Hypnobehavioral treatment of self-destructive behavior: trichotillomania and bulimia in the same patient

A case of trichotillomania and bulimia nervosa in a patient with adult-onset attention-deficit/hyperactivity disorder (ADHD)

Key Clinical Message

Identifying any potential comorbidity such as bulimia nervosa (BN) and ADHD in trichotillomania patients is essential for a thorough treatment plan. Combining a multidisciplinary approach was found to be feasible and effective in the treatment.

Abstract

Trichotillomania is frequently considered an isolated disorder; nevertheless, emerging evidence suggests that other psychiatric conditions, including obsessive-compulsive disorder (OCD), eating disorders, and attention-deficit/hyperactivity disorder (ADHD), are often found to coexist. Several studies showed that eating disorders, such as bulimia nervosa, were found in chronic hair-pullers, while OCD was considered a factor in predicting the prevalence of eating disorders, as well as the severity of trichotillomania in the populations. While the relationship between trichotillomania and OCD has been quite well-documented, the evidence of its association with bulimia nervosa and ADHD remains limited. Here, we report a case of trichotillomania with comorbid bulimia nervosa, major depressive disorder, and ADHD.

Impulse control disorders in women with eating disorders

We compared symptom patterns, severity of illness, and comorbidity in individuals with eating disorders with and without impulse control disorders (ICD), and documented the temporal pattern of illness onset. Lifetime ICD were present in 16.6% of 709 women with a history of eating disorders. The most common syndromes were compulsive buying disorder and kleptomania. ICD occurred more in individuals with binge eating subtypes, and were associated with significantly greater use of laxatives, diuretics, appetite suppressants and fasting, and with greater body image disturbance, higher harm avoidance, neuroticism, cognitive impulsivity, and lower self-directedness. In addition, individuals with ICD were more likely to have obsessive-compulsive disorder, any anxiety disorder, specific phobia, depression, cluster B personality disorder, avoidant personality disorder, and to use psychoactive substances. Among those with ICD, 62% reported the ICD predated the eating disorder and 45% reported the onset of both disorders within the same 3-year window. The presence of a lifetime ICD appears to be limited to eating disorders marked by binge eating and to be associated with worse eating-related psychopathology, more pathological personality traits, and more frequent comorbid Axis I and II conditions. Untreated ICD may complicate recovery from eating disorders.

Impulse control disorders in eating disorders: clinical and therapeutic implications

OBJECTIVE

Few studies have explored impulse control disorders (ICDs) in women with bulimia nervosa (BN). We explored the prevalence of lifetime ICDs in women with BN, compared the severity of eating disorder symptoms in women with BN with and without ICD, and compared their personality profiles to females with one form of ICD, namely, pathologic gambling.

METHOD

A total sample of 269 female patients consecutively admitted to our unit participated in the current study (173 BN without comorbid ICD [BN - ICD]; 54 BN with comorbid ICD [BN + ICD]; and 42 pathologic gamblers [PG]). All participants were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria.

EVALUATION

Assessment measures included the Symptom Checklist-90 revised and the Temperament and Character Inventory-revised, as well as a number of other clinical and psychopathologic indices.

RESULTS

In BN, the observed lifetime prevalence of ICD was 23.8%. Lifetime compulsive buying (17.6%) and intermittent explosive disorder (13.2%) were the most frequently reported ICD. Bulimia nervosa subtype was not significantly associated with lifetime ICD (P = .051) or with ICD subtype (P = .253). After using multinomial regression models, we observed that BN + ICD and PG showed the highest scores on novelty seeking (P < .0001). But BN + ICD women had the lowest scores on self-directedness (P < .03) and higher scores on general psychopathology (P < .01) and drug abuse (P < .01).

CONCLUSIONS

Individuals with BN + lifetime ICD presented more extreme personality profiles, especially on novelty seeking and impulsivity, and general psychopathology than individuals with BN without ICD. On some personality traits, those BN + ICD more closely resembled individuals with PG than those with BN without ICD.

Trichotillomania

Trichotillomania is a neglected psychiatric disorder with dermatologic expression that has only recently received research attention. On the basis of clinical data, trichotillomania appears to be far more common than previously believed. Like obsessive-compulsive disorder, the hair-pulling behavior is recognized as senseless and undesirable but is performed in response to several emotions and affects, such as increasing anxiety, or unconscious conflicts with resultant tension relief. The condition may be episodic but is usually chronic and difficult to treat. On the basis of possible medical and psychiatric complications, it is important that the diagnosis is exact and early. We describe the comorbidity and the phenomenology of trichotillomania, paying attention to the possible available treatments. (J Am Acad Dermatol 2002;46:807-21.)

