Correspondence
Long-Term Treatment of Trichotillomania (Hair Pulling)
N Engl J Med 1993; 329:141-142July 8, 1993
- Article
To the Editor:
In 1989 we reported that clomipramine was superior to desipramine in reducing hair-pulling symptoms in trichotillomania1. Three of the 13 subjects completing the initial double-blind crossover trial had complete remissions during the five weeks of clomipramine treatment, and 9 had at least a 50 percent reduction in the severity of symptoms. These benefits were maintained for six months. The chronicity of the disorder and reports of relapses after prolonged drug treatment1-3 raised the question of long-term outcome.
Follow-up information was obtained, by in-person interviews at 2 to 3 years and telephone updates at 4.3 ±0.6 years (range, 3.5 to 5.3), from the first 16 women with trichotillomania who were treated in our clinic, including the 13 reported on in 1989. Improvement (or worsening) was defined on the basis of the mean percent change from base line in the scores on three rating scales: the trichotillomania symptom-severity scale, the trichotillomania global-impairment scale, and the physician's rating of clinical progress1.
For the group as a whole, there was a 40 percent (moderate) reduction in the severity of symptoms at a mean of 4.3 years of follow-up. One patient had a complete remission after medication was withdrawn; however, all the other patients required continued treatment to reduce symptoms. As at base line, coexisting psychopathologic conditions appeared to influence symptom status1. Patients with an anxiety disorder or borderline personality disorder had poorer outcomes (e.g., 7.5 percent mean improvement for those with a borderline personality disorder as compared with 50 percent for other patients). The subjects were evenly divided between those without discernible long-term benefit (seven patients) and those with at least moderate improvement (seven patients); two additional patients had minimal improvement. Seven patients were receiving medication at follow-up. Interim treatments included psychotherapy (2 patients), behavior therapy (6), and a variety of medications (alone or in combination with other drugs), including clomipramine (11) and fluoxetine (10) (both selectively block the reuptake of serotonin), lithium (2), buspirone (3), and fenfluramine (1). Adverse effects during drug therapy included weight gain, dry mouth, and sedation. No subjects reported reduced sexual response, which is a point of concern during the long-term administration of serotonin-reuptake blockers.
These results suggest that pharmacotherapy with serotonin-reuptake blockers may be of long-term benefit to some patients with trichotillomania. On the basis of our clinical experience with more than 60 patients with trichotillomania,4 we believe that a combination of drug treatment and behavior therapy may provide maximal benefit.
4 ReferencesSusan E. Swedo, M.D.
Marge C. Lenane, M.S.W.
Henrietta L. Leonard, M.D.
National Institute of Mental Health, Bethesda, MD 208921
Swedo SE ,Leonard HL ,Rapoport JL ,Lenane MC ,Goldberger EL ,Cheslow DL . A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling). N Engl J Med 1989;321:497-501
Full Text | Web of Science | Medline2
Azrin NH ,Nunn RG ,Frantz SE . Treatment of hairpulling (trichotillomania): a comparative study of habit reversal and negative practice training. J Behav Ther Exp Psychiatry 1980;11:13-20
CrossRef | Web of Science3
Pollard CA ,Ibe IO ,Krojanker DN ,Kitchen AD ,Bronson SS ,Flynn TM . Clomipramine treatment of trichotillomania: a follow-up report on four cases. J Clin Psychiatry 1991;52:128-130
Web of Science | Medline4
Swedo SE ,Leonard HL . Trichotillomania: an obsessive compulsive spectrum disorder? Psychiatr Clin North Am 1992;15:777-790
Web of Science | Medline
- Citing Articles (21)
Citing Articles
1
Jon E. Grant, Brian L. Odlaug, Samuel R. Chamberlain, Suck Won Kim. (2011) Dronabinol, a cannabinoid agonist, reduces hair pulling in trichotillomania: a pilot study. Psychopharmacology 218:3, 493-502
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Arnold P. Oranje, Jeroen Novak, Robert A. C. Bilo. 2011. Physiological Habits, Self-Mutilation and Factitious Disorders. , 180.1-180.14.
