Structural brain network connectivity in trichotillomania (hair-pulling disorder).

Neuroimaging studies suggest involvement of frontal, striatal, limbic and cerebellar regions in trichotillomania, an obsessive-compulsive related disorder. However, findings regarding the underlying neural circuitry remains limited and inconsistent. Graph theoretical analysis offers a way to identify structural brain networks in trichotillomania. T1-weighted MRI scans were acquired in adult females with trichotillomania (n = 23) and healthy controls (n = 16). Graph theoretical analysis was used to investigate structural networks as derived from cortical thickness and volumetric FreeSurfer output. Hubs, brain regions with highest connectivity in the global network, were identified, and group differences were determined. Regions with highest connectivity on a regional level were also determined. There were no differences in small-worldness or other network measures between groups. Hubs in the global network of trichotillomania patients included temporal, parietal, and occipital regions (at 2SD above mean network connectivity), as well as frontal and striatal regions (at 1SD above mean network connectivity). In contrast, in healthy controls hubs at 2SD represented different frontal, parietal and temporal regions, while at 1SD hubs were widespread. The inferior temporal gyrus, involved in object recognition as part of the ventral visual pathway, had significantly higher connectivity on a global and regional level in trichotillomania. The study included women only and sample size was limited. This study adds to the trichotillomania literature on structural brain network connectivity. Our study findings are consistent with previous studies that have implicated somatosensory, sensorimotor and frontal-striatal circuitry in trichotillomania, and partially overlap with structural connectivity findings in obsessive-compulsive disorder.

Actualización en tricoscopia / Trichoscopy: An Update

La tricoscopia es una técnica sencilla y no invasiva que se puede realizar durante la consulta con un dermatoscopio manual o digital. Esta herramienta ha ganado popularidad en los últimos años, ya que la visualización e identificación de estructuras y signos característicos puede ser la clave en el diagnóstico de alopecias y enfermedades del cuero cabelludo. El enfoque de esta revisión es el estudio y actualización de los hallazgos tricoscópicos en las alopecias más frecuentes en la práctica clínica habitual. Así pues, existen algunas alopecias como la alopecia areata, la tricotilomanía o la alopecia frontal fibrosante en las que los hallazgos con la tricoscopia resultan clave para su diagnóstico y seguimiento. El reconocimiento de estas estructuras distintivas puede ser de gran ayuda y, por ello, como dermatólogos debemos estar familiarizados con las mismas (AU)

Trichoscopy is a simple, noninvasive office procedure that can be performed using a handheld or digital dermatoscope. This tool has gained popularity in recent years, because it provides useful diagnostic information for hair loss and scalp disorders by enabling the visualization and identification of distinctive signs and structures. We present an updated review of the trichoscopic features described for some of the most common hair loss disorders seen in clinical practice. Dermatologists should be familiar with these helpful features, as they can significantly aid the diagnosis and follow-up of numerous conditions, such as alopecia areata, trichotillomania, and frontal fibrosing alopecia (AU)

[Translated article] Trichoscopy: An Update / Actualización en tricoscopia

Trichoscopy is a simple, noninvasive office procedure that can be performed using a handheld or digital dermatoscope. This tool has gained popularity in recent years, because it provides useful diagnostic information for hair loss and scalp disorders by enabling the visualization and identification of distinctive signs and structures. We present an updated review of the trichoscopic features described for some of the most common hair loss disorders seen in clinical practice. Dermatologists should be familiar with these helpful features, as they can significantly aid the diagnosis and follow-up of numerous conditions, such as alopecia areata, trichotillomania, and frontal fibrosing alopecia (AU)

La tricoscopia es una técnica sencilla y no invasiva que se puede realizar durante la consulta con un dermatoscopio manual o digital. Esta herramienta ha ganado popularidad en los últimos años, ya que la visualización y la identificación de estructuras y de signos característicos puede ser la clave en el diagnóstico de alopecias y enfermedades del cuero cabelludo. El enfoque de esta revisión es el estudio y la actualización de los hallazgos tricoscópicos en las alopecias más frecuentes en la práctica clínica habitual. Así pues, existen algunas alopecias, como la alopecia areata, la tricotilomanía o la alopecia frontal fibrosante, en las que los hallazgos con la tricoscopia resultan clave para su diagnóstico y su seguimiento. El reconocimiento de estas estructuras distintivas puede ser de gran ayuda y, por ello, como dermatólogos debemos estar familiarizados con ellas (AU)

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.

