Childhood trichotillomania: clinical phenomenology, comorbidity, and family genetics

The genetics of trichotillomania and excoriation disorder: A systematic review

BACKGROUND

Trichotillomania (TTM) and excoriation disorder (ED) are impairing obsessive-compulsive related disorders that are common in the general population and for which there are no clear first-line medications, highlighting the need to better understand the underlying biology of these disorders to inform treatments. Given the importance of genetics in obsessive-compulsive disorder (OCD), evaluating genetic factors underlying TTM and ED may advance knowledge about the pathophysiology of these body-focused repetitive behaviors.

AIM

In this systematic review, we summarize the available evidence on the genetics of TTM and ED and highlight gaps in the field warranting further research.

METHOD

We systematically searched Embase, PsycInfo, PubMed, Medline, Scopus, and Web of Science for original studies in genetic epidemiology (family or twin studies) and molecular genetics (candidate gene and genome-wide) published up to June 2023.

RESULTS

Of the 3536 records identified, 109 studies were included in this review. These studies indicated that genetic factors play an important role in the development of TTM and ED, some of which may be shared across the OCD spectrum, but there are no known high-confidence specific genetic risk factors for either TTM or ED.

CONCLUSIONS

Our review underscores the need for additional genome-wide research conducted on the genetics of TTM and ED, for instance, genome-wide association and whole-genome/whole-exome DNA sequencing studies. Recent advances in genomics have led to the discovery of risk genes in several psychiatric disorders, including related conditions such as OCD, but to date, TTM and ED have remained understudied.

Clinical Characteristics of Youth with Trichotillomania (Hair-Pulling Disorder) and Excoriation (Skin-Picking) Disorder

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.

Predictive Value of Grooming Behavior for Development of Dermatitis in Selectively Bred P Rats as a Model of Trichotillomania Hair Pulling Disorder

Trichotillomania (TTM) is a body-focused repetitive disorder affecting as much as 0.5 to 2% of the population, with women four times more likely to be affected than men. This disorder causes impairment in daily function and significant distress. A potential animal model for this disorder is the inbred C57BL/6J mouse which displays clinical signs and behavioral characteristics similar to those described for people affected by this disorder. Because alcohol-preferring P rats also display similar clinical signs and behavioral characteristics, it was hypothesized that this selectively bred stock could be an additional animal model. In this study, 112 female P rats were recorded on digital media for 15 min after being sprayed with a mist of water and assessed for grooming patterns—oral, manual, and scratching. Significant elevations in scratching and oral grooming behavior were predictive of the future development of skin lesions. These findings suggest that P rats may be an additional model to study TTM, with the advantage of increased genetic variation (i.e., non-inbred) which mirrors the human population. The use of this model may help to identify preventative and therapeutic interventions for humans and other animals with similar body-focused repetitive disorders.

Current Understanding of the Genetics of Tourette Syndrome

Gilles de la Tourette syndrome (TS) is a common, childhood-onset psychiatric disorder characterized by persistent motor and vocal tics. It is a heterogeneous disorder in which the phenotypic expression may be affected by environmental factors, such as immune responses. Furthermore, several studies have shown that genetic factors play a vital role in the etiology of TS, as well as its comorbidity with other disorders, including attention deficit hyperactivity disorder, obsessive-compulsive disorder, and autism spectrum disorder. TS has a complex inheritance pattern and, according to various genetic studies, several genes and loci have been correlated with TS. Genome-wide linkage studies have identified Slit and Trk-like 1 (SLITRK1) and histidine decarboxylase (HDC) genes, and candidate gene association studies have extensively investigated the dopamine and serotonin system genes, but there have been no consistent results. Moreover, genome-wide association studies have implicated several genetic loci; however, larger study cohorts are needed to confirm this. Copy number variations, which are polymorphisms in the number of gene copies due to chromosomal deletions or duplications, are considered another significant source of mutations in TS. In the last decade, whole genome/exome sequencing has identified several novel genetic mutations in patients with TS. In conclusion, more studies are needed to reveal the exact mechanisms of underlying TS, which may help to provide more information on the prognosis and therapeutic plans for TS.

Hair loss in an infant presenting with failure to thrive

An 11-month-old male child with a complex past medical history presented for admission due to failure to thrive. He had hair loss throughout his scalp, and his abdomen was distended. There was parental report of hair pulling and hair in his stool. An upper gastrointestinal (GI) radiograph with fluoroscopy was performed and showed a filling defect in the gastric lumen. On endoscopy, he was found to have a gastric bezoar consisting of hair, nail, and food material. The trichobezoar was removed, and he began to tolerate feeds and showed consistent weight gain. There were no recurrence of symptoms 8 months following removal. While inadequate caloric intake is a common reason for failure to thrive, mechanical obstruction from a trichobezoar as a cause is rare and to our knowledge has not been reported in a child this young.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Family functioning in pediatric trichotillomania, obsessive compulsive disorder, and healthy comparison youth

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.

