The age
at onset typically ranges from early childhood to young adulthood. Peak ages at
presentation may be bimodal, with an earlier peak about age 5 to 8 years among
children in whom it has a self-limited course, whereas among patients who
present to clinicians in adulthood the mean age at onset is approximately 13
years (Rothbaum et al., 1993).
Initial onset after young adulthood is apparently uncommon. There have been
reports of onset as early as 14 months of age and as late as 61 years.
Trichotillomania
may be one of the earliest occurring con-ditions in psychiatry. Some parents
insist that their child began pulling hair before 1 year of age. When
trichotillomania begins before age 6 years it tends to be a milder condition.
It often re-sponds to simple interventions and may be self-limited, with a
duration of several weeks to several months, even if not treated. It often
occurs in association with thumb-sucking. In some cases it remits spontaneously
when therapeutic attention is directed at concurrent, severe thumb-sucking. It
has been suggested that trichotillomania in childhood may be associated with
severe intrapsychic or familial psychiatric conditions. But there is no
.
reliable evidence that supports such a conclusion. Indeed, some have suggested
that because it may be common and frequently self-limiting, it should be
considered a normal behavior among young children.
Some
individuals have continuous symptoms for decades. For others, the disorder may
come and go for weeks, months, or years at a time. Sites of hair-pulling may
vary over time. Circumscribed periods of hair-pulling (weeks to months)
fol-lowed by complete remission are reported among children.
Progression
of the condition appears to be unpredictable. Waxing and waning of the severity
of hair-pulling and number of hair-pulling sites occur in most individuals. It
is not known which factors may predict a protracted and unremitting course.
Because
of the unavailability of longitudinal studies of tricho-tillomania,
generalizations about prognosis cannot be made. Patients who present in
research clinics typically have histories of many years (up to decades) of
hair-pulling. Presentation after age 40 years appears to be far less common
than in the previous three decades of life, suggesting that the condition may
eventu-ally remit spontaneously, even when untreated. It is likely that the
persistent cases seen in research environments reflect the more severe end of
the spectrum. As noted earlier, trichotillomania in children may often be a
time-limited phenomenon.
Treatment
of trichotillomania typically occurs in an outpatient setting. Eradication of
hair-pulling behavior is the general focus of treatment. Distress, avoidant
behaviors and cosmetic impair-ment are secondary to the hair-pulling behavior
and would be likely to remit if the hair-pulling behavior is controlled.
However, if sufficient control of hair-pulling cannot be attained, treatment
goals should emphasize these associated problems as well. Even if hair-pulling persists,
therapeutic interventions may be targeted at reducing secondary avoidance and
diminishing distress.
Treatment
may be considered in three phases:
Initial Contact The diagnosis is made and the
patient and psy-chiatrist agree on a strategy that may incorporate both
pharma-cological and psychological interventions. If distress is severe,
supportive interventions should be immediately considered in anticipation of
incomplete treatment response or of a delay of weeks to months before
interventions may be beneficial.
Acute Treatment Even when treatment of
hair-pulling behav-ior is optimally successful, there may be a delay of several
weeks to months before adequate control is attained. Therefore, the acute
treatment phase may be prolonged.
Maintenance It is not known how long patients
must maintain active treatment
interventions to prevent relapse. It should be anticipated that a substantial
number of patients require ongo-ing treatment for an extended time.
Pharmacological treatments may need to be maintained for open-ended periods.
Behavioral or hypnotic intervention may require periodic “booster shots” to
support continuation of benefits.
It is
important to bear in mind the particular nature of embar-rassment that often
accompanies this condition. Several factors contribute to feelings of shame for
many people with trichotil-lomania. When hair-pulling has had its onset in
childhood oradolescence, there is often a history of the hair-pulling being
treated as a family secret. Patients have been frequently casti-gated by
parents or spouses for lack of self-control. In addition, there may be a
feeling that the problem is largely cosmetic, caus-ing some individuals to fear
they do not have the “right” to utilize health resources for its treatment.
This may also be manifest as fears of having their problem minimized or of
being derided for seeking help. It is helpful for the psychiatrist to share
with pa-tients an understanding that the problem pervades their daily life and may
result in meaningful distress and functional inhibition.
A variety
of treatment approaches have been advocated for trichotillomania. However,
there have, as yet, been few controlled studies of the efficacy of any
treatment approach. A number of in-vestigations of the use of antidepressants
with specific inhibition of serotonin reuptake (i.e., fluoxetine and
clomipramine) have yielded mixed results. A multimodal approach, simultaneously
utilizing several complementary treatment options, may turn out to be the most
effective approach for most patients. While a num-ber of treatment options can
be currently offered to individuals with trichotillomania, the durability of
long-term outcomes is unclear
Before
embarking on a course of treatment, the psychiatrist and the patient should
first consider the course and severity of the in-dividual’s condition. Because
early remission may occur in cases of recent onset, mild trichotillomania of
short duration does not necessarily require immediate intervention. In
particular, if the hair-pulling first occurred during a period of stress, the
behav-ior may spontaneously diminish as the stressful circumstances abate. In
such circumstances, therapeutic attention may best be directed toward examining
and seeking to diminish the basis for stress. Teaching alternative stress
reduction methods may be useful in reducing recent-onset trichotillomania.
