The use of pharmacologic pain sensitization in the treatment of repetitive hair-pulling

Pain perception and physiological correlates in body-focused repetitive behavior disorders

BACKGROUND

Behaviors typical of body-focused repetitive behavior disorders such as trichotillomania (TTM) and skin-picking disorder (SPD) are often associated with pleasure or relief, and with little or no physical pain, suggesting aberrant pain perception. Conclusive evidence about pain perception and correlates in these conditions is, however, lacking.

METHODS

A multisite international study examined pain perception and its physiological correlates in adults with TTM (n = 31), SPD (n = 24), and healthy controls (HCs; n = 26). The cold pressor test was administered, and measurements of pain perception and cardiovascular parameters were taken every 15 seconds. Pain perception, latency to pain tolerance, cardiovascular parameters and associations with illness severity, and comorbid depression, as well as interaction effects (group × time interval), were investigated across groups.

RESULTS

There were no group differences in pain ratings over time (P = .8) or latency to pain tolerance (P = .8). Illness severity was not associated with pain ratings (all P > .05). In terms of diastolic blood pressure (DBP), the main effect of group was statistically significant (P = .01), with post hoc analyses indicating higher mean DBP in TTM (95% confidence intervals [CI], 84.0-93.5) compared to SPD (95% CI, 73.5-84.2; P = .01), and HCs (95% CI, 75.6-86.0; P = .03). Pain perception did not differ between those with and those without depression (TTM: P = .2, SPD: P = .4).

CONCLUSION

The study findings were mostly negative suggesting that general pain perception aberration is not involved in TTM and SPD. Other underlying drivers of hair-pulling and skin-picking behavior (eg, abnormal reward processing) should be investigated.

Trichotillomania

Trichotillomania is a relatively uncommon condition that classically occurs in young females. It can result in trichobezoar formation, which is usually managed successfully by surgical intervention, although rarely it can be fatal. This article presents a brief review of trichotillomania. A literature search was performed for ‘trichotillomania’ using the PubMed database, and relevant papers and their references were researched. This review commences by defining the condition and considering its presentation and its prevalence. Diagnostic dilemmas including differential diagnosis and the uncertainty about structural abnormalities in the brain as indicated by magnetic resonance imaging findings are then reviewed. Finally we examine the current treatment options of this interesting condition.

Trichotillomania

Patients with trichotillomania often first present to dermatologists, as patients may be unaware of or deny hair pulling and seek an etiology for their hair loss. It therefore becomes the job of the dermatologist to correctly diagnose trichotillomania as well as offer treatment options. There appear to be three groups characterized by age of onset: preschool-age children, preadolescents to young adults, and adults. Young children often have a self-limited course of hair pulling. Adults frequently have psychiatric conditions associated with their trichotillomania. Preadolescents to young adults may benefit the most from active intervention, such as increasing awareness of hair pulling behaviors and behavior modification training. The approach of a patient by age of onset is helpful in guiding a dermatologist towards effective treatment options.

Pharmacological strategies for trichotillomania

Pharmacotherapy for trichotillomania (TTM) is not well established, due to a paucity of positive, controlled, long-term studies. Although selective-serotonin re-uptake inhibitors (SSRIs) seem to be the safest and best-established medication choices, positive treatment response is not consistent in the literature. Treatment response is often disrupted by significant relapse. Behavioural therapy may be a more effective treatment for some patients. For other patients, other antidepressants, neuroleptics or even topical agents may be helpful. Future investigations should include more controlled studies and longer observation for relapse.

Hypnosis as a vehicle for choice and self-agency in the treatment of children with Trichotillomania

Three pediatric cases of Trichotillomania were treated with direct hypnotic suggestion with exclusive emphasis on sensitizing and alerting the patients to impending scalp hair pulling behaviors. These children had presented with total lack of awareness of their scalp hair pulling behaviors until they had actually twisted and pulled off clumps of hair. It was also suggested, under hypnosis, that upon learning to recognize impending scalp hair pulling behaviors, the patients would become free to choose to willfully pull their hair or to resist the impulse and not pull. At no point was the explicit suggestion given that they stop pulling their hair. A preliminary condition was agreed to by the parents that redefined the patients' hair as their own property and affirmed their sole responsibility for its care and maintenance. An element of secondary gain was identified in each of these cases. Scalp hair pulling was hypothesized to provide these particular patients with a vehicle with which to oppose their overbearing and over-involved parents. The technique of direct suggestion under hypnosis, aimed at alerting the patients to impending scalp hair pulling behaviors was combined with forming contracts with the parents to relinquish their authority over matters regarding the patients' hair. This combination provided an effective treatment that extinguished the scalp hair pulling in 7 visits or less. These cases received follow-up at intervals up to 6 months and no evidence of relapse was found.

