Neurobiology of subtypes of trichotillomania and skin picking disorder.

BACKGROUND: Trichotillomania (TTM) and skin picking disorder (SPD) are common and often debilitating mental health conditions, grouped under the umbrella term of body-focused repetitive behaviors (BFRBs). Recent clinical subtyping found that there were three distinct subtypes of TTM and two of SPD. Whether these clinical subtypes map on to any unique neurobiological underpinnings, however, remains unknown. METHODS: Two hundred and fifty one adults [193 with a BFRB (85.5% [n = 165] female) and 58 healthy controls (77.6% [n = 45] female)] were recruited from the community for a multicenter between-group comparison using structural neuroimaging. Differences in whole brain structure were compared across the subtypes of BFRBs, controlling for age, sex, scanning site, and intracranial volume. RESULTS: When the subtypes of TTM were compared, low awareness hair pullers demonstrated increased cortical volume in the lateral occipital lobe relative to controls and sensory sensitive pullers. In addition, impulsive/perfectionist hair pullers showed relative decreased volume near the lingual gyrus of the inferior occipital-parietal lobe compared with controls. CONCLUSIONS: These data indicate that the anatomical substrates of particular forms of BFRBs are dissociable, which may have implications for understanding clinical presentations and treatment response.

Prevalence and Correlates of Hair Pulling Disorder and Skin Picking Disorder in an Acute Psychiatric Sample.

ABSTRACT: Hair pulling disorder (HPD; trichotillomania) and skin picking disorder (SPD; excoriation disorder) are understudied psychiatric disorders. The aim of this study was to examine the prevalence and correlates of HPD and SPD in an acute psychiatric sample. Semistructured interviews and self-report measures were administered to patients in a psychiatric partial hospital (N = 599). The past-month prevalence of HPD and SPD was 2.3% and 9%, respectively. HPD and SPD had highly similar clinical characteristics and a strong co-occurrence. Patients with HPD/SPD were significantly younger than other patients and more likely to be female. Logistic regression controlling for age and sex showed that diagnosis of HPD/SPD was not significantly associated with suicidal ideation, suicidal behaviors, nonsuicidal self-injury, or emotional disorder diagnoses (e.g., borderline personality disorder, major depressive disorder). HPD/SPD status was significantly associated with an increased risk of generalized anxiety disorder. However, patients with HPD/SPD did not differ from other patients on self-report measures of generalized anxiety, depression, and distress intolerance. HPD and SPD are common and frequently co-occurring disorders in psychiatric settings.

Pain perception and physiological correlates in body-focused repetitive behavior disorders.

BACKGROUND: Behaviors typical of body-focused repetitive behavior disorders such as trichotillomania (TTM) and skin-picking disorder (SPD) are often associated with pleasure or relief, and with little or no physical pain, suggesting aberrant pain perception. Conclusive evidence about pain perception and correlates in these conditions is, however, lacking. METHODS: A multisite international study examined pain perception and its physiological correlates in adults with TTM (n = 31), SPD (n = 24), and healthy controls (HCs; n = 26). The cold pressor test was administered, and measurements of pain perception and cardiovascular parameters were taken every 15 seconds. Pain perception, latency to pain tolerance, cardiovascular parameters and associations with illness severity, and comorbid depression, as well as interaction effects (group × time interval), were investigated across groups. RESULTS: There were no group differences in pain ratings over time (P = .8) or latency to pain tolerance (P = .8). Illness severity was not associated with pain ratings (all P > .05). In terms of diastolic blood pressure (DBP), the main effect of group was statistically significant (P = .01), with post hoc analyses indicating higher mean DBP in TTM (95% confidence intervals [CI], 84.0-93.5) compared to SPD (95% CI, 73.5-84.2; P = .01), and HCs (95% CI, 75.6-86.0; P = .03). Pain perception did not differ between those with and those without depression (TTM: P = .2, SPD: P = .4). CONCLUSION: The study findings were mostly negative suggesting that general pain perception aberration is not involved in TTM and SPD. Other underlying drivers of hair-pulling and skin-picking behavior (eg, abnormal reward processing) should be investigated.

Clinical Characteristics of Youth with Trichotillomania (Hair-Pulling Disorder) and Excoriation (Skin-Picking) Disorder.

