Department of Psychology, American University, 4400 Massachusetts Avenue NW, Washington, DC 20016-8062
| | - Martha J Falkenstein
- McLean Hospital OCD Institute/Harvard Medical School, 115 Mill Street, Mail Stop #207, Belmont, MA 02478
| | - Megan Boyd
- Department of Psychology, American University, 4400 Massachusetts Avenue NW, Washington, DC 20016-8062
| | - David A F Haaga
- Department of Psychology, American University, 4400 Massachusetts Avenue NW, Washington, DC 20016-8062
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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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Moritz S, Penney D, Bruhns A, Weidinger S, Schmotz S. Habit Reversal Training and Variants of Decoupling for Use in Body-Focused Repetitive Behaviors. A Randomized Controlled Trial. COGNITIVE THERAPY AND RESEARCH 2023; 47:109-122. [PMID: 36415779 PMCID: PMC9672630 DOI: 10.1007/s10608-022-10334-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2022] [Indexed: 11/18/2022]
Abstract
Background Behavioral interventions hold promise in improving body-focused repetitive behaviors (BFRBs), such as hair pulling and skin picking. The effect of combining different treatment techniques is currently unknown. Methods In the framework of a randomized controlled crossover trial, 334 individuals with at least one BFRB were allocated either to a waitlist control or to three experimental conditions (1:1:1:1). Participants in the experimental condition received self-help manuals teaching habit reversal training (HRT), decoupling (DC) and decoupling in sensu (DC-is) during a six-week period. Treatment conditions differed only in the order of manual presentation. We examined whether applying more than one technique would lead either to add-on or interference effects. Results The three treatment conditions were significantly superior to the waitlist control group in the improvement of BFRBs according to intention-to-treat analyses at a medium effect size (all p ≤ 0.002, d = 0.52 - 0.54). The condition displaying DC first significantly reduced depressive symptoms (p = 0.003, d = 0.47) and improved quality of life (p = 0.011, d = 0.39) compared to the waitlist control. Those using more techniques concurrently showed the strongest decline in BFRB symptoms, even after controlling for days practiced. Participants rated all manuals favorably, with standard DC and HRT yielding greatest acceptability. Discussion Results tentatively suggest the concurrent application of different behavioral treatments for BFRBs leads to add-on effects. Results were superior when DC was practiced first, with positive effects extending to depressive symptoms and quality of life. Integrating the three techniques into one self-help manual or video along with other treatment procedures (e.g., stimulus control techniques) is recommended.
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Affiliation(s)
- Steffen Moritz
- grid.13648.380000 0001 2180 3484Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Danielle Penney
- grid.412078.80000 0001 2353 5268Centre Intégré Universitaire de Santé et de Services Sociaux de l’Ouest-de-l’Île-de-Montréal Douglas Mental Health University Institute, Verdun, Canada
| | - Alina Bruhns
- grid.13648.380000 0001 2180 3484Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sarah Weidinger
- grid.13648.380000 0001 2180 3484Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stella Schmotz
- grid.13648.380000 0001 2180 3484Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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8
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Ricketts EJ, Peris TS, Grant JE, Valle S, Cavic E, Lerner JE, Lochner C, Stein DJ, Dougherty DD, O'Neill J, Woods DW, Keuthen NJ, Piacentini J. Clinical Characteristics of Youth with Trichotillomania (Hair-Pulling Disorder) and Excoriation (Skin-Picking) Disorder. Child Psychiatry Hum Dev 2022:10.1007/s10578-022-01458-w. [PMID: 36315372 DOI: 10.1007/s10578-022-01458-w] [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] [Received: 04/15/2022] [Revised: 10/02/2022] [Accepted: 10/08/2022] [Indexed: 11/24/2022]
Abstract
Body-focused repetitive disorders (BFRBDs) are understudied in youth and understanding of their underlying mechanisms is limited. This study evaluated BFRBD clinical characteristics, and two factors commonly implicated in their maintenance - emotion regulation and impulsivity - in 53 youth aged 11 to 17 years: 33 with BFRBDs and 20 controls. Evaluators administered psychiatric diagnostic interviews. Participants rated BFRBD severity, negative affect, quality of life, family functioning, emotion regulation, distress tolerance, and impulsivity. Youth with BFRBDs showed poorer distress tolerance and quality of life, and higher impulsivity and negative affect than controls, with no differences in family impairment. BFRBD distress/impairment, but not BFRBD severity, correlated with anxiety and depression, and poorer distress tolerance. Findings suggest youth with BFRBDs show clinical patterns aligning with prior research; highlight the role of distress tolerance in child BFRBDs; and suggest the utility of acceptance and mindfulness-based therapies for unpleasant emotions in BFRBDs. Continued research should evaluate factors underlying BFRBDs in youth.