Trichoscopy: An Update. / Actualización en tricoscopia.

Trichoscopy is a simple, noninvasive office procedure that can be performed using a handheld or digital dermatoscope. This tool has gained popularity in recent years, because it provides useful diagnostic information for hair loss and scalp disorders by enabling the visualization and identification of distinctive signs and structures. We present an updated review of the trichoscopic features described for some of the most common hair loss disorders seen in clinical practice. Dermatologists should be familiar with these helpful features, as they can significantly aid the diagnosis and follow-up of numerous conditions, such as alopecia areata, trichotillomania, and frontal fibrosing alopecia.

Neural basis of associative learning in Trichotillomania and skin-picking disorder.

Disorders such as Trichotillomania (TTM) and skin-picking disorder (SPD) are associated with reduced flexibility and increased internally focused attention. While the basal ganglia have been hypothesized to play a key role, the mechanisms underlying learning and flexible accommodation of new information is unclear. Using a Bayesian Learning Model, we evaluated the neural basis of learning and accommodation in individuals with TTM and/or SPD. Participants were 127 individuals with TTM and/or SPD (TTM/SPD) recruited from three sites (age 18-57, 84% female) and 26 healthy controls (HC). During fMRI, participants completed a shape-button associative learning and reversal fMRI task. Above-threshold clusters were identified where the Initial Learning-Reversals BOLD activation contrast differed significantly (p < .05 FDR-corrected) between the two groups. A priori, effects were anticipated in predefined ROIs in bilateral basal ganglia, with exploratory analyses in the hippocampus, dorsolateral prefrontal cortex (dlPFC), and dorsal anterior cingulate cortex (dACC). Relative to HC, individuals with TTM/SPD demonstrated reduced activation during initial learning compared to reversal learning in the right basal ganglia. Similarly, individuals with TTM/SPD demonstrated reduced activation during initial learning compared to reversal learning in several clusters in the dlPFC and dACC compared to HC. Individuals with TTM/SPD may form or reform visual stimulus-motor response associations through different brain mechanisms than healthy controls. The former exhibit altered activation within the basal ganglia, dlPFC, and dACC during an associative learning task compared to controls, reflecting reduced frontal-subcortical activation during initial learning. Future work should determine whether these neural deficits may be restored with targeted treatment.

Reward processing in trichotillomania and skin picking disorder.

Trichotillomania (hair pulling disorder) and skin picking disorder are common and often debilitating mental health conditions, grouped under the umbrella term of body focused repetitive behaviors (BFRBs). Although the pathophysiology of BFRBs is incompletely understood, reward processing dysfunction has been implicated in the etiology and sustention of these disorders. The purpose of this study was to probe reward processing in BFRBs. 159 adults (125 with a BFRB [83.2% (n = 104) female] and 34 healthy controls [73.5% (n = 25) female]) were recruited from the community for a multi-center between-group comparison using a functional imaging (fMRI) monetary reward task. Differences in brain activation during reward anticipation and punishment anticipation were compared between BFRB patients and controls, with stringent correction for multiple comparisons. All group level analyses controlled for age, sex and scanning site. Compared to controls, BFRB participants showed marked hyperactivation of the bilateral inferior frontal gyrus (pars opercularis and pars triangularis) compared to controls. In addition, BFRB participants exhibited increased activation in multiple areas during the anticipation of loss (right fusiform gyrus, parahippocampal gyrus, cerebellum, right inferior parietal lobule; left inferior frontal gyrus). There were no significant differences in the win-lose contrast between the two groups. These data indicate the existence of dysregulated reward circuitry in BFRBs. The identified pathophysiology of reward dysfunction may be useful to tailor future treatments.

