Trichotillomania is more related to Tourette disorder than to obsessive-compulsive disorder

The relationship between sensory phenomena and interoception across the obsessive-compulsive spectrum: a systematic review

BACKGROUND

Uncomfortable sensations preceding repetitive behaviours, known as sensory phenomena, have been documented across the obsessive-compulsive spectrum. Indirect evidence suggests altered interoception may play a role in these shared experiences of sensory phenomena; however, research explicitly measuring this relationship is limited. The current systematic review aimed to establish the nature of sensory phenomena and interoception in obsessive-compulsive and related disorders (OCRDs) and tic disorders as potential maintaining factors of these disorders.

METHODS

PsycINFO, PubMed, and Scopus databases were searched from 2007 to April 2024, yielding 65 studies.

RESULTS

While the majority of studies presented low risk of bias, significant overlap and ambiguity characterised the measurement and conceptualisation of sensory phenomena and interoception. Overall, higher sensory phenomena was associated with greater symptom severity in several obsessive-compulsive spectrum disorders. Obsessive-compulsive disorder and tic disorder samples were characterised by lower interoceptive accuracy, with mixed findings on interoceptive sensibility. Some limited research emerged suggesting altered interoceptive abilities may be associated with greater sensory phenomena in obsessive-compulsive disorder and tic disorders.

CONCLUSIONS

Sensory phenomena are experienced across the obsessive-compulsive spectrum. Future research should explore interoceptive abilities across the OCRDs, and build upon evidence supporting a relationship between sensory phenomena and interoception in OCD and tic disorders.

TRIAL REGISTRATION

CRD42023422817.

Validation and assessment of the self-injurious behavior scale for tic disorders (SIBS-T)

Self-injurious behavior (SIB) is a well-known phenomenon in patients with chronic tic disorders (CTD). To investigate prospectively symptomatology of SIB in adults with CTD, we developed and validated the self-injurious behavior scale for tic disorders (SIBS-T). Patients completed the SIBS-T and a variety of assessments for tics and comorbidities. We investigated SIB frequency, internal consistency of the SIBS-T, and carried out an exploratory factor analysis (EFA). We enrolled n = 123 adult patients with CTD. SIB was reported by n = 103 patients (83.7%). The most frequently reported SIB were beating/pushing/throwing and were found in 79.6% of cases. Patients with SIB had significantly higher tic severity measured with the Adult Tic Questionnaire (ATQ) (p = 0.002) as well as higher severity of psychiatric comorbidities such as obsessive-compulsive symptoms (OCS) (p < 0.001,), attention deficit/hyperactivity disorder (ADHD) (p < 0.001,), and anxiety (p = 0.001). In addition, patients with SIB had significantly lower quality of life (p = 0.002). Pearson correlations demonstrated significant associations between SIB and severity of tics (p < 0.001), depression (p = 0.005), ADHD (p = 0.008), and borderline personality traits (p = 0.014). Consequently, higher SIBS-T also correlated with greater impairment of quality of life (p < 0.001). The internal consistency of the SIBS-T was good (α = 0.88). The EFA confirmed a single factor underlying the SIBS-T.

Comparing the 'When' and the 'Where' of Electrocortical Activity in Patients with Tourette Syndrome, Body-Focused Repetitive Behaviors, and Obsessive Compulsive Disorder

Background/Objectives: Tourette Syndrome (TS), Obsessive Compulsive Disorder (OCD), and Body-Focused Repetitive Behaviors (BFRB) are three disorders that share many similarities in terms of phenomenology, neuroanatomy, and functionality. However, despite the literature pointing toward a plausible spectrum of these disorders, only a few studies have compared them. Studying the neurocognitive processes using Event-Related Potentials (ERPs) offers the advantage of assessing brain activity with excellent temporal resolution. The ERP components can then reflect specific processes known to be potentially affected by these disorders. Our first goal is to characterize 'when' in the processing stream group differences are the most prominent. The second goal is to identify 'where' in the brain the group discrepancies could be. Methods: Participants with TS (n = 24), OCD (n = 18), and BFRB (n = 16) were matched to a control group (n = 59) and were recorded with 58 EEG electrodes during a visual counting oddball task. Three ERP components were extracted (i.e., P200, N200, and P300), and generating sources were modelized with Standardized Low-Resolution Electromagnetic Tomography. Results: We showed no group differences for the P200 and N200 when controlling for anxiety and depressive symptoms, suggesting that the early cognitive processes reflected by these components are relatively intact in these populations. Our results also showed a decrease in the later anterior P300 oddball effect for the TS and OCD groups, whereas an intact oddball effect was observed for the BFRB group. Source localization analyses with sLORETA revealed activations in the lingual and middle occipital gyrus for the OCD group, distinguishing it from the other two clinical groups and the controls. Conclusions: It seems that both TS and OCD groups share deficits in anterior P300 activation but reflect distinct brain-generating source activations.

