Sleep Disturbances in Pediatric Body-Focused Repetitive Behaviors: A Preliminary Investigation

Body-focused repetitive behaviors (BFRBs) are repeated actions to one's body resulting in physical damage. Limited research has examined sleep, a known factor in psychological health, within the context of pediatric BFRBs. The current study sought to explore the connection between disordered sleep and BFRBs in a community sample. Aim 1 of the study was to determine the predictive power of group membership [control group (no BFRB symptoms reported), subthreshold BFRB group (mild BFRB symptoms reported; severity score of 2 or less out of 9), and those with symptoms characteristic of BFRBs (more than mild BFRB symptoms reported; severity score of 3 or higher out of 9)] for level of sleep disturbance. A hierarchical regression revealed that there was a significant effect of group membership after controlling for anxiety (F (3, 410) = 152.976, p < .001). Aim 2 of the study was to test whether there was a relationship between sleep disturbance and BFRB severity. The hierarchical regression revealed that at Step 1, anxiety accounted for 23.1% of the variance in BFRB severity (β = 0.48, t = 8.87, p < 0.001). At Step 2, sleep disturbance total score accounted for an additional 7.2% of the variance, suggesting this variable makes a unique contribution to overall BFRB severity (SDSC: β = 0.40, t = 5.18, p < 0.001). The findings of this study suggest that sleep could be a clinical factor to consider when conceptualizing a child with BFRBs.

Usefulness of three-dimensional computed tomography venography differentiating calvarium subperiosteal hematoma crossing the suture lines due to hair pulling from subgaleal hematoma: case report and review of the literature

This case showed a 13-year-old boy presented with calvarium subperiosteal hematoma crossing the suture lines caused by hair pulling, and 3D-CTV can differentiate calvarium subperiosteal hematoma crossing the suture lines from subgaleal hematoma. He was treated successfully.

Characterizing the content, messaging, and tone of trichotillomania on YouTube: A content analysis

BACKGROUND

Trichotillomania is associated with secrecy and reluctance to seek help due to shame and lack of knowledge. Social media can connect people with similar lived experience. However, there is no literature regarding online communities related to trichotillomania. This study is a content analysis of depictions of trichotillomania on YouTube to identify the potential role of social media in this disorder.

METHODS

We used a cross-sectional observational study to examine the 100 most-viewed YouTube videos for trichotillomania content until June 2018. Up to 96 variables were abstracted from each video including demographics, characteristics of the videos, and depictions of trichotillomania.

RESULTS

View counts ranged from 9,186 to 15,597,149. Uploaders had a mean age of 20.1 years, were mostly female (85%) and appearing Caucasian (63%). Nearly half of the videos were self-filmed stories (48%). Most had a neutral message (44%), provided strategies to stop hair-pulling (31%), or focused on stimulating discussion (17%). Approximately half had a factual tone (51%) and many were hopeful (44%). Videos accurately described hair-pulling and associated characteristics.

LIMITATIONS

This study was limited to an analysis of video content. Future research should examine the comments on the videos as well as other social media platforms. It may also be important to assess the socioeconomic status of video uploaders and ensure the broader accessibility of positive messages on trichotillomania.

CONCLUSIONS

People with trichotillomania may find positive messages, information, and helpful recommendations on YouTube. This may represent an under-leveraged venue to improve clinical outcomes for people with trichotillomania.

Sex Differences in Age at Onset and Presentation of Trichotillomania and Trichobezoar: A 120-Year Systematic Review of Cases

Trichotillomania (hair-pulling disorder) has high female preponderance. It has been suggested that onset in early childhood represents a distinct developmental subtype that is characterized by higher prevalence of males compared to later onset cases. However, the empirical literature is scarce. We conducted a systematic review of case reports to examine the distribution of age at onset/presentation in males and females with trichotillomania or trichobezoar (a mass of hair in the gastrointestinal tract resulting from ingesting hair). We identified 1065 individuals with trichotillomania and 1248 with trichobezoar. In both samples, males, compared to females, had earlier age at presentation and greater proportion of cases in early childhood. These sex differences remained after potential confounding variables were accounted for. The results showed similar sex differences for age at onset, which was reported in 734 and 337 of the trichotillomania and trichobezoar cases, respectively. The findings may reflect neurodevelopmental underpinnings in early childhood trichotillomania.

