Systematic review: pharmacological and behavioral treatment for trichotillomania.

Trichotillomania is a psychiatric condition characterized by compulsive hair pulling. Three interventions have been studied in the treatment of trichotillomania: habit-reversal therapy (HRT) and pharmacotherapy with either selective-serotonin reuptake inhibitors (SSRI) or clomipramine. This systematic review compared the efficacy of these interventions in blinded, randomized clinical trials. The electronic databases of Medline, Premedline, PsychINFO, Embase, and the Cochrane Central Register of Controlled Trials were searched for relevant trials using the search terms "trichotillomania" or "hair pulling." Trials were eligible for inclusion if they compared habit-reversal therapy, SSRI pharmacotherapy, or clomipramine pharmacotherapy to each other or placebo and employed randomization and blinded assessment of outcome. Our primary outcome measure was mean change in trichotillomania severity. The summary statistic was standardized mean difference. Seven studies were eligible for inclusion in this review. Overall, meta-analysis demonstrated that habit-reversal therapy (effect size [ES] = -1.14, 95% confidence interval [CI] = -1.89, -.38) was superior to pharmacotherapy with clomipramine (ES = -.68, 95% CI = -1.28, -.07) or SSRI (ES = .02, 95% CI = -.32, .35). Clomipramine was more efficacious than placebo, while there was no evidence to demonstrate that SSRI are more efficacious than placebo in the treatment of trichotillomania. Future studies on trichotillomania should seek to determine if HRT can demonstrate efficacy against more rigorous control conditions that account for non-specific effects of therapy and determine if HRT can be an effective intervention for trichotillomania beyond the few sites where it is currently practiced in research studies. Future therapy and pharmacotherapy studies in trichotillomania should employ larger sample sizes and intention-to-treat analysis and seek to validate clinical rating scales of trichotillomania severity.     

Multifaceted behavioral intervention for nocturnal enuresis

A ten-year-old girl, who had a lifetime history of nocturnal enuresis, was treated successfully by a multifaceted behavioral intervention. Treatment included a combination of conditioning, a modification of overlearning and token reinforcement. Previous conditioning alone, psychiatric treatment and medication had been ineffective.     

Behavioral plus pharmacological treatment versus pharmacological treatment only for chronic migraine with medication overuse after day-hospital withdrawal

Chronic migraine with medication overuse is a difficult problem to manage. Different withdrawal approaches have been tried, with different results. Withdrawal in a day-hospital setting is a recent modality. Results obtained from this last approach have been encouraging. Behavioral techniques combined with pharmacological therapies are effective to enforce the clinical improvement in chronic migraine patients with medication overuse. In this study, a clinical experience where day-hospital withdrawal is followed by pharmacological treatment and on the other side pharmacological treatment is combined with behavioral approach is discussed.

     

Behavioral plus pharmacological treatment versus pharmacological treatment only for chronic migraine with medication overuse after day-hospital withdrawal

Chronic migraine with medication overuse is a difficult problem to manage. Different withdrawal approaches have been tried, with different results. Withdrawal in a day-hospital setting is a recent modality. Results obtained from this last approach have been encouraging. Behavioral techniques combined with pharmacological therapies are effective to enforce the clinical improvement in chronic migraine patients with medication overuse. In this study, a clinical experience where day-hospital withdrawal is followed by pharmacological treatment and on the other side pharmacological treatment is combined with behavioral approach is discussed.     

Pilot study of pharmacological treatment for frontotemporal dementia: Effect of Yokukansan on behavioral symptoms

The aim of the present study was to investigate the efficacy of Yokukansan in improving behavioral symptoms of frontotemporal dementia. This study was a prospective, open‐label trial of daily Yokukansan for 4 weeks in 20 frontotemporal dementia patients. Yokukansan treatment was found to significantly improve scores for the Neuropsychiatric Inventory and the Stereotypy Rating Inventory. No adverse effects or significant changes in physical findings and laboratory data occurred except for hypokalemia in two cases. The results indicate that Yokukansan can alleviate the behavioral symptoms of frontotemporal dementia. (The clinical trial registration number is UMIN000002704).     