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Danny C. Duke, Mary L. Keeley, Gary R. Geffken, Eric A. Storch. (2010) Trichotillomania: A current review. Clinical Psychology Review 30:2, 181-193
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Yvonne R.A. van Zeeland, Berry M. Spruit, T. Bas Rodenburg, Bernd Riedstra, Yvonne M. van Hierden, Bart Buitenhuis, S. Mechiel Korte, Johannes T. Lumeij. (2009) Feather damaging behaviour in parrots: A review with consideration of comparative aspects. Applied Animal Behaviour Science 121:2, 75-95
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Catherine Mancini, Michael Van Ameringen, Beth Patterson, William Simpson, Christine Truong. (2009) Trichotillomania in youth: a retrospective case series. Depression and Anxiety 26:7, 661-665
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Lucinda S. Buescher, David Resch. 2008. The Biopsychosocial Aspects of Hair Disease. , 267-275.
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Deborah E Sah, John Koo, Vera H Price. (2008) Trichotillomania. Dermatologic Therapy 21:1, 13-21
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David F. Tolin, Martin E. Franklin, Gretchen J. Diefenbach, Emily Anderson, Suzanne A. Meunier. (2007) Pediatric Trichotillomania: Descriptive Psychopathology and an Open Trial of Cognitive Behavioral Therapy. Cognitive Behaviour Therapy 36:3, 129-144
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Shapiro, Jerry, . (2007) Hair Loss in Women. New England Journal of Medicine 357:16, 1620-1630
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Michael H. Bloch, Angeli Landeros-Weisenberger, Philip Dombrowski, Ben Kelmendi, Ryan Wegner, Jake Nudel, Christopher Pittenger, James F. Leckman, Vladimir Coric. (2007) Systematic Review: Pharmacological and Behavioral Treatment for Trichotillomania. Biological Psychiatry 62:8, 839-846
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Douglas W. Woods, Christopher Flessner, Martin E. Franklin, Chad T. Wetterneck, Michael R. Walther, Emily R. Anderson, Dodanid Cardona. (2006) Understanding and Treating Trichotillomania: What We Know and What We Don't Know. Psychiatric Clinics of North America 29:2, 487-501
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Kelda H Walsh, Christopher J McDougle. (2005) Pharmacological strategies for trichotillomania. Expert Opinion on Pharmacotherapy 6:6, 975-984
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Hani Raoul Khouzam, Matthew A. Battista, Phyllis E. Byers. (2002) An Overview of Trichotillomania and Its Response to Treatment with Quetiapine. Psychiatry: Interpersonal and Biological Processes 65:3, 261-270
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Susan Boughn, Julie Ann Jaarsma Holdom. (2002) Trichotillomania: Women's reports of treatment efficacy. Research in Nursing & Health 25:2, 135-144
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Kelda H. Walsh, Christopher J. McDougle. (2001) Trichotillomania. American Journal of Clinical Dermatology 2:5, 327-333
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Gretchen J Diefenbach, David Reitman, Donald A Williamson. (2000) Trichotillomania. Clinical Psychology Review 20:3, 289-309
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David Taylor. (2000) Unnatural injuries. Eye 14:2, 123-150
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Angela M. Neal-Barnett, Brenda J. Ward-Brown, Michelle Mitchell, Michael Krownapple. (2000) Hair-pulling in African Americans--Only your hairdresser knows for sure: An exploratory study.. Cultural Diversity & Ethnic Minority Psychology 6:4, 352-362
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Dan J. Stein, Colin Bouwer, Catherine M. Maud. (1997) Use of the selective serotonin reuptake inhibitor citalopram in treatment of trichotillomania. European Archives of Psychiatry and Clinical Neuroscience 247:4, 234-236
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Iulian Iancu, Abraham Weizman, Seth Kindler, Yehuda Sasson, Joseph Zohar. (1996) Serotonergic Drugs in Trichotillomania: Treatment Results in 12 Patients. The Journal of Nervous & Mental Disease 184:10, 641-644
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Barbara Olasov Rothbaum, Philip T. Ninan. (1994) The assessment of trichotillomania. Behaviour Research and Therapy 32:6, 651-662
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