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Trichotillomania

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Handbook of DSM-5 Disorders in Children and Adolescents

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Abstract

Trichotillomania (TTM), characterized in DSM V under the category of OCD and related disorders, is a condition in which individuals fail to resist urges to pull out their own hair. TTM is associated with significant functional impairment and psychiatric comorbidity across the developmental spectrum. Disorder onset is typically seen in childhood or adolescence, yet the research literature involving pediatric samples remains sparse. Efficacious treatments have been developed for adults, in particular cognitive-behavioral interventions involving procedures collectively known as habit reversal training, yet relapse appears to be common. The pediatric treatment literature contains only two randomized studies thus far, and thus clinicians must interpolate over the empirical gaps to make empirically informed recommendations to parents who seek help for their children who pull. Dissemination of information about TTM and its treatment is a critical next step in the field, since many affected individuals and families cannot readily access treatment providers with knowledge to deliver the interventions found most promising in reducing pulling behavior.

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References

  • American Psychiatric Association [APA]. (1987). Diagnostic and statistical manual of mental disorders. (3rd ed., revised). Washington, DC: Author.

    Google Scholar 

  • American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders. (4th ed., text revision). Washington, DC: Author.

    Google Scholar 

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

    Book  Google Scholar 

  • Azrin, N. H., & Nunn, R. G. (1973). Habit-reversal: A method of eliminating nervous habits and tics. Behaviour Research and Therapy, 11, 619–628.

    Article  PubMed  Google Scholar 

  • Beidas, R. S., Marcus, S., Aarons, G. A., Hoagwood, K. E., Schoenwald, S., Evans, A. C., … Mandell, D. S. (2015). Predictors of community therapists’ use of therapy techniques in a large public mental health system. JAMA Pediatrics, 169(4), 374–382. doi:10.1001/jamapediatrics.2014.3736.

    Article  PubMed  PubMed Central  Google Scholar 

  • Bloch, M. H., Landeros-Weisenberger, A., Dombrowski, P., Kelmendi, B., Wegner, R., Nudel, J., … Coric, V. (2007). Systematic review: Pharmacological and behavioral treatment for trichotillomania. Biological Psychiatry, 62, 839–846.

    Article  PubMed  Google Scholar 

  • Bloch, M. H., Panza, K. E., Grant, J. E., Pittenger, C., & Leckman, J. F. (2013). N-acetylcysteine in the treatment of pediatric trichotillomania: A randomized, double-blind, placebo-controlled add-on trial. Journal of the American Academy of Child & Adolescent Psychiatry, 52, 231–240.

    Article  Google Scholar 

  • Boudjouk, P. J., Woods, D. W., Miltenberger, R. G., & Long, E. S. (2000). Negative peer evaluation in adolescents: Effects of tic disorders and trichotillomania. Child & Family Behavior Therapy, 22, 17–28.

    Article  Google Scholar 

  • Bouwer, C., & Stein, D. J. (1998). Trichobezoars in trichotillomania: Case report and literature overview. Psychosomatic Medicine, 60, 658–660.

    Article  PubMed  Google Scholar 

  • Chamberlain, S. R., Menzies, L., Sahakian, B. J., & Fineberg, N. A. (2007). Lifting the veil on trichotillomania. American Journal of Psychiatry, 164, 568–574.

    Article  PubMed  Google Scholar 

  • Chamberlain, S. R., Odlaug, B. R., Boulougouris, V., Fineberg, N. A., & Grant, J. E. (2009). Trichotillomania: Neurobiology and treatment. Neuroscience and Biobehavioral Reviews, 33, 831–842.

    Article  PubMed  Google Scholar 

  • Christenson, G. A., Chernoff-Clementz, E., & Clementz, B. A. (1992). Personality and clinical characteristics in patients with trichotillomania. Journal of Clinical Psychiatry, 53, 407–413.

    PubMed  Google Scholar 

  • Christenson, G. A., & Mackenzie, T. B. (1995). Trichotillomania, body dysmorphic disorder, and obsessive-compulsive disorder. Journal of Clinical Psychiatry, 56, 211–212.

    PubMed  Google Scholar 

  • Christenson, G. A., Mackenzie, T. B., & Mitchell, J. E. (1991a). Characteristics of 60 adult chronic hair pullers. American Journal of Psychiatry, 148, 365–370.

    Article  PubMed  Google Scholar 

  • Christenson, G. A., & Mansueto, C. S. (1999). Trichotillomania: Descriptive characteristics and phenomenology. In Trichotillomania (pp. 1–41). Arlington, VA: American Psychiatric Association.

