Severe obsessive-compulsive disorder with and without comorbid hair pulling: comparisons and clinical implications

OBJECTIVE: Chronic hair pulling and trichotillomania are putative obsessive-compulsive spectrum disorders. This study determined the prevalence of hair pulling in an inpatient obsessive-compulsive disorder (OCD) population and compared clinical characteristics and treatment response between subgroups with and without comorbid hair pulling. METHOD: Patients with severe DSM-IV-diagnosed OCD (N = 154) who were consecutively admitted to an OCD residential treatment facility between August 2000 and July 2003 were included. Clinician-rated (Yale-Brown Obsessive Compulsive Scale) and patient-rated (Massachusetts General Hospital Hairpulling Scale, Beck Depression Inventory, and Posttraumatic Diagnostic Scale) measures were administered at index evaluation. OCD patients with and without moderate to severe hair pulling were statistically compared on clinical and treatment characteristics and treatment response. RESULTS: Of the OCD subjects, 18.8% (N = 29) endorsed any hair pulling, 15.6% (N = 24) had moderate to severe hair pulling, and 7.8% (N = 12) had severe hair pulling comparable to that of a specialty trichotillomania clinic population. OCD patients with moderate to severe hair pulling were more likely to be women (p < .001), endorse > 1 comorbid tic (p < .05), and have earlier-onset OCD (p = .001). This cohort also had fewer contamination obsessions (p = .04) and checking compulsions (p = .04) and was more likely to be receiving stimulant (p = .006) or venlafaxine (p = .02) medication than those patients without hair pulling. Posttraumatic Diagnostic Scale scores were nearly significantly higher in the OCD + hair pulling group (p = .08). OCD treatment response was unaffected by the presence of comorbid hair pulling. CONCLUSION: Hair pulling is a highly common comorbidity in severe OCD. Women and early-onset OCD patients appear to be more vulnerable to comorbid hair pulling. OCD sufferers with comorbid hair pulling also exhibit an increased risk for tics and may present with different OCD symptomatology.     

Hypnosis as a vehicle for choice and self-agency in the treatment of children with Trichotillomania

Three pediatric cases of Trichotillomania were treated with direct hypnotic suggestion with exclusive emphasis on sensitizing and alerting the patients to impending scalp hair pulling behaviors. These children had presented with total lack of awareness of their scalp hair pulling behaviors until they had actually twisted and pulled off clumps of hair. It was also suggested, under hypnosis, that upon learning to recognize impending scalp hair pulling behaviors, the patients would become free to choose to willfully pull their hair or to resist the impulse and not pull. At no point was the explicit suggestion given that they stop pulling their hair. A preliminary condition was agreed to by the parents that redefined the patients' hair as their own property and affirmed their sole responsibility for its care and maintenance. An element of secondary gain was identified in each of these cases. Scalp hair pulling was hypothesized to provide these particular patients with a vehicle with which to oppose their overbearing and over-involved parents. The technique of direct suggestion under hypnosis, aimed at alerting the patients to impending scalp hair pulling behaviors was combined with forming contracts with the parents to relinquish their authority over matters regarding the patients' hair. This combination provided an effective treatment that extinguished the scalp hair pulling in 7 visits or less. These cases received follow-up at intervals up to 6 months and no evidence of relapse was found.     

Trichotillomania associated with dementia: a case report.

Trichotillomania represents a syndrome of hair pulling in which patients compulsively and ritualistically pluck their hair in response to a sense of tension or urgency. This report documents a case of hair pulling associated with dementia. Neuropsychological testing demonstrated the deficits to be localized predominantly to the frontal lobe dysfunction.     

Treatment of obsessive-compulsive hair pulling (Trichotillomania) by behavioral and cognitive contingency manipulation

A case of trichotillomania of 11 yr duration in a 21-yr-old female was successfully treated using contingency management for both hair pulling behavior and the urge to pull hair. During treatment of approximately two months, the hair pulling behavior was associated with a mild aversive procedure and her awareness of the urge to pull hair was used as a cue to initiate hair grooming. She remains essentially symptom free of hair pulling and has a markedly reduced awareness of urges to pull her hair at 7-months follow-up.     

