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Trichotillomania

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amanda post

on 13 February 2014

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Transcript of Trichotillomania

Diagnosis and Treatment
Trichotillomania
beginnings
The history...
So How Do We Think About TTM?
Behaviorally-Based Disorder
What Do We Know About The
Etiology of TTM?
1889, French dermatologist Henri Hallopeau coined the term "Trichotillomania;" first case was of a young man who pulled out clumps of his hair in attempt to relieve pruiritis
The Psychodynamics...
In the beginning half of the 1900's, C. Berg believe TTM represented a conflict between sexuality and the ego/superego
But it turns out... TTM is a behaviorally-based problem, thus psychodynamics lost out... this shift happened in the 1960's, and there has been no evidence that family dynamics or early trauma play critical roles in the development of the disorder
Behavioral Components
- Behavior can be intrinsically rewarding, so it is repeated

- Certain moods, locations, activities can become connected to the act of pulling... the learned connections then become triggers to pull

- Pulling can then become automatic, an over-learned response
The DSM!
the IV...
A. Recurrent pulling out of one's hair resulting in
noticeable
hair loss.
B. An increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior.
C. Pleasure, gratification or relief when pulling out the hair.
D. The
disturbance
is not better accounted for by another mental disorder or not 2/2 a GMC (e.g., a dermatological condition).
E. The
disturbance
causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
The DSM!
the 5...
A. Recurrent pulling out of one's hair resulting in hair loss.
B. The hair pulling causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
C. The hair pulling is not due to the direct physiological effects of a substance (cocaine, methamphetamines) or 2/2 a GMC (e.g., a dermatological condition).
D. The hair pulling is not restricted to the symptoms of another mental disorder (e.g. hair pulling due to preoccupation with appearance as in Body Dysmorphic Disorder).
Obsessive-Compulsive Spectrum Disorders
Disorders of
Bodily Preoccupation
OCD
*Habit/Grooming
Disorders*
Neurological
Disorders
Impulse Control Disorders
What Do We Know About The
Etiology of TTM?
Treatment
Pharmacotherapy...
Treatment
Pharmacotherapy...
Treatment
*Habit Reversal Training*
Epidemiology
- Bimodal presentation: Onset < 6yo and adolescent (ages 11-16). Appearance after age 20 is uncommon.
- 4.4% lifetime rate in psychiatric patients; 4.6% in OCD patients
- Adults: more common in women
- Children: 7x more prevalent (compared to adults); usual onset between ages of 11-16 years; no difference in sex
- 1-3% of the population has TTM
Assessment
*Confirm diagnosis
- Define frequency
- Sites? Tools?
- Precipitating factors
- Maintaining factors
- What does the patient feel like before and after pulling? What is the pulling style?
- What does the patient do with the hair following the behavior?
Habit Reversal Training
Behavioral therapy designed to retrain the brain through disruption of the association between internal and external triggers, and the urge to pull... aim is to ultimately reduce the intensity and frequency of the urge altogether.
The HRT Process
1. Psychoeducation
Animal Models
Canine Acral Lick Dermatitis, Feline Psychogenic Alopecia, Avian Feather-Plucking, etc...
Sapap3 Knockout Mice: Exhibit excessive grooming behaviors and anxiety, treatable by fluoxetine.
- Cortico-striatal synaptic defects

Hoxb8 Gene Mutant Mice: Exhibit pathological, excessive grooming behaviors leading to baldness (of self and littermates), self-mutilation by biting and licking, skin lesions.
- In mouse brain, hoxb8 expressed in caudate, putamen, orbitofrontal cortex, anterior cingulate gyrus, cerebellum, brainstem and hippocampus.
Humans
Genetics:
Twin Study: Heritability Estimate = 76%

(Novak et al., 2009)
Genetics:
1. Sapap3: common variants associated with Habit Disorders; rare missense found in TTM

2. SLITRK1: rare mutations found in TTM families

3. 5-HT 2a receptor T102T genotype associated with TTM
Structural Neuroimaging
Smaller volume of left putamen, left inferior frontal gyrus, cerebellum
(O’Sullivan et al, 1997; Keuthen et al, 2007)

Larger volume of right cuneus
(Grachev et al, 1997)


Greater grey matter density in left putamen, amygdala, hippocampus, bilateral cingulate cortex, and prefrontal cortex regions
(Chamberlain et al, 2008)

Low Fractional Anisotropy (directional organization of white matter tracts) in anterior cingulate, temporal, and supplementary motor cortex.
(Chamberlain et al, 2010)
Functional Neuroimaging
FDG-PET: Abnormally high glucose metabolism in cerebellum and superior parietal cortex
(Swedo et al, 1991)

fMRI Study of Implicit Sequence Learning: Trichotillomania patients and controls showed the same pattern and amount of regional brain activation.
(Rauch et al, 2007)
SSRI's: Not consistently effective, often lose effect over time.
- Clomipramine > Placebo (by extension SSRI)
- Fluoxetine = Placebo
- SSRI's excellent for co-morbid mood and anxiety disorders, still might be 1st choice for pharmacotherapy.