    Google Scholar 

  • Christenson, G. A., Pyle, R. L., & Mitchell, J. E. (1991b). Estimated lifetime prevalence of trichotillomania in college students. Journal of Clinical Psychiatry, 52, 415–417.

    PubMed  Google Scholar 

  • Conelea, C. A., Walther, M. R., Flessner, C. A., Woods, D. W., Franklin, M. E., Keuthen, N. J., & Piacentini, J. C. (2012). The incremental validity of criteria B and C for diagnosis of trichotillomania in children and adults. Journal of Obsessive-Compulsive and Related Disorders, 1, 98–103.

    Article  Google Scholar 

  • de Sousa, A. (2008). A: An open-label pilot study of naltrexone in childhood-onset trichotillomania. Journal of Child and Adolescent Psychopharmacology, 18, 30–33.

    Article  PubMed  Google Scholar 

  • Diefenbach, G. J., Tolin, D. F., Crocetto, J., Maltby, N., & Hannan, S. (2005). Assessment of trichotillomania: A psychometric evaluation of hair-pulling scales. Journal of Psychopathology & Behavioral Assessment, 27, 169–178.

    Article  Google Scholar 

  • Dougherty, D. D., Loh, R., Jenike, M. A., & Keuthen, N. J. (2006). Single modality versus dual modality treatment for trichotillomania: Sertraline, behavioral therapy, or both? Journal of Clinical Psychiatry, 67, 1086–1092.

    Article  PubMed  Google Scholar 

  • du Toit, P. L., van Kradenburg, J., Niehaus, D. H. J., & Stein, D. J. (2001). Characteristics and phenomenology of hair-pulling: An exploration of subtypes. Comprehensive Psychiatry, 42, 247–256.

    Article  PubMed  Google Scholar 

  • Flessner, C. A., Penzel, F., Trichotillomania Learning Center–Scientific Advisory Board, & Keuthen, N. J. (2010). Current treatment practices for children and adults with trichotillomania: Consensus among experts. Cognitive and Behavioral Practice, 17, 290–300.

    Article  Google Scholar 

  • Flessner, C. A., Woods, D. W., Franklin, M. E., Cashin, S. E., & Keuthen, N. J. (2008). The milwaukee inventory for subtypes of trichotillomania-adult version (MIST-A): Development of an instrument for the assessment of “focused” and “automatic” hair pulling. Journal of Psychopathology and Behavioral Assessment, 30, 20–30.

    Article  Google Scholar 

  • Flessner, C. A., Woods, D. W., Franklin, M. E., Keuthen, N. J., Piacentini, J., Cashin, S. E., & Moore, P. S. (2007). The Milwaukee inventory for styles of trichotillomania-child version (MIST-C): Initial development and psychometric properties. Behavior Modification, 31, 896–918.

    Article  PubMed  Google Scholar 

  • Franklin, M. E., Edson, A. L., Ledley, D. A., & Cahill, S. P. (2011a). Behavior therapy for pediatric trichotillomania: A randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 50, 763–771.

    Article  Google Scholar 

  • Franklin, M. E., Edson, A. L., & Freeman, J. B. (2010). Behavior therapy for pediatric trichotillomania: Exploring the effects of age on treatment outcome. Child and Adolescent Psychiatry and Mental Health, 4. doi:http://dx.doi.org/10.1186/1753-2000-4-18.

  • Franklin, M. E., Flessner, C. A., Woods, D. W., Keuthen, N. J., Piacentini, J. C., Moore, P., … Wilson, M. A. (2008). The child and adolescent trichotillomania impact project: Descriptive psychopathology, comorbidity, functional impairment, and treatment utilization. Journal of Developmental and Behavioral Pediatrics, 29, 493–500.

    Article  PubMed  Google Scholar 

  • Franklin, M., Sapyta, J., Freeman, J., Khanna, M., Compton, S., Almirall, D., et al. (2011b). Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive-compulsive disorder: The pediatric OCD treatment study II (POTS II). Journal of the American Medical Association, 306, 1224–1232.

    Article  PubMed  PubMed Central  Google Scholar 

  • Franklin, M. E., & Tolin, D. F. (2007). Treating trichotillomania: Cognitive behavioral therapy for hair pulling and related problems. New York, NY: Springer Science and Business Media.

    Book  Google Scholar 

  • Glisson, C., Schoenwald, S. K., Hemmelgarn, A., et al. (2010). Randomized trial of MST and ARC in a two-level evidence-based treatment implementation strategy. Journal of Consulting and Clinical Psychology, 78, 537–550.