Trichotillomania: What Do We Know So Far?

Trichotillomania is defined as an obsessive-compulsive or related disorder in which patients recurrently pull out hair from any region of their body. The disease affects mainly female patients, who often deny the habit, and it usually presents with a bizarre pattern nonscarring patchy alopecia with short hair and a negative pull test. Trichoscopy can reveal the abnormalities resulting from the stretching and fracture of hair shafts, and biopsy can be necessary if the patient or parents have difficulties in accepting the self-inflicted nature of a trichotillomania diagnosis. Trichotillomania requires a comprehensive treatment plan and interdisciplinary approach. Physicians should always have a nonjudgmental, empathic, and inviting attitude toward the patient. Behavioral therapy has been used with success in the treatment of trichotillomania, but not all patients are willing or able to comply with this treatment strategy. Pharmacotherapy can be necessary, especially in adolescents and adult patients. Options include tricyclic antidepressants, selective serotonin reuptake inhibitors, and glutamate-modulating agents. Glutamate-modulating agents such as N-acetylcysteine are a good first-line option due to significant benefits and low risk of side effects. Physicians must emphasize that the role of psychiatry-dermatology liaison is extremely necessary with concurrent support services for the patient and parents, in case of pediatric patients. In pediatric cases, parents should be advised and thoroughly educated that negative feedback and punishment for hair pulling are not going to produce positive results. Social support is a significant pillar to successful habit reversal training; therefore, physicians must convey the importance of familial support to achieving remission. This is a review article that aims to discuss the literature on trichotillomania, addressing etiology, historical aspects, clinical and trichoscopic features, main variants, differential diagnosis, diagnostic clues, and psychological and pharmacological management.

Development of the social concerns in individuals with body-focused repetitive behaviors (SCIB) scale

Body-focused repetitive behaviors (BFRBs) include such disorders as compulsive hair pulling, skin picking, nail biting, and cheek biting, which can lead to significant psychosocial impairment (American Psychiatric Association, 2013). As such, social concerns (i.e., concerns about how others view their behavior or affected body sites) are common in these individuals, and may significantly associate with BFRB symptomology (Snorrason et al., 2012). Currently, there are no measures to adequately assess social concerns specific to BFRBs. To this end, we developed a new self-report measure called the Social Concerns in Individuals with BFRBs (SCIB) that aimed to assess these concerns using two independent samples of individuals reporting elevated BFRB symptoms. Results showed that the overall level of social concerns reported on the SCIB significantly explained the variance in hair pulling and skin picking symptom severity even after controlling for the influence of other general social concern and emotional distress measures. Exploratory and confirmatory factor analyses provided psychometric evidence for the two-factor structure of the SCIB: (1) Concern about Physical Unattractiveness and (2) Concern about Social Disapproval, which were found to assess distinguishable aspects of BFRB-relevant social concerns. Overall, the findings suggest that the SCIB is a useful measure that can be used to evaluate social concerns in those with BFRB disorders.

Trichotillomania in Children and the Different Approaches between Dermatological and Behavioral Health Professionals at an Urban Tertiary Care Center

Background

Trichotillomania (TTM) is a complex disease with varying clinical characteristics, and psychosocial impairment is noted in many TTM patients. Despite its prevalence in childhood, there is limited research on pediatric TTM.

Objective

To analyze the clinical and epidemiologic features of TTM in children evaluated by dermatologists and behavioral health specialists.

Method

We performed a retrospective chart review of 137 pediatric patients seen at the Children's Hospital of Philadelphia with initial presentation of TTM at age 17 or younger. Patients were treated by dermatology or behavioral health.