Initial psychometrics, outcomes, and correlates of the Repetitive Body Focused Behavior Scale: Examination in a sample of youth with anxiety and/or obsessive-compulsive disorder

BACKGROUND

Body-Focused Repetitive Behaviors (BFRBs), including skin-picking, hair-pulling, and nail-biting, commonly occur in youth, even at elevated/problematic levels, and are associated with a number of other psychiatric symptoms. The present study examined the internal consistency of a brief screening tool for BFRBs as well as the prevalence, severity, and correlates of BFRBs in a sample of youth with a primary anxiety or obsessive-compulsive disorder (OCD).

METHODS

Ninety-three youth-parent dyads presenting for treatment for anxiety or OCD completed study measures including the Repetitive Body Focused Behavior Scale - Parent (RBFBS), which includes subscales for skin-picking, hair-pulling, and nail-biting, as well as a number of additional clinician-, parent-, and child-rated scales.

RESULTS

The RBFBS demonstrated good to excellent internal consistency. BFRBs were endorsed in 55% of youths, with elevated levels in 27%. Skin-picking was the most common BFRB (38%), followed by nail-biting (34%) and hair-pulling (4%). Youth with BFRBs, as compared to those without, were rated as more avoidant by their parents. Among those with BFRBs, more avoidant tendencies, anxiety sensitivity, and child-rated panic, separation, and generalized anxiety symptoms were associated with elevated BFRB severity. BFRBs were equally common but more likely to be elevated among youth with a primary anxiety, than OCD, diagnosis.

DISCUSSION

Results provide initial support for the RBFBS as a brief screening tool for the three common BFRBs. In addition, the results suggest avoidant tendencies and physical manifestations of distress may be particularly relevant to the escalation of BFRB symptoms in youth.

A Practical Approach to the Diagnosis and Management of Hair Loss in Children and Adolescents

Hair loss or alopecia is a common and distressing clinical complaint in the primary care setting and can arise from heterogeneous etiologies. In the pediatric population, hair loss often presents with patterns that are different from that of their adult counterparts. Given the psychosocial complications that may arise from pediatric alopecia, prompt diagnosis and management is particularly important. Common causes of alopecia in children and adolescents include alopecia areata, tinea capitis, androgenetic alopecia, traction alopecia, trichotillomania, hair cycle disturbances, and congenital alopecia conditions. Diagnostic tools for hair loss in children include a detailed history, physical examination with a focused evaluation of the child’s hair and scalp, fungal screens, hair pull and tug test, and if possible, light microscopy and/or trichoscopy. Management of alopecia requires a holistic approach including psychosocial support because treatments are only available for some hair loss conditions, and even the available treatments are not always effective. This review outlines the clinical presentations, presents a diagnostic algorithm, and discusses management of these various hair loss disorders.

Some Reflections on Infancy-Onset Trichotillomania

Whether infancy-onset trichotillomania is best regarded as a habit, an early sign of obsessive compulsive disorder, a symptom of anxiety, or a sign of severe deprivation has been a topic of continuous debate. In this paper, we describe our clinical experience with nine consecutive cases of infancy-onset trichotillomania and detail the evaluation process and treatment course in one case. A distinct psychosocial stressor was identified in all cases, often accompanied by loss in the parents' histories. Most of the children had no transitional object. In six infants, the symptom resolved after treatment and did not recur, while in three others improvement was partial. Length of treatment varied from four to twenty-one sessions and outcome was unrelated to treatment duration. In all cases, mother-child interactions were characterized by a lack of maternal physical contact and warmth, sharp maternal transitions between under-involvement and intrusiveness, lack of mutual engagement, and no elaboration of symbolic play. The infant's behavior during play was marked by anxiety, irritability, and momentary withdrawal from the interaction. Our cases reveal an impaired affective interpersonal communication between mother and child, often masked by a fair overallfamily instrumental functioning. It is tenta- tively suggested that infancy-onset trichotillomania represents an end-point symptom of several factors, such as a disturbed parent-infant relationship, a low pain threshold in the infant, and a parental hypersensitivity to overt expressions of aggressive impulses and negative affects. Issues related to treatment modalities are also addressed. Discussion focused on our experience that early-onset cases of trichotillomania are often not benign or homogenous in terms of etiology, course, or response to treatment and require much further study.