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Affiliation(s)
- Emily J Ricketts
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA.
| | - Tara S Peris
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jon E Grant
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
| | - Stephanie Valle
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
| | - Elizabeth Cavic
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
| | - Juliette E Lerner
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
| | - Christine Lochner
- SA MRC Unit on Risk & Resilience in Mental Disorders, Department of Psychiatry, University of Stellenbosch, Stellenbosch, South Africa
| | - Dan J Stein
- SA MRC Unit on Risk & Resilience in Mental Disorders, Department of Psychiatry and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Darin D Dougherty
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph O'Neill
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
| | - Douglas W Woods
- Department of Psychology, Marquette University, Milwaukee, WI, USA
| | - Nancy J Keuthen
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - John Piacentini
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
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The Potential of N-Acetylcysteine for Treatment of Trichotillomania, Excoriation Disorder, Onychophagia, and Onychotillomania: An Updated Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19116370. [PMID: 35681955 PMCID: PMC9180086 DOI: 10.3390/ijerph19116370] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/21/2022] [Accepted: 05/22/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Trichotillomania (TTM), excoriation disorder, onychophagia, and onychotillomania are categorized as body focused repetitive behavior (BFRB) disorders, causing damage to the skin, hair, and/or nails with clinically significant psychosocial consequences. Currently, there are no standardized treatments for these compulsive, self-induced disorders. Studies on treatment of these disorders using psychotropic drugs (i.e., selective serotonin reuptake inhibitors, tricyclic antidepressants, anticonvulsants) have shown variable efficacy. Recently, there is a growing interest in N-acetylcysteine (NAC) for treating BFRBs. NAC is a glutamate modulator that has shown promise in successfully reducing the compulsive behaviors in BFRB disorders. This article provides an updated review of the literature on the use of NAC in TTM, excoriation disorder, onychophagia, and onychotillomania. METHODS Relevant articles were searched in the PubMed/MEDLINE database. RESULTS Twenty-four clinical trials, retrospective cohort studies, and case reports assessing the efficacy of NAC in TTM, excoriation disorder, and onychophagia were included. No studies for onychotillomania were found in our search. CONCLUSIONS Although NAC has proven successful for treatment of BFRB disorders, data is derived from few clinical trials and case reports assessing small numbers of patients. Larger studies with longer durations are needed to fully establish the efficacy of NAC in these disorders.
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Nemeh MN, Hogeling M. Pediatric skin picking disorder: A review of management. Pediatr Dermatol 2022; 39:363-368. [PMID: 35194832 DOI: 10.1111/pde.14953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/29/2022] [Accepted: 02/06/2022] [Indexed: 12/16/2022]
Abstract
Skin picking disorder (SPD) commonly presents in childhood; often, families will first turn to dermatologists for evaluation. It is imperative that dermatologists accurately diagnose and treat the disorder as children are vulnerable to face significant negative psychosocial impacts. This article reviews the limited literature on the management of SPD in pediatric patients to better prepare dermatologists for educating families and recommending treatment options. We discuss studies evaluating behavioral and pharmacologic therapies, as well as emerging skin barrier treatments.
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Affiliation(s)
- Michael N Nemeh
- University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Marcia Hogeling
- Division of Dermatology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Abstract
ABSTRACT Body-focused repetitive behavior (BFRB) is a significantly underrecognized phenomenon that can cause physical complications and marked mental distress. Understanding the condition and offering patients pharmacologic as well as psychotherapeutic support may effectively reduce adverse health outcomes. This article reviews BFRBs, which can present clinically in multiple settings.
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Affiliation(s)
- Deanna Bridge Najera
- Deanna Bridge Najera practices in the ED at MedStar Montgomery Medical Center in Olney, Md.; in the Reproductive Health Clinic at the Carroll County Health Department in Westminster, Md.; and in psychiatric medical management at True North Wellness Services in Hanover, Pa. The author has disclosed no potential conflicts of interest, financial or otherwise
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12
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Scrandis DA, Duarte AC. Trichotillomania and excoriation disorder: Primary care implications. Nurse Pract 2021; 46:51-55. [PMID: 34397774 DOI: 10.1097/01.npr.0000753840.44209.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Trichotillomania and excoriation disorder are two psychiatric conditions that have similar origins to obsessive compulsive disorder. Both can cause patients significant distress and lead to medical consequences. It is important that primary care NPs identify and refer these individuals for psychiatric treatment.