CBD: A Potential Lead against Hair Loss, Alopecia, and its Potential Mechanisms

BACKGROUND

Nowadays, the majority of the population suffers from the problem of hair loss. It leads to disturbed mental health, lower self-confidence, and a lot more problems. A lot of the hair loss therapies available are not reliable and lead to recurrence and side effects after some time. Cannabinoids (CBD) have recently become quite popular for their benefits against hair loss. CBD oil preparations have been used both internally and externally for oral and topical use, respectively. Due to the presence of the endocannabinoid system (ECS) in the body, which naturally targets CB1 and CB2 receptors, the control of hair fall is possible. CBD is used topically for hair loss, whereas it is administered orally for the treatment and management of a medical condition, i.e., alopecia.

AIM/OBJECTIVE

The present review aimed to provide an in-depth study on hair loss and its management using CBD and its associated mechanisms.

METHODS

Electronic databases, such as ScienceDirect, Google Scholar, PubMed, Wiley, Springer, and Scopus, were thoroughly searched for information about how CBD is used, how it works, and what role it plays in treating alopecia and hair loss.

RESULTS

This review has highlighted the use of CBD-based hair loss therapy, and described various types of hair loss and their treatments. This review also details the phytocannabinoids and the potential mechanisms of CBD's activity against hair loss and alopecia.

CONCLUSION

The data obtained from the literature regarding CBD and hair loss provide a scientific basis for CBD use in alopecia. Additionally, a more precise and comprehensive study concerning CBD needs to be carried out at the pre-clinical and clinical levels.

Tourette syndrome and obsessive-compulsive disorder: A comprehensive review of structural alterations and neurological mechanisms

Currently, it is possible to study the pathogenesis of Tourette's syndrome (TS) in more detail, due to more advanced methods of neuroimaging. However, medical and surgical treatment options are limited by a lack of understanding of the nature of the disorder and its relationship to some psychiatric disorders, the most common of which is obsessive-compulsive disorder (OCD). It is believed that the origin of chronic tic disorders is based on an imbalance of excitatory and inhibitory influences in the Cortico-Striato-Thalamo-Cortical circuits (CSTC). The main CSTCs involved in the pathological process have been identified by studying structural and neurotransmitter disturbances in the interaction between the cortex and the basal ganglia. A neurotransmitter deficiency in CSTC has been demonstrated by immunohistochemical and genetic methods, but it is still not known whether it arises as a consequence of genetically determined disturbances of neuronal migration during ontogenesis or as a consequence of altered production of proteins involved in neurotransmitter production. The aim of this review is to describe current ideas about the comorbidity of TS with OCD, the involvement of CSTC in the pathogenesis of both disorders and the background of structural and neurotransmitter changes in CSTC that may serve as targets for drug and neuromodulatory treatments.

The Sapap3-/- mouse reconsidered as a comorbid model expressing a spectrum of pathological repetitive behaviours

Symptom comorbidity is present amongst neuropsychiatric disorders with repetitive behaviours, complicating clinical diagnosis and impeding appropriate treatments. This is of particular importance for obsessive-compulsive disorder (OCD) and Tourette syndrome. Here, we meticulously analysed the behaviour of Sapap3 knockout mice, the recent rodent model predominantly used to study compulsive-like behaviours, and found that its behaviour is more complex than originally and persistently described. Indeed, we detected previously unreported elements of distinct pathologically repetitive behaviours, which do not form part of rodent syntactic cephalo-caudal self-grooming. These repetitive behaviours include sudden, rapid body and head/body twitches, resembling tic-like movements. We also observed that another type of repetitive behaviour, aberrant hindpaw scratching, might be responsible for the flagship-like skin lesions of this mouse model. In order to characterise the symptomatological nature of observed repetitive behaviours, we pharmacologically challenged these phenotypes by systemic aripiprazole administration, a first-line treatment for tic-like symptoms in Tourette syndrome and trichotillomania. A single treatment of aripiprazole significantly reduced the number of head/body twitches, scratching, and single-phase grooming, but not syntactic grooming events. These observations are in line with the high comorbidity of tic- and compulsive-like symptoms in Tourette, OCD and trichotillomania patients.