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be familiar with clinical and histologic aspects of trichotillomania and should be able to cope with the risks of medical and psychiatric complications in these patients. Finally, participants will be able to easily interact with psychiatrists, when needed, to identify the most successful treatment.

Trichotillomania: a challenge to research and practice

This review explores several aspects of trichotillomania relevant to clinical theory and practice. It is concluded that research outlining the phenomenology and patterns of comorbidity of trichotillomania have been advanced significantly in recent years. However, no current diagnostic category appropriately classifies trichotillomania. Research with nonclinical populations suggests that trichotillomania is more common than previously believed and that additional epidemiological research is warranted. Continued elaboration of existing etiological models incorporating varying theoretical perspectives is also encouraged. Assessment of trichotillomania could also be improved by the continued development of reliable and valid standardized measures. This article reviews both pharmacological and psychological treatments for trichotillomania, with an emphasis on habit-reversal training. Though some interventions appear effective in the short-term, reported relapse rates are high and future research on treatment for trichotillomania should focus on improving long-term outcomes. It is clear that despite a recent flux of research centering on trichotillomania, significant challenges for understanding and treating this psychological disorder still exist for researchers and clinicians. Based on this review of the literature, and on our clinical experience with trichotillomania, we propose directions for future research with this underserved psychiatric group.

Obsessive-compulsive disorder, trichotillomania, and anorexia nervosa: a case report

We report a case study of an 18-year-old female who presented with symptoms associated with several discrete diagnostic syndromes: obsessive-compulsive disorder, trichotillomania, major depression, and anorexia nervosa. Improvement in each occurred after treatment with the serotonin selective reuptake inhibitor, fluoxetine, suggesting that such syndromes share a common serotonin neurotransmitter disturbance. Furthermore, the combined effects of medication and psychotherapy resulted in improvement in assertiveness, sense of security, self-worth, flexibility, and self-regulation. We discuss the pharmacological and psychotherapeutic implications of possible psychophysiologic similarities among the previously mentioned syndromes.

Trichotillomania

The present study examines some of the beliefs about trichotillomania such as those concerning the sex and age of afflicted individuals. Information was gathered from an exhaustive literature review and surveys of the general public and college students. Data on such factors as prevalence, sex, age distribution, onset, codiagnosis, and details of the hair-pulling act are presented, and reviews of explanations and treatment are provided.

Hair loss in children and adolescents

No other body system is more exposed to the public eye than the skin and the hair. Pediatric nurse practitioners (PNPs) frequently encounter patients in their practice settings with the complaint of "hair loss." The most often diagnosed causes of hair loss include tinea capitis, alopecia areata, traction alopecia, and trichotillomania. This article defines these conditions, explores the causes for them, and describes the incidences. Emphasis is placed on the PNP's role on making a differential diagnosis based on the presenting clinical manifestations, patient history, and laboratory testing. Treatment for these conditions as well as nursing goals and PNP interventions for management and family education also are discussed.

Annotation: trichotillomania

In spite of intriguing new information about trichotillomania, the most basic information about its prevalence, natural history, and treatment is lacking. While there is evidence that trichotillomania is more common than expected, epidemiological data are needed to establish the true frequency and pattern of associated disorders, and cross-cultural work would also be of great interest. The natural history of the disorder remains uncertain, although there are apparently both chronic and remitting forms, which may differ in age of onset and sex distribution. Finally (as with obsessive compulsive disorder), the relative effectiveness, and long-term benefits, of behavioral and drug treatments are not established. Child psychologists, psychiatrists and pediatricians need to be more aware of this disorder, as the misery from trichotillomania has been greatly under-recognized, and continued research could extend our understanding of developmental psychopathology.

Self-injurious behavior as a habit and its treatment

The definition of self-injurious behavior applies to persons who hurt or harm themselves without the motive of suicide or of sexual deviation. The different aspects of self-injurious behavior and the theories explaining them are reviewed. For 5 years a young, intelligent woman had inflicted injuries upon herself with sharp instruments while ostensibly caring for her face and legs. The short-term hypnobehavioral treatment included keeping daily reports of her self-inflicted injuries and of her thoughts while executing them, finding alternative activities to replace her habit, and practicing self-hypnosis once a day. Increasing the level of understanding of her inner conflict and accenting ways of breaking the habit by means of positive autosuggestion proved very effective. The treatment was successful after 13 sessions.