Behavioral Treatment of Trichotillomania

Once considered a rare clinical condition, trichotillomania is now recognized as a psychological disorder that is more prevalent than previously thought. The behavioral treatment of a 21-year old college woman with a longstanding history of chronic hair pulling is described in this case study. The extent of the trichotillomania was measured during an 11-day baseline period (self-monitoring, photographs) followed by 4 months of behavioral treatment including prominent components of habit-reversal training. The results of the interventionwere suggestive of a substantial reduction in hair pulling incidents, hair regrowth in the affected parts of her scalp, and self-reported improvements in mood, anxiety, and self-esteem. Limitations of these data are reviewed and recommendations for clinicians who intend on treating trichotillomania are provided.

A family study of trichotillomania and chronic hair pulling

Little is known about the etiology of hair pulling (HP) and its relationship to other obsessive compulsive (OC) spectrum disorders. In a large-sample family study, we examined the familial aggregation of HP and co-transmission of obsessive compulsive disorder (OCD) and skin picking (SP). Our sample consisted of 110 proband cases with HP and 48 controls without HP, plus 128 first-degree case relatives and 50 first-degree control relatives. Case versus control relatives had higher recurrence risk estimates for both HP and OCD but not SP. The finding that HP is familial is consistent with the only existing twin study. Additional analyses suggest that there may be a familial subtype of HP with comorbid OCD. Those adult proband cases with HP + OCD had more anxiety and depression than cases without OCD. Probands with HP + OCD also had earlier onset of OCD. Identification of an HP subtype with comorbid OCD may have significant theoretical and treatment implications. The data did not provide evidence for an etiologic relationship between HP and SP. Replication of these findings in future studies with larger cohorts of case and control relatives is warranted.

Habit reversal training in trichotillomania: guide for the clinician

Trichotillomania (hair-pulling disorder) involves repetitive hair pulling that can cause significant distress and impairment in functioning. Both children and adults suffer from the disorder. Habit reversal training (HRT) is the trichotillomania treatment with the most empirical support. HRT begins with developing an in-depth understanding of the client's unique pulling behaviors. The major components of HRT can then be carried out in a way that targets the client's specific needs. These include awareness training and self-monitoring, stimulus control and competing response procedures. Within each of these components the client learns to recognize his or her pulling urges, avoid situations in which pulling is more likely and adopt behaviors that can be used instead of pulling. Future work will involve evaluating the efficacy of adding therapy models such as mindfulness meditation in order to further enhance the effectiveness of HRT, and studying the long-term efficacy of HRT for children and adults.

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.

The genetic factors influencing the development of trichotillomania

Trichotillomania (TTM), an obsessive-compulsive spectrum disorder (OCSD), is a psychiatric condition characterized by repetitive hair pulling. Evidence from family and twin studies suggest a heritable link of TTM. Functional polymorphisms in genes involved in neuronal pathways might influence the susceptibility to TTM. This review is an attempt to compile the genetic factors reported to modify the development of TTM.

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.

Pediatric trichotillomania

Trichotillomania (TTM) is an impulse control disorder characterized by chronic hair-pulling, distress, and impairment. Although the negative effects of TTM are documented and often readily evident, there remains a paucity of psychopathology and treatment research on this disorder, particularly in pediatric populations. In an effort to improve assessment of pediatric TTM, several TTM-specific instruments for youth have now been developed to reliably identify symptoms and examine related phenomenology. Instrument development has now yielded instruments to evaluate TTM and related symptoms in the context of clinical trials of youth, and the first randomized controlled trial of any treatment for pediatric TTM was recently published. Using the initial pediatric TTM studies as building blocks, future research is now needed to create a stronger body of knowledge about the relative and combined efficacy of potential interventions for TTM in youth, as well as to examine the effects of TTM phenomenology and comorbidity on treatment outcome. Dissemination efforts must also be heightened for this knowledge to best reach these vulnerable populations.

Pediatric trichotillomania: clinical presentation, treatment, and implications for nursing professionals

Trichotillomania (TTM), or compulsive hair pulling, is a disorder that typically onsets in childhood. It is mistaken to believe that children will "age out" of this behavior, as pediatric TTM often has a chronic, debilitating course that does not remit without treatment, resulting in considerable psychological and physical impairment. Because most children with TTM will be seen initially by nursing professionals in the practices of dermatologists, pediatricians, gastroenterologists, and other disciplines, raising nurses' awareness of this disorder is of the utmost importance for accurate nursing diagnosis and assessment. As the health care providers who spend the greatest amount of time with patients, nurses' detection and diagnosis of TTM can make a critical difference in the initiation of early intervention. Therefore, the purpose of this article is to provide an overview of pediatric TTM, including its epidemiology, clinical presentation, and treatment options, from the perspective of nurses who may interact with such patients in their workplace.