Naltrexone: 50mg/day > placebo in 2 small studies.
- Some patients need 100-200mg/day.
N-Acetylcysteine: glutamate modulator
For Adults:
- 1200-2400mg/day > placebo
- 56% responded vs 16% for placebo
For Children (ages 8-17):
- No difference from placebo
Adjunctive Pimozide, Risperidone, Quetiapine, and Aripiprazole: good in case reports and open trials.
- Well proven, superior to SSRI's, CMI and placebo
- Works well for both children and adults
- When added to SSRI treatment, HRT converted 55% of SSRI-nonresponders into treatment responders
- Can be enhanced by ACT or DBT
Behavioral Components
Similarities to OCD
- Repetitive behavior that is hard to control
- Behaviors are not related to rational ideas and are often resisted
- Compulsions and hair-pulling can relieve anxiety
Differences from OCD
- Hair-pulling is usually not driven by recurrent intrusive thoughts or to prevent harm
- Younger peak age of onset for TTM
- Females > males in TTM
- There is a sensory component to TTM
Where do patients pull?
When Do Patients Pull?
The HRT Process
7. Stimulus Control
- Develop reminders to help them stop (post-its, other people)
The HRT Process
- There can be extensive rituals following the pull.
- Some will inspect the hair, looking at color, texture, whether root is attached or not.
- Some will line them up, or split them.
- Some will rub hair around their mouths.
- Some will chew or bite hairs.
- Some will lick hairs.
- 10% will eat the hairs, and this must be assessed in every TTM patient.
What Is Done With The Hair?
Antipsychotics:
Olanzapine: mean dose 10.8mg/day > placebo
- 56% responded vs 16% for placebo
(Van Ameringen et al, 2010)
- Role of the habit
- Cycle of pulling
3. Behavioral Analysis
- Info regarding the behavior, triggers (internal and external), urges, people/places/things, thought processes and feelings involved
- Info regarding activities, times and places when the patient does NOT pull
Financial Disclosures!
The HRT Process
.... sadly no.
Final Thoughts...
4. Self-Monitoring Homework
- Use of recording sheet; gather info for at least 2 weeks to obtain baseline, continue throughout therapy
5. Relaxation Training
- Diaphragmatic Breathing
- Progressive Muscle Relaxation
- Guided Imagery
6. Competing Response
- Either physical or mental; doing something else with their hands that is incompatible with pulling, 1-3 minutes
- Habit blockers; use barrier methods to break cycle by increasing awareness and making pulling more difficult (hat on head, gloves, cover mirror, etc)
8. Practice/Review/Monitor (Ongoing)
- Patient completes homework assignments of new response, records progress, debriefs in session. Utilize problem-solving and positive reinforcement.
2. Enhancing Motivation
- Outline costs of continuing habit, and benefits to stopping
9. Teach New Coping Methods
- To address emotional needs/stress
- Exercise, assertiveness training, support system, cognitive restructuring
10. Maintenance and Relapse Prevention
- Continue to practice HRT... continue to be aware of and handle triggers, stressors
- Be prepared for slips
Trichotillomania Learning Center
- Resources for patients and families
- Resources for clinicians
http://www.trich.org
(Franklin et al., 2007; Novak et al., 2009; Duke et al., 2010; Lochner & Stein, 2010)
(Hemmings et al., 2006)
(Bienvenu et al., 2009)
(Greer and Capecchi, 2002)
(Welch et al., 2007)
1. Automatic Pulling: outside of conscious awareness (tactile antecedents?)

2. Focused Pulling: in response to an urge, impulse or negative emotional state

=> Mixture of impulsivity (failure to inhibit reward-seeking) and compulsivity (desire to reduce harm)
(*DeSousa, 2008; O'Sullivan et al., 1999)
(Bloch et al., 2007)
(Christenson et al., 1991; Streichenwein & Thornby, 1995)
(Azrin & Nunn, 1973; Dougherty et al., 2006; Keuthen, et al., 2006 & 2011; Woods, et al., 2006)
I have nothing to disclose.
(Zuchner et al., 2006)
Style of Pulling
(Grant, et al, 2009)
(Bloch et al, 2013)
The Order of Things...
- History
- Overview of Trichotillomania (TTM)
- Etiology (genetics & neuroanatomy)
- Epidemiology
- Assessment
- Treatment
- Pharmacology
- Habit Reversal Therapy
Big Thanks To...
The UCSD OCD Clinic

Dr. Sanjaya Saxena

Dr. Danielle Haber
Full transcript