Body-focused repetitive disorders (BFRBDs) are understudied in youth and understanding of their underlying mechanisms is limited. This study evaluated BFRBD clinical characteristics, and two factors commonly implicated in their maintenance - emotion regulation and impulsivity - in 53 youth aged 11 to 17 years: 33 with BFRBDs and 20 controls. Evaluators administered psychiatric diagnostic interviews. Participants rated BFRBD severity, negative affect, quality of life, family functioning, emotion regulation, distress tolerance, and impulsivity. Youth with BFRBDs showed poorer distress tolerance and quality of life, and higher impulsivity and negative affect than controls, with no differences in family impairment. BFRBD distress/impairment, but not BFRBD severity, correlated with anxiety and depression, and poorer distress tolerance. Findings suggest youth with BFRBDs show clinical patterns aligning with prior research; highlight the role of distress tolerance in child BFRBDs; and suggest the utility of acceptance and mindfulness-based therapies for unpleasant emotions in BFRBDs. Continued research should evaluate factors underlying BFRBDs in youth.

A latent profile analysis of age of onset in trichotillomania.

BACKGROUND: Trichotillomania (TTM) onset may occur across the lifespan; however, adolescent onset is most frequently reported. Several studies have explored clinical differences between TTM age-of-onset groups with mixed results. We investigated empirically defined age-of-onset groups in adults with TTM, and clinical differences between groups. METHODS: Participants included 1,604 adult respondents to an internet survey who endorsed DSM-IV-TR TTM criteria. Latent profile analysis was performed to identify TTM age-of-onset subgroups, which were then compared on demographic and clinical features. RESULTS: The most optimal model was a 2-class solution comprised of a large group with average TTM onset during adolescence (n = 1,539; 95.9% of the sample; mean age of onset = 12.4) and a small group with average onset in middle adulthood (n = 65; 4.1% of the sample; mean age of onset = 35.6). The late-onset group differed from the early-onset group on several clinical variables (eg, less likely to report co-occurring bodyfocused repetitive behaviors). CONCLUSIONS: Findings suggest the presence of at least 2 distinct TTM age-of-onset subgroups: an early-onset group with onset during adolescence, and a late-onset group with onset in middle adulthood. Future research is needed to further validate these subgroups and explore their clinical utility.

Prevalence and predictors of hair pulling disorder and excoriation disorder in Tourette syndrome.

Trichotillomania/hair pulling disorder (HPD) and excoriation/skin picking disorder (SPD) are childhood-onset, body-focused repetitive behaviors that are thought to share genetic susceptibility and underlying pathophysiology with obsessive-compulsive disorder (OCD) and Tourette syndrome (TS). We sought to determine the prevalence of DSM-5 HPD and SPD in TS patients, and to identify clinical factors most associated with their co-morbidity with TS. Participants included 811 TS patients recruited from TS specialty clinics for a multi-center genetic study. Patients were assessed using standardized, validated semi-structured interviews. HPD and SPD diagnoses were determined using a validated self-report questionnaire. HPD/SPD prevalence rates were calculated, and clinical predictors were evaluated using regression modeling. 3.8 and 13.0% of TS patients met DSM-5 criteria for HPD and SPD, respectively. In univariable analyses, female sex, OCD, and both tic and obsessive-compulsive symptom severity were among those associated with HPD and/or SPD. In multivariable analyses, only lifetime worst-ever motor tic severity remained significantly associated with HPD. Female sex, co-occurring OCD, ADHD, and motor tic severity remained independently associated with SPD. This is the first study to examine HPD and SPD prevalence in a TS sample using semi-structured diagnostic instruments. The prevalence of HPD and SPD in TS patients, and their association with increased tic severity and co-occurring OCD, suggests that clinicians should screen children with TS and related disorders for HPD/SPD, particularly in females and in those with co-occurring OCD. This study also helps set a foundation for subsequent research regarding HPD/SPD risk factors, pathophysiology, and treatment models.

Predictors of comorbid eating disorders and association with other obsessive-compulsive spectrum disorders in trichotillomania.