Early childhood trichotillomania: Initial considerations on phenomenology, treatment, and future directions

Historically, trichotillomania (TTM) in young children (0-3 years old) generally has been considered to be a benign habit that is clinically distinct from the TTM seen in older children and adults. However, early childhood TTM can be an impairing pathological disorder that merits formal intervention. The present article reviews the extant literature on TTM in young children, highlighting the limited available phenomenological data. We discuss a behavioral approach to conceptualization and treatment, highlighting core intervention strategies in three early childhood TTM cases seen in our clinic. We conclude by discussing areas in need of further empirical attention.

Trichotillomania and its treatment: a review and recommendations

Trichotillomania (TTM) is characterized as an impulse control disorder in which individuals fail to resist urges to pull out their own hair, and is associated with significant functional impairment and psychiatric comorbidity across the developmental spectrum. Onset in childhood or adolescence appears to be the norm, yet the research literature involving pediatric samples is particularly sparse. Efficacious treatments have been developed, in particular cognitive-behavioral interventions involving procedures collectively known as habit reversal training, yet relapse in adults appears to be common. Recent developments in pharmacotherapies for TTM and in combining cognitive-behavioral therapy approaches with medication hold promise, and efforts to examine their relative and combined efficacy are needed. Dissemination of information about TTM and its treatment is a critical next step in the field, since many affected individuals and families cannot find local treatment providers with sufficient knowledge to deliver interventions known to reduce hair pulling behavior.

Pediatric psychocutaneous disorders: a review of primary psychiatric disorders with dermatologic manifestations

Psychocutaneous disorders (PCDs) are conditions that are characterized by psychiatric and skin manifestations. Classifications of PCDs and their nomenclature are matters of debate. For the purpose of this review, we adopted the classification that distinguishes primary dermatologic disorders with psychiatric co-morbidity (PDDPC) from primary psychiatric disorders with dermatologic manifestations (PPDDM). PDDPC includes the psychophysiologic disorders such as atopic eczema, psoriasis, vitiligo, and alopecia areata. PPDDM includes impulse control disorders, obsessive-compulsive disorders, factitious disorder, factitious disorder by proxy, self-mutilation, delusions of parasitosis, psychogenic purpura/Gardner-Diamond syndrome, and cutaneous sensory disorders. Diagnosis and treatment of PCDs are challenging and require that the underlying psychopathology be addressed. A specific PCD may have different underlying psychopathologies and, at times, multiple overlapping psychopathologies may coexist. Most often, both non-pharmacologic management and psychopharmacologic treatment are necessary. The choice of psychopharmacologic agent depends on the nature of the underlying psychopathology (e.g. anxiety, depression, obsessive-compulsive disorder, psychosis). This article reviews the spectrum of PPDDM in children.

Validation of a classification system of obsessive-compulsive spectrum disorder symptoms in a non-clinical sample

Controversy surrounds the classification of obsessive-compulsive spectrum disorder (OCSD) symptoms. In this study, we tested whether a broad OCSD symptoms model consisting of obsessive-compulsive, body dysmorphic, health anxiety, trichotillomania, pathological skin picking, impulsivity, and anxiety symptoms displayed sufficient data fit. Alternatively, we tested whether a reduced OCSD symptoms model consisting of obsessive-compulsive, body dysmorphic, health anxiety, trichotillomania, and pathological skin picking symptoms demonstrated superior fit. The reduced OCSD symptoms model demonstrated good data fit. However, the broader OCSD symptoms model only displayed marginal data fit. In context with other findings, results of this study support an OCSD symptoms dimension that includes obsessive-compulsive, body dysmorphic, health anxiety, trichotillomania, and pathological skin picking symptoms. Implications of these findings are discussed as they relate to proposed changes in the forthcoming edition of the Diagnostic and Statistical Manual.

Family-based genetic association study of DLGAP3 in Tourette Syndrome

Tourette syndrome (TS) is a childhood-onset neuropsychiatric disorder that is familial and highly heritable. Although genetic influences are thought to play a significant role in the development of TS, no definite TS susceptibility genes have been identified to date. TS is believed to be genetically related to both obsessive-compulsive disorder (OCD) and grooming disorders (GD) such as trichotillomania (TTM). SAP90/PSD95-associated protein 3 (SAPAP3/DLGAP3) is a post-synaptic scaffolding protein that is highly expressed in glutamatergic synapses in the striatum and has recently been investigated as a candidate gene in both OCD and GD studies. Given the shared familial relationship between TS, OCD and TTM, DLGAP3 was evaluated as a candidate TS susceptibility gene. In a family-based sample of 289 TS trios, 22 common single nucleotide polymorphisms (SNPs) in the DLGAP3 region were analyzed. Nominally significant associations were identified between TS and rs11264126 and two haplotypes containing rs11264126 and rs12141243. Secondary analyses demonstrated that these results cannot be explained by the presence of comorbid OCD or TTM in the sample. Although none of these results remained significant after correction for multiple hypothesis testing, DLGAP3 remains a promising candidate gene for TS.