    Article  PubMed  PubMed Central  Google Scholar 

  • Grant, J. E., & Odlaug, B. L. (2008). Clinical characteristics of trichotillomania with trichophagia. Comprehensive Psychiatry, 49, 579–584.

    Article  PubMed  PubMed Central  Google Scholar 

  • Grant, J. E., Odlaug, B. L., & Kim, S. W. (2009). N-Acetylcysteine, a glutamate modulator, in the treatment of trichotillomania. Archives of General Psychiatry, 66, 756–763.

    Article  PubMed  Google Scholar 

  • Grant, J. E., Odlaug, B. L., & Potenza, M. N. (2007). Addicted to hair pulling? How an alternate model of trichotillomania may improve treatment outcome. Harvard Review of Psychiatry, 15, 80–85.

    Article  PubMed  Google Scholar 

  • Grant, J. E., Odlaug, B. L., Schreiber, L. R. N., & Kim, S. W. (2014). The opiate antagonist, naltrexone, in the treatment of trichotillomania: Results of a double-blind, placebo-controlled study. Journal of Clinical Psychopharmacology, 34, 134–138.

    Article  PubMed  Google Scholar 

  • Hajcak, G., Franklin, M. E., Simons, R., & Keuthen, N. J. (2006). Hairpulling and skin picking in a large college sample: Prevalence and relationship to affective distress and obsessive-compulsive symptoms. Journal of Psychopathology & Behavioral Assessment, 28, 179–187.

    Article  Google Scholar 

  • Hallopeau, H. (1889). Alopecia par grattage (trichomanie ou trichotillomanie). Annales de Dermatologie et de Syphiligraphie, 10, 440–441.

    Google Scholar 

  • Hanna, G. L. (1997). Trichotillomania and related disorders in children and adolescents. Child Psychiatry and Human Development, 27, 255–268.

    Article  PubMed  Google Scholar 

  • Houghton, D. C., Balsis, S., Stein, D. J., Compton, S. N., Twohig, M. P., Saunders, S. M.,. .. Woods, D. W. (2015). Examining DSM criteria for trichotillomania in a dimensional framework: Implications for DSM-5 and diagnostic practice. Comprehensive Psychiatry, doi:http://dx.doi.org/10.1016/j.comppsych.2015.04.011.

  • Keuthen, N. J., Altenburger, E. M., & Pauls, D. (2014). A family study of trichotillomania and chronic hair pulling. American Journal of Medical Genetics Part B: Neuropsychiatric Genetics, 165, 167–174.

    Article  Google Scholar 

  • Keuthen, N. J., Fama, J., Altenburger, E. M., Allen, A., Raff, A., & Pauls, D. (2013). Family environment in adolescent trichotillomania. Journal of Obsessive-Compulsive and Related Disorders, 2, 366–374.

    Article  Google Scholar 

  • Keuthen, N. J., Rothbaum, B. O., Fama, J., Altenburger, E., Falkenstein, M. J., Sprich, S. E., … Welch, S. S. (2012). DBT-enhanced cognitive-behavioral treatment for trichotillomania: A randomized controlled trial. Journal of Behavioral Addictions, 1, 106–114.

    Article  PubMed  Google Scholar 

  • Keuthen, N. J., Rothbaum, B. O., Welch, S. S., Taylor, C., Falkenstein, M., Heekin, M., … Jenike, M. A. (2010). Pilot trial of dialectical behavior therapy-enhanced habit reversal for trichotillomania. Depression and Anxiety, 27, 953–959.

    Article  PubMed  Google Scholar 

  • King, R. A., Scahill, L., Vitulano, L. A., & Schwab-Stone, M. (1995). Childhood trichotillomania: Clinical phenomenology, comorbidity, and family genetics. Journal of the American Academy of Child & Adolescent Psychiatry, 34, 1451–1459.

    Article  Google Scholar 

  • Lanoue, J. L., & Arkovitz, M. S. (2003). Trichobezoar in a four-year-old-girl. New England Journal of Medicine, 348, 1242.

    Article  PubMed  Google Scholar 

  • Leckman, J. F., Riddle, M. A., Hardin, M. T., Ort, S. I., Swartz, K. L., Stevenson, J., & Cohen, D. J. (1989). The Yale Global Tic Severity Scale (YGTSS): Initial testing of a clinical-rated scale of tic severity. Journal of the American Academy of Child and Adolescent Psychiatry, 28, 566–573.

