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Trichotillomania: An Overview

Trichotillomania: An Overview. David Dia, PhD, LCSW, CCBT University of Tennessee. Disclosures. No financial disclosures or conflicts of interest to report

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Trichotillomania: An Overview

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  1. Trichotillomania: An Overview David Dia, PhD, LCSW, CCBT University of Tennessee

  2. Disclosures • No financial disclosures or conflicts of interest to report • Information is presented as educational. It is not intended to diagnosis, treat, or be a substitute for expert medical or mental health care.

  3. Overview • General information • Medication • Psychosocial Treatments

  4. What is in a name? • Trich = hair • Tillo = pulling • Mania = impulse

  5. Diagnosis – DSM IV-TR • Impulse Control Disorder • May be related to Obsessive compulsive disorder (anxiety) or tic disorder • Pathological Gambling

  6. Diagnosis – DSM IV-TR • Criteria • Recurrent pulling out of one’s hair with noticeable hair loss • Sense of tension before pulling or when attempting to resist • Pleasure, gratification, or relief when pulling out hair • Causes clinically significant impairment

  7. Other terms to know • Trichophagia – eating the hairs • Bezoars – hair balls • Alopecia – hair loss

  8. General Facts • Estimated 2.5 million people (.6% lifetime) • Average age of onset = 13 years old • 3.4% Females vs. 1.5% of Males hair loss • Tends to have a waxing and waning course

  9. General Facts • Can be triggered and exacerbated by anxiety • Two types, not mutually exclusive • Focused vs. automatic

  10. General Facts • Only 15% of adults experience significant improvement with community treatment! • Most (55%) believed their clinician • Did not have significant knowledge of the disorder • Did not have knowledge of evidenced based treatment

  11. Adult Sample Mood Anxiety Substance abuse Personality D/O Pediatric Sample Anxiety Depression Disruptive Behavioral Tics Comorbidity

  12. Consequences • Lower life satisfaction • Higher levels of stress • Lower self-esteem

  13. Suspected Causes • Genetic Component • 5HT2A, hoxB8, and SLITRT1 • Neurotransmitters • Dopamine • Monoamine system (MAOI) • Gultamate (precursor to GABA) • Neuroadrenaline system • Serotonin?

  14. Suspected Causes • Inferior frontal cortex – cognition • Amygdala-hippocampal formation – affect regulation • Putamen – habit learning • VTA and Nucleus accumbens • Mediates reward process

  15. Compulsive Skin Picking • General Information • 2 to 4% of the population • More common in females • Bimodal onset -- • Late childhood to early adolescents • 30 to 45 years old • Causes • Genetic (hoxb8)

  16. Overview of Treatment • No randomized control studies with pediatric • Behavioral treatments with adults demonstrate efficacy • Uncontrolled studies with pediatric show similar results as adults • SSRIs (double blind, placebo controlled) have no efficacy

  17. Overview of Treatment • Supportive or psychodynamic therapy no or minimal affect

  18. Treatment -- Medications • Mancini et al. (2009) -- pediatric • Retrospective chart review (N = 11) • 10 tried on SRI and 1 on antipsychotic • 2 on SRI and 9 on antipsychotic • 2 remitted • Results favored antipsychotics • Risperidone (Risperdol) • Quetiapine (Seroquel)

  19. Medications - Adults • SSRI vs. control condition • 3 studies • Tricyclic vs. control • Clomipramine (Anafranil) 2 studies • HRT vs. SSRI • HRT vs. Clomipramine • Clomipramine vs. SSRI (SSRIs – fluvoxamine, fluoxetine, , sertraline, citalopram)

  20. Medications – Experimental -- Adults • Opioid antagonist = Naltrexone and Nalmefene • Mood Stabilizers = lithium and Valproic acid (Depakote) • Dopamine reuptakers inhibitors = Focalin, Ritalin, Wellburtrin) • Norepinephrine inhibitor – clomipramine • Glutamatergic – N-acetylcysteine

  21. Medical • Neurosurgery, Transcranial Magnetic Stimulation (TMS), ECT • No evidence

  22. Psychosocial Treatments • HRT/CBT vs. control • 5 studies pediatric • 77% to 61 % “clinically significant changes” • For example, 16 to 5 of the MBHHPS • 5 controlled studies with adults • 91% to 61% reduction • Hypnotherapy • Two uncontrolled, small studies with adults

  23. Treatment Guidelines Pediatric • Psychoeducation • 0 to 7 years • Response prevention implemented with parents • Older than 7 years • Habit reversal therapy

  24. Treatment Guidelines Pediatric • “If there continues to be significant impairment from trich despite prolonged behavioral treatment with experienced clinician consider” • N-acetylcysteine • Initial dose 600mg, titrated to a max does of 1200mg BID • Clomipramine (Medications, including OTR, needs to be dispensed/recommended by physician)

  25. Treatment - CSP • One Double Blind Study • Fluoxetine – improvement in 2 or 3 outcome measures • Open label • Fluvoxamine, Fluoxetine, Lamotrigine, Escitalopram, N-acetylcysteine

  26. Treatment - CSP • 3 Psychosocial studies • HRT with 3 month F/U • HRT + ACT • Internet based treatment – 62% “responders” • 115 participants • 15% completed all three phases

  27. Comprehensive ModelMansueto et al. (1999) • Phase I • Assessment and functional analysis • Phase 2 • Identify and target modalities • Phase 3 • Identify and implement strategies • Phase 4 • Evaluation and modification

  28. Phase I • Two types of antecedents to pulling • Cues that trigger the urge to pull • Discriminative stimuli that facilitates pulling • Actually pulling • Consequences of pulling • Maintains pulling • Terminate pulling

  29. Phase I • Cues • External – settings and implements associated • Internal – affective states, visual or tactile sensations, cognitive cues • Discrimitive stimuli (set the stage) • External – environment free of potential observers, presences of pull instruments • Internal – urge, posture cues, cognitive

  30. Phase I • Preparation • Specific Hair selected • Disposition of hair • Discarded • Retrain • Inspect • Bite/swallow • Wrapping hair / tickle

  31. Intervention Phase I • Self-monitoring

  32. Phase 2 • Cognitive modality • Cognitive restructuring, guided self dialogue • Affective modality • Relaxation exercises, exposure, positive imagery, stress management • Motoric modality • Finger tip bandages, gloves, bracelets, eye glasses, scarf's, etc. • Silly putty, worry beads, soft brush

  33. Phase 2 • Sensory modality • Numbing cream, brushing hair, washing hair vigorously, shampoo • Gummy bears, sunflower seeds, dental floss, koosh balls, frayed blankets • Dying hair, cutting finger nails • Environmental • Removing tweezers, covering mirrors • Behavioral plans, stimulus control

  34. Phase 2 • Habit reversal • Self-monitoring • Awareness training • Hair pulling and high risk situations • Stimulus control • Decrease opportunities or interfere • Competing response intervention

  35. Phase 3 • Identify and choose treatment strategies • Client to use strategy for at least one week • Primary issue – getting the client to use strategy consistently

  36. Phase 4 • Evaluation and Modification

  37. Questions

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