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Dermatillomania: Strategies for Developing Protective Biomaterials/Cloth. Pharmaceutics 2021; 13:pharmaceutics13030341. [PMID: 33808008 PMCID: PMC8001957 DOI: 10.3390/pharmaceutics13030341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 01/30/2023] Open
Abstract
Dermatillomania or skin picking disorder (SPD) is a chronic, recurrent, and treatment resistant neuropsychiatric disorder with an underestimated prevalence that has a concerning negative impact on an individual’s health and quality of life. The current treatment strategies focus on behavioral and pharmacological therapies that are not very effective. Thus, the primary objective of this review is to provide an introduction to SPD and discuss its current treatment strategies as well as to propose biomaterial-based physical barrier strategies as a supporting or alternative treatment. To this end, searches were conducted within the PubMed database and Google Scholar, and the results obtained were organized and presented as per the following categories: prevalence, etiology, consequences, diagnostic criteria, and treatment strategies. Furthermore, special attention was provided to alternative treatment strategies and biomaterial-based physical treatment strategies. A total of six products with the potential to be applied as physical barrier strategies in supporting SPD treatment were shortlisted and discussed. The results indicated that SPD is a complex, underestimated, and underemphasized neuropsychiatric disorder that needs heightened attention, especially with regard to its treatment and care. Moreover, the high synergistic potential of biomaterials and nanosystems in this area remains to be explored. Certain strategies that are already being utilized for wound healing can also be further exploited, particularly as far as the prevention of infections is concerned.
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Aydın EP, Kenar JG, Tutan A, Akil Özer Ö, Oğuz Karamustafalıoğlu K. Repetitive Transcranial Magnetic Stimulation for Treatment of Trichotillomania: Case Series. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2020; 18:631-635. [PMID: 33124597 PMCID: PMC7609214 DOI: 10.9758/cpn.2020.18.4.631] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/14/2019] [Accepted: 06/27/2019] [Indexed: 11/25/2022]
Abstract
Trichotillomania is a psychiatric disorder characterised by compulsive pulling out of one’s hair resulting in hair loss, which is included in the Diagnostic and Statistical Manual of Mental Disorders 5th edition category ‘obsessive-compulsive disorder and related disorders’. Behavioural therapy and some medications are suggested for the treatment of trichotillomania, though these are not effective for all patients. Therefore, new treatment options are needed. Five female patients diagnosed with trichotillomania applied low-frequency repetitive transcranial magnetic stimulation (rTMS) over bilateral supplementary motor area for 3 weeks. Baseline and after rTMS, patients were given Beck Depres-sion Inventory, Beck Anxiety Inventory and Massachusetts General Hospital Hair Pulling Scale to evaluate the severity of disorder at baseline and post-rTMS. In this case series, three of five patients with trichotillomania obtained a substantial benefit from treatment, while one patient obtained a partial symptom reduction. The last patient experienced a mild increase in severity of disease after rTMS treatment. rTMS treatment can be effective in some patients with trichotillomania and can be a promising option in treatment of trichotillomania.
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Affiliation(s)
- Efruz Pirdoğan Aydın
- Department of Psychiatry, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Jülide Güler Kenar
- Department of Psychiatry, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Aslı Tutan
- Department of Psychiatry, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Ömer Akil Özer
- Department of Psychiatry, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
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Kwon C, Sutaria N, Khanna R, Almazan E, Williams K, Kim N, Elmariah S, Kwatra SG. Epidemiology and Comorbidities of Excoriation Disorder: A Retrospective Case-Control Study. J Clin Med 2020; 9:jcm9092703. [PMID: 32825621 PMCID: PMC7564859 DOI: 10.3390/jcm9092703] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 12/18/2022] Open
Abstract
Excoriation disorder is a psychocutaneous disorder characterized by repetitive skin-picking and associated with significant morbidity. Currently, epidemiological data in patients with excoriation disorder are lacking so we sought to characterize common patient demographics and comorbidities. We conducted a retrospective case-control study comparing 250 patients with excoriation disorder with 250 age-, race- and sex-matched controls identified between 2007 and 2019 at a single tertiary care center. We found that the majority of excoriation disorder patients were female (76%), Caucasian (82%) and unmarried (62%), with a mean age of 49 years. Compared to the matched controls, patients with excoriation disorder had increased odds of several psychiatric illnesses, including obsessive compulsive disorder (odds ratio (OR) 28.48, 95% confidence interval (CI): 1.68, 481.75), substance use disorder (OR 24.33, 95% CI: 5.81, 101.77), post-traumatic stress disorder (OR 8.23, 95% CI: 2.24, 129.40), depression (OR 8.19, 95% CI: 4.86, 13.80), bipolar disorder (OR 7.55, 95% CI: 2.22, 25.65), attention-deficit/hyperactivity disorder (OR 5.63, 95% CI: 1.62, 19.57), and anxiety (OR 5.01, 95% CI: 2.92, 8.62). Only a minority (42%) of patients were given psychiatry referrals and of those referred, a majority (64%) did not follow-up with psychiatry. The outcomes were also generally unfavorable as only 21% of patients experienced a resolution or improvement in their symptoms. This highlights the need for a multidisciplinary approach to manage patients with excoriation disorder, involving both dermatologists and psychiatrists.