Diagnostic Accuracy of Trichoscopy in Trichotillomania: A Systematic Review.

Trichotillomania is formally classified as a mental health disorder, but it is commonly diagnosed by dermatologists. The aim of this systematic review is to assess the diagnostic value of trichoscopy in diagnosing trichotillomania. The analysis identified the 7 most specific trichoscopic features in trichotillomania. These features had the following prevalence and specificity: trichoptilosis (57.5%; 73/127 and 97.5%, respectively), v-sign (50.4%; 63/125 and 99%), hook hairs (43.1%; 28/65 and 100%), flame hairs (37.1%; 52/140 and 96.5%), coiled hairs (36.8%; 46/125 and 99.6%), tulip hairs (36.4%; 28/77 and 89.6%), and hair powder (35.6%; 42/118 and 97.9%). The 2 most common, but least specific, features were broken hairs and black dots. In conclusion, trichoscopy is a reliable new diagnostic method for hair loss caused by hair pulling. Trichoscopy should be included as a standard procedure in the differential diagnosis of trichotillomania in clinical practice.

Neurochemical correlates of behavioral treatment of pediatric trichotillomania.

BACKGROUND: Trichotillomania (TTM) is a chronic and impairing psychiatric disorder with suspected dysfunctional cortico-striato-thalamo-cortical (CSTC) circuit activity reflecting excitatory/inhibitory signaling imbalance. TTM neurochemistry is understudied, with no prior research using magnetic resonance spectroscopy (MRS). This pilot investigation examined associations between TTM diagnosis, symptom severity, and response to behavioral treatment with MRS neurometabolites glutamate (Glu) and γ-aminobutyric acid (GABA) in CSTC structures. METHODS: Proton echo-planar spectroscopic imaging (PEPSI) MRS was acquired from bilateral pregenual anterior cingulate cortex (pACC), caudate, putamen, globus pallidus, thalamus, and proximal white matter in 10 unmedicated girls with TTM, ages 9-17 years, before and after treatment, and from 13 age- and sex-matched healthy controls. RESULTS: Nine of 10 TTM patients were treatment responders. Pretreatment mean Glu and GABA did not differ significantly between participants and controls. Pretreatment TTM symptoms were correlated with Glu in (left + right) pACC (r = 0.88, p = 0.02) and thalamus (r = 0.82, p = 0.012), and were negatively correlated with pACC GABA (r = -0.84, p = 0.034). Mean GABA in putamen increased 69% (baseline to post-treatment) (p = 0.027). Higher pretreatment Glu in caudate, putamen, globus pallidus, and thalamus predicted greater symptom decreases with treatment (all r < -0.6, p < 0.05); higher caudate GABA predicted less treatment-related symptom decline (r = 0.86, p = 0.014). LIMITATIONS: Small sample, GABA quantified with spectral fitting rather than editing. CONCLUSION: Consistent with other neuroimaging, MRS reveals discrete CSTC chemical changes with effective behavior therapy, and possibly with TTM etiology. TTM symptoms relate to excess excitatory versus inhibitory signaling in pACC and thalamus; symptom improvement may reflect reduced excitatory drive of the CSTC direct-pathway activity.

Duration of illness and cortical thickness in trichotillomania: Preliminary evidence for illness change over time.