Trichotillomania (TTM) and eating disorders (ED) share many phenomenological similarities, including ritualized compulsive behaviors. Given this, and that comorbid EDs may represent additional functional burden to hair pullers, we sought to identify factors that predict diagnosis of an ED in a TTM population. Subjects included 555 adult females (age range 18-65) with DSM-IV-TR TTM or chronic hair pullers recruited from multiple sites. 7.2% (N=40) of our TTM subjects met criteria for an ED in their lifetime. In univariable regression analysis, obsessive-compulsive disorder (OCD), Yale-Brown Obsessive Compulsive Scale (Y-BOCS) worst-ever compulsion and total scores, certain obsessive-compulsive spectrum disorders, anxiety disorder, attention-deficit/hyperactivity disorder (ADHD), and substance disorder all met the pre-specified criteria for inclusion in the multivariable analysis. In the final multivariable model, diagnosis of OCD (OR: 5.68, 95% CI: 2.2-15.0) and diagnosis of an additional body-focused repetitive behavior disorder (BFRB) (OR: 2.69, 95% CI: 1.1-6.8) were both associated with increased risk of ED in TTM. Overall, our results provide further support of the relatedness between ED and TTM. This finding highlights the importance of assessing for comorbid OCD and additional BFRBs in those with TTM. Future research is needed to identify additional predictors of comorbid disorders and to better understand the complex relationships between BFRBs, OCD and EDs.

The assessment of skin picking in adolescence: psychometric properties of the Skin Picking Scale-Revised (German version).

BACKGROUND: Skin picking disorder has received growing attention since the release of DSM-5, yet there are no evidence-based assessment instruments for adolescent samples. AIM: The present study examines the psychometric properties of the Skin Picking Scale-Revised (SPS-R, German version) in adolescents. METHODS: A total of 76 adolescents (96% female) completed the SPS-R, the Clinical Psychological Diagnostic System (KPD-38), and a questionnaire assessing demographics and clinical characteristics online. RESULTS: The SPS-R had high internal consistency (α = 0.89) and significant small-to-medium correlations with reduced competence skills, psychological impairment, general life satisfaction, social support, and social problems on the KPD-38. Similar to prior findings for adults, an exploratory factor analysis suggested a two-factor model for the SPS-R in adolescents. Group comparisons failed to show significant differences on SPS-R scores between participants with and without dermatological conditions. CONCLUSIONS: The current results suggest that the SPS-R can be useful in adolescent samples as a reliable and valid instrument for the assessment of skin picking severity. Future research investigating scale validity and factor structure in a clinical sample of adolescent skin pickers is warranted.

Trichotillomania and its clinical relationship to depression and anxiety.

OBJECTIVE: Trichotillomania (TTM) is associated with high rates of co-occurring depression and anxiety disorders. What the co-occurrence of TTM, depression or anxiety disorders means clinically and cognitively, however, has garnered little research attention. METHODS: About 530 adults with TTM were examined on a variety of clinical measures including symptom severity, psychosocial measures of functioning, psychiatric comorbidity and neurocognitive testing assessing motor inhibition and cognitive flexibility. Clinical features and cognitive functioning were compared between TTM patients with current comorbid major depressive disorder (MDD), a current anxiety disorder, both MDD and an anxiety disorder, or neither. RESULTS: Of 530 participants, 58 (10.3%) had MDD only, 97 (18.3%) had an anxiety disorder only, 58 (10.3%) had both MDD and an anxiety disorder, and 317 (59.8%) had neither. For almost all clinical measures, those with MDD only reported worse symptoms than those with an anxiety disorder only, and the combination of MDD and an anxiety disorder reported the worst level of symptom severity. CONCLUSIONS: These results suggest that adults with TTM and co-occurring MDD and anxiety disorders exhibit unique clinical differences. The clinical differences may also have treatment implications.

A comparison of clinical vs subclinical skin pickers in Israel.