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Affiliation(s)
- Christina Kwon
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (C.K.); (N.S.); (R.K.); (E.A.); (K.W.); (N.K.)
| | - Nishadh Sutaria
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (C.K.); (N.S.); (R.K.); (E.A.); (K.W.); (N.K.)
| | - Raveena Khanna
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (C.K.); (N.S.); (R.K.); (E.A.); (K.W.); (N.K.)
| | - Erik Almazan
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (C.K.); (N.S.); (R.K.); (E.A.); (K.W.); (N.K.)
| | - Kyle Williams
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (C.K.); (N.S.); (R.K.); (E.A.); (K.W.); (N.K.)
| | - Noori Kim
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (C.K.); (N.S.); (R.K.); (E.A.); (K.W.); (N.K.)
| | - Sarina Elmariah
- Department of Dermatology, Massachusetts General Hospital, Boston, MA 02114, USA;
| | - Shawn G. Kwatra
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (C.K.); (N.S.); (R.K.); (E.A.); (K.W.); (N.K.)
- Correspondence: ; Tel.: +1-410-955-8662
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Mareeva AN, Pichugina IM. Trichoteiromania in adults. VESTNIK DERMATOLOGII I VENEROLOGII 2020. [DOI: 10.25208/vdv1127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
This paper describes two clinical cases of a rare auto-destructive hair pathology trichoteiromania. In the literature a few cases of trichoteiromania are described, it leads to non-cicatricial hair loss as a result of their rubbing and is characterized by splitting and damaging of the hair shaft.
The clinical picture features, trichoscopic signs of the disease are presented: foci of baldness in the scalp, hair shafts not more than 1.5 cm long, curved, scaling as a result of scratching the skin. Trichoscopic features: broken hair up to 1,5 сm length, splitting of the distal end of the hair shaft (trichoptilosis), scaling.
The data on the differential diagnosis of the disease with other hair pathologies, the possible symptomatic, psychotherapeutic, psychopharmacological treatment of trichoiteromania are presented.
These clinical cases are of interest in connection with rare descriptions in the literature, the importance of trichoscopy in the differential diagnosis of alopecia, the possibility of interaction between a dermatologist and a psychiatrist, a psychotherapist are indicated.
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Everett GJ, Jafferany M, Skurya J. Recent advances in the treatment of trichotillomania (hair-pulling disorder). Dermatol Ther 2020; 33:e13818. [PMID: 32531098 DOI: 10.1111/dth.13818] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/09/2020] [Accepted: 06/10/2020] [Indexed: 12/16/2022]
Abstract
Trichotillomania (TTM) is a condition in which affected individuals pull out their hair resulting in hair loss. This disorder affects roughly 0.5% to 2.0% of the population and can have significant psychological morbidity. Behavioral therapy has been used with success in the treatment of TTM, but not all patients are willing or able to comply with this treatment strategy. There is a need for effective pharmacological treatment options. Historically, pharmacotherapy for TTM has been inadequate in most cases, but recent advances have been made in this regard. Fluoxetine, clomipramine, olanzapine, and naltrexone have all been used in the treatment of TTM, but evidence of benefit has varied, and side effect profiles can limit practical utility. Recent advances in the understanding of the pathophysiology of TTM, as well as evidence of benefit seen with some glutamate-modulating agents such as N-acetylcysteine and dronabinol, have provided newer potential pharmacotherapy options.