Trichotillomania is a psychiatric condition characterized by repetitive pulling out of one's hair, leading to marked functional impairment. The aim of this study was to examine the association between duration of trichotillomania (defined as time between initial age of onset and current age) and structural brain abnormalities by pooling all available global data. Authors of published neuroimaging studies of trichotillomania were contacted and invited to contribute de-identified MRI scans for a pooled analysis. Freesurfer pipelines were used to examine whether cortical thickness and sub-cortical volumes were associated with duration of illness in adults with trichotillomania. The sample comprised 50 adults with trichotillomania (100% not taking psychotropic medication; mean [SD] age 34.3 [12.3] years; 92% female). Longer duration of illness was associated with lower cortical thickness in bilateral superior frontal cortex and left rostral middle frontal cortex. Volumes of the a priori sub-cortical structures of interest were not significantly correlated with duration of illness (all p > 0.05 uncorrected). This study is the first to suggest that trichotillomania is associated with biological changes over time. If this finding is supported by prospective studies, it could have important implications for treatment (i.e. treatment might need to be tailored for stage of illness). Viewed alongside prior work, the data suggest that brain changes in trichotillomania may be differentially associated with vulnerability (excess thickness in right inferior frontal cortex) and with chronicity (reduced thickness in medial and superior frontal cortex). Longitudinal research is now indicated.

White matter volume alterations in hair-pulling disorder (trichotillomania).

Trichotillomania (TTM) is a disorder characterized by repetitive hair-pulling resulting in hair loss. Key processes affected in TTM comprise affective, cognitive, and motor functions. Emerging evidence suggests that brain matter aberrations in fronto-striatal and fronto-limbic brain networks and the cerebellum may characterize the pathophysiology of TTM. The aim of the present voxel-based morphometry (VBM) study was to evaluate whole brain grey and white matter volume alteration in TTM and its correlation with hair-pulling severity. High-resolution magnetic resonance imaging (3 T) data were acquired from 29 TTM patients and 28 age-matched healthy controls (CTRLs). All TTM participants completed the Massachusetts General Hospital Hair-Pulling Scale (MGH-HPS) to assess illness/pulling severity. Using whole-brain VBM, between-group differences in regional brain volumes were measured. Additionally, within the TTM group, the relationship between MGH-HPS scores, illness duration and brain volumes were examined. All data were corrected for multiple comparisons using family-wise error (FWE) correction at p < 0.05. Patients with TTM showed larger white matter volumes in the parahippocampal gyrus and cerebellum compared to CTRLs. Estimated white matter volumes showed no significant association with illness duration or MGH-HPS total scores. No significant between-group differences were found for grey matter volumes. Our observations suggest regional alterations in cortico-limbic and cerebellar white matter in patients with TTM, which may underlie deficits in cognitive and affective processing. Such volumetric white matter changes may precipitate impaired cortico-cerebellar communication leading to a reduced ability to control hair pulling behavior.

Formation of a temporary gastrostomy to aid delivery of gastric trichobezoar and decrease incidence of wound infection.

Trichobezoars are relatively uncommon problems with a known female predominance. We report two female children with gastric bezoars. Main presenting symptoms were abdominal distension, weight loss and anaemia. Upper abdominal mass was palpable in both. Diagnosis was suspected on initial abdominal radiograph and ultrasound scan then confirmed by upper endoscopy. No bowel extension was recorded in either case. We report here a modification of the surgical technique in which the gastrostomy cut edges were anchored to the laparotomy skin. This modification aided easy and complete delivery of hair balls avoiding any spillage or wound contamination.

An fMRI Pilot Study of Cognitive Flexibility in Trichotillomania.

Trichotillomania is a relatively common psychiatric condition, although its neurobiological basis is unknown. Abnormalities of flexible responding have been implicated in the pathophysiology of obsessive-compulsive disorder and thus may be relevant in trichotillomania. The purpose of this study was to probe reversal learning and attentional set-shifting in trichotillomania. Twelve adults with trichotillomania and 13 matched healthy control subjects undertook a functional MRI task of cognitive flexibility. Group-level activation maps for extradimensional and reversal switches were independently parcellated into discrete regions of interest using a custom watershed algorithm. Activation magnitudes were extracted from each region of interest and study subject and compared at the group level. Reversal events evoked the expected patterns of insula and parietal regions and activity in the frontal dorsal cortex extending anterior to the frontal poles, whereas extradimensional shifts evoked the expected frontal dorsolateral and parietal pattern of activity. Trichotillomania was associated with significantly increased right middle frontal and reduced right occipital cortex activation during reversal and set-shifting. Elevated frontal activation coupled with reduced activation in more posterior brain regions was identified. These pilot data suggest potentially important neural dysfunction associated with trichotillomania.

