Article Topic: Exploring the Therapeutic Aspects of Trichotillomania.
Author: Amani Alfdool.
Editor: Rahmeh Adel.
Reviewer: Ethar Hazaimeh

Keywords: Trichotillomania, Habit Reversal Training, Hair pulling, Psychocutaneous, Repetitive compulsive behavior.

Abbreviation: Trichotillomania (TTM), Obsessive-Compulsive Disorder (OCD), Habit Reversal Training (HRT).

Abstract

Trichotillomania is a psychocutaneous condition characterized by repetitive compulsive pulling out of one’s hair, associated with hair loss and functional impairment. The pathophysiology of trichotillomania is poorly understood and is thought to involve changes in both neural activity and cognitive function. Even though trichotillomania was recently grouped with OCD in the DSM-5, treatment approaches can differ from those used to treat OCD behavioral treatment options are limited and showed only modest efficacy. Additionally, no medications have been approved by the U.S. Food and Drug Administration for its treatment. This article aims to provide a comprehensive review of pharmacological agents that have demonstrated efficacy in individual randomized clinical trials, as well as the use of habit reversal training (HRT) for trichotillomania (TTM) management.

Overview

Trichotillomania, characterized by recurrent pulling out of one’s hair, is classified as a dermatological-psychiatric disorder that results in marked functional impairment and decreased quality of life. (1) Individuals affected by trichotillomania tend to have repetitive compulsive behavior to pull out their hair usually from the scalp, eyebrows, eyelashes, or elsewhere, that results in noticeable hair loss. (2)

Since the 19th century, trichotillomania has been documented in medical literature. (3) However, it was not officially involved as a mental health disorder in the American Psychiatric Association’s Diagnostic and Statistical Manual until the DSM-III-R (1987). (4) With the release of the DSM-5, Trichotillomania was reclassified as a part of the chapter on obsessive-compulsive and related disorders, such as obsessive-compulsive disorder (OCD), excoriation disorder, body dysmorphic disorder, and hoarding disorder. (5) The current diagnostic criteria for trichotillomania include the following: 1) irresistible act of pulling out one’s hair, resulting in hair loss; 2) multiple attempts to decrease or stop hair pulling; 3) the hair pulling causes clinically noticeable distress or impairment in social, occupational, or other important areas of functioning; 4) the hair pulling or hair loss is not related to another medical condition such as a dermatological condition; 5) the hair pulling is not more accurately explained by the symptoms of another mental disorder (for instance, attempts to improve a perceived defect or flaw in appearance associated with body dysmorphic disorder). (6)

Although trichotillomania is recognized as a distinct disorder, recent studies have revealed the presence of three subtypes within this condition: sensory-sensitive pullers (Subtype 1), low-awareness pullers (Subtype 2), and impulsive/perfectionist pullers (Subtype 3). (3) Trichotillomania often presents with other mental health disorders (7). The presence of comorbid conditions, especially anxiety disorders and obsessive-compulsive disorder (OCD), plays a significant role in determining a patient’s functional impairment. (8) Recent studies indicate that natural recovery from trichotillomania; defined as the resolution of symptoms without therapy or medication correlates with significantly lower rates of comorbid conditions. (9) Therefore, it is important to address the comorbid conditions associated with trichotillomania to ensure comprehensive care and enhance treatment outcomes. (10)

The management of trichotillomania employs a multimodal approach that involves both behavioral and pharmacological methods. Although various behavioral and pharmacological therapies have been recognized as possible options for improving the symptoms of trichotillomania, further large-scale randomized trials are required to understand their efficacy and safety profiles fully. Presently there are no medications have been approved by the U.S. Food and Drug Administration specifically for the treatment of trichotillomania. (10)

Habit Reversal Training

The treatment of trichotillomania (TTM) demonstrates significant challenges. Current research suggests that cognitive behavioral therapy with habit reversal training components (BT‐HRT) is effective. (11) Habit reversal training consists of three main components: (a) awareness training, which involves self‐monitoring techniques to determine urges and hair-pulling behaviors, (b) competing response training, aimed at developing alternative behaviors that physically prevent hair-pulling whenever individuals experience the urge or initiate the hair pulling, and (c) social support and involvement of important individuals to ensure adherence to BT‐HRT. (12)