Age of onset of trichotillomania symptoms: investigating clinical correlates

Pathological hair-pulling with onset in very early childhood is thought to represent a different disorder from that with later onset. We examined whether there are differences between adult hair-pullers with very early onset (VEO, i.e., <6 years), early onset (EO, i.e., 6 years to <18 years), and late onset (LO, i.e., ≥18 years) trichotillomania symptomatology. Participants with VEO (n = 76; 5%), EO (n = 1280; 80%), and LO (n = 248; 15%) symptoms of trichotillomania did not differ significantly from one another in terms of hair-pulling phenomenologies, comorbidity, functional impact, and perceived treatment response. However, hair-pulling sites varied across the groups; the VEO and EO groups were significantly more likely to pull eyelashes whereas the EO group was more likely to pull pubic hair. Study subjects had current hair-pulling, so biasing the sample to those with more enduring symptoms, despite differences in age of onset of initial pulling. The lack of significant differences found here does not support subtyping hair-pulling by age of onset in patients who present in adulthood.

Behavior therapy for pediatric trichotillomania: Exploring the effects of age on treatment outcome

BACKGROUND

A randomized controlled trial examining the efficacy of behavior therapy for pediatric trichotillomania was recently completed with 24 participants ranging in age from 7 - 17. The broad age range raised a question about whether young children, older children, and adolescents would respond similarly to intervention. In particular, it is unclear whether the younger children have the cognitive capacity to understand concepts like "urges" and whether they are able to introspect enough to be able to benefit from awareness training, which is a key aspect of behavior therapy for trichotillomania.

METHODS

Participants were randomly assigned to receive either behavior therapy (N = 12) or minimal attention control (N = 12), which was included to control for repeated assessments and the passage of time. Primary outcome measures were the independent evaluator-rated NIMH-Trichotillomania Severity Scale, a semi-structured interview often used in trichotillomania treatment trials, and a post-treatment clinical global impression improvement rating (CGI-I).

RESULTS

The correlation between age and change in symptom severity for all patients treated in the trial was small and not statistically significant. A 2 (group: behavioral therapy, minimal attention control) x 2 (time: week 0, 8) x 2 (children < 9 yrs., children > 10) ANOVA with independent evaluator-rated symptom severity scores as the continuous dependent variable also detected no main effects for age or for any interactions involving age. In light of the small sample size, the mean symptom severity scores at weeks 0 and 8 for younger and older patients randomized to behavioral therapy were also plotted. Visual inspection of these data indicated that although the groups appeared to have started at similar levels of severity for children /= 10; the week 8 data show that the three younger children did at least as well as if not slightly better than the nine older children and adolescents.

CONCLUSIONS

Behavior therapy for pediatric trichotillomania appears to be efficacious even in young children. The developmental and clinical implications of these findings will be discussed.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00043563.

A toddler with hair fascination

Joseph is a 24-months old boy referred by his pediatrician because of an "obsession" with pulling and eating hair. When Joseph was 14 months old, he enjoyed touching and twirling his mother's long hair. She observed that it seemed to provide comfort to him. At 18 months, he initiated pulling out and eating his own hair, twirling his mother's hair around his thumb and then sucking on it. Currently, he searches the carpet or a hard floor and looks for hair to eat. The identical behavior is observed at daycare. Joseph's teacher commented, "He pulled hair from a girl who has the longest hair of all the children. We try to distract him from this habit, but he is not distracted for long." Less frequently, Joseph has also eaten sand, chalk, and crayons at daycare. Joseph's mother describes him as a "happy and outgoing" child who interacts with his peers and has a best friend at the daycare. There have not been recent changes or stressful events in his life. Joseph separates from his mother with ease and he sleeps comfortably through the night in his own bed. There have been no episodes of nausea, vomiting, abdominal pain, or constipation. Strands of hair are occasionally seen in the stool. Prenatal and perinatal history was unremarkable. Joseph was breast-fed for 11 months, described as an "easy" baby, achieved motor, social, and language developmental milestones at the usual time, and has been in excellent health. He lives with his mother and maternal grandparents; the biological father has never been involved in his care. At 20 months, Joseph's pediatrician suggested cutting his hair. After several haircuts, Joseph stopped pulling his own hair. However, he continued to search the floor for hair. Hemoglobin and a blood lead level were normal. Joseph appeared pleasant and friendly with normal growth parameters and facial features. He was sitting comfortably on his mother's lap, sucking on his thumb. Social interactions with his mother were appropriate and reciprocal. He warmed up quickly to the examiner and engaged in play. He spoke in two to three word sentences and responded to questions with a speech pattern that was 50% intelligible. Physical and developmental examinations were normal. At the end of the examination, Joseph searched his mother's purse and located a piece of hair. He twirled the hair around his thumb and sucked on it. Initially, he refused to remove his thumb from his mouth. With gentle persuasion, he eventually removed his thumb and agreed to throw the hair in the trash. He did not appear distressed.