Striatal abnormalities in trichotillomania: a multi-site MRI analysis.

Trichotillomania (hair-pulling disorder) is characterized by the repetitive pulling out of one's own hair, and is classified as an Obsessive-Compulsive Related Disorder. Abnormalities of the ventral and dorsal striatum have been implicated in disease models of trichotillomania, based on translational research, but direct evidence is lacking. The aim of this study was to elucidate subcortical morphometric abnormalities, including localized curvature changes, in trichotillomania. De-identified MRI scans were pooled by contacting authors of previous peer-reviewed studies that examined brain structure in adult patients with trichotillomania, following an extensive literature search. Group differences on subcortical volumes of interest were explored (t-tests) and localized differences in subcortical structure morphology were quantified using permutation testing. The pooled sample comprised N=68 individuals with trichotillomania and N=41 healthy controls. Groups were well-matched in terms of age, gender, and educational levels. Significant volumetric reductions were found in trichotillomania patients versus controls in right amygdala and left putamen. Localized shape deformities were found in bilateral nucleus accumbens, bilateral amygdala, right caudate and right putamen. Structural abnormalities of subcortical regions involved in affect regulation, inhibitory control, and habit generation, play a key role in the pathophysiology of trichotillomania. Trichotillomania may constitute a useful model through which to better understand other compulsive symptoms. These findings may account for why certain medications appear effective for trichotillomania, namely those modulating subcortical dopamine and glutamatergic function. Future work should study the state versus trait nature of these changes, and the impact of treatment.

Trichoscopy of alopecia areata: An update.

The diagnosis of alopecia areata is usually based on clinical manifestations. However, there are several hair and scalp disorders that share similar clinical features with alopecia areata, such as tinea capitis, trichotillomania or traction alopecia. Trichoscopy as a fast, non-invasive and easy-to-perform technique may help to identify subtle details and establish the correct diagnosis. The aim of this review is to present the spectrum of trichoscopic findings in alopecia areata. A systematic review of the published work was performed by searching the PubMed, Scopus and EBSCO databases, complemented by a thorough hand search of reference lists. Of 427 articles retrieved, 30 studies were eligible for quantitative analysis. The reported features of alopecia areata were: yellow dots (6-100% patients), short vellus hairs (34-100%), black dots (0-84%), broken hairs (0-71%) and exclamation mark hairs (12-71%). Tapered hairs (5-81%) were reported in few studies, but a relatively high frequency of this finding in alopecia areata may indicate their important role in the differential diagnosis of hair loss. Rarely reported features, which include upright regrowing hairs (11-96%), pigtail (circle) hairs (4-61%) and Pohl-Pinkus constrictions (2-10%), may also be helpful in the diagnosis of alopecia areata. There is no pathognomonic trichoscopic marker for alopecia areata and the most common trichoscopic features are not the most specific. Therefore, the diagnosis should be based on the coexistence of several trichoscopic findings, not on the presence of a single feature.

The relationship between microstructural alterations of the brain and clinical measurements in children and adolescents with hair pulling disorder.