BACKGROUND: Skin-picking disorder (SPD) was recognized as its own entity for the first time in DSM-5. The existing SPD literature is limited and, to date, no study has examined the differences between clinical and sub- clinical SPD. Identifying differences between these 2 groups may improve diagnostic accuracy, treatment, and prevention efforts. METHODS: Israeli adults (N = 4,325) from 2 previous studies were examined for the presence of clinical and subclinical SPD. Individuals with clinical SPD (n = 150) vs subclinical SPD (n = 219) were compared on skin-picking characteristics, psychological phenomena, and clinical correlates. RESULTS: There were many similarities between clinical and subclinical skin pickers. Individuals with clinical SPD, however, had more severe skin picking, greater associated functional impairment, greater perceived stress, and greater depressive and obsessive-compulsive symptoms, and were also more likely to have a first-degree relative with SPD. CONCLUSIONS: This study suggests that although there are some similarities between clinical and subclinical SPD, there also are distinct differences in the clinical presentation. Understanding these differences may be an important factor in treatment and prevention planning.

Sex differences in trichotillomania.

BACKGROUND: Trichotillomania (TTM) appears to be a fairly common disorder, yet little is known about sex differences in its clinical presentation. Long thought to be a primarily female disorder, males with TTM may have unique clinical presentations. METHODS: Participants with TTM (N = 462) were examined on a variety of clinical measures including symptom severity, functioning, and psychiatric comorbidity. Clinical features were compared between males (n = 27) and females (n = 435). RESULTS: There were many similarities in the clinical presentations of males and females with TTM. Males with TTM, however, were more likely to pull from their face, arms, and torso, and were more likely to suffer from a co-occurring substance use disorder. Females were more likely to be younger and less likely to be married. CONCLUSIONS: This study suggests that, although few males seek treatment for TTM, sex differences may be an important clinical factor when assessing and treating this disorder. Further research is needed to validate these findings and identify whether treatments should be tailored differently for males and females with TTM.

Does comorbidity matter in body-focused repetitive behavior disorders?

BACKGROUND: Trichotillomania (TTM) and skin-picking disorder (SPD) have been characterized as body-focused repetitive behavior disorders (BFRBs). Because BFRBs frequently co-occur, we sought to discover the similarities and differences for individuals having both TTM and SPD as opposed to 1 of these disorders. METHODS: Participants with primary TTM (N = 421) were evaluated regarding the comorbidity of SPD, and participants with primary SPD (N = 124) were evaluated regarding the comorbidity of TTM. The effects of comorbidity overlap on demographic and clinical measures were evaluated. RESULTS: Of the 421 participants with primary TTM, 61 (14.5%) had co-occurring SPD. Of 124 participants with primary SPD, 21 (16.9%) had comorbid TTM. Participants with primary TTM and comorbid SPD had significantly more severe trichotillomania symptoms and were more likely to have major depressive disorder than those with TTM alone. Participants with primary SPD and comorbid TTM reported significantly more severe skin-picking symptoms than those who had only SPD. CONCLUSIONS: Individuals with co-occurring TTM and SPD may have more problematic symptoms with the primary repetitive behavior. Hair pullers with comorbid SPD were more likely to have comorbid depression. Evaluating patients for multiple BFRBs may be important to assess the severity of symptoms and may have treatment implications.

Predictors of comorbid obsessive-compulsive disorder and skin-picking disorder in trichotillomania.

BACKGROUND: Trichotillomania (TTM), obsessive-compulsive disorder (OCD), and skin-picking disorder (SPD) frequently occur together and share overlapping phenomenology, pathophysiology, and possible genetic underpinnings. This study sought to identify factors that predict OCD and SPD in hair pullers. METHODS: Five hundred fifty-five adult female hair pullers were recruited from specialty clinics and assessed using standardized, semi-structured interviews and self-reports. Clinical predictors and multivariate models were evaluated using logistic regression modeling. RESULTS: Hair pullers met criteria for OCD (18.9%), SPD (19.5%), or chronic skin picking (CSP) (5%), or both comorbid diagnoses, respectively. In the final multivariate model for OCD, family history of OCD and an eating disorder diagnosis were associated with an increased risk of OCD in TTM. A nail-biting diagnosis was associated with a decreased risk of OCD in TTM. In the final multivariate model for SPD/CSP, only family history of OCD was associated with an increased risk of SPD/CSP in TTM. CONCLUSIONS: Identification of factors predicting OCD and SPD in TTM provides evidence for the relatedness of these disorders and supports their collective classification as obsessive-compulsive and related disorders (OCRDs) in DSM-5. The findings of this study further underscore the importance of assessing for comorbid OCRDs and family histories of OCRDs in clinical practice.