However, when individuals with trichotillomania present to the psychiatrist, it
is often likely to have been a persistent condition and may have been present
for many years or decades. Among such patients, stress reduction may also be
useful in reducing trichotillomania but complete remission is less likely.
A variety
of medications have been used in the treatment of trichotillomania. Initial
reports appeared demonstrating the ap-parent benefits of fluoxetine and
clomipramine. Clomipramine was found to be superior to desipramine (and
fluoxetine was re-ported beneficial in open treatment. Although reports for
more than 60 patients have subsequently added support for the use of these
medications, the two double-blind studies in which fluox-etine has been
compared with placebo did not demonstrate any improvement compared with
placebo. Fluvoxamine, citalopram and venlafaxine have been reported to be
efficacious in open tri-als. Although further controlled studies of SSRIs are
needed, the use of such medications would be a prudent first step if a
pharma-cological approach has been agreed upon.
Initial
evidence of improvement is usually first reported by the patient as greater
awareness of the inclination to pull hair. This is usually followed by an
ability to abort hair-pulling epi-sodes more quickly than in the past. The
ability to resist the urge follows. In cases with a good outcome, the
inclination to pull di-minishes and may eventually disappear. Patients who pull
from several sites may find that the rate of improvement varies from site to
site.
There
have been conflicting reports of early relapse of symptoms in some patients
treated with clomipramine or fluox-etine. Although good maintenance of benefit
has been reported for some patients 6 months and longer after the initiation of
treatment, early relapse after several weeks to months has been reported as
well. Keuthen and coworkers (2001) have provided long-term data on maintenance
of response over time. Following a group of individuals who had varying forms
of treatment (phar-macologic and psychological) for several years after an
index evaluation, the authors concluded that initial improvement was common,
but over time there was an increase in symptom scores and self-esteem scores
worsened in the group over time. This problem remains to be further evaluated
in long-term treatment studies. If early relapse does turn out to be common, it
would distinguish trichotillomania from depression and OCD, in which, once
established, medication benefits are often well maintained as long as
medication is continued. Optimal duration of treatment for well-treated individuals
is also still unknown. In accordance with standards developed for the treatment
of other conditions, it would be reasonable to continue medication for at least
6 months before tapering. Reinitiation of treatment may be necessary
There
have been reports of successful treatment with lithium. Ad-junctive treatment
with pimozide, a neuroleptic agent, has been advocated for some patients who
are refractory to other medica-tions. The potential benefits of neuroleptics
has been reported and individuals have been described for whom SSRIs provided
insufficient benefits. The addition of atypical neuroleptics much improved
their outcomes. The greater margin of safety and tol-erability associated with
atypical neuroleptics have made this a more viable treatment option.
Van
Ameringen and colleagues (1999) described the use of haloperidol in nine
patients with trichotillomania. Six had previously failed treatment with SSRIs.
Eight of nine patients responded to the haloperidol. The possible superiority
of neu-roleptics prompted these authors to speculate that trichotilloma-nia may
be similar to Tourette’s syndrome (TS), which responds preferentially to
neuroleptics.
Behavioral Treatment Various
behavioral techniques have been tried.
The most successful technique, habit reversal, is based on designing
competitive behaviors that should inhibit the behavior of hair-pulling. For
example, if hair-pulling requires raising the arm to the scalp and contracting
the muscles of the hand to grasp a hair, the behaviorist may design a
behavioral program in which the patient is taught to lower the arm and extend
the muscles of the hand. As with behavioral techniques in general, these
inter-ventions are most successful when the patient is strongly moti-vated and
compliant. In addition, the treating psychiatrist should be experienced in the
use of such techniques. If necessary, a re-ferral should be made to such an
experienced individual. Modi-fied behavioral approaches have been described for
children and adolescents.
Cognitive Behavioral Therapy (CBT) CBT has
been devel-oped for, and applied to, individuals with trichotillomania. At this
time, the potential for the efficacy of this treatment approach appears good.
Ninan and colleagues (2000) compared CBT with clomipramine in the treatment of
trichotillomania. The authors reported that CBT had a dramatic effect in
reducing symptomsof trichotillomania and was significantly more effective than
clomipramine (P 5 0.016) or placebo (P 5 0.026). Clomipramine resulted in
symptom reduction greater than that with placebo, but the difference fell short
of statistical significance. Placebo response was minimal.
Hypnotherapy There are no formal studies of
the use of hypno-sis for trichotillomania, but there are many published reports
of beneficial treatment. Benefits may be variable. Some patients may have
dramatic improvement. For some who improve, the benefits may be short-lived. As
with behavioral interventions, the benefits of this approach are sometimes
dependent on a highly motivated patient who can regularly carry out
self-hypnotic measures as in-structed by the psychiatrist. Some patients who
have obtained partial benefits from either hypnosis or medication do well when
both treatments are combined. Successful use of hypnotherapy for children with
trichotillomania has also been reported.