The initial step in the process involves educating the patients about HRT and helping them recognize their behaviors. This includes identifying their hair-pulling habits and acknowledging them. Subsequently, the patient is then made aware of any activities that may trigger the repetitive behavior occurrence. Additionally, this phase includes self-monitoring and documenting when the repetitive behavior occurs. (13) Increased self-awareness among patients can help them identify triggers of their behaviors. Stimulus control is a key component of HRT that aims to decrease stimuli that may lead to repetitive behavior. If an individual realizes that they pull their hair during a specific activity, then it may be beneficial to recommend the patient to avoid that activity. Thus, awareness is an essential part of HRT because one must be aware of the situations that increase their repetitive behaviors. Relaxation training also plays an important role in reducing the urge, and stress that can be a trigger for a repetitive behavior. Practicing relaxation techniques can also be used to change one’s behavior in a calm state, reducing the likelihood of unwanted actions. (14)

The next step involves the competing response phase. This approach helps patients practice strategies in response to an event that may trigger hair-pulling or repetitive behavior. Various approaches and strategies include fist clenching, using stress balls, sitting on hands, or clapping. The goal for these responses is to be discrete and non-harmful. (15) Additionally, identifying a social support person is important for patients. This person would offer encouragement when the patient successfully performs the competing response and provide feedback for any mistakes. The competing response can also be beneficial as it helps the patients to understand that their urges will subside over time, even if they do not perform the hair-pulling. (16) Self-monitoring demonstrates a beneficial effect in HRT. (14)

Patients are encouraged to maintain a comprehensive record of each hair-pulling or repetitive behavior incident, including detailed information about the incident, such as the time, context, and any related emotions. Self-monitoring also involves addressing issues with the therapist or clinician when certain behaviors have occurred. A team approach is important where the clinician and patient work together to develop techniques aimed at minimizing unwanted behaviors. (16)

Relapse in HRT can happen even with all these strategies and techniques, There are several approaches clinicians can take when such an event occurs. Initially, highlighting the patient’s progress in reducing the behavior and how it was a result of their behavior. (17) Another strategy is to encourage the patient to examine why the event occurred, rather than amplifying its significance. This can help them to carry out further changes to prevent similar behaviors in the future. Additionally, the patient may even need to consider lifestyle modifications, such as changes in occupation or social activities to enhance the effectiveness of their treatment. (14)

Pharmacological Treatment

When considering medications, there are no pharmacological treatments widely recognized as first-line options for trichotillomania. (18) However, several different pharmacological agents have been studied. Early studies focused on agents employed for the treatment of obsessive‐compulsive disorder, including clomipramine (CMI) and selective serotonin reuptake inhibitors. (11,19) Recent randomized controlled trials (RCTs) have evaluated additional agents that might be involved in TTM pathophysiology, including glutamatergic modulators (N‐acetylcysteine), and opioid antagonists (naltrexone). (20–22) Additionally, Selective serotonin reuptake inhibitors (SSRI) and other medications that inhibit serotonin reuptake, such as the tricyclic antidepressant and monoamine oxidase inhibitors, have been studied as treatment options in patients with trichotillomania. (23)

Findings from multiple randomized controlled trials (RCT) indicate that behavioral therapy or a combination of behavioral therapy and medication is more effective for trichotillomania than SSRIs alone. (24) One 12-week study of 43 patients with trichotillomania receiving either behavioral therapy or fluoxetine found that patients who underwent behavioral therapy had significantly greater improvement in symptoms compared to those treated with fluoxetine. (24) In addition, a 9-week, placebo-controlled, randomized trial involving 23 patients found that those receiving cognitive behavioral therapy (CBT) demonstrated greater improvements than those receiving medication. Moreover, clomipramine did not prove to be significantly more effective than placebo in reducing trichotillomania symptoms. (25)