Body Focused Repetitive Behavior Disorders: Behavioral Models and Neurobiological Mechanisms

OBJECTIVE

Body Focused Repetitive Behaviors (BFRB) is an umbrella term for undesirable, repetitive motor activities such as Trichotillomania (TTM), Skin Picking Disorder (SPD), nail biting, cheek chewing, lip biting, finger sucking, finger cracking and teeth grinding. Such behaviors are engaged in to eliminate a part of the body and may result in impaired functionality. The frequency of presentation to clinicians is low since BFRB are defined as harmless, although the number of studies on this condition has increased rapidly recently, including those making a clear determination of epidemiological data, those investigating the etiopathogenesis and those providing treatment guidelines, although they remain inadequate. The present study provides a review of studies investigating the etiology of BFRB to date.

METHOD

Articles published between 1992 and 2021 stored in the Pubmed, Medline, Scopus and Web of Science databases were reviewed, and the prominent research studies of the condition identified were included in the evaluation.

RESULTS

Studies investigating the etiopathogenesis of BFRB were found in most cases to investigate adult populations, and were hampered by such confounding factors as clinical heterogeneity, high rates of comorbid psychiatric diseases and small sample sizes. The identified studies reveal that attempts have been made to explain BFRB based on behavioral models, and that the condition is inherited at a high rate. Treatment planning is mostly associated with monoamine systems (especially glutamate and dopamine) and interventions were directed to addiction elements. Furthermore, cognitive flexibility and motor inhibition defects in neurocognitive area and cortico-striato-thalamocortical cycle abnormalities in neuroimaging studies have been reported.

CONCLUSION

Studies investigating the clinical features, incidence, etiopathogenesis and treatment of BFRB, which holds a controversial place in psychiatric classification systems, would contribute to a better understanding of the disease and a more appropriate definition of the condition.

Disruption of Astrocyte-Dependent Dopamine Control in the Developing Medial Prefrontal Cortex Leads to Excessive Grooming in Mice

BACKGROUND

Astrocytes control synaptic activity by modulating perisynaptic concentrations of ions and neurotransmitters including dopamine (DA) and, as such, could be involved in the modulating aspects of mammalian behavior.

METHODS

We produced a conditional deletion of the vesicular monoamine transporter 2 (VMAT2) specifically in astrocytes (aVMTA2cKO mice) and studied the effects of the lack of VMAT2 in prefrontal cortex (PFC) astrocytes on the regulation of DA levels, PFC circuit functions, and behavioral processes.

RESULTS

We found a significant reduction of medial PFC (mPFC) DA levels and excessive grooming and compulsive repetitive behaviors in aVMAT2cKO mice. The mice also developed a synaptic pathology, expressed through increased relative AMPA versus NMDA receptor currents in synapses of the dorsal striatum receiving inputs from the mPFC. Importantly, behavioral and synaptic phenotypes were rescued by re-expression of mPFC VMAT2 and L-DOPA treatment, showing that the deficits were driven by mPFC astrocytes that are critically involved in developmental DA homeostasis. By analyzing human tissue samples, we found that VMAT2 is expressed in human PFC astrocytes, corroborating the potential translational relevance of our observations in mice.

CONCLUSIONS

Our study shows that impairment of the astrocytic control of DA in the mPFC leads to symptoms resembling obsessive-compulsive spectrum disorders such as trichotillomania and has a profound impact on circuit function and behaviors.

Trends of Tourette Syndrome in children from 2011 to 2021: A bibliometric analysis

Objective

Analyze the research status of Tourette Syndrome (TS) in children by CiteSpace and determine the current research hotspots and frontiers.