Volitional disorders: a proposal for DSM-V

In the DSM-IV-TR, specific impulse control disorders not elsewhere classified (ICD) have been designated following four principles: (1) through the addition of an adjective that emphasizes the aberrant character of an otherwise normal behaviour (e.g., pathological gambling); (2) by means of metaphors (such as in intermittent explosive disorder); (3) according to the presumably quintessential nature of their main signs and symptoms, such as impulsive (e.g., impulse control disorders not elsewhere classified), compulsive (e.g., compulsive shopping), or addictive (e.g., internet addiction); or (4) using Greek suffix mania (e.g., kleptomania, pyromania, and trichotillomania). Given this flagrant inconsistency, we argue that time has come to adopt a less arbitrary way of describing these disorders, at least until it becomes clearer whether they are really impulsive, compulsive or addictive or if the preoccupation with this distinction is valid. In keeping with DSM's emphasis on descriptive phenomenology rather than on unsupported theory, a less biased terminology is in order. Therefore, we would like to suggest: (1) the substitution of the term ICD by the more neutral expression 'volitional disorders not elsewhere classified'; (2) the use of the classical Greek suffix mania, already present in some DSM-IV-TR ICDs, as the main naming principle to be adopted in the DSM-V; and (3) the creation of compulsive, impulsive, and mixed subtypes of the 'volitional disorders not elsewhere classified', since they are beginning to be validated by treatment trials.

Chronic hair-pulling: phenomenology-based subtypes

Distinct subtypes of trichotillomania (TTM)/chronic hair-pulling may exist. The aim of this study was to extend an earlier analysis by our group to a larger sample of patients with chronic hair-pulling, and to assess the validity and clinical utility of several putative subtypes. Eighty patients with various putative hair-pulling subtypes were compared on sociodemographic and clinical variables. Gender and disability due to pulling accounted for a number of important differences; for example, females more commonly had earlier age of onset of pulling, less comorbidity, and more disability than males. Also, those who met DSM-IV criteria B and C of TTM appeared to have a more disabling course of illness than those who did not. These data appear to support a dimensional rather than a categorical approach to subtyping. Future work, incorporating further investigation of the role of gender and psychobiological and treatment outcomes, is needed before definitive conclusions about hair-pulling subtypes can be drawn.

Recent Advances in the Understanding and Treatment of Trichotillomania

Trichotillomania (TTM), or chronic hair pulling, is associated with significant levels of distress and impairment. While research is in its infancy, more data are accumulating regarding the impact, phenomenology, maintaining variables, etiology, and treatment of TTM. Behavior therapy and clomipramine have been moderately effective in reducing TTM symptoms in clinical trials. Enhancing behavior therapy with techniques designed to address TTM patients' emotional control tendencies (e.g., acceptance-based procedures) represents a promising direction in treating TTM.

Trichotillomania: A current review

This review provides a broad and thorough synthesis of the Trichotillomania (TTM) literature as a resource for health professionals seeking the most current and complete information available. For the treatment provider, up to date information can help inform assessment, treatment, or referral decisions. For the student, this review provides a general overview and broad background information necessary to better understand hair-pulling and associated problems. For the researcher, information can help inform study planning. Prevalence, gender distributions, comorbidities, subtypes, and phenomenological characteristics are presented. Etiological theories are reviewed, and assessment and treatment options are offered. The validity of current DSM requirements is discussed and psychological and psychiatric treatment options are presented and evaluated for their strength of recommendation. Challenges to research and treatment are presented and directions for future research are suggested.

A twin concordance study of trichotillomania

Trichotillomania (TTM) is a disorder with putative genetic underpinnings. Family studies report higher than expected rates of TTM among relatives of affected individuals, but no twin concordance studies have been completed to estimate heritability rates. Same-sex twin pairs with hair pulling in at least one co-twin were included. Subjects were recruited following phone screens and questionnaire completion for zygosity and hair pulling variables. Three sets of criteria were used to define hair pulling and TTM. Two other sets of criteria were widened to include skin picking and bothersome hair manipulation. Fisher exact tests assessed pairwise concordance rates for monozygotic and dizygotic twin pairs and heritability estimates were calculated where significant differences existed. Among 34 identified twin pairs, 24 were monozygotic (MZ) and 10 were dizygotic (DZ). Respective concordance rates for MZ and DZ twin pairs were significantly different at 38.1% and 0% for DSM-IV TTM criteria, 39.1% and 0% using modified DSM criteria, and 58.3% and 20% for noticeable non-cosmetic hair pulling (heritability estimates 76.2%). MZ and DZ concordance rates were not significantly different when broadening hair pulling criteria to include skin picking or when including bothersome hair manipulation. Concordance rates from this study suggest that genetic factors play a significant role in the etiology of TTM. Given the reported discordance rates among the MZ twins, further research is required to fully understand contributory non-genetic factors.

