Comparison of clinical characteristics in trichotillomania and obsessive-compulsive disorder

Fifteen patients with trichotillomania (TM) and 25 patients with obsessive-compulsive disorder (OCD) were studied. All patients were evaluated using the structured clinical interview for DSM-III-R (SCID-P). TM and OCD patients were compared with respect to demographic variables and the scores obtained from the various scales. The TM group had a greater percentage of women and showed an earlier age at onset. There was no significant difference for depression and anxiety assessed with the STAI, HRSA, and HRSD between the groups. Compared to OCD patients, TM patients had significantly lower scores on the Y-BOCS. The two groups were similar on the measures of resistance to and control of the hair pulling/compulsive symptoms. We found significantly higher incidence of anxiety and depressive disorders, and Axis II personality disorders for OCD patients. These findings are discussed in the view of results from earlier reports.     

Clinical characteristics and psychiatric comorbidity in children with trichotillomania.

Ten children with trichotillomania (hair pulling) were systematically evaluated with structured psychiatric interviews and rating scales assessing anxiety, depression, life events, self-esteem, and family functioning. Six of the subjects met diagnostic criteria for overanxious disorder on the Diagnostic Interview for Children and Adolescents--Revised--Child or Adolescent Version and/or Diagnostic Interview for Children and Adolescents--Revised--Parent Version. Two met the criteria for dysthymia, including one of the subjects with overanxious disorder. No children reported associated obsessions or compulsions. Only one subject experienced tension before hair pulling and relief associated with hair pulling. The DSM-III-R criteria for trichotillomania, which currently require an increasing sense of tension before hair pulling and gratification with hair pulling, may be overly restrictive and in need of redefinition. Additional research with increased sample size is necessary to define diagnostic criteria for trichotillomania and clarify its relationship with other psychiatric diagnoses.     

Clinical characteristics of trichotillomania with trichophagia

Objective

Little is known about trichophagia in individuals with trichotillomania. Although studies have mentioned the behavior, no previous studies have examined clinical correlates of trichophagia.

Method

We examined the clinical correlates of trichophagia in 68 subjects with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, trichotillomania (85.3% females; mean age, 35.0 ± 12.5). Comorbidity data were obtained with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Trichotillomania severity was assessed with the Psychiatric Institute Trichotillomania Scale and the Massachusetts General Hospital Hairpulling Scale. Social/occupational functioning was examined using the Sheehan Disability Scale. All variables were compared in trichotillomania subjects with and without trichophagia.

Results

Of the 68 subjects with trichotillomania, 14 (20.6%; 95% confidence interval, 12.7%-31.6%) reported current trichophagia, and an additional 9 (13.2%) ate their hair or the root episodically. There were far more similarities than differences in trichotillomania subjects with current trichophagia and those without, although those with trichophagia were significantly more likely to be male (P = .013) and have more severe trichotillomania (according to the Massachusetts General Hospital Hairpulling Scale) (P = .010).

Conclusions

These preliminary results suggest that trichophagia is not uncommon in individuals with trichophagia. Subjects with and without trichophagia were similar in most domains that were examined.     

Clinical characteristics of trichotillomania and its response to fluoxetine.

BACKGROUND: In general, effective treatments for trichotillomania have been elusive. Although behavioral therapies and hypnosis have provided benefits to some, adult patients with chronic hair pulling have often proved refractory to treatment. Medication has generally been unhelpful until the recent introduction of serotonin reuptake inhibitors for the treatment of this condition. Furthermore, there has been little systematic study of the clinical characteristics of these patients. METHOD: Twenty individuals with trichotillomania were interviewed and were characterized on the basis of hair-pulling patterns, comorbidity, obsessionality, and the presence of symptoms of depression and anxiety. Twelve patients participated in an open 16-week trial of fluoxetine (up to 80 mg/day). RESULTS: Compared with baseline scores derived from a scale of trichotillomania severity, severity scores at endpoint decreased (improved) by 34% (p less than .025). Among the 8 responders, the mean decrease in severity scores was 60%. Fifty-five percent (11 of 20) had current or past additional DSM-III-R Axis I diagnoses (disorders of mood, anxiety, and psychoactive substance use). CONCLUSION: We conclude that in an open 16-week trial, patients treated with fluoxetine improved significantly. Data are presented on comorbid conditions, depressive symptoms, and anxiety. Baseline behavioral assessments of patients with trichotillomania suggest that substantial differences exist between this syndrome and obsessive compulsive disorder.     

Personality disorder diagnoses in patients with bulimia nervosa: clinical correlates and changes with treatment.