[A Self-Report Instrument for the Assessment of Dermatillomania: Reliability and Validity of the German Skin Picking Scale-Revised]. / Ein Selbstbeurteilungsinstrument zur Erfassung von Dermatillomanie: Reliabilität und Validität der deutschsprachigen Version der Skin Picking Scale-Revised.

At least since the introduction of the official diagnosis Excoriation (Skin-Picking) Disorder in the DSM-5 [1], dermatillomania is an important and growing field of research. Despite the high importance currently a huge lack of German assessment instruments exists. Aim of the present study was the examination of the psychometric properties of the German translation of the Skin Picking Scale-Revised [2]. For this purpose an open online study has been conducted. The analysis of N=2 065 data sets indicated a high internal consistency with Cronbachs Alpha being 0.93. Furthermore positive associations with the 3 problem areas psychological impairment, general physical condition, social problems as well as with reduced competence skills, general life satisfaction and social support indicate a good constructvalidity. Another sign for validity is a significant effect in terms of gender: As expected women showed higher skin picking scores than men. Overall the results of the present study suggest that the German version of the SPS-R can be seen as a reliable and valid instrument for the assessment of dermatillomania.

Open-label study of duloxetine for the treatment of obsessive-compulsive disorder.

BACKGROUND: This study sought to investigate the efficacy of duloxetine for the treatment of obsessive-compulsive disorder (DSM-IV). METHODS: Twenty individuals were enrolled in a 17-week, open-label trial of duloxetine at Massachusetts General Hospital. Data were collected between March 2007 and September 2012. Study measures assessing obsessive-compulsive disorder symptoms, quality of life, depression, and anxiety were administered at baseline and weeks 1, 5, 9, 13, and 17. The primary outcome measures were the Yale-Brown Obsessive Compulsive Scale and Clinical Global Improvement scale. RESULTS: For the 12 study completers, pre- and posttreatment analyses revealed significant improvements (P<.05) on clinician- and self-rated measures of obsessive-compulsive disorder symptoms and quality of life. Among the 12 completers, more than one-half (n=7) satisfied full medication response criteria. Intention-to-treat analyses (n=20) showed similar improvements (P<.05) on primary and secondary study outcome measures. CONCLUSION: The results of this study suggest that duloxetine may provide a significant reduction in symptoms for patients with obsessive-compulsive disorder. ClinicalTrials.gov NCT00464698; http://clinicaltrials.gov/ct2/show/NCT00464698?term=NCT00464698&rank=1.

Getting the word out: cognitive-behavioral therapy for trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder.

BACKGROUND: To date, there has been no investigation of dissemination outcomes for cognitive-behavioral training programs for body-focused repetitive behaviors (BFRBs). METHODS: Sixty-three past participants of the Trichotillomania Learning Center (TLC) intensive professional training institutes completed an online survey assessing referral sources, skills utilization, and treatment outcomes before and after training. The intensive training focused on the treatment of trichotillomania (hair-pulling) disorder and excoriation (skin-picking) disorder using in-person or videotaped didactics, role playing, and case presentations with supervision upon request. RESULTS: Participants endorsed a greater number of referral sources and BFRB patients after attending training. Paired t tests indicated significant pre- to post-training increases in self-reported utilization of all individual cognitive-behavioral therapy (CBT) skills as well as overall mean skills usage (both P<.001). Changes after training in the reported percent of abstinent patients and mean reduction in symptom severity were also noted. CONCLUSIONS: The TLC intensive professional training institutes may be useful for disseminating CBT skills for the treatment of BFRBs, but additional research is warranted.

Predictors of life disability in trichotillomania.

BACKGROUND: Limited research has investigated disability and functional impairment in trichotillomania (TTM) subjects. This study examined the relationships between hair pulling (HP) style and severity and disability while controlling for mood severity. Disability was measured in individual life areas (work, social, and family/home life) instead of as a total disability score as in previous studies. METHODS: One hundred fifty three adult hair pullers completed several structured interviews and self-report instruments. HP style and severity, as well as depression, anxiety, and stress were correlated with work, social, and family/home life impairment on the Sheehan Disability Scale (SDS). Multiple regression analyses were performed to determine significant predictors of life impairment. RESULTS: Depressive severity was a significant predictor for all SDS life areas. In addition, interference/avoidance associated with HP was a predictor for work and social life disability. Distress from HP was a significant predictor of social and family/home life disability. Focused HP score and anxiety were significant predictors of family/home life disability. CONCLUSIONS: As expected, depression in hair pullers predicted disability across life domains. Avoiding work and social situations can seriously impair functioning in those life domains. Severity of distress and worry about HP may be most elevated in social situations with friends and family and thus predict impairment in those areas. Finally, since HP often occurs at home, time spent in focused hair pulling would have a greater negative impact on family and home responsibilities than social and work life.