The Trichotillomania Impact Project in Young Children (TIP-YC): Clinical Characteristics,Comorbidity, Functional Impairment and Treatment Utilization

The aim was to investigate clinical characteristics of young children with a hair pulling problem. Parents/caregivers of young children (0–10 years old) with a hair pulling problem (N = 110) completed an online survey. The majority reported that their child experienced mild to moderate impairment/distress due to hair pulling, and overall clinical characteristics were similar to adult samples, although some differences were noted (e.g., less awareness of pulling). We also compared preschool-aged and school-aged children within the sample. Symptom severity, pleasure during pulling and gender ratio remained stable across the age groups. The preschool-aged children demonstrated less impairment/distress, comorbidity, and treatment seeking; pulled from fewer body areas; and were less likely to be aware of the act or experience tension prior to pulling. In conclusion, clinical characteristics of childhood hair pulling are largely similar to adult/adolescent hair pulling problems, but there are some notable differences, particularly among pre-school aged children.     

Lithium and hair texture

Patients receiving lithium who had noticed changes in hair texture since starting that drug, described variously as hair losing its curl or wave, have a greater lithium concentration in hair than patients on lithium with no such complaints.     

A comparison of relaxation training and competing response training to eliminate hair pulling and nail biting

A 17-year-old female with a 14-year history of hair pulling and nail biting was treated with relaxation training and competing response training. While introduction of relaxation training produced an initial decline in hair pulling, there was a gradual recovery of the maladaptive behavior to baseline levels. The competing response procedure consisted of clenching fists for 3 min whenever hair pulling or nail biting occurred or were likely to occur. By the use of the competing response hair pulling and nail biting decreased, eventually to zero. Follow-up over a 2-year period revealed that the treatment effects were maintained.     

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.     

Treatment of early onset hair pulling as a simple habit

The authors evaluated the effects of response prevention, a treatment previously shown to be effective for routine thumb sucking and suggested to be effective for early onset trichotillomania, applied to hair pulling in a 2-year-old. Response prevention was used alone in two settings (bedtime and naptime) and combined with a brief time out in another (daytime). The authors also used a novel assessment, weight of hairs pulled, and the results indicated complete cessation of hair pulling. Corresponding photographic evidence indicated complete regrowth of hair lost to pulling. These results add to a growing literature suggesting early onset hair pulling may be more appropriately classified as a benign habit than as trichotillomania.     

Pilot trial of dialectical behavior therapy‐enhanced habit reversal for trichotillomania

Background: Not all hair pullers improve acutely with cognitive–behavioral treatment (CBT) and few maintain their gains over time. Methods: We conducted an open clinical trial of a new treatment that addresses affectively triggered pulling and emphasizes relapse prevention in addition to standard CBT approaches. Ten female participants satisfying DSM‐IV criteria for trichotillomania (TTM) at two study sites received Dialectical Behavior Therapy (DBT)‐enhanced CBT consisting of 11 weekly sessions and 4 maintenance sessions over the following 3 months. Independent assessors rated hair pulling impairment and global improvement at several study time points. Participants completed self‐report measures of hair pulling severity and emotion regulation. Results: Significant improvement in hair pulling severity and emotion regulation, as well as hair pulling impairment and anxiety and depressive symptoms, occurred during acute treatment and were maintained during the subsequent 3 months. Significant correlations were reported between changes in emotion regulation and hair pulling severity during both the acute treatment and maintenance phases. Conclusions: This study offers preliminary evidence for the efficacy of DBT‐enhanced CBT for TTM and suggests the importance of addressing emotion regulation during TTM treatment. Depression and Anxiety, 2010. © 2010 Wiley‐Liss, Inc.     

Hair pulling and its affective correlates in an African-American university sample

Like other clinical phenomena, repetitive hair pulling in African-Americans has attracted little systematic investigation. Slightly over 200 participants were recruited from a historically black university. Participants completed the Hair Pulling Scale [Stanley, M. A., Borden, J. W., Bell, G. E., & Wagner, A. L. (1994). Nonclinical hair pulling: phenomenology and related psychopathology. Journal of Anxiety Disorders, 8, 119-130], the Beck Depression Inventory, and the Beck Anxiety Inventory (BAI). Ten percent of the African-American sample thought about pulling out hair and 6.3% actually pulled out hair. A variety of types of affect was reported before, during, and after pulling or picking. Several statistically significant relationships were found: status as a person who thinks about pulling out hair is significantly correlated with anxiety as measured by the BAI (r=.265, p=.000), status as a person who pulls hair is significantly correlated with anxiety as measured by the BAI (p=.192, r=.007). Implications are discussed.     