BACKGROUND: In view of reports of a high incidence of Axis II disorders among patients with bulimia nervosa, we assessed personality diagnoses and traits in a sample of bulimic patients both preceding and following treatment for the eating disorder. METHOD: The Personality Disorder Examination, a structured interview to assess DSM-III-R personality disorders, was administered to 34 in-patients and 49 outpatients with bulimia nervosa entering treatment. Thirty of 49 outpatients were reassessed after 6 weeks of treatment with desipramine or placebo. RESULTS: At initial assessment, 38% of inpatients (N = 13) and 29% of outpatients (N = 14) fulfilled criteria for at least one personality disorder, most frequently borderline personality disorder. There were significant correlations between Personality Disorder Examination trait scores and clinical measures of eating disorder and depressive symptoms. Of 30 outpatients who were reinterviewed following treatment, 3 of 9 patients lost one or more personality diagnoses at post-treatment assessment, and 2 of 21 patients without initial Personality Disorder Examination diagnoses received one or more diagnoses at the second interview. Changes in Personality Disorder Examination trait scores, but not diagnoses, were correlated with changes in some clinical measures. CONCLUSION: These data suggest that the assessment of Axis II disorders in patients with bulimia nervosa is problematic and raise the possibility that personality features in this group may be influenced by the course of their Axis I disorder.     

Opiate sensitivity test in patients with stereotypic movement disorder and trichotillomania

Preliminary data about the therapeutic effect of opiate receptor manipulation in self-injurious behavior (SIB) suggest that endogenous opioid mechanisms may have a pathophysiological role in that condition and their involvement may be dependent on the severity of the SIB. The aim of this study was to use fentanyl-induced prolactin response as an opiate receptor sensitivity test in patients with stereotypic movement disorder (SMD) manifesting SIB (skin picking). Healthy volunteers and trichotillomanic patients were enrolled as comparison subjects. Individuals with trichotillomania (TTM) manifest repetitive, less serious self-mutilation (hair pulling) and are classified under different DSM-IV category than SMD. Therefore, they were considered as patient controls. Ten healthy subjects received 0.05 mg/70 kg and another 10 were given 0.1 mg/70 kg dose of fentanyl intravenously in the AM hours. Five of them had placebo trials. A dose of 0.05 mg/70 kg fentanyl was administered to patients with SMD (n = 10) and TTM (n = 12). Serial blood sampling was performed for prolactin measurements. Fentanyl elevated plasma prolactin in a dose-dependent manner. Patients with skin picking, but not with hair pulling, showed significantly increased responses. This finding supports the involvement of endogenous opioids in the pathomechanism of serious SIB.     

Longitudinal follow-up of naturalistic treatment outcome in patients with trichotillomania

BACKGROUND: Little is known about the longitudinal course of treatment outcome in patients with trichotillomania. The authors conducted a second follow-up assessment on a cohort of hair pullers previously studied. METHOD: Forty-four subjects completed a hair-pulling questionnaire and paper-and-pencil measures of hair-pulling severity and impact, psychosocial functioning, depression, anxiety, and self-esteem. Mean time elapsed between the first and second follow-up assessment was 2.5 years (index evaluation to first follow-up = 3.5 years). RESULTS: Twenty-seven subjects (61.4%) had active treatment since the first follow-up. No significant changes in hair pulling, depression, anxiety, or psychosocial functioning were reported from first to second follow-up. Self-esteem scores significantly worsened during this period (p = .000). A trend toward worsening also existed for psychosocial impact scores. Comparison of scores at index evaluation with second follow-up still showed significant improvement over time for hair pulling (p = .001) but significant worsening in self-esteem (p = .000). Treatment and responder status were unrelated to clinical functioning, with the exception of depression and psychosocial impact. CONCLUSION: Although hair pullers exhibit initial improvement with treatment, scale scores plateau or worsen by second follow-up. Significant worsening in self-esteem at second follow-up may be related to the absence of further improvements in hair-pulling severity. Future research should focus on the interrelationships among self-esteem, depression, and hair pulling during treatment for this disorder.     

Characterization of trichotillomania. A phenomenological model with clinical relevance to obsessive-compulsive spectrum disorders.

Multiple approaches to characterization of TTM have been developed, including categoric definitions and dimensional considerations. When TTM is viewed in the context of other disorders with common comorbidities and overlapping similar phenomenologies, such as OCD, body dysmorphic disorder, skin picking, TS, and olfactory reference syndrome, clinical approaches to assessment and differential diagnosis are more complex. This article presents a general overview of TTM included as a background for a heuristic clinical framework for assessing obsessive-compulsive spectrum disorders. A comprehensive behavioral model of TTM as a template is presented in the context of a broader, phenomenologic approach to assessment of several other disorders. These additional conditions were chosen on clinical grounds because they seem to share some phenomenologic characteristics with TTM. It is hoped that combining a phenomenologic approach to the differentiation of repetitive behaviors (as has been valuable in advancing the understanding of repetitive behaviors in TS and OCD), coupled with a paradigmatic comprehensive behavioral assessment and treatment model of TTM, may foster the validation of such approaches for other putative obsessive-compulsive spectrum disorders. Also, the relative intensity and frequency ascribed to the various behavioral and phenomenologic components of the conditions depicted represent clinical impressions, with varying degrees of empiric support, and require objective validation. This approach is meant to serve as a point of departure for clinical assessment of these complex, interesting, and sometimes incompletely diagnosed and inadequately treated conditions. It is hoped that empiric validation or refutation of this conceptualization will stimulate additional research and provide clinicians with a general framework for assessing patients suffering from these difficult conditions. For more information about trichotillomania, contact The Trichotillomania Learning Center (TLC), 1215 Mission Street, Santa Cruz, CA 95060 (831-457-1004; www.trich.org).     

