Comprehending trichotillomania.

Sir,

Trichotillomania (TTM) is an impulse control disorder characterized by hair-pulling, with a rising urge or tension prior to pulling or when attempting to resist, and pleasure, relief or gratification during or after pulling. It is a debilitating condition causing significant functional impairment apart from noticeable hair loss. Serotonergic and dopaminergic dysfunction are implicated in the pathophysiology of TTM. Disorganization of white matter tracts involved in motor habit generation and suppression, along with affective regulation is believed to occur in TTM. In a study subjects with trichotillomania exhibited significantly reduced fractional anisotropy in anterior cingulate, presupplementary motor area, and temporal cortices.[1]

A study sought to examine the nature of attentional processing toward hair cues among individuals with TTM. An exogenous cueing task that presented hair cues, general threat cues, and neutral cues at three varying stimulus durations (250 ms, 500 ms, and 1500 ms) showed that individuals with TTM showed enhanced attentional disengagement from hair cues at later stages of attentional processing (i.e., 1500 ms). Also the magnitude of attentional avoidance from hair cues was significantly associated with TTM severity. This may reflect the individual's effort to down-regulate negative emotions associated with the pulling-related cues.[2]

Dialectical behavior therapy (DBT)-enhanced habit reversal treatment (HRT) offers promise for improved long-term treatment results in TTM. A study reported that following DBT-enhanced HRT, significant improvement was seen from baseline at 3- and 6-month follow-up on all measures of hair pulling severity and emotion regulation. Significant correlations were reported at both follow-up time points between changes in hair pulling severity and emotion regulation capacity.[3] Behavioral therapy (BT) was tested against minimal attention control (MAC) and was found that with BT the 8th week mean National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS) score was significantly lower than that of the MAC condition. Upon completion of acute treatment at week 8, the BT group's gains were maintained through an 8-week maintenance treatment phase.[4]

Dronabinol, a cannabinoid agonist, may reduce the excito-toxic damage caused by glutamate release in the striatum and offers promise in reducing compulsive behavior. In a study use of dronabinol (11.6±4.1 mg/day) decreased Massachusetts General Hospital Hair Pulling Scale (MGH-HPS) scores from a mean of 16.5±4.4 at baseline to 8.7±5.5. About 64% responded with ≥35% reduction on the MGH-HPS and “much or very much improved” Clinical Global Impression scale.[5]

Aripiprazole, a D2 partial agonist, was tested in an 8-week, open-label, flexible-dose study (7.5 mg/d) in the treatment of TTM. There was a significant mean reduction in both Massachusetts General Hospital Hair Pulling Scale (MGHHPS) and MGHHPS Actual Pulling Subscale (MGHHPS-APS).[6]

In another study, olanzapine (10.8±5.7 mg/d), showed significant improvement of TTM (responders) as per Clinical Global Impressions-Improvement (CGI-I) scale. There was a significant change from baseline to end point in the Yale-Brown Obsessive Compulsive Scale for Trichotillomania (TTM-YBOCS) and the Clinical Global Impressions-Severity of Illness (CGI-S) scale.[7] Methylphenidate also showed some efficacy in TTM.

Our understanding of TTM has been improving and the results of research studies have enabled us better options to manage this once perplexing entity.