Acceptability of treatments for trichotillomania. Effects of age and severity

Based on the literature, trichotillomania (TTM, chronic hair pulling) in children and adults appears to be responsive to behavioral interventions such as habit reversal. However, some have questioned the generality and acceptability of such procedures. This study compared the acceptability ratings of four interventions targeting TTM (habit reversal, hypnosis, medication, and punishment). In the study, 233 college students read case vignettes in which the age of the analogue client and the severity of the hair pulling were manipulated. Results showed significant differences between the four treatment conditions, with hypnosis and habit reversal being rated most acceptable. Age of the analogue client and severity of TTM did not significantly influence acceptability ratings.

Trichotillomania. Presentation, etiology, diagnosis and therapy

Trichotillomania (TTM) is an impulse disorder, in which patients chronically pull hair from the scalp and/or other sites. Very early onset of hair pulling in children under the age of 6 may be more benign and self-limiting than the more common syndrome of late childhood onset hair pulling. While far more women and adolescent girls appear for treatment, survey studies suggest chronic hair pulling also occurs in males. Diagnosis may be complicated by patient and family denial or ignorance of the hair pulling; accurate scalp examination and biopsy can be critical. Classic scalp biopsies for TTM feature trichomalacia, pigment clumps, peribulbar hemorrhage and hair canal pigment casts, and lack lymphocytic infiltrates seen in alopecia areata. Treatment is difficult: the tricyclic antidepressant clomipramine is the most promising agent, although many patients find it difficult to tolerate at adequate dosages, and treatment response may not be maintained over the long term. More benign medications have not demonstrated efficacy in controlled studies. Augmentation with topical preparations or psychotropic medications may be helpful for patients experiencing limited efficacy or relapse. Specialized psychotherapy, known as habit reversal training, is highly recommended; however, the treatment is intensive and highly specialized. Skilled therapists are difficult to locate.

Trichotillomania: a challenge to research and practice

This review explores several aspects of trichotillomania relevant to clinical theory and practice. It is concluded that research outlining the phenomenology and patterns of comorbidity of trichotillomania have been advanced significantly in recent years. However, no current diagnostic category appropriately classifies trichotillomania. Research with nonclinical populations suggests that trichotillomania is more common than previously believed and that additional epidemiological research is warranted. Continued elaboration of existing etiological models incorporating varying theoretical perspectives is also encouraged. Assessment of trichotillomania could also be improved by the continued development of reliable and valid standardized measures. This article reviews both pharmacological and psychological treatments for trichotillomania, with an emphasis on habit-reversal training. Though some interventions appear effective in the short-term, reported relapse rates are high and future research on treatment for trichotillomania should focus on improving long-term outcomes. It is clear that despite a recent flux of research centering on trichotillomania, significant challenges for understanding and treating this psychological disorder still exist for researchers and clinicians. Based on this review of the literature, and on our clinical experience with trichotillomania, we propose directions for future research with this underserved psychiatric group.

The coming of age of self-mutilation

Self-mutilation (SM), the deliberate, nonsuicidal destruction of one's own body tissue, occurs in such culturally sanctioned practices as tattooing; body piercing; and healing, spiritual, and order-preserving rituals. As a symptom, it has typically been regarded as a manifestation of borderline behavior and misidentified as a suicide attempt. It has begun to attract mainstream media attention, and many more who suffer from it are expected to seek treatment. This review suggests that SM can best be understood as a morbid self-help effort providing rapid but temporary relief from feelings of depersonalization, guilt, rejection, and boredom as well as hallucinations, sexual preoccupations, and chaotic thoughts. Major SM includes infrequent acts such as eye enucleation and castration, commonly associated with psychosis and intoxication. Stereotypic SM includes such acts as head banging and self-biting most often accompanying Tourette's syndrome and severe mental retardation. Superficial/moderate SM includes compulsive acts such as trichotillomania and skin picking and such episodic acts as skin-cutting and burning, which evolve into an axis I syndrome of repetitive impulse dyscontrol with protean symptoms.