Materials and methods

We chose publications indexed in the Web of Science Core Collection (WoSCC) database for studies related to TS in children from 2011 to 2021. We built online cooperation maps of countries/regions, institutions, authors, journals, references, and keywords by CiteSpace, and identified hotspots and frontiers of study for children’s TS.

Results

A total of 1,232 publications about TS in children were downloaded from the WoSCC. The USA (414) was the country with the highest rate of production, and University College London (87) was the institution that had the highest publication rate. Andrea Eugenio Cavanna was the most prolific author (39 papers). There was inactive cooperation between institutions, countries/regions, and authors. The Journal of European Child &amp; Adolescent Psychiatry was the most active journal. Hot topics focused on epidemiology, comorbidities, deep brain stimulation, behavioral therapy, basal ganglia, pharmacological treatment, and risk factors of TS in children.

Conclusion

According to the CiteSpace results, this study found that authors, countries/regions, and institutions were not actively working together. Current research hotspots mainly consist of epidemiology, comorbidities, deep brain stimulation, behavior therapy, and basal ganglia. The main research trends include comorbidities, pharmacological treatment, and risk factors. Therefore, international cooperation should be strengthened in the future, and it should be mindful of the psychiatric comorbidities of TS, the choice of intervention measures, and early warning of risk factors.

«Doctora, yo como pelo». Tricotilomanía con tricofagia

Se presenta caso de mujer que dice que se come el pelo desde la infancia para lograr alivio momentáneo en situaciones estresantes. En la anamnesis, refiere antecedentes familiares con otros comportamientos compulsivos, incluyendo un familiar que también come pelo. Conclusiones: es clave una anamnesis bien estructurada que explore trastornos neurológicos y psiquiátricos bien definidos, así como el diseño de un árbol genealógico lo más exhaustivo posible para descartar implicaciones genéticas. Descartar trastornos dermatológicos con la dermatoscopia. Es fundamental concienciar a la paciente de posibles complicaciones y comorbilidades como las obstrucciones digestivas y avanzar la pobre eficacia de los tratamientos con psicofármacos. Palabras clave: tricotilomanía, tricofagia, compulsión.

Pharmacotherapy for trichotillomania

BACKGROUND

Trichotillomania (TTM; hair-pulling disorder) is a prevalent and disabling disorder characterised by recurrent hair-pulling. Here we update a previous Cochrane Review on the effects of medication for TTM.

OBJECTIVES

To assess the effects of medication for trichotillomania (TTM) in adults, children and adolescents compared with placebo or other medication.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, eleven other bibliographic databases, trial registries and grey literature sources (to 26 November 2020). We checked reference lists and contacted subject experts.