Several studies have evaluated gray matter abnormalities and white matter integrity in adults with hair pulling disorder (HPD). However, no prior studies have defined the relationship between neuroimaging parameters and clinical measurements in children and adolescents with HPD. The purposes of this study were to determine the correlation between magnetic resonance imaging (MRI) indices and clinical measurements in children and adolescents with HPD, and to compare HPD patients with age- and sex- matched healthy controls (HC). Pediatric HPD patients (n = 9) and HC subjects (n = 10), aged 9-17 years, were recruited. Three-dimensional T1-weighted structural MRI (3D T1W) and diffusion-tensor imaging (DTI) scans were obtained for each subject. Gray matter and white matter volumes were calculated from 3D T1W. Fractional anisotropy (FA) and average diffusion coefficients (Dav) were mapped from DTI. Voxel-based and region-of-interest correlations between MRI indices and clinical measurements were analyzed. In addition, two-sample t-tests were used to compare voxel-based tissue volumes, FA, and Dav maps between the two groups. Alterations in both brain tissue volume and white matter integrity were associated with symptom severity, especially in the precuneus, anterior cingulate, temporal cortex, and frontal cortex regions. FA values in HPD patients were significantly higher than those observed in HC subjects, particularly in the cerebellum and cuneus regions. Alterations of brain tissue volumes and microstructural changes are associated with severity of clinical symptoms in children and adolescents with HPD. Fractional anisotropy is the most sensitive method to distinguish pediatric HPD patients from healthy children. The results of this study can facilitate use of MRI indices to follow the transition from pediatric HPD to adult HPD.

Systematic Review of Published Primary Studies of Neuropsychology and Neuroimaging in Trichotillomania.

OBJECTIVES: Existing models of trichotillomania (TTM; hair pulling disorder) rely heavily on a biological predisposition or biological pathogenesis of the disorder, but fail to capture the specific neuropsychological mechanisms involved. The present systematic review aims to scope existing neuropsychological studies of TTM to explore gaps in current models. METHODS: A systematic literature search was conducted to detect all published primary studies using neuropsychological and neuroimaging measures in a cohort of individuals experiencing TTM. Studies addressing neuropsychological function were divided into domains. Findings from imaging studies were considered within brain regions and across methodology. RESULTS: Thirty studies with a combined 591 participants with TTM, 372 healthy controls and 225 participants in other types of control group were included. Sixteen studies investigated neuropsychological parameters, and 14 studies pursued neuroimaging technologies. Available studies that used neuropsychological assessments and reported a statistically significant difference between those with TTM and controls ranged in effect size from 0.25 to 1.58. All domains except verbal ability and visual ability reported a deficit. In neuroimaging studies, several structural and functional brain changes were reported that might be of significance to TTM. Only tentative conclusions can be made due to the use of multiple methodologies across studies, a major limitation to meaningful interpretations. CONCLUSIONS: Positive neuropsychological and neuroimaging results require replication, preferably with multi-site studies using standardized methodology. Increased standardized testing and analyses across the literature, as a whole, would improve the utility and interpretability of knowledge in this field. (JINS, 2018, 24, 188-205).

Cortical thickness abnormalities in trichotillomania: international multi-site analysis.

Trichotillomania is a prevalent but often hidden psychiatric condition, characterized by repetitive hair pulling. The aim of this study was to confirm or refute structural brain abnormalities in trichotillomania by pooling all available global data. De-identified MRI scans were pooled by contacting authors of previous studies. Cortical thickness and sub-cortical volumes were compared between patients and controls. Patients (n = 76) and controls (n = 41) were well-matched in terms of demographic characteristics. Trichotillomania patients showed excess cortical thickness in a cluster maximal at right inferior frontal gyrus, unrelated to symptom severity. No significant sub-cortical volume differences were detected in the regions of interest. Morphometric changes in the right inferior frontal gyrus appear to play a central role in the pathophysiology of trichotillomania, and to be trait in nature. The findings are distinct from other impulsive-compulsive disorders (OCD, ADHD, gambling disorder), which have typically been associated with reduced, rather than increased, cortical thickness. Future work should examine sub-cortical and cerebellar morphology using analytic approaches designed for this purpose, and should also characterize grey matter densities/volumes.

[Psychosomatic disorders of the scalp]. / Psychosomatik der Kopfhaut.

Psychosomatic disorders of the scalp have some special characteristics due to the visibility, possible stigmatization, and amount/patterns of hair. Of practical relevance is trichotillomania, which is now classified as an obsessive-compulsive disorder (OCD). Patients who are obsessed with normal physiological hair loss represent a further psychodermatological challenge. Psychosomatic therapy includes basic psychosomatic care, behavior therapy, or treatment with psychopharmaceuticals.