Depression, anxiety, and functional impairment in children with trichotillomania

BACKGROUND

Trichotillomania (TTM) remains understudied in children. Adult research suggests that TTM is accompanied by significant depression, anxiety, and functional impairment. The purpose of this study is to examine the occurrence of depression and anxiety in a relatively large sample of youth with TTM and the extent to which these symptoms mediate the relationship between TTM severity and associated impairment.

METHODS

The study utilized data from the Child and Adolescent Trichotillomania Impact Project (CA-TIP), an internet-based sample of 133 youth aged 10-17 (inclusive) with TTM.

RESULTS

Over 45% of children with TTM endorsed depressive symptoms and 40% endorsed anxiety symptoms in excess of one standard deviation (SD) above published community norms. More remarkably, 25% of our sample reported depressive and 20% reported anxiety symptoms in excess of 2 SD above these norms. Older participants reported more symptoms of depression and anxiety than younger ones; age of onset (children with later onset), but not duration of illness, was predictive of higher reports of both depressive and anxiety symptoms. Neither depressive nor anxiety symptoms were related to pulling site. Depressive symptoms partially mediated the relationship between TTM severity and functional impairment.

CONCLUSIONS

Based on an internet sample recruited from the homepage of the Trichotillomania Learning Center, data from this study suggests that symptoms of depression and anxiety may be pervasive among youth with TTM and likely impact functional impairment. Longitudinal studies using directly assessed samples are needed to replicate and extend these findings.

Assessing the validity of current mouse genetic models of obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a disorder characterized by unwanted and intrusive thoughts, images, or impulses and/or repetitive behavior. OCD is a major cause of disability; however, the genetic factors and pathophysiological mechanisms underlying this complex, heterogeneous disorder remain largely unknown. During the past decade, a number of putative mouse genetic models of OCD have been developed for the purpose of studying the neural mechanisms underlying this disorder and developing novel treatments. This review presents and evaluates these experimental preparations to date. Models using knockout or transgenic approaches, as well as those examining variation in genetically diverse populations, are evaluated and discussed.

Affective and Sensory Correlates of Hair Pulling in Pediatric Trichotillomania

Hair pulling in pediatric populations has not received adequate empirical study. Investigations of the affective and sensory states contributing to the etiology and maintenance of hair pulling may help to elucidate the classification of trichotillomania (TTM) as an impulse control disorder or obsessive-compulsive spectrum disorder. The current study aimed to examine children's self-reported affective and sensory states associated with hair pulling. Fifteen participants completed a questionnaire assessing children's experiences during first and recent hair pulling episodes. Results revealed that pulling hair for the first time was associated with pleasure and pain whereas recent hair pulling was associated with pleasure only, suggesting that the punishing quality of hair pulling may diminish over time. The findings also support the notion that hair pulling may be maintained primarily through positive reinforcement, which is consistent with its classification as an impulse control disorder.

Trichotillomania: a case of response to valproic acid

Trichotillomania (TTM) is a commonly undiagnosed psychiatric illness with known medical complications whose symptoms interfere markedly with daily functioning. Studies regarding the pharmacological treatment of TTM in the adult or pediatric population are sparse, and there is a lack of consensus on drug treatment for TTM. The current trend is to use selective serotonin reuptake inhibitors (SSRIs) on the basis of the current hypothesis that TTM may be a part of the obsessive compulsive spectrum of disorders. However, attempts to substantiate the efficacy of SSRI use in TTM has produced conflicting results. There is increasing evidence that mood stabilizers decrease symptoms of TTM. We present the case of a 10-year-old girl whose lifelong hair-plucking symptoms showed remarkable sustained improvement in response to increased levels of valproic acid. This report, the first with valproic acid, indicates that this drug is potentially effective in significantly reducing symptoms of TTM in a sustained manner. This single case report calls for further investigation regarding the utility of valproic acid in the treatment of TTM.