SELECTION CRITERIA

We selected randomised controlled trials of medication versus placebo or other medication for TTM in adults, children and adolescents.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Twelve studies were included. We identified 10 studies in adults (286 participants) with a mean sample size of 29 participants per trial; one study in children and adolescents (39 participants); and, one study in adults and adolescents (22 participants: 18 adults and 4 adolescents). All studies were single-centre, outpatient trials. Eleven studies compared medication and placebo (334 participants); one study compared two medications (13 participants). Studies were 5 to 13 weeks duration. We undertook meta-analysis only for opioid antagonists as other comparisons contained a single study, or reported insufficient data. Antioxidants versus placebo in adults There was little to no difference in treatment response between antioxidant (35.7%) and placebo groups (28.6%) after six weeks, based on a single trial of silymarin (risk ratio (RR) 2.25, 95% confidence interval (CI) 0.84 to 5.99; 36 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (18 participants; low-certainty evidence). Antioxidants versus placebo in adolescents There was little to no difference in treatment response between antioxidant (50%) and placebo groups (25%) after six weeks, based on a single trial of silymarin (RR 2.00, 95% CI 0.28 to 14.20; 8 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (8 participants; low-certainty evidence). Antipsychotics versus placebo in adults There may be greater treatment response in the antipsychotic group (85%) compared to the placebo group (17%) after 12 weeks, based on a single trial of olanzapine (RR 5.08, 95% CI 1.4 to 18.37; 25 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (25 participants; low-certainty evidence). Cell signal transducers versus placebo in adults There was little to no difference in treatment response between cell signal transducer (42.1%) and placebo groups (31.6%) after 10 weeks, based on a single trial of inositol (RR 1.33, 95% CI 0.57 to 3.11; 38 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (38 participants; low-certainty evidence). Glutamate modulators versus placebo in adults There is probably greater treatment response in the glutamate modulator group (56%) compared to the placebo group (16%) after 12 weeks, based on a single trial of N-acetylcysteine (RR 3.5, 95% CI 1.34 to 9.17; 50 participants; moderate-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (50 participants; low-certainty evidence). Glutamate modulators versus placebo in children and adolescents There was little to no difference in treatment response between the glutamate modulator (25%) and placebo groups (21.1%) in children and adolescents, based on a single trial of N-acetylcysteine (RR 1.19, 95% CI 0.37 to 3.77; 39 participants; low-certainty evidence). There was little to no difference in dropouts due to adverse events between glutamate modulator (5%) and placebo (0%) groups, based on a single trial (RR 2.86, 95% CI 0.12 to 66.11; 39 participants; low-certainty evidence). Opioid antagonists versus placebo in adults There may be little to no difference in treatment response between opioid antagonist (37.5%) and placebo groups (25%) after six to eight weeks, based on two studies of naltrexone, but the evidence is very uncertain (RR 2.14, 95% CI 0.25 to 18.17; 2 studies, 68 participants; very low-certainty evidence). No data were available regarding dropouts due to adverse events. Selective serotonin reuptake inhibitors (SSRIs) versus placebo in adults There were no data available for treatment response to SSRIs. There was little to no difference in dropouts due to adverse events in the SSRI group (5.1%) compared to the placebo group (0%) after 6 to 12 weeks, based on two trials of fluoxetine (RR 3.00, 95% CI 0.33 to 27.62; 2 studies, 78 participants; low-certainty evidence). Tricyclic antidepressants (TCAs) with predominantly serotonin reuptake inhibitor (SRI) actions versus placebo in adults There may be greater treatment response in the TCAs with predominantly SRI actions group (40%) compared to the placebo group (0%) after nine weeks, but the evidence is very uncertain, based on a single trial of clomipramine (RR 5.73, 95% CI 0.36 to 90.83; 16 participants; very low-certainty evidence). There may be increased dropouts due to adverse events in the TCAs with predominantly SRI actions group (30%) compared to the placebo group (0%), but the evidence is very uncertain (RR 4.45, 95% CI 0.27 to 73.81; 16 participants; very low-certainty evidence). TCAs with predominantly SRI actions versus other TCAs in adults There may be greater treatment response in the TCAs with predominantly SRI actions group compared to the other TCAs group after five weeks, based on a single trial comparing clomipramine to desipramine (mean difference (MD) -4.00, 95% CI -6.13 to -1.87; 26 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (26 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

There was insufficient evidence from meta-analysis to confirm or refute the efficacy of any agent or class of medication for the treatment of TTM in adults, children or adolescents. Preliminary evidence suggests there may be beneficial treatment effects for N-acetylcysteine, clomipramine and olanzapine in adults based on four trials, albeit with relatively small sample sizes.

A Comprehensive Review of Tic Disorders in Children

Tics are characterized by sudden, rapid, recurrent, nonrhythmic movement or vocalization, and are the most common movement disorders in children. Their onset is usually in childhood and tics often will diminish within one year. However, some of the tics can persist and cause various problems such as social embarrassment, physical discomfort, or emotional impairments, which could interfere with daily activities and school performance. Furthermore, tic disorders are frequently associated with comorbid neuropsychiatric symptoms, which can become more problematic than tic symptoms. Unfortunately, misunderstanding and misconceptions of tic disorders still exist among the general population. Understanding tic disorders and their comorbidities is important to deliver appropriate care to patients with tics. Several studies have been conducted to elucidate the clinical course, epidemiology, and pathophysiology of tics, but they are still not well understood. This article aims to provide an overview about tics and tic disorders, and recent findings on tic disorders including history, definition, diagnosis, epidemiology, etiology, diagnostic approach, comorbidities, treatment and management, and differential diagnosis.

Sensory symptoms in body-focused repetitive behaviors, restless legs syndrome, and Tourette syndrome: An overlap?

