Psychological treatments for trichotillomania: update and future directions

Extended follow-up of a comprehensive behavioral (ComB) treatment sample during the COVID-19 pandemic

This study provides the longest follow-up yet for comprehensive behavioral (ComB) treatment of trichotillomania (TTM) (M = 24.59 months after pre-treatment and 15.92 months after the last follow-up point in a recent clinical trial (Carlson et al., 2021), which had shown ComB to be significantly more efficacious than minimal attention at post-treatment). This study also examined changes in TTM severity from before to during the COVID-19 pandemic. Participants (N = 23) completed a survey assessing current TTM symptoms, the impact of the pandemic on their coping with TTM, and their experience with ComB treatment. Self-reported symptom severity at this follow-up evaluation fell between the scores obtained at the clinical trial's pre-treatment assessment and at its last follow-up before the pandemic and did not significantly differ from either time point. Most participants (73%) reported some change in their TTM management since onset of the pandemic, with changes to their environment/routine (61%) and in anxiety (32%) being the most common. Pandemic-related changes were associated with variable outcomes, improving symptoms and management for some while worsening them for others. Use of strategies from ComB had declined since the most recent follow-up, but more than half (55%) of participants reported that strategies from ComB remained useful.

Pharmacotherapy for trichotillomania

BACKGROUND

Trichotillomania (TTM; hair-pulling disorder) is a prevalent and disabling disorder characterised by recurrent hair-pulling. Here we update a previous Cochrane Review on the effects of medication for TTM.

OBJECTIVES

To assess the effects of medication for trichotillomania (TTM) in adults, children and adolescents compared with placebo or other medication.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, eleven other bibliographic databases, trial registries and grey literature sources (to 26 November 2020). We checked reference lists and contacted subject experts.

SELECTION CRITERIA

We selected randomised controlled trials of medication versus placebo or other medication for TTM in adults, children and adolescents.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Twelve studies were included. We identified 10 studies in adults (286 participants) with a mean sample size of 29 participants per trial; one study in children and adolescents (39 participants); and, one study in adults and adolescents (22 participants: 18 adults and 4 adolescents). All studies were single-centre, outpatient trials. Eleven studies compared medication and placebo (334 participants); one study compared two medications (13 participants). Studies were 5 to 13 weeks duration. We undertook meta-analysis only for opioid antagonists as other comparisons contained a single study, or reported insufficient data. Antioxidants versus placebo in adults There was little to no difference in treatment response between antioxidant (35.7%) and placebo groups (28.6%) after six weeks, based on a single trial of silymarin (risk ratio (RR) 2.25, 95% confidence interval (CI) 0.84 to 5.99; 36 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (18 participants; low-certainty evidence). Antioxidants versus placebo in adolescents There was little to no difference in treatment response between antioxidant (50%) and placebo groups (25%) after six weeks, based on a single trial of silymarin (RR 2.00, 95% CI 0.28 to 14.20; 8 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (8 participants; low-certainty evidence). Antipsychotics versus placebo in adults There may be greater treatment response in the antipsychotic group (85%) compared to the placebo group (17%) after 12 weeks, based on a single trial of olanzapine (RR 5.08, 95% CI 1.4 to 18.37; 25 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (25 participants; low-certainty evidence). Cell signal transducers versus placebo in adults There was little to no difference in treatment response between cell signal transducer (42.1%) and placebo groups (31.6%) after 10 weeks, based on a single trial of inositol (RR 1.33, 95% CI 0.57 to 3.11; 38 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (38 participants; low-certainty evidence). Glutamate modulators versus placebo in adults There is probably greater treatment response in the glutamate modulator group (56%) compared to the placebo group (16%) after 12 weeks, based on a single trial of N-acetylcysteine (RR 3.5, 95% CI 1.34 to 9.17; 50 participants; moderate-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (50 participants; low-certainty evidence). Glutamate modulators versus placebo in children and adolescents There was little to no difference in treatment response between the glutamate modulator (25%) and placebo groups (21.1%) in children and adolescents, based on a single trial of N-acetylcysteine (RR 1.19, 95% CI 0.37 to 3.77; 39 participants; low-certainty evidence). There was little to no difference in dropouts due to adverse events between glutamate modulator (5%) and placebo (0%) groups, based on a single trial (RR 2.86, 95% CI 0.12 to 66.11; 39 participants; low-certainty evidence). Opioid antagonists versus placebo in adults There may be little to no difference in treatment response between opioid antagonist (37.5%) and placebo groups (25%) after six to eight weeks, based on two studies of naltrexone, but the evidence is very uncertain (RR 2.14, 95% CI 0.25 to 18.17; 2 studies, 68 participants; very low-certainty evidence). No data were available regarding dropouts due to adverse events. Selective serotonin reuptake inhibitors (SSRIs) versus placebo in adults There were no data available for treatment response to SSRIs. There was little to no difference in dropouts due to adverse events in the SSRI group (5.1%) compared to the placebo group (0%) after 6 to 12 weeks, based on two trials of fluoxetine (RR 3.00, 95% CI 0.33 to 27.62; 2 studies, 78 participants; low-certainty evidence). Tricyclic antidepressants (TCAs) with predominantly serotonin reuptake inhibitor (SRI) actions versus placebo in adults There may be greater treatment response in the TCAs with predominantly SRI actions group (40%) compared to the placebo group (0%) after nine weeks, but the evidence is very uncertain, based on a single trial of clomipramine (RR 5.73, 95% CI 0.36 to 90.83; 16 participants; very low-certainty evidence). There may be increased dropouts due to adverse events in the TCAs with predominantly SRI actions group (30%) compared to the placebo group (0%), but the evidence is very uncertain (RR 4.45, 95% CI 0.27 to 73.81; 16 participants; very low-certainty evidence). TCAs with predominantly SRI actions versus other TCAs in adults There may be greater treatment response in the TCAs with predominantly SRI actions group compared to the other TCAs group after five weeks, based on a single trial comparing clomipramine to desipramine (mean difference (MD) -4.00, 95% CI -6.13 to -1.87; 26 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (26 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

