Day # 98: Trichotillomania and Excoriation

Today we will continue our current theme of the "OCD related disorders" which includes body dysmorphic disorder (BDD), hoarding disorder (HD), trichotillomania (hair-pulling disorder), and excoriation (skin-picking disorder). Today we will discuss trichotillomania (hair-pulling disorder) and excoriation (skin-picking disorder).


Today's Content Level: Intermediate



INTRODUCTION 1


Trichotillomania

  • Trichotillomania = "Hair-Pulling Disorder"

  • Characterized by recurrent pulling out of one's hair which results in hair loss.

  • The term trichotillomania was coined by a French dermatologist (Hallopeau) in the 1800s and was given attention in the early 1900s when a large case series was published by two surgeons who operated on individuals with trichobezoar (after swallowing hair after hair-pulling)


Excoriation

  • Excoriation = "Skin-Picking Disorder"

  • Characterized by recurrent skin picking resulting in lesions.

  • Excoriation disorder is new to DSM-5, however cases of "neurotic excoriation" or "psychogenic excoriation" have long been described in the medical literature.



DIAGNOSTIC CRITERIA 2


Trichotillomania (Hair-Pulling Disorder)

  • Recurrent pulling out of one's hair which results in hair loss.

  • Repeated attempts to decrease or stop hair pulling.

  • Causes significant distress or impairment in functioning (social, occupational, etc.).

  • Symptoms are not better explained by another medical/psychiatric condition.


Excoriation (Skin-Picking Disorder)

  • Recurrent skin picking resulting in skin lesions.

  • Repeated attempts to decrease or stop skin picking.

  • Causes significant distress or impairment in functioning (social, occupational, etc.).

  • Not better explained by another medical/substance/psychiatric condition.



EPIDEMIOLOGY / PATHOGENESIS 3, 4, 5, 6


Trichotillomania (Hair-Pulling Disorder)

  • Lifetime prevalence 1-2% of the adult population. More common in woman than in men (10:1 ratio).

  • In women, the most common age of onset is near menarche. Keep in mind that some studies suggest that non-cosmetic hair-pulling occurs in greater than 10% of college students, however only 1-3% meet criteria for trichotillomania.

  • Risk factors include genetic risk (family and twin studies; genetic studies [SAPAP3 and SLITRK1), childhood trauma (non-specific), and relationship to OCD and other OCD related disorders.

  • Has been associated with impairment in various neuropsychological domains including deficits in working memory and visual-spatial learning.

  • Studies have suggested some involvement in the cortico-striatal-thalamo-cortical (CSTC) circuits that play a role in OCD, although the data is limited. There is also evidence of involvement in the pathways of reward processing and affect regulation.


Excoriation (Skin-Picking Disorder)

  • Lifetime prevalence 1.5-3.5% of the adult population. There is variability among studies regarding gender prevalence, but most estimate that >75% of diagnoses are women.

  • Mean age of onset is 12 years old, typically coinciding with the onset of puberty.

  • Risk factors include genetic risk (family and twin studies; genetic studies [SAPAP3), and relationship to OCD and other OCD related disorders.

  • Like trichotillomania and OCD, there is also some evidence for involvement of the CSTC circuits.

  • Animal data suggest that the dopaminergic system plays a role.



CLINICAL PEARLS 7, 8


  • Clinical pearls for trichotillomania and excoriation are similar. This section will be combined to avoid redundancy.

  • Onset of symptoms frequently occur at the time of puberty, are often associated with a stressful event, and symptoms may be chronic with waxing and waning periods.

  • Important questions to consider during evaluation: age of onset; course of symptoms (ex: has it gone away and come back?); type and severity of symptoms; sites of picking/pulling; negative consequences of picking/pulling; presence of comorbid symptoms/disorders; and safety assessment.

  • Both disorders are highly comorbid with each other, OCD, and MDD.

  • Both disorders can result in significant complications (scarring, infection, trichobezoar, alopecia, eye irritation, tendonitis, low self-esteem, shame, avoidance, suicide, etc.).

  • Clinical pearls specific to trichotillomania -> not done for cosmetic reasons but rather an irresistible urge to pull out their hair; specific hair textures may be preferred; may be from any area of the body but most commonly from scalp, eyebrows, eyelashes, and pubic area; some patients may mouth the hair once its pulled or even swallow the hair (important to screen for since trichobezoar leads to significant medical risks; rule out a causal dermatological condition and body dysmorphic disorder (attempt to improve a perceived defect/flaw).

  • Clinical pearls specific to excoriation -> may occur from any area of the body but most frequently the face, hands, fingers, arms, and legs; average of 4.5 sites; rule out skin picking secondary to substance abuse (ex: cocaine), another medical condition (ex: scabies; dermatologic conditions), and psychiatric conditions (ex: body dysmorphic disorder or tactile hallucinations).



TREATMENT 9, 10


  • Treatment for all OCD and related disorders are similar, so we have written a detailed post titled "Treatment of OCD" where we discuss treatment options in detail. Please refer to that post for a more thorough discussion.

  • Psychotherapy: Both trichotillomania and excoriation disorder are treated with a specialized form of CBT called habit reversal therapy (HRT). Core elements of treatment include psychoeducation, awareness training, competing response training, and social support. Stimulus control is also utilized to change the patients environment, so that hair-pulling and skin picking requires more effort and is less reinforcing. Other therapies have some evidence to include dialectical behavior therapy (DBT) and acceptance and commitment therapy (ACT).

  • Pharmacotherapy: SSRIs (or clomipramine) are first-line medications for OCD and related disorders including trichotillomania and excoriation disorder. The evidence, unfortunately, has not consistently demonstrated a robust treatment response. Other, more experimental, drugs used in the treatment of these disorders includes venlafaxine, antipsychotics (ex: olanzapine), N-Acetylcysteine (NAC), lamotrigine, naltrexone, and inositol. See pharmacotherapy section in the "Treatment of OCD" lesson to see additional details.



CONCLUSION


Great work today. This is the last lesson of our current theme of OCD and related disorders. Next up will be a review quiz and after that we will move on to our next theme of trauma and adjustment disorders.


Resources for today's post include: Kaplan and Sadock's Comprehensive Textbook of Psychiatry, DSMV, and First Aid for the Psychiatry Clerkship.













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