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.     

The use of operant self-control procedures in the treatment of compulsive hair-pulling

Two young female patients with a 10-and 5-year history of compulsive hair pulling were individually treated by the same operant self-control procedure. Zero pulling was achieved at weeks 6 and 13, and maintained at follow-up 15 months later. These findings are discussed in the light of previous behavioural treatments, and the importance of eliciting an appropriate aversive consequence for habit control is stressed.     

Behavioral treatment of chronic hair pulling in a two year old

Chronic hair pulling, exhibited by a 27 month-old boy was ameliorated in a 15-week treatment. The methodology focused on teaching the parents to apply a specific combination of differential reinforcement and response-chain interruption procedures. Follow-ups at 6 and 12 months revealed neither the recurrence of hair pulling nor the appearance of other problematic behaviors.     

Is it trichotillomania? Hair pulling in childhood: a developmental perspective

A cohort of children with hair pulling as the presenting symptom was followed up to enhance clinical understanding of the nature of hair-pulling behaviour in childhood. Thirty-eight children were clinically assessed for a diagnosis of trichotillomania, co-morbidity, co-existing habits and other relevant factors. Intervention consisted of a combination of behavioural strategies, self-esteem work, supportive family approaches, attachment-focused parenting models and medication. In this group of children it was difficult to define their symptoms as a clinical diagnosis of trichotillomania, using ICD-1O/DSM-IV. This article concludes that hair pulling, as a symptom in children, is a heterogeneous condition. It is useful to approach this issue from a developmental perspective. Our data warrant reappraisal of the diagnosis of trichotillomania in childhood. We explore the framework of a developmental continuum to understand and manage the problem of hair pulling in childhood.     

Trichotillomania and related disorders in children and adolescents

Eleven chronic hair pullers, 11 subjects with obsessive-compulsive disorder (OCD), and 11 subjects with a non-OCD anxiety disorder were assessed with structured interviews and the Child Behavior Checklist (CBCL). Only 4 hair pullers (36%) reported both rising tension and relief with hair pulling. Each group had significantly more internalizing than externalizing symptoms on the CBCL. Seven hair pullers (64%) had a lifetime history of at least one other axis I diagnosis. The results provide further evidence that trichotillomania in referred children and adolescents is usually a chronic disorder often associated with internalizing symptoms and psychiatric comorbidity. Rising tension followed by relief with hair pulling may be an unnecessary restriction in the diagnosis of childhood trichotillomania.     

Alopecia and mood stabilizers: Two case reports

Two cases of alopecia observed during treatment with lithium and valproate are described, and the recent literature on this subject is reviewed. Our clinical observations confirm earlier reports. These toxic alopecias are characterized by a diffuse but rarely total hair loss. After stopping medication, the hair grows back generally and completely. Two cases of toxic alopecia are presented where hair grew back following a substitution of lithium by valproate in the first case and after stopping valproate in the second. The evaluation and therapeutic attitude in the presence of alopecia in patients needing mood stabilizers are also discussed.     

Positive reinforcement and punishment in the treatment of childhood trichotillomania

A comprehensive behavioral treatment package was developed during 13 treatment sessions and was communicated to a mother of a five year old girl with a four year history of hair pulling which had resulted in almost total baldness. Treatment consisted of a variety of positive reinforcement procedures which resulted in a gradual decrease in the hair pulling behavior, and finally the use of punishment which led to a rapid decrease and virtual elimination of the problem. The child was symptom free with shoulder length hair at a 16 month follow-up. The growing literature on behavioral treatment of trichotillomania and the ethical implications of the use of punishment are reviewed.     

Childhood trichotillomania treated indirectly by punishing thumb sucking

Trichotillomania was treated in a developmentally normal three-year-old by punishing thumb sucking. A behavioral analysis indicated a chain of behaviors that began with hair pulling and terminated in thumb sucking. The parents punished the thumb sucking by applying a bad tasting substance to the thumb. Both hair pulling and thumb sucking were rapidly eliminated. The child remained symptom free at 40 month follow-up. This study represents the third time trichotillomania has been treated in a preschooler indirectly by targeting finger sucking as the behavior to change. The significance of treating trichotillomania indirectly is discussed.