Impulsivity and compulsivity in patients with trichotillomania or skin picking compared with patients with obsessive-compulsive disorder

To compare impulsivity and compulsivity, we performed a case control study comparing a group of 20 patients with obsessive-compulsive disorder with a group of 20 patients with skin picking and/or trichotillomania (SP/T). The instruments used were Structured Clinical Interview for DSM-IV Axis I Diagnosis, Yale-Brown Obsessive-Compulsive Scale, Schalling Impulsivity Scale, and Hamilton Anxiety and Depression Inventories. A Multidimensional Impulsive-Compulsive Spectrum Assessment Instrument was designed for this particular study. The Yale-Brown Obsessive-Compulsive Scale scores were significantly higher in patients with obsessive-compulsive disorder, compared with patients with SP/T (F = 90.29; P < .001). The Hamilton Inventories and Schalling Impulsivity Scale revealed no significant intergroup differences. The Multidimensional Impulsive-Compulsive Spectrum Assessment Instrument allowed us to find 6 statistically significant differences between groups: the ability or inability to delay an impulse, quick response or action planning, feelings of pleasure or guilt during or after an act, ritualization, and whether the patient believes he/she has losses or benefits if prevented from acting. In conclusion, SP/T should deserve further attention about their classification in future versions of diagnostic manuals because, as in International Classification of Diseases, Tenth Revision, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition includes these disorders in the same chapter as pathological gambling, kleptomania, pyromania and others. Despite their resemblance to compulsions, their classification under the Obsessive-Compulsive Spectrum needs particular phenomenological and neurobiologic investigation.     

Personality characteristics and sleep variables.

In a sleep study of 14 normal healthy adults an investigation was made of sleep measurements of a baseline record for its eventual relationship to the percentage of increase of REM percentage of the 1st recovery night following partial differential REM deprivation (PDRD), as well as to personality characteristics. The percentage of change in NREM sleep of the 1st recovery night was compared with the baseline record andthen compared with corresponding values of REM sleep. The results are summarized as follows. No significant correlation exists between the percentage of increase in the REM percentage of the 1st recovery night and sleep measures of the baseline record. An investigation of the relationship between sleep measures of the baseline record and personality characteristics revealed that stage SWS(%) was significantly greater in the introvert than in the extrovert, in the neurotic than in the non-neurotic, and in the nervous than in the optimistic. Comparison of the changes in NREM and REM sleep percentages of the 1st recovery night with the baseline record was made between paired personality characteristics. A significantly high percentage of increase in REM percentage was almost always associated with a significantly high percentage of decrease in stage 2 percentage. From these results it was inferred that an increase in REM percentage occurs at the expense of stage 2 percentage.     

Hypnotherapy in adolescents with trichotillomania: three cases.

Trichotillomania is not rare in adolescence. Psychotherapy is often ineffective, and cognitive behavioral therapy in combination with serotonin-specific reuptake inhibitors seems to be the treatment of choice. Some cases are resistant to all therapy. This paper reports on three adolescents with pure trichotillomania who responded to the imaginative hypnotherapy technique with Ericksonian suggestions. The patients described their hair as weak and vulnerable and needy of protection. In therapy, the patient was assigned the role of "patron of the hair" thereby giving him/her control of the situation. Hair pulling was significantly reduced, and the improvement was sustained throughout the 6-month follow-up. These cases suggest that imaginative techniques may be effective in adolescents with trichotillomania. Further controlled studies in adolescent population are needed to confirm this assumption.     

Behavioral treatment of children and adolescents with trichotillomania.

Trichotillomania is a behavior disorder with onset generally in childhood, characterized by repetitive, compulsive pulling out of hair from the scalp, eyebrows, or other parts of the body, often leading to disfigurement. Trichotillomania tends to be persistent and is often resistant to counselling and standard psychiatric care. A systematic behavioral treatment program for children and adolescents and pilot findings with three patients are described. Methodological issues in relation to compliance and assessment are discussed. The relative safety and potential effectiveness of behavioral techniques suggest a useful role for this approach, perhaps in conjunction with pharmacological, family, and other treatment modalities.     