Tourette syndrome (TS) is a neurodevelopmental condition characterized by multiple tics. Sensory symptoms play a key role in the clinical phenomenology and pathophysiology of TS, as most patients report premonitory urges driving tic expression. Interestingly, sensory symptoms have also been reported in other conditions characterized by repeated behaviors. This review explores the nature of sensory symptoms reported by patients with body focused repetitive behaviors (BFRBs, especially trichotillomania and skin picking disorder) and restless legs syndrome (RLS) in comparison to TS. A sense of mounting inner tension and reinforcement mechanisms driven by gratification and relief on expression of the tic or repetitive behavior appear to be implicated across all conditions. Subjective urges can be temporarily suppressed by patients with TS and selected BFRBs, whereas patients with RLS tend to report dysesthesia more frequently than a suppressible urge to move. The observed similarities in the phenomenology of sensory symptoms across these conditions raise the possibility of a comparable underlying pathophysiology. Preliminary findings suggest an overlap of neural pathways encompassing the insula, basal ganglia (putamen), and posterior cingulate cortex.

Neurochemical correlates of behavioral treatment of pediatric trichotillomania

BACKGROUND

Trichotillomania (TTM) is a chronic and impairing psychiatric disorder with suspected dysfunctional cortico-striato-thalamo-cortical (CSTC) circuit activity reflecting excitatory/inhibitory signaling imbalance. TTM neurochemistry is understudied, with no prior research using magnetic resonance spectroscopy (MRS). This pilot investigation examined associations between TTM diagnosis, symptom severity, and response to behavioral treatment with MRS neurometabolites glutamate (Glu) and γ-aminobutyric acid (GABA) in CSTC structures.

METHODS

Proton echo-planar spectroscopic imaging (PEPSI) MRS was acquired from bilateral pregenual anterior cingulate cortex (pACC), caudate, putamen, globus pallidus, thalamus, and proximal white matter in 10 unmedicated girls with TTM, ages 9-17 years, before and after treatment, and from 13 age- and sex-matched healthy controls.

RESULTS

Nine of 10 TTM patients were treatment responders. Pretreatment mean Glu and GABA did not differ significantly between participants and controls. Pretreatment TTM symptoms were correlated with Glu in (left + right) pACC (r = 0.88, p = 0.02) and thalamus (r = 0.82, p = 0.012), and were negatively correlated with pACC GABA (r = -0.84, p = 0.034). Mean GABA in putamen increased 69% (baseline to post-treatment) (p = 0.027). Higher pretreatment Glu in caudate, putamen, globus pallidus, and thalamus predicted greater symptom decreases with treatment (all r < -0.6, p < 0.05); higher caudate GABA predicted less treatment-related symptom decline (r = 0.86, p = 0.014).

LIMITATIONS

Small sample, GABA quantified with spectral fitting rather than editing.

CONCLUSION

Consistent with other neuroimaging, MRS reveals discrete CSTC chemical changes with effective behavior therapy, and possibly with TTM etiology. TTM symptoms relate to excess excitatory versus inhibitory signaling in pACC and thalamus; symptom improvement may reflect reduced excitatory drive of the CSTC direct-pathway activity.

Pharmacotherapy for trichotillomania in adults

INTRODUCTION

Currently conceptualized as an obsessive compulsive and related disorder, trichotillomania, or hair-pulling disorder, is a common illness that causes significant distress or functional impairments in various life domains. Most individuals with trichotillomania also have other comorbid diagnoses. Treating trichotillomania with pharmacotherapy is complicated since there are currently no FDA-approved drugs for its treatment.

AREAS COVERED

The databases PubMed, PsychINFO, CINAHL, Evidence-based Medicine Reviews, and Cochrane Database of Systematic Reviews were searched, yielding a total of 10 open trials and 10 controlled trials selected. This review aims to examine pharmacotherapeutic options for the treatment of trichotillomania in adults and makes recommendations for the assessment and management of the disorder.

EXPERT OPINION

There is preliminary evidence that clomipramine, olanzapine, and N-acetylcysteine may be effective in cases of trichotillomania, however, given the paucity of controlled studies with large sample sizes, decisions regarding the use of drugs should be made on a case-by-case basis taking into account the severity of trichotillomania and the nature of psychiatric comorbidity.