Alternative pharmacotherapeutic options for trichotillomania treatment include antipsychotic medications, particularly atypical antipsychotic olanzapine which has been studied the most. A 12-week randomized controlled trial evaluating olanzapine for the management of trichotillomania revealed that a significant percentage of patients receiving olanzapine had positive treatment responses compared to those on placebo. (26) Similarly, an open-label, flexible-dose study involving 18 adult patients with trichotillomania found that monotherapy with olanzapine (administered at doses up to 10 mg/day) resulted in a 66% reduction in hair-pulling behaviors from baseline (p < 0.001) and a 63% decrease in mean anxiety scores (p < 0.05). (27)

Other atypical antipsychotics, such as aripiprazole and quetiapine, have been studied, though not as extensively. Aripiprazole’s capability to alter dopamine signaling and the brain reward systems linked to hair-pulling behavior makes it a promising therapeutic option for trichotillomania. An 8-week open-label study involving 12 adults treated with aripiprazole revealed a significant average decrease in hair-pulling behaviors at the end of the treatment period compared to the initial assessment. (28) Limited case reports suggest that quetiapine may also reduce hair-pulling behavior in adults suffering from trichotillomania. (29)

Glutamate modulators, such as N-acetylcysteine and memantine, have also been studied for their potential in treating trichotillomania. These compounds may help reduce compulsive behaviors by enhancing glutamate activity in the nucleus accumbens. (21) A recent randomized controlled trial by Grant et al. assessed memantine’s effectiveness in decreasing hair-pulling and skin-picking behaviors. In this study, one hundred participants were randomly assigned to receive either memantine or placebo over 8 weeks. The findings demonstrated that those treated with memantine have significant improvements in symptom severity, disability, and overall impressions compared to the placebo group. (30) Additionally, in a 12-week double-blind, placebo-controlled trial involving 50 adults with trichotillomania, participants treated with N-acetylcysteine had significantly greater reductions in trichotillomania symptoms, with clinical improvements observed as early as 9 weeks after starting treatment. (21)

Several other medication classes are being explored as possible treatments for trichotillomania. A case study highlighted the effectiveness of valproate, an anticonvulsant, in a 13-year-old patient with persistent motor tic disorder and trichotillomania. Monotherapy with valproate (1,200 mg daily) resulted in a reduction in both the severity and frequency of tics as well as a marked decrease in hair-pulling behavior. (31) Naltrexone, an opioid antagonist, is utilized in the treatment of alcohol dependence due to its effects on the limbic system. Its ability to influence reward pathways has made it an agent of interest for treating other impulsion-driven behaviors, including trichotillomania, or hair-pulling. (32) However, research on naltrexone’s effectiveness for trichotillomania treatment is limited, and the results vary. In an open-label pilot study involving 14 participants with adult-onset trichotillomania, 11 of them were found to show positive changes in their hair-pulling behaviors after receiving naltrexone. (33)

Another cannabinoid agent, dronabinol, may reduce glutamate-induced neuronal excitation when taken orally, which aids in reducing compulsive behaviors linked to trichotillomania symptomatology. In an open-label treatment trial of 14 female patients with trichotillomania, significant reductions in hair pulling after 12 weeks of treatment were recorded. (34)

Conclusion

Trichotillomania is a chronic condition that frequently causes significant psychosocial dysfunction and that can, in rare cases, lead to life-threatening medical issues. Managing hair pulling is therefore critical for maintaining long-term health and enhancing the quality of life.

Although it has recently been recognized as a distinct disorder, there are still considerable gaps in knowledge regarding its underlying pathophysiology, diagnostic criteria, and effective treatment options. Many different treatment approaches have been introduced to reduce these repetitive behaviors. While pharmacological interventions have shown mixed results, they tend to be more effective with comorbid depression, anxiety, and OCD. Further trials are required to identify other effective medications for TTM and to assess the relative effectiveness of current options. Among psychotherapies, habit reversal training HRT has demonstrated the most success rates in treating trichotillomania and has the strongest evidence base for reducing trichotillomania symptoms.

References

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