The trichotillomania scale for children: development and validation

Trichotillomania (TTM) is a chronic impulse control disorder characterized by repetitive hair-pulling resulting in alopecia. Although this condition is frequently observed in children and adolescents, research on pediatric TTM has been hampered by the absence of validated measures. The aim of the present study was to develop and test a new self-report measure of pediatric TTM, the Trichotillomania Scale for Children (TSC), a measure that can be completed by children and/or their parents. One hundred thirteen children meeting self-report criteria for TTM, and 132 parents, provided data over the internet. An additional 41 child-parent dyads from an outpatient clinic also provided data. Replicated principal components analysis, with elimination of poorly-loading items, yielded two components, which we labeled Severity (five items) and Distress/Impairment (seven items). The TSC total score and subscales showed adequate internal consistency and test-retest reliability. Parent-child agreement was good in the internet sample, but more modest in the clinic sample. Children's TSC scores correlated significantly with other measures of TTM severity, although some exceptions were noted. Parents' TSC scores correlated significantly with other measures of parent-rated TTM severity in the internet sample, but showed more attenuated relationships with child- and interviewer-rated TTM severity in the clinic sample. The present results suggest that the TSC may be a useful measure of TTM for child and adolescent samples, although additional clarification of convergent validity is needed.

Is it trichotillomania? Hair pulling in childhood: a developmental perspective

A cohort of children with hair pulling as the presenting symptom was followed up to enhance clinical understanding of the nature of hair-pulling behaviour in childhood. Thirty-eight children were clinically assessed for a diagnosis of trichotillomania, co-morbidity, co-existing habits and other relevant factors. Intervention consisted of a combination of behavioural strategies, self-esteem work, supportive family approaches, attachment-focused parenting models and medication. In this group of children it was difficult to define their symptoms as a clinical diagnosis of trichotillomania, using ICD-1O/DSM-IV. This article concludes that hair pulling, as a symptom in children, is a heterogeneous condition. It is useful to approach this issue from a developmental perspective. Our data warrant reappraisal of the diagnosis of trichotillomania in childhood. We explore the framework of a developmental continuum to understand and manage the problem of hair pulling in childhood.

Pediatric trichotillomania: descriptive psychopathology and an open trial of cognitive behavioral therapy

In study 1, 46 children and adolescents with trichotillomania who sought treatment at 2 specialty outpatient clinics were assessed. Most children reported pulling hair from multiple sites on the body, presented with readily visible alopecia, reported spending 30-60 minutes per day pulling or thinking about pulling, and reported experiencing significant distress about their symptoms. Most were described by their parents as having significant problems in school functioning. Few children met criteria for obsessive-compulsive disorder or tic disorder. Child and family rates of other forms of psychopathology were high. In study 2, 22 of these children were enrolled in an open trial of individual cognitive behavioral therapy with particular attention to relapse prevention. Trichotillomania severity decreased significantly and 77% of children were classified as treatment responders at post-treatment and 64% at 6-month follow-up.

An open-label pilot study of naltrexone in childhood-onset trichotillomania

OBJECTIVE

This pilot open study evaluates the safety and efficacy of naltrexone in the management of patients with childhood onset trichotillomania (TTM).

METHODS

A total of 14 patients with childhood-onset TTM were treated with naltrexone (25-100 mg/day) and were assessed at each visit for frequency of hair pulling, urge to pull hair, and symptom severity. Liver function was monitored during the treatment. The duration of the study was 10 months.

RESULTS

A mean dose of 66.07 +/- 22.23 mg/day naltrexone was well tolerated and 11 out of 14 subjects showed a positive response. The mean age of the children was 9 +/- 1.88 years. The mean age of onset of symptoms in the group was 7.07 +/- 0.91 years. No abnormality in liver function was noted in the study. No adverse effects were reported by the children.

CONCLUSIONS

This encouraging pilot open study has promising findings suggesting the use of naltrexone in childhood-onset TTM. However, results are needed from larger and more definitive trials before any conclusions are made.

Brain activation during implicit sequence learning in individuals with trichotillomania

Trichotillomania (TTM) may be related to obsessive-compulsive disorder (OCD) and other neuropsychiatric conditions characterized by cortico-striatal dysfunction. Functional imaging studies of OCD using an implicit learning task have found abnormalities in striatal and hippocampal activation. The current study investigated whether similar abnormalities occur in TTM. Functional MRI and the serial reaction time (SRT) task were used to assess striatal and hippocampal activation during implicit sequence learning in TTM and healthy control (HC) subjects. The results for 20 age- and education-matched participants (10 TTM, 10 HC) are reported. In comparison with HC participants, those with TTM exhibited no significant differences in implicit learning, or in activation within the striatum, hippocampus, or other brain regions. The current findings do not provide evidence for cortico-striatal dysfunction in TTM. Future studies directly comparing OCD and TTM subjects are warranted to confirm the specificity of abnormal striatal and hippocampal findings during implicit sequence learning in OCD.