A behavioral/pharmacological intervention for the treatment of severe self-injurious behavior

The effects of haloperidol and a mild punishment on the severe self-injurious behavior and several collateral behaviors of a 17-year-old profoundly retarded male were assessed. A 12-month analysis using a withdrawal design suggested that neither the medication nor the behavioral intervention alone was effective in significantly reducing the frequency of self-injurious behavior. When combined, however, these interventions produced dramatic reductions in the subject's self-injurious behavior. The haloperidol may have acted as a “setting event”for the successful use of the punishment. Suppression of this behavior was maintained at 6 months and 1 year following the end of the analysis. The collateral behaviors were differentially affected by the behavioral and pharmacological interventions. Time spent in bed and the appearance of drooling increased with the introduction of the haloperidol, while percent correct on a fine-motor task increased only when the interventions were applied simultaneously. The results point out the importance of a careful behavioral analysis for both pharmacological and behavioral interventions and their possible combined actions.     

Dysthymia: a review of pharmacological and behavioral factors

Although dysthymia, a chronic, low-grade form of depression, has a morbidity rate as high as that of major depression, and increases the risk for major depressive disorder, limited information is available concerning the etiology of this illness. In the present report we review literature concerning the biological and characterological features of dysthymia, the effectiveness of antidepressant treatments, the influence of stressors in the precipitation and maintenance of the disorder, and both quality of life and psychosocial correlates of the illness. We also provisionally suggest that dysthymia may stem from disturbances of neuroendocrine and neurotransmitter functioning (eg, corticotropin releasing hormone and arginine vasopressin within the hypothalamus, or alternatively monoamine variations within several extrahypothalamic sites), and may also involve cytokine activation. The central disturbances may reflect phenotypic variations of neuroendocrine processes or sensitization of such mechanisms. It is suggested that chronic stressor experiences or stressors encountered early in life lead to the phenotypic neurochemical alterations, which then favor the development of the dysthymic state. Owing to the persistence of the neurochemical disturbances, vulnerability to double depression is increased, and in this instance treatment with antidepressants may attenuate the symptoms of major depression but not those of the basal dysthymic state. Moreover, the residual features of depression following treatment may be indicative of underlying neurochemical disturbances, and may also serve to increase the probability of illness recurrence or relapse.     

Non-pharmacological and pharmacological treatment of the cognitive and behavioral symptoms of Alzheimer disease

This paper discusses the various pharmacological and behavioral treatments for the cognitive, emotional, and behavioral symptoms of Alzheimer disease (AD). The medications that are currently FDA-approved for the treatment of the cognitive/functional deficits of AD will first be discussed. Next, neuropsychiatric behavioral disturbances, including hallucinations and delusions, agitation and aggression, activity disturbances, depression, and anxiety will be described along with treatment interventions. Sleep disturbance and its treatment in AD and the issue of fitness to drive a motor vehicle are also reviewed. Principles of behavioral management, tips for communication, and recommendations for caregivers are discussed. Lastly, risk and protective factors and their relevance to delaying the expression of dementia are also examined.     

Efficacy of behavioral versus triazolam treatment in persistent sleep-onset insomnia

OBJECTIVE: This study compared differential effects of behavioral therapy and triazolam in a clinical population with sleep-onset insomnia. Triazolam was hypothesized to decrease sleep latency and frequency and duration of awakening, with some effects during the first night's administration. But at follow-up, sleep measures were predicted to return to baseline levels. Behavioral treatment was hypothesized to effect sleep after 2 or more weeks of training which persisted at follow-up. METHOD: Thirty patients with average sleep latencies of 81.48 minutes, who reported chronic insomnia for an average of 2.6 years, were randomly assigned to one of two treatment groups: behavioral stimulus control/relaxation training and triazolam. RESULTS: Both treatments decreased sleep latency but differentially. Triazolam was effective immediately but maintained only some gains at follow-up. Behavioral treatment decreased sleep latency beginning the second week, when subjects expected no improvement, with gains maintained at follow-up. Comparisons showed that triazolam group latencies returned toward baseline, while behavioral group gains were maintained at follow-up. CONCLUSIONS: Triazolam treatment showed superior immediate treatment effects, while behavioral treatment showed superior treatment effects at follow-up, effects that accrued during the training period and differentially persisted at follow-up. One treatment strategy implied by these results would be to combine these two interventions concurrently. This would seem to use the immediate effects produced by the medication until the behavioral skills were learned, at which point medication would be terminated. This strategy could offer immediate relief and sustained effects at drug termination.     