Excoriation (skin-picking) disorder in adults: a cross-cultural survey of Israeli Jewish and Arab samples.

OBJECTIVE: We sought to estimate the lifetime prevalence of Excoriation (Skin-Picking) Disorder (SPD) in the Israeli adult population as a whole and compare SPD prevalence in the Jewish and Arab communities. We also explored demographic, medical and psychological correlates of SPD diagnosis. METHODS: Questionnaires and scales screening for SPD, and assessing the severity of perceived stress, depression, obsessive-compulsive disorder (OCD), body dysmorphic disorder (BDD), alcohol use, illicit drug use, and medical disorders were completed in a sample of 2145 adults attending medical settings. RESULTS: The lifetime prevalence of SPD was 5.4% in the total sample; it did not differ between genders or within Jewish and Arab subsamples. Severity of depression (p<0.001), OCD (p<0.001) and perceived stress (p=<0.001) were greater in the SPD positive sample. Similarly, diagnoses of BDD (p=0.02) and generalized anxiety (p=0.03) were significantly more common in the SPD-positive respondents. Alcohol use and illicit substance use were significantly more common among SPD positive respondents in the total sample (both p's=0.01) and the Jewish subsample (p=0.03 and p=0.02, respectively). Hypothyroidism was more prevalent in the SPD-positive Jewish subsample (p=0.02). In the total sample, diabetes mellitus was more common in women than in men (p=0.04). CONCLUSION: Lifetime SPD appears to be relatively common in Israeli adults and associated with other mental disorders. Differences in the self-reported medical and psychiatric comorbidities between the Jewish and Arab subsamples suggest the possibility of cross-cultural variation in the correlates of this disorder.

The relationship between hair pulling style and quality of life.

BACKGROUND: Past research has found different associations between hair pulling (HP) variables and quality of life (QOL), especially after controlling for depression. This study examined HP styles (automatic vs focused) for their associations with QOL and whether depression accounted for these relationships. METHODS: Our sample consisted of 187 adults who met DSM-IV diagnostic criteria for trichotillomania (TTM) or chronic HP (TTM criteria except B and/or C). Clinician-administered interviews were used to diagnose TTM/HP. Participants completed self-report scales for HP style and severity, QOL, and severity of depression. RESULTS: Significant correlations were reported between QOL and the focused style of HP, as well as with interference and distress from HP. Exploratory analyses also revealed a correlation between number of HP sites and QOL. None of the correlations remained significant after controlling for severity of depression. CONCLUSIONS: These results indicate that future research on HP style also should consider the impact of co-occurring depressive symptoms. Interventions addressing both depression and HP should be considered in treatment planning to optimize outcomes.

A family study of trichotillomania and chronic hair pulling.

Little is known about the etiology of hair pulling (HP) and its relationship to other obsessive compulsive (OC) spectrum disorders. In a large-sample family study, we examined the familial aggregation of HP and co-transmission of obsessive compulsive disorder (OCD) and skin picking (SP). Our sample consisted of 110 proband cases with HP and 48 controls without HP, plus 128 first-degree case relatives and 50 first-degree control relatives. Case versus control relatives had higher recurrence risk estimates for both HP and OCD but not SP. The finding that HP is familial is consistent with the only existing twin study. Additional analyses suggest that there may be a familial subtype of HP with comorbid OCD. Those adult proband cases with HP + OCD had more anxiety and depression than cases without OCD. Probands with HP + OCD also had earlier onset of OCD. Identification of an HP subtype with comorbid OCD may have significant theoretical and treatment implications. The data did not provide evidence for an etiologic relationship between HP and SP. Replication of these findings in future studies with larger cohorts of case and control relatives is warranted.