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Affiliation(s)
- Gregory J Everett
- Division of Psychodermatology, Central Michigan University, Saginaw, Michigan, USA
| | - Mohammad Jafferany
- Division of Psychodermatology, Central Michigan University, Saginaw, Michigan, USA
| | - Jonathon Skurya
- Division of Psychodermatology, Central Michigan University, Saginaw, Michigan, USA
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Skurya J, Jafferany M, Everett GJ. Habit reversal therapy in the management of body focused repetitive behavior disorders. Dermatol Ther 2020; 33:e13811. [PMID: 32542916 DOI: 10.1111/dth.13811] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 06/09/2020] [Indexed: 11/28/2022]
Abstract
Body-focused repetitive behavior disorders are a group of disorders characterized by repetitive actions that include skin picking, hair pulling, nail biting, and other compulsions. These disorders can range from a common habit to a pathological disorder, that negatively impacts the psychiatric health and social well-being of an individual. Diagnosis can be made clinically, and monitored using different scales and assessments. Various treatments have been tried with differing successes. There are currently no first line curative medications for these disorders, but cognitive behavioral therapy has seen the most success in treatment. Specifically habit reversal therapy has shown the most promise in reducing the repetitive behaviors and symptoms seen in these disorders. Habit reversal therapy has also seen success through augmentation with additional therapies such as mindfulness, or treatment with a selective serotonin reuptake inhibitor in a patient with comorbid obsessive compulsive disorder. This paper aims to explore the efficacy of different treatment modalities specifically the effectiveness and approach of habit reversal therapy.
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Abstract
OBJECTIVES Skin picking disorder (SPD) falls into the category of "obsessive-compulsive disorder and related disorders" in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). Repetitive transcranial magnetic stimulation (rTMS) treatment has been reported to be a promising therapy in obsessive-compulsive disorder-related disorders. The purpose of this study was to demonstrate the efficacy of rTMS treatment in patients with SPD. METHODS Fifteen patients with SPD were assigned to receive 3 weeks' treatment with either active (n = 8) or sham rTMS targeting the pre-supplementary motor area. Patients were evaluated using the Beck Depression Inventory, Beck Anxiety Inventory, Skin Picking Impact Scale, and the Yale-Brown Obsessive Compulsive Scale Modified for Neurotic Excoriation. Response to treatment was defined as a ≥35% decrease on Yale-Brown Obsessive Compulsive Scale modified for Neurotic Excoriation. RESULTS Treatment response was achieved in 62.5% of patients (5/8) in the active group and 33.3% of patients (2/6) in the sham group. However, there were no significant differences between the groups in terms of primary and secondary outcomes. CONCLUSIONS In this exploratory study, active rTMS could not be demonstrated to be superior over sham in treatment of SPD. The results of this study indicate the need for further rTMS studies to be conducted with larger sample sizes and subtypes of SPD.
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Reddy YCJ, Sudhir PM, Manjula M, Arumugham SS, Narayanaswamy JC. Clinical Practice Guidelines for Cognitive-Behavioral Therapies in Anxiety Disorders and Obsessive-Compulsive and Related Disorders. Indian J Psychiatry 2020; 62:S230-S250. [PMID: 32055066 PMCID: PMC7001348 DOI: 10.4103/psychiatry.indianjpsychiatry_773_19] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 12/16/2019] [Indexed: 12/05/2022] Open
Affiliation(s)
- Y C Janardhan Reddy
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Paulomi M Sudhir
- Department of Clinical Psychology, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - M Manjula
- Department of Clinical Psychology, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Shyam Sundar Arumugham
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Janardhanan C Narayanaswamy
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
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Patchy evidence in skin-picking disorder supports management with combined behavioural and drug treatments. DRUGS & THERAPY PERSPECTIVES 2019. [DOI: 10.1007/s40267-019-00674-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Luca M, Luca A. Comment to the contribution, “Assessment and treatment of trichotillomania (hair pulling disorder) and excoriation (skin picking) disorder,” by Jones and colleagues. Clin Dermatol 2019; 37:289-290. [DOI: 10.1016/j.clindermatol.2019.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
Skin-picking disorder, also known as excoriation disorder or psychogenic skin excoriations, is an obsessive-compulsive and related disorder that is classified with other body-focused repetitive-behavior disorders in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Skin-picking disorder is associated with significant comorbidity and psychosocial dysfunction. The disorder has a female predominance across studies, and the average age of onset is variable but commonly in adolescence and adulthood. A full clinical and dermatologic examination and multidisciplinary approach is important in the diagnosis of this condition. There is no specific or recommended treatment option, but cognitive-behavioral therapy, particularly habit-reversal therapy and acceptance and commitment therapy have shown promise. Various pharmacological interventions have also been described to treat this condition in case reports and open and controlled trials. Specific classes of agents implemented include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors, antipsychotics, and glutaminergic-modulating agents. SSRIs and N-acetylcysteine have been shown to be the most effective of the pharmacological interventions.
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Affiliation(s)
- Mohammad Jafferany
- Central Michigan University College of Medicine, 3201 Hallmark Court, Saginaw, MI, 48603, USA.
| | - Arsh Patel
- Central Michigan University College of Medicine, 3201 Hallmark Court, Saginaw, MI, 48603, USA
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