Obsessive-compulsive disorder: pharmacological treatment

Obsessive-compulsive disorder (OCD) in children and adolescents is often a disabling condition, which demands treatment with medication. Research shows that serotonin is involved in the disorder and empirical treatment studies show that antidepressants with serotonin activity are effective. The first choice of treatment in the psychopharmacological approach to OCD in children and adolescents are the SSRI agents, which have been documented as being effective as well as well-tolerated in children and adolescents. The best-documented SSRI to this point is sertraline. However, fluoxetine and fluoxamine have also undergone systematic studies in children and adolescents. Clomipramine has been proven effective, however, side effects caused by this agent would suggest that an SSRI is a better choice. Treatment with an SSRI seems to have effect in approximately 75% of patients with OCD. There are still no systematic studies analyzing augmenting medication for children and adolescents with OCD. Research indicates that the combination of medication and psychotherapy (cognitive behavioural therapy) is important in most cases. Based on a few long-term follow-up studies on OCD children and adolescents there is not evidence that all children and adolescents suffer a lifetime course of the disease. It is therefore recommended, that discontinuation is attempted after 1–1.5 years of successful treatment.

     

Obsessive-complusive disorder: pharmacological treatment

Obsessive-compulsive disorder (OCD) in children and adolescents is often a disabling condition, which demands treatment with medication. Research shows that serotonin is involved in the disorder and empirical treatment studies show that antidepressants with serotonin activity are effective. The first choice of treatment in the psychopharmacological approach to OCD in children and adolescents are the SSRI agents, which have been documented as being effective as well as well-tolerated in children and adolescents. The best-documented SSRI to this point is sertraline. However, fluoxetine and fluoxamine have also undergone systematic studies in children and adolescents. Clomipramine has been proven effective, however, side effects caused by this agent would suggest that an SSRI is a better choice. Treatment with an SSRI seems to have effect in approximately 75 % of patients with OCD. There are still no systematic studies analyzing augmenting medication for children and adolescents with OCD. Research indicates that the combination of medication and psychotherapy (cognitive behavioural therapy) is important in most cases. Based on a few long-term follow-up studies on OCD children and adolescents there is not evidence that all children and adolescents suffer a lifetime course of the disease. It is therefore recommended that discontinuation is attempted after 1-1.5 years of successful treatment.     

Individual versus group cognitive behavioral treatment for obsessive–compulsive disorder: Follow up

Aim: To compare the effectiveness of two forms of cognitive behavioral treatment (CBT; group and individual) in a sample of patients with obsessive–compulsive disorder (OCD) at 6‐month and 12‐month follow up. Method: Thirty‐eight subjects meeting DSM‐IV‐TR OCD criteria completed 20 sessions of individual and group CBT. They were assessed using the Yale–Brown Obsessive–Compulsive Scale and the Hamilton Anxiety and Depression Scales at baseline, after treatment and at 6‐month and 12‐month follow up. Results: The clinical improvement obtained at the end of the treatment was maintained at 6‐month and 12‐month follow up. The clinical outcome of the individual treatment (IT) and the group treatment (GT) was the same. The dropout rates were significantly higher in women than in men, but were similar for IT and GT. Conclusions: CBT was effective in a sample of OCD patients. Individual and group CBT had similar results at 6‐month and 12‐month follow up. The clinical implications of these findings are discussed.     

Different rates of improvement of different symptoms in combined pharmacological and behavioral treatment of agoraphobia

This study was designed to see whether the high vs low serum level of imipramine influenced the outcome of in vivo exposure therapy on patients with agoraphobia. Thirty-six subjects completed the Hopkins Symptom Checklist-90 one week before treatment and weekly throughout treatment. Both groups demonstrated equal improvement. It was noted that the rate of improvement differed for different symptom subscales: (1) Hostility, Paranoia and Psychotic symptom ratings improved over the first three weeks of treatment, (2) Interpersonal Sensitivity, Anxiety and Depression ratings improved throughout the first seven weeks of treatment and (3) Phobic Anxiety, Somatization and Obsessive Compulsure symptom ratings continued to improve throughout the entire 12 week course of treatment. Responsive vs nonresponsive subjects could be significantly differentiated after one week of treatment on the basis of their responses to the Psychoticism subscale.     

Verapamil treatment in clozapine-induced sleep-related enuresis: a case report

Enuresis is an embarrassing rare side effect of clozapine treatment. Using single-blind placebo-control design, the antienuretic activity of the calcium channel blocker verapamil (up to 80 mg/day per os, at 21.00 hours) was evaluated in a schizophrenic patient with comorbid obsessive-compulsive disorder (OCD) who developed nocturnal functional enuresis during clozapine treatment. Verapamil (80 mg/day) displayed antienuretic activity. No correlation between the bradycardiac effect and the antienuretic activity of verapamil was detected.