    Article  PubMed  Google Scholar 

  • Lerner, J., Franklin, M. E., Meadows, E. A., Hembree, E., &, Foa, E. B. (1998). Effectiveness of a cognitive-behavioral treatment program for trichotillomania: An uncontrolled evaluation. Behavior Therapy 29, 157-171.

    Google Scholar 

  • Lochner, C., Grant, J. E., Odlaug, B. L., Woods, D. W., Keuthen, N. J., & Stein, D. J. (2012). DSM-5 field survey: Hair-pulling disorder (trichotillomania). Depression and Anxiety, 29, 1025–1031.

    Article  PubMed  Google Scholar 

  • Lochner, C., Stein, D. J., Woods, D., Pauls, D. L., Franklin, M. E., Loerke, E. H., & Keuthen, N. J. (2011). The validity of DSM-IV-TR criteria B and C of hair-pulling disorder (trichotillomania): Evidence from a clinical study. Psychiatry Research, 189, 276–280.

    Article  PubMed  Google Scholar 

  • McElroy, S. L., Hudson, J. I., Pope, H. G., Keck, P. E., & Aizley, H. G. (1992). The DSM-III—R impulse control disorders not elsewhere classified: Clinical characteristics and relationship to other psychiatric disorders. The American Journal of Psychiatry, 149, 318–327.

    Article  PubMed  Google Scholar 

  • Moore, P. S., Franklin, M. E., Keuthen, N. J., Flessner, C. A., Woods, D. W., Piacentini, J. A., … Loew, B. (2009). Family functioning in pediatric trichotillomania. Child & Family Behavior Therapy, 31, 255–269.

    Article  Google Scholar 

  • Novak, C. E., Keuthen, N. J., Stewart, S. E., & Pauls, D. L. (2009). A twin concordance study of trichotillomania. American Journal of Medical Genetics Part B, 150B, 944–949.

    Article  Google Scholar 

  • Panza, K. E., Pittenger, C., & Bloch, M. H. (2013). Age and gender correlates of pulling in pediatric trichotillomania. Journal of the American Academy of Child & Adolescent Psychiatry, 52, 241–249.

    Article  Google Scholar 

  • Reeve, E. (1999). Hair pulling in children and adolescents. In D. J. Stein, G. A. Christenson, & E. Hollander (Eds.), Trichotillomania (pp. 201–224). Washington, DC: American Psychiatric Association Press, Inc.

    Google Scholar 

  • Rogers, K., Banis, M., Falkenstein, M. J., Malloy, E. J., McDonough, L., Nelson, S. O., … Haaga, D. A. F. (2014). Stepped care in the treatment of trichotillomania. Journal of Consulting and Clinical Psychology, 82, 361–367.

    Article  PubMed  PubMed Central  Google Scholar 

  • Rothbaum, B. O., & Ninan, P. T. (1994). The assessment of trichotillomania. Behaviour Research and Therapy, 32, 651–662.

    Article  PubMed  Google Scholar 

  • Seedat, S., & Stein, D. J. (1998). Psychosocial and economic implications of trichotillomania: A pilot study in a South African sample. CNS Spectrums, 3, 40–43.

    Article  Google Scholar 

  • Shafran, R., Clark, D. M., Fairburn, C. G., et al. (2009). Mind the gap: Improving the dissemination of CBT. Behaviour Research and Therapy, 47, 902–909.

    Article  PubMed  Google Scholar 

  • Simpson, H. B., Foa, E. B., Liebowitz, M. R., Ledley, D. A., Huppert, J. D., Cahill, S. P., … Petkova, E. (2008). A randomized controlled trial of cognitive-behavioral therapy for augmenting pharmacotherapy in obsessive-compulsive disorder. American Journal of Psychiatry, 165, 621–630.

    Article  PubMed  PubMed Central  Google Scholar 

  • Stemberger, R. M. T., Thomas, A. M., Mansueto, C. S., & Carter, J. G. (2000). Personal toll of trichotillomania: Behavioral and interpersonal sequelae. Journal of Anxiety Disorders, 14, 97–104.

    Article  PubMed  Google Scholar 

  • Stein, D. J., Grant, J. E., Franklin, M. E., Keuthen, N., Lochner, C., Singer, H. S., & Woods, D. W. (2010). Trichotillomania (hair pulling disorder), skin picking disorder, and stereotypic movement disorder: Toward DSM-V. Depression and Anxiety, 27, 611–626.

    Article  PubMed  Google Scholar 

  • Stewart, R. S., & Netjek, V. A. (2003). An open-label, flexible-dose study of olanzapine in the treatment of trichotillomania. Journal of Clinical Psychiatry, 64, 49–52.

