Psychopharmacology Perspectives
Trichotillomania Across the Life Span

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Key Points

  • No randomized clinical trials have been conducted in children with trichotillomania. Research examining the clinical course and natural history of childhood-onset trichotillomania is equally sparse.

  • Behavioral treatments such as habit reversal therapy have demonstrated efficacy in the treatment of adults with trichotillomania. Large uncontrolled trials have suggested similar efficacy of behavioral therapies in children.

  • Several double-blind, randomized, clinical trials have demonstrated that

Hair-Pulling in Preschool Children

Although epidemiological, treatment, and longitudinal follow-up studies are lacking in younger children, experts have hypothesized that hair-pulling in preschool-aged children (0–6 years) is a separate entity and has a distinct natural course compared with TTM that occurs in older children and adults.5 Hair pulling in preschool children is often accompanied by comorbid habit disorders, such as scratching, skin-picking, and thumb-sucking, and commonly occurs around bed or nap times. Complete

Assessment

Table 2 provides a mnemonic device to help remember the essential elements in a diagnostic assessment of TTM. A proper assessment in childhood TTM includes getting a detailed history of hair-pulling. This involves having the child or the parents recount the first instance in which pulling occurred as well as their current pulling behaviors. When discussing hair-pulling behaviors, it is important to discuss antecedent cognitions, behaviors and feelings before pulling, the settings in which the

Behavioral Treatments

Habit reversal therapy (HRT) is a behavioral therapy designed originally in the 1960s for the treatment of TTM and tics. Habit reversal therapy is a manual-based behavioral technique that is administered over a period of 2 to 3 months with an additional maintenance period for relapse prevention. Habit reversal therapy involves several different components, including self-monitoring, awareness training, stimulus control, and competing response training. The self-monitoring component of HRT

Pharmacological Treatments

Initial case reports and uncontrolled trials suggest the possible efficacy of selective-serotonin reuptake inhibitors (SSRIs) in the treatment of adults with TTM. However, three subsequent double-blind, placebo-controlled trials of adults with TTM have demonstrated no efficacy of SSRIs.2 Because TTM symptoms are known to wax and wane in severity, TTM patients often present to psychiatric attention when their symptoms are at the worst and psychoeducation can help alleviate some of the

Discussion

Trichotillomania can cause significant social, academic, and medical consequences in affected children. Psychoeducational material for patients and clinicians, patient support groups, and referrals to experienced clinicians can be found through the Trichotillomania Learning Center (www.trich.org). Behavioral therapies have shown great efficacy in the treatment of adults with TTM and in uncontrolled trials with children. Randomized controlled trials of behavioral interventions for childhood TTM

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References (9)

  • MH Bloch et al.

    Systematic review: pharmacological and behavioral treatment for trichotillomania

    Biol Psychiatry

    (2007)
  • GA Christenson et al.

    Characteristics of 60 adult chronic hair pullers

    Am J Psychiatry

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  • DW Woods et al.

    The Trichotillomania Impact Project (TIP): exploring phenomenology, functional impairment, and treatment utilization

    J Clin Psychiatry

    (2006)
  • ME Franklin et al.

    The Child and Adolescent Trichotillomania Impact Project: descriptive psychopathology, comorbidity, functional impairment, and treatment utilization

    J Dev Behav Pediatr

    (2008)
There are more references available in the full text version of this article.

Cited by (33)

  • Prevalence and gender distribution of trichotillomania: A systematic review and meta-analysis

    2022, Journal of Psychiatric Research
    Citation Excerpt :

    Trichotillomania (TTM, or hair-pulling disorder) is a psychiatric condition characterized by repeated pulling out of one's hair leading to noticeable hair loss and associated impairment/distress despite attempts to decrease or stop pulling (Grant and Chamberlain, 2016; Woods and Houghton, 2014). TTM usually onsets in adolescence and presents with a chronic course of waxing-and-waning symptom severity throughout the lifetime (Bloch, 2009). Individuals with TTM often feel ashamed of their appearance and hair-pulling behavior, which may lead to avoidance of personal relationships, social activities, job interviews or school/university classes (Woods et al., 2006).

  • The prevalence and clinical correlates of body-focused repetitive behaviors in pediatric Tourette Syndrome

    2019, Journal of Obsessive-Compulsive and Related Disorders
    Citation Excerpt :

    As well, the characteristics of the premonitory urges and sensations that often precede tic and BFRB performance are also very similar. Additionally, habit reversal training is considered to be the first-line treatment for both tics and BFRBs (Ganos et al., 2013; Grant et al., 2012; Greer & Capecchi, 2002; Hayes et al., 2009; Kratochvil, 2009). Both TS and BFRBs can be conceptualized by dysregulated habit formation and the impaired inhibition of motor responses to a sensory urge; as such, developing a better understanding of the relationship between them may help elucidate their underlying pathophysiological mechanisms and guide future studies.

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Psychopharmacology Perspectives aims to discuss practical approaches to everyday issues in pediatric pharmacotherapy. The discussions may address aspects of clinical care related to psychopharmacology for which we do not have adequate applicable controlled trials. Given the need to address symptoms in youths with often complex, severe, and comorbid disorders, recommendations are likely to be off-label from the perspective of the U.S. Food and Drug Administration. We fully appreciate that for virtually all disorders, medication is only one aspect of comprehensive care. This column focuses primarily on psychopharmacological management. Although it is important that clinicians address psychosocial issues in the evaluation and treatment of their patients, such discussion is beyond the specific scope of this feature. These are not meant to be practice guidelines, but rather examples of the thought process that may go into pharmacotherapy decision making.

This article was reviewed under and accepted by Deputy Editor John T. Walkup, M.D.

The author thanks the National Institute of Mental Health support of the Yale Child Study Center Research Training Program, the National Institute of Health Loan Repayment Program, and the APIRE/Eli Lilly Psychiatric Research Fellowship. The author also thanks Kaitlyn E. Panza, B.A., for help in revising this article.

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