Results

The majority of the patients were females, with an average diagnosis age around 8 years. Over half had a psychiatric comorbidity, and over a quarter had a skin disorder. Skin disorders were more commonly present in those evaluated by dermatology, and psychiatric comorbidities were more commonly present in those evaluated by behavioral health. The most common form of treatment was behavioral therapy, with medications prescribed more often by dermatologists.

Conclusions

TTM patients choose to present to behavioral health or dermatology; however, there are distinctive differences between the two cohorts. With behavioral and pharmacologic treatment options, a relationship between dermatologists and behavioral health specialists is necessary for multifactorial management of TTM.

Disentangling Reward Processing in Trichotillomania: 'Wanting' and 'Liking' Hair Pulling Have Distinct Clinical Correlates

Trichotillomania (TTM; hair-pulling disorder) is characterized by an irresistible urge or desire to pull out one's own hair, and a sense of pleasure when hair is pulled out. Evidence from translational neuroscience has shown that 'wanting' (motivation to seek a reward) and 'liking' (enjoyment when reward is received) are each mediated by overlapping but distinct neural circuitry, and that 'wanting' contributes to addictive/compulsive behaviors more so than 'liking'. In the present study, we developed the Hair Pulling Reward Scale (HPRS), a self-report measure that consists of two subscales designed to assess (a) cue-triggered urges and appetitive motivation to pull hair (i.e., putative correlates of 'wanting'), and (b) momentary pleasure and gratification during pulling episodes (i.e., putative correlates of 'liking'). We administered the HPRS to 259 individuals with TTM and examined its psychometric properties. Confirmatory factor analysis supported a two-factor model reflecting correlated Wanting and Liking scales. Consistent with predictions, Wanting, much more than Liking, had robust correlations with TTM severity, impulsiveness, difficulties in emotion regulation, psychiatric symptoms, and sleep dysfunction. The results suggest that the HPRS is a psychometrically sound instrument that can be used as a symptom-level measure of reward processing in TTM.

Confirmatory factor analysis of the SLEEP-50 Questionnaire in Trichotillomania (Hair-Pulling Disorder) and Excoriation (Skin-Picking) Disorder

The study objective was to perform a confirmatory factor analysis of the SLEEP-50 Questionnaire (SLEEP-50) in Trichotillomania (Hair-Pulling Disorder) and Excoriation (Skin-Picking) Disorder and compare sleep complaints in adults with Trichotillomania, Excoriation Disorder and non-affected controls. Participants were 234 adults with Trichotillomania, 170 with Excoriation Disorder, and 146 non-affected controls. Participants rated sleep using the SLEEP-50 and Pittsburgh Sleep Quality Index (PSQI). Confirmatory factor analysis was used to assess fit of the originally-proposed SLEEP-50 factors within Trichotillomania and Excoriation Disorder. Findings revealed acceptable to good fit of the original factors. Internal consistency was excellent in Trichotillomania and good in Excoriation Disorder for the total score and poor to good for subscales. Convergent validity was strong for the total and weak to strong for subscales in both groups. Findings suggest greater sleep complaints in Trichotillomania and Excoriation Disorder than in the general population. Trichotillomania and Excoriation Disorder groups reported greater rates of sleep apnea, narcolepsy, restless leg syndrome/periodic limb movement disorder, circadian rhythms sleep disorder, and sleep-related affective disorder relative to controls. There were no significant differences for insomnia, sleep state misperception, sleepwalking, nightmares, or hypersomnia. Results underscore the importance of clinical assessment of sleep disorders in Trichotillomania and Excoriation Disorder.