    Article  PubMed  Google Scholar 

  • Swedo, S. E., & Leonard, H. L. (1992). Trichotillomania: An obsessive compulsive spectrum disorder? Psychiatric Clinics of North America, 15, 777–790.

    PubMed  Google Scholar 

  • Swedo, S. E., Leonard, H. L., Rapoport, J. L., Lenane, M., Goldberger, E. L., & Cheslow, D. (1989). A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling). New England Journal of Medicine, 321, 497–501.

    Article  PubMed  Google Scholar 

  • Tolin, D. F., Franklin, M. E., Diefenbach, G. J., Anderson, E., & Meunier, S. A. (2007). Pediatric trichotillomania: Descriptive psychopathology and an open trial of cognitive-behavioral therapy. Cognitive Behaviour Therapy, 36, 129–144.

    Article  PubMed  Google Scholar 

  • Van Ameringen, M., Mancini, C., Patterson, B., Bennett, M., & Oakman, J. (2010). A randomized, double blind, placebo-controlled trial of olanzapine in the treatment of trichotillomania. Journal of Clinical Psychiatry, 71, 1336–1343.

    Article  PubMed  Google Scholar 

  • Walther, M. R., Snorrason, I., Flessner, C. A., Franklin, M. E., Burkel, R., & Woods, D. W. (2014). The trichotillomania impact project in young children (TIP-YC): Clinical characteristics, comorbidity, functional impairment and treatment utilization. Child Psychiatry and Human Development, 45, 24–31.

    Article  PubMed  Google Scholar 

  • Weiss, B., & DiLullo, D. (2009). ABCT members Franklin and woods receive first-ever NIMH R01 grants for behavioral treatment of trichotillomania. The Behavior Therapist, 32, 189–190.

    Google Scholar 

  • Wetterneck, C. T., Woods, D. W., Norberg, M. M., & Begotka, A. M. (2006). The social and economic impact of trichotillomania: Results from two nonreferred samples. Behavioral Interventions, 21, 97–109.

    Article  Google Scholar 

  • Woods, D. W., Flessner, C. A., Franklin, M. E., Keuthen, N. J., Goodwin, R. D., Stein, D. J., & Walther, M. R. (2006a). The trichotillomania impact project (TIP): Exploring phenomenology, functional impairment, and treatment utilization. Journal of Clinical Psychiatry, 67, 1877–1888.

    Article  PubMed  Google Scholar 

  • Woods, D. W., Flessner, C. A., Franklin, M. E., Wetterneck, C. T., Walther, M., Anderson, E., & Cardona, D. (2006b). Understanding and treating trichotillomania: What we know and what we don’t know. Psychiatric Clinics of North America, 29, 487–501.

    Article  PubMed  Google Scholar 

  • Woods, D. W., Piacentini, J. C., Himle, M. B., & Chang, S. (2005). Initial development and psychometric properties of the premonitory urge for tics scale (PUTS) in children with Tourette syndrome. Journal of Developmental and Behavioral Pediatrics, 26, 397–403.

    Article  PubMed  Google Scholar 

  • Woods, D. W., Wetterneck, C. T., & Flessner, C. A. (2006c). A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania. Behaviour Research and Therapy, 44, 639–656.

    Article  PubMed  Google Scholar 

  • Wright, H. H., & Holmes, G. R. (2003). Trichotillomania (hair pulling) in toddlers. Psychological Reports, 92, 228–230.

    Article  PubMed  Google Scholar 

  • Zohar, J., & Ben-Arush, O. (2012). Review of trichotillomania, skin picking, and other body-focused repetitive behaviors. The American Journal of Psychiatry, 169, 337–338.

    Article  Google Scholar 

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Authors and Affiliations

  1. Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Martin E. Franklin

  2. Neurology, Learning and Behavior Center, Salt Lake City, UT, USA

    Sarah Morris

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  1. Martin E. Franklin
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Correspondence to Martin E. Franklin .

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  1. Neurology, Learning and Behavior Center, Salt Lake City, Utah, USA

    Sam Goldstein

  2. Intermountain Healthcare, Salt Lake City, Utah, USA

    Melissa DeVries

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Franklin, M.E., Morris, S. (2017). Trichotillomania. In: Goldstein, S., DeVries, M. (eds) Handbook of DSM-5 Disorders in Children and Adolescents. Springer, Cham. https://doi.org/10.1007/978-3-319-57196-6_12

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