________________________________________________________________________ Behavioral Addictions
• Recurrent pulling out of one’s hair, resulting in hair loss • Repeated attempts to decrease or stop hair pulling • The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning • The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatologic condi- tion) • The hair pulling is not better explained by the symp- toms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder) TREATMENT Persons with trichotillomania rarely seek professional mental health treatment, largely due to concerns that providers do not understand the disorder or fears over the reactions of professionals. Others avoid seeking help from social embarrass- ment, believing their condition is just a bad habit or that it is untreatable. With early diagnosis and appropriate treatment, up to 50% of patients may attain at least short-term symptom reduction [307]. As noted, trichotillomania often co-occurs with anxiety disor- ders, and persons with trichotillomania frequently report their hair-pulling worsens during increased anxiety. Adult patients with trichotillomania and comorbid anxiety disorders show significantly worse hair pulling symptoms, are likely to have co-occurring depression and first-degree relatives with OCD, and show significantly worse motor inhibition. Male patients with trichotillomania are more likely to have substance use disorder comorbidity, older age, and marriage status than female patients [313; 327]. Psychological Interventions The evidence base for psychotherapy in trichotillomania is small, and habit reversal therapy has the greatest empirical support. Habit reversal therapy is a behavioral therapy initially introduced for the treatment of nervous habits and tics. The core components of habit reversal therapy include self-monitor- ing (e.g., asking the patient to track hair-pulling or skin-picking events), awareness training, competing response training, and stimulus control procedures (e.g., removing hair-pulling or skin-picking cues from the patient’s environment) [322]. Habit reversal therapy is generally delivered in weekly 60-min- ute sessions for 4 to 22 weeks, with more frequent sessions for patients with greater symptom severity. It can be delivered individually, in a group format, or online using a self-help manual [328]. The clinical benefits of trichotillomania symp- tom reduction have been augmented by adding components of acceptance and commitment therapy or dialectical behavior therapy [329; 330]. Patient gains from habit reversal therapy
are usually maintained for three to six months. Many clinicians combine habit reversal therapy and CBT, but published data support habit reversal therapy use as a stand-alone, first-line psychotherapy approach in trichotillomania [307]. One small study reported success combining metacognitive therapy with habit-reversal techniques for treatment of trichotillomania [331]. Pharmacologic Interventions The classification of trichotillomania as an OCD-spectrum dis- order has interfered with identifying effective drug treatment. SSRIs have been repeatedly evaluated in trichotillomania, without benefit [308]. The only antidepressant with partial efficacy in trichotillomania is clomipramine, a tricyclic agent [332]. An update of this review found that while there may be beneficial treatment effects for NAC, clomipramine, and olanzapine in adults, the results were based on small sample sizes [333]. Clinical experience and results from a single clinical trial indi- cate that NAC (1,200 mg twice daily) can reduce hair-pulling urges and may be considered as initial pharmacotherapy. Importantly, NAC may require daily adherence for up to nine weeks for benefits to appear. NAC is well-tolerated, with gen- erally mild side effects of abdominal bloating and flatulence [334]. An updated literature review found that while NAC has proven successful for treatment of trichotillomania, the data are derived from few clinical trials and case reports assessing small numbers of patients [335]. The atypical antipsychotic olanzapine was evaluated over 12 weeks (mean dose: 10.8 mg/day) and showed significant reduc- tions in trichotillomania symptoms compared with placebo [336]. The propensity to cause metabolic syndrome requires that benefits be carefully weighed against this drug’s side effect profile [307]. Dronabinol is synthetic delta-9 tetrahydrocannabinol (THC), the primary psychoactive constituent of cannabis. THC binds to cannabinoid receptors (CB); CB1 receptor activation inhibits glutamate overproduction and resultant excitotoxicity implicated in trichotillomania [308]. A 12-week uncontrolled trial of dronabinol (mean dose: 11.6 mg/day) led to marked reductions in trichotillomania symptoms. Side effects of mild sedation were reported, and no significant effects were found on memory, attention, executive function, or psychomotor speed [337]. Thirty-four adults with trichotillomania were recruited for a randomized, double-blind, placebo-controlled study. Participants received 10-week treatment either with dronabinol (5–15 mg/day) or placebo. Both dronabinol and placebo treatment were associated with significant reductions in symptoms, but dronabinol did not differ significantly from placebo on any measure of efficacy [338].
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