There was insufficient evidence from meta-analysis to confirm or refute the efficacy of any agent or class of medication for the treatment of TTM in adults, children or adolescents. Preliminary evidence suggests there may be beneficial treatment effects for N-acetylcysteine, clomipramine and olanzapine in adults based on four trials, albeit with relatively small sample sizes.

Pharmacotherapy for trichotillomania in adults

INTRODUCTION

Currently conceptualized as an obsessive compulsive and related disorder, trichotillomania, or hair-pulling disorder, is a common illness that causes significant distress or functional impairments in various life domains. Most individuals with trichotillomania also have other comorbid diagnoses. Treating trichotillomania with pharmacotherapy is complicated since there are currently no FDA-approved drugs for its treatment.

AREAS COVERED

The databases PubMed, PsychINFO, CINAHL, Evidence-based Medicine Reviews, and Cochrane Database of Systematic Reviews were searched, yielding a total of 10 open trials and 10 controlled trials selected. This review aims to examine pharmacotherapeutic options for the treatment of trichotillomania in adults and makes recommendations for the assessment and management of the disorder.

EXPERT OPINION

There is preliminary evidence that clomipramine, olanzapine, and N-acetylcysteine may be effective in cases of trichotillomania, however, given the paucity of controlled studies with large sample sizes, decisions regarding the use of drugs should be made on a case-by-case basis taking into account the severity of trichotillomania and the nature of psychiatric comorbidity.

Comprehensive Behavioral Therapy of Trichotillomania: A Multiple-Baseline Single-Case Experimental Design

Despite rapidly increasing knowledge about Trichotillomania (TTM), no gold-standard evidence-based psychological intervention has been identified. In the current study, we evaluated the potential efficacy of an eight-session psychological intervention for TTM, namely the Comprehensive Behavioral Model (ComB) treatment, using a multiple-baseline single-case experimental design with three Italian women with TTM. The study included three phases: baseline, intervention, and 3-month follow-up. We assessed the intervention using daily self-monitoring of number of hair-pulling episodes, number of pulled hairs per episode, degree of resistance to pulling urges, and degree of associated distress. We also assessed for reliable improvement in general distress from baseline to post-intervention. All participants completed treatment and showed improvements on those symptom measures that were most relevant to their individualized case conceptualization. However, no participants recovered completely or demonstrated reliable improvement in general distress. Our results provide initial evidence for the utility of the ComB treatment for TTM in an Italian clinical setting. Furthermore, they support the delivery of individualized and flexible psychological treatments when treating TTM.

Trichotillomania (hair pulling disorder)

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

Trichotillomania

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