Dynamic Psychotherapy Many
psychoanalytically oriented descriptions
of individuals with trichotillomania have been published. These reports
generally describe the psychodynamic formulations of individual cases and
should not be the basis for generalizations about most individuals with
trichotillomania. Al-though patients with trichotillomania may benefit from
explora-tion and attempts to reduce intrapsychic conflict, the literature does
not provide persuasive evidence of the efficacy of this ap-proach in reducing
hair-pulling.
Self-help and Other Groups Self-help
groups for patients with trichotillomania
have appeared. Some are based in the structure of other 12-step programs. Some
patients appear to experience meaningful reduction in hair-pulling symptoms
after begin-ning participation in such a group. Although the efficacy of such
groups in reducing symptoms remains to be established, most patients with trichotillomania
can benefit from meeting other individuals with similar symptoms. Because of
the lack of gen-eral awareness of trichotillomania, these individuals
frequently believe that they are “oddball” individuals with a behavior that is
unique. Many have experienced parental condemnation for the behavior and have
been frequently castigated for a “habit” that may be viewed by others as under
their voluntary control. The experience of meeting others with the condition is
extremely supportive for such individuals and may help to reduce the at-tendant
stress while supporting self-esteem. Where programs specifically oriented
toward trichotillomania may not be gener-ally available, these individuals may
benefit from groups oriented toward OCD.
Depression,
dysthymic disorder and anxiety symptoms occur frequently in patients with
trichotillomania. Successful treat-ment of depression may not be associated
with reduction in trichotillomania. If depression or dysthymic disorder is
present and independently provides an indication for medication, one of the
antidepressants discussed earlier should be chosen. If fluox-etine is used, the
psychiatrist should be aware that a dose that is sufficient for reduction of
the depressive symptoms may not be sufficient for reduction of
trichotillomania. If panic disorder is present, either medication may still be
used, but fluoxetine may initially exacerbate panic attacks in such patients
and initiation of treatment at low doses (2.5–5 mg/day) should be considered.
With slow titration upward, the patient should generally be able to tolerate
usual doses with concomitant amelioration of the panic disorder. Combined
treatment with anxiolytics may be use-ful for some and may contribute to the
reduction in symptoms of trichotillomania. Other conditions that may be
present, such as OCD or eating disorders, may require special attention.
Although fluoxetine may be useful for patients with eating disorders,
medi-cation treatment alone is unlikely to be adequate and the usual multimodal
approaches for the treatment of bulimia nervosa or anorexia are appropriate.
OCD may respond to treatment di-rected at trichotillomania, but adjunctive
behavioral treatment of symptoms of OCD may be desirable.
When
trichotillomania presents in early childhood, the condi-tion may be likely to
be inherently self-limited. Often, all that may be necessary is to draw the
child’s attention to the behavior in some systematic way and to clarify for the
child that the be-havior is undesirable. Such methods include daily application
of a nonmedicinal ointment to the affected region and reminding the child that
the purpose is elimination of the hair-pulling habit. Some suggest that the
child be given the responsibility of apply-ing the ointment with parental
supervision. Others suggest that parents should monitor the child as much as
possible and respond with reminders that the hair should not be pulled and
rewards with verbal encouragement for ceasing to pull hair. There have been no
systematic studies of the benefits of such interventions, but dermatologists
who specialize in the treatment of children have noted that hair-pulling
behavior may frequently disappear within a few weeks of initiating such an
approach. In circum-stances in which childhood trichotillomania is more
persistent, the parent and psychiatrist are faced with a dilemma. More
elabo-rate behavioral interventions, such as habit reversal, should be tried.
This, however, may be difficult with a child. Hypnosis has been also used in
the treatment of habit disorders in children. Medication should be cautiously
considered in the treatment of childhood trichotillomania. Although medication
may be useful, the absence of data supporting the benefits of such treatments
in children indicates a conservative approach. If medication is con-sidered,
the use of medication in the treatment of childhood OCD should serve as a
guideline.
Should
the psychiatrist be presented with trichotillomania in a person of advanced
age, special attention should be paid to usual concerns regarding the use of
these medications in the el-derly. Lower doses of medication should be
considered because of potential altered pharmacokinetics in older persons.
Medications with anticholinergic side effects (such as clomipramine) may
present greater hazards for the older person. Sedative-hypnotic anxiolytics
should be used sparingly because of greater vulner-ability to cognitive side
effects and the increased risk of falling.
Women of
childbearing potential (perhaps the majority of individuals who may present for
treatment) should be advised re-garding the potential risks of these
medications to a developing fetus. If the patient is pregnant or considering
pregnancy, behav-ioral treatments may be favored.
The
psychiatrist should be sensitive to the interaction be-tween cultural values
and trichotillomania. Women of certain cultures may be more prone to distress
if trichotillomania is per-ceived as a hindrance to achieving valued goals,
such as mar-riage. It should also be noted that in some communities, wigs and
other hair accessories are generally acceptable and may present a comfortable
means of diminishing the cosmetic impact of hair loss. In other communities,
such accoutrements may themselves draw undesired attention.
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