Hypnotherapy in adolescents with trichotillomania: three cases

Behavioral Treatment of Trichotillomania

Once considered a rare clinical condition, trichotillomania is now recognized as a psychological disorder that is more prevalent than previously thought. The behavioral treatment of a 21-year old college woman with a longstanding history of chronic hair pulling is described in this case study. The extent of the trichotillomania was measured during an 11-day baseline period (self-monitoring, photographs) followed by 4 months of behavioral treatment including prominent components of habit-reversal training. The results of the interventionwere suggestive of a substantial reduction in hair pulling incidents, hair regrowth in the affected parts of her scalp, and self-reported improvements in mood, anxiety, and self-esteem. Limitations of these data are reviewed and recommendations for clinicians who intend on treating trichotillomania are provided.

Hypnotherapy in child psychiatry: the state of the art

Children are more easily hypnotized than adults, and hypnotherapy as a method responds to the general developmental needs of children by addressing their ability for fantasy and imagination. Hypnotherapy and self-hypnosis are tools with which to assess and develop protective factors, and enhance positive adjustment. Meta-analyses and overviews have demonstrated the effect of hypnotherapy in paediatric disorders like asthma, chronic and acute pain, and in procedure-related distress in cancer patients. We wanted to examine the use and benefits of hypnotherapy when applied to child psychiatric disorders. A review of a literature search from PubMed, PsychINFO and the Cochrane databases revealed 60 publications, mostly case reports based on 2-60 cases, addressing the use of hypnotherapy in various child psychiatric conditions. Findings indicate that hypnotherapy may be useful for a wide range of disorders and problems, and may be particularly valuable in the treatment of anxiety disorders and trauma-related conditions. In conclusion, knowledge of hypnosis is useful in clinical practice and hypnotherapy may play an important role as an adjunctive therapy in cognitive-behavioural treatment and family therapy. Additional qualitative and quantitative studies are needed to assess the place for hypnosis/hypnotherapy in child psychiatry.

Psychodermatology: a guide to understanding common psychocutaneous disorders

OBJECTIVE

This review focuses on classification and description of and current treatment recommendations for psychocutaneous disorders. Medication side effects of both psychotropic and dermatologic drugs are also considered.

DATA SOURCES

A search of the literature from 1951 to 2004 was performed using the MEDLINE search engine. English-language articles were identified using the following search terms: skin and psyche, psychiatry and dermatology, mind and skin, psychocutaneous, and stress and skin.

DATA SYNTHESIS

The psychotropic agents most frequently used in patients with psychocutaneous disorders are those that target anxiety, depression, and psychosis. Psychiatric side effects of dermatologic drugs can be significant but can occur less frequently than the cutaneous side effects of psychiatric medications. In a majority of patients presenting to dermatologists, effective management of skin conditions requires consideration of associated psychosocial factors. For some dermatologic conditions, there are specific demographic and personality features that commonly associate with disease onset or exacerbation.

CONCLUSIONS

More than just a cosmetic disfigurement, dermatologic disorders are associated with a variety of psychopathologic problems that can affect the patient, his or her family, and society together. Increased understanding of biopsychosocial approaches and liaison among primary care physicians, psychiatrists, and dermatologists could be very useful and highly beneficial.

Factitial dermatoses in children

PURPOSE OF REVIEW

Factitial skin diseases are characterized by unusual patterns of skin lesions that do not conform to any known dermatologic condition and that are consciously or subconsciously fabricated by the patient. This review summarizes the current literature regarding the diagnosis and management of factitial dermatoses in children.

RECENT FINDINGS

Neurotic excoriations, acne excoriee and trichotillomania are the most common factitial skin diseases seen in children. Dermatitis artefacta is also seen in children, but is less common. In many cases, the development of factitial skin disease is associated with a comorbid psychiatric condition or identifiable psychosocial stressor. With regard to the management of factitial dermatoses in children, it is of paramount importance for the clinician to establish an appropriate physician-patient-family relationship. Although controlled studies in children are lacking, pharmacologic and/or nonpharmacologic adjunctive therapy can be helpful in the treatment of these difficult conditions.

SUMMARY

The diagnosis and management of factitial skin diseases in children is a challenge. Clinicians caring for children should be able to recognize the common factitial dermatoses that are seen in the pediatric population. The conveyance of support and acceptance by the physician is essential to the treatment process. Both psychotherapy and psychopharmacology can be important adjunctive treatments.

Diagnosis and management of trichotillomania in children and adolescents

Trichotillomania (TTM), a disorder characterized by the repeated non-cosmetic pulling out of hair from any part of the body, was first described in 1889. The disorder can be associated with serious social and psychologic dysfunction, as well as medical problems. A large proportion of the published scientific literature on TTM consists of case reports, and the disorder has only received significant clinical and research attention over the last 20 years. The disorder occurs across age groups and tends to follow a chronic course in the majority of cases. There is evidence for a bimodal onset, with peaks in the pre-school years and in early adolescence. TTM in child and adolescent populations has not been extensively studied, and the etiology, natural course, and best treatment approaches for the disorder are not known. Assessment for TTM in children and adolescents focuses on making the diagnosis and documenting the response to treatment. Despite the lack of validity studies in child and adolescent populations, most assessments for TTM use one or more formal TTM measures. Although classified as an impulse control disorder in the Diagnostic and Statistical Manual of Mental Disorders (4th Edition), there is some controversy about making the diagnosis in child populations because of criteria B (pattern of rising tension prior to pulling) and C (relief after pulling). There is no consensus for the treatment of TTM in children and adolescents. As in adults, a variety of interventions have been reported, including dynamic therapy, behavioral therapy, and psychopharmacology. Use of pharmacologic interventions in the pre-school age group is rare, but becomes more common as the child ages into adolescence. The most frequently used agents include clomipramine, fluoxetine, and paroxetine. The effectiveness of psychopharmacologic interventions for TTM in children and adolescents is, at best, mixed. A multiple modal approach that includes behavioral, pharmacologic, and other therapies may be the best strategy. There have been no controlled treatment trials in child and adolescent populations. Case reports favor a behavioral approach as the first-line single modality of treatment. Controlled studies of single modalities and combined treatment approaches are clearly needed.

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.

Hypnosis provoked pseudoseizures: a case report and literature review

Only a few studies have been reported in which suggestion was used to provoke pseudoseizures (PS). In these studies PS were video EEG monitored, and saline injections were administered as placebo. This method may be somewhat unethical and carries a low success rate. The authors, two child psychiatrists (GZ and DS) and a neurologist (NG), applied hypnosis to provoke PS which were monitored by video-EEG. Pre-, intra- and post-ictal serum prolactin levels were determined. The first hypnotic session was diagnostic and for this reason featured controlled attempts to determine whether there might be childhood trauma material. The following sessions easily provoked PS during which the EEG was normal and pre-, intra- and post-ictal serum prolactin levels were identical and within normal values. We conclude that hypnosis (with informed consent) for PS monitored by video-EEG telemetry, seems to be an ethical, cheap and quite easy way to demonstrate PS.