Computerized response inhibition training for children with trichotillomania

Evidence suggests that trichotillomania is characterized by impairment in response inhibition, which is the ability to suppress pre-potent/dominant but inappropriate responses. This study sought to test the feasibility of computerized response inhibition training for children with trichotillomania. Twenty-two children were randomized to the 8-session response inhibition training (RIT; n = 12) or a waitlisted control (WLT; n = 10). Primary outcomes were assessed by an independent evaluator, using the Clinical Global Impression-Improvement (CGI-I), and the NIMH Trichotillomania Severity (NIMH-TSS) and Impairment scales (NIMH-TIS) at pre, post-training/waiting, and 1-month follow-up. Relative to the WLT group, the RIT group showed a higher response rate (55% vs. 11%) on the CGI-I and a lower level of impairment on the NIMH-TIS, at post-training. Overall symptom reductions rates on the NIMH-TSS were 34% (RIT) vs. 21% (WLT) at post-training. The RIT's therapeutic gains were maintained at 1-month follow-up, as indicated by the CGI-I responder status (= 66%), and a continuing reduction in symptom on the NIMH-TSS. This pattern of findings was also replicated by the 6 waitlisted children who received the same RIT intervention after post-waiting assessment. Results suggest that computerized RIT may be a potentially useful intervention for trichotillomania.

Types of avoidance in hair-pulling disorder (trichotillomania): An exploratory and confirmatory analysis

Hair-pulling disorder (HPD) or Trichotillomania is a complex disorder with frequent relapses. Avoidance has been highlighted as an important behavioural feature in HPD. To improve our understanding of avoidance, two studies were conducted to identify the types of avoidance that may be experienced by those who pull hair. Internet questionnaires were used to collect data. Data from study one was split into two subsets. An exploratory factor analysis was conducted to identify the different types of avoidance experienced by those reporting symptoms of hair pulling (subset one, n = 278), followed by a confirmatory factor analysis (subset two, n = 295). In study two a MANOVA was conducted (n = 300) to examine whether levels of avoidance differed between controls and those with hair pulling symptoms. Participants with hair pulling symptoms had greater levels of avoidance on each of the five types: 'Avoidance of non-social goals', 'Self-concealment', 'Behavioural social avoidance', 'Avoidance of relationship problem solving' and 'Avoidance of thinking about the future'. These data expand on the current literature, which has predominantly focused on experiential avoidance. Future research will need to validate these findings in a clinical group.

The Dermoscopic "Pluck Out Sign" for Beard Trichotillomania

Beard trichotillomania (TTM) is a rather uncommon entity. Hair is not easily plucked from the beard area, as patients need forceps or tweezers to perform their task. The diagnosis of beard TTM can be quite tricky as the location is not the most frequent one. Dermoscopy might in these cases be helpful to achieve the correct diagnosis. In this article, we describe for the first time the "pluck out sign" for beard TTM.

Defining treatment response in trichotillomania: a signal detection analysis

The Massachusetts General Hospital Hairpulling Scale (MGH-HPS) and the NIMH Trichotillomania Severity Scale (NIMH-TSS) are two widely used measures of trichotillomania severity. Despite their popular use, currently no empirically-supported guidelines exist to determine the degrees of change on these scales that best indicate treatment response. Determination of such criteria could aid in clinical decision-making by defining clinically significant treatment response/recovery and producing accurate power analyses for use in clinical trials research. Adults with trichotillomania (N=69) participated in a randomized controlled trial of psychotherapy and were assessed before and after treatment. Response status was measured via the Clinical Global Impressions-Improvement Scale, and remission status was measured via the Clinical Global Impressions-Severity Scale. For treatment response, a 45% reduction or 7-point raw score change on the MGH-HPS was the best indicator of clinically significant treatment response, and on the NIMH-TSS, a 30-40% reduction or 6-point raw score difference was most effective cutoff. For disorder remission, a 55-60% reduction or 7-point raw score change on the MGH-HPS was the best predictor, and on the NIMH-TSS, a 65% reduction or 6-point raw score change was the best indicator of disorder remission. Implications of these findings are discussed.

Trichotillomania by proxy

Trichotillomania is a disorder of an impulsive hair pulling that occurs in both adults and children alike. Trichotillomania is seen in children and often has other psychiatric comorbidity. Here, we present an interesting case of a mother who had trichotillomania and recovered with treatment following which she resorted to pulling hair of her child and brought her child for treatment saying that the child too had trichotillomania and that we should help the child recover like her. After interviewing the child, it was revealed that it was, in fact, the mother who used to pull the child's hair as a release for her hair-pulling urges.