Personality and background characteristics of suicidal mental patients

The present study has compared the personality traits and background characteristics of 30 psychiatric patients admitted to a State hospital subsequent to a suicide attempt with a group of nonsuicidal psychiatric patients. The two groups were matched on sex, age, race and marital status. All patients completed a form designed to elicit data on various demographic, clinical, and past history variables. They also completed a personality instrument designed to evaluate the relative importance in the life of an individual of eight basic emotions. The suicidal patients scored considerably higher on feelings of depression and aggression and lower on feelings of fear. Other variables such as the following also differentiated between the two groups: more suicidal patients were only children, raised by their mothers alone; a large number of the suicidal group reported regular usage of such drugs as marajuana and heroin, whereas none of the nonsuicidals so reported; the suicidals more frequently reported recent losses; and there were more schizophrenics in the nonsuicidal group. Implications for the timing of discharge and follow-up care were discussed.     

Personality characteristics of exhibitionists.

Forty-one exhibitionists were examined clinically and thirty-four psychometrically. The data does not support any definitive character type or evidence of severe pathology. If specific reference to their symptom of exhibiting is omitted they do not appear to be strikingly abnormal. Exhibiting was viewed as a unique way of expressing unconscious aggressive strivings, without provoking the retaliatory response that more direct aggression might stimulate.     

Personality characteristics and affective status related to cognitive test performance and gender in patients with memory complaints.

The aims are to study personality characteristics of patients with memory complaints and to assess the presence of objective (OMI) versus subjective (SMI) memory impairment, the affective status, as well as potential gender differences. The patients were assessed by means of a neuropsychiatric examination and a neuropsychological test-battery. The Swedish version of the revised NEO Personality Inventory (NEO PI-R) and the Hospital Anxiety and Depression Scale (HADS) were used. The 57 patients (38 women, 19 men, mean age 56.9) differed from the Swedish normative group in three of the five personality factors: neuroticism, extraversion and agreeableness. This was mainly because of the scores of the female patients. Approximately half of the patients had OMI. No differences regarding personality factors or affective status were found between OMI and SMI patients. The female patients scored significantly higher than the male patients on symptoms of anxiety and depression. Neuroticism and symptoms of depression interacted with memory performance and gender. Our findings demonstrate the importance of applying an objective assessment of memory functions and a gender perspective when studying patients with memory complaints.     

Personality traits and smoking in patients with obsessive-compulsive disorder.

As opposed to other psychiatric populations, subjects with obsessive-compulsive disorder (OCD) smoke less than the general population. The present study aims at further investigating the relationship between smoking in OCD subjects and personality traits. Sixty-four subjects with OCD were interviewed concerning their smoking habits. Personality traits were evaluated using the Karolinska Scales of Personality, and specific obsessive-compulsive personality traits were elicited through self-report questionnaires. Non-smokers were more easily fatigued, more inclined to worry, more remorseful, less self-confident, less impulsive and became uneasy more frequently when urged to speed up, than smokers with OCD. Additionally, non-smokers fulfilled significantly more obsessive-compulsive personality disorder criteria as compared to the smokers (P < 0.001). We propose a clinical subtype of OCD related to non-smoking, psychasthenia, anxiety, and pronounced obsessive-compulsive personality disorder traits.     

Muscle biopsy, macro EMG, and clinical characteristics in patients with schizophrenia.

BACKGROUND: In a previous study of motor unit properties in patients with schizophrenia, muscle fiber histologic and electrophysiologic abnormalities were observed. The present study was designed to compare patients with schizophrenia with healthy control subjects with regard to muscle fiber histology and motor unit function. A second objective was to relate these variables to clinical characteristics. METHODS: Twelve patients with first-episode schizophrenia and fifteen patients with chronic schizophrenia (DSM-III-R) and 27 matched control subjects were included in the study. Muscle biopsies were performed either in m. tibialis anterior or m. vastus lateralis. Electromyographic recordings (macro EMG) were made from the m. tibialis anterior motor units. Psychiatric ratings included the PANSS and extrapyramidal side effects. RESULTS: Seven of the muscle biopsy specimens from the patients and one from the control subjects were classified as abnormal (p =.049). The most frequent abnormality was atrophic muscle fibers. Eight patients and no control subjects exhibited pathological macro EMG (p =.032). The findings were present in chronic as well as in first-episode patients with schizophrenia. CONCLUSIONS: In approximately 50% of the patients, neuromuscular abnormalities were found either in the muscle biopsy or the macro EMG investigations.The results indicate that either a common pathologic process or different pathological processes are at hand in the neuromuscular system in patients with schizophrenia. The findings are compatible with a disturbed cell membrane function.