Christenson G. A., Pyle, R. L., Mitchell, J. E (1991) Estimated lifetime prevalence of trichotillomania in college students, The Journal of Clinical Psychiatry, 52, 10, 415–417.
Tricho is known to not last a person's whole lifetime. It is most prevalent in preteen through teen years, and often continues into one's early twenties. But it is usually gone by the time the person is in their mid-20s. This study was done with the DSM-III definition of TTM. Surveys were given out to college freshmen in 2 different states, and they were asked questions about whether or not elements of the DSM-III diagnosis of trichotillomania applies to them. 3 years after graduating, the same students were given the same survey, and asked to report about their symptoms to see if any were still remaining. A 1.6% lifetime presence of tricho was found among over 2000 students. Hair pulling in general was found in 1.5% of males and 3.4% of the females who answered the survey, but it was not up to code with the DSM-III definition of TTM. The researchers concluded that trichotillomania is not as rare as they previously thought, and noted its presence in both males and females. They also concluded that TTM is not a lifelong struggle.
2. Diefenbach G, S. Mouton-Odum, M. A. Stanley (2002) Affective correlates of trichotillomania, Behaviour Research and Therapy, 40, 1305-1315.
This study was done in order to establish if there are any affective states (emotions) attached to trichotillomania. In this study, 44 people diagnosed with trichotillomania were asked to complete the Hair Pulling Survey before, during, and after an episode of hair pulling. The results of the study concluded that there are senses of boredom and guilt related to trichotillomania, before and after pulling, respectively. The guilt rises from the participant knowing what they did and feeling like it may have altered their appearance in an unfavorable way, which can happen if, for example, someone pulls out so much scalp hair they create a bald spot, or if they pull out all of their eyelashes, or most if not all of an eyebrow. Boredom is associated with focused pulling, when the person is aware of what they are doing, and typically remove pieces of hair with differing textures to the rest. It also may become another activity for the person to do when they are feeling bored. Other feelings associated with trichotillomania are relief during pulling, and reduced tension and anxiety afterwards. Many people pull as a stress/anxiety response, and feel calmer after pulling; it supposedly alleviates some of the stress the person was going through. But, feelings of sadness and anger were multiplied through this experience. The person may feel upset and angry with themself for pulling, especially if they are in therapy or in some other way are actively trying to break the habit. They also might feel like they let their family/other important people in their life down by pulling. If a patient goes a long time without pulling, then one day cannot control themself and pulls out a lot of hair, they may grow disheartened and wonder why they ever tried to stop in the first place; if the patient feels like they cannot control themself, they may not be able to, and may struggle to suppress TTM-related urges.
3. Grant J, Darian D, Samuel C (2020) Prevalence, gender correlates, and co-morbidity of trichotillomania, Psychiatry Research, 288.
Many previous studies were done on trichotillomania, and it seems that many had conflicting results on whether trichotillomania is more present in males or females, and generally how prevalent it is in similar areas. So, this study aims to make a more representative investigation into TTM, and form a general conclusion about tricho's prevalence, and correlations to other disorders, and gender. 10,169 people ages 18-69 were given a two-part online survey: part 1 was screening for TTM and gathering background on the participants (age, gender, etc), and part 2 was for people who answered that they exhibited symptoms of tricho. 1.7% of the sample had TTM, and there was no statistically significant difference between the number of males and females with the disorder. But, within those two groups, the females had more severe instances with TTM, and reported a greater impact on their lives than the males. The prevalence of trichotillomania was greater in age groups below 50 years old. Anxiety disorders (53%) are the most common comorbid disorders with this group, then depression (45%), then ADHD (29%), PTSD (29%), and OCD (29%), and finally, skin-picking disorder (24%). Many other studies in the past supported the idea that TTM is more common in women than men, and some smaller studies, along with this one, proved that it is more equal than we thought. So, a study this wide showing these results is huge support for the men who may have been afraid to speak out since TTM was associated with women, as well as potentially providing support for all the women who have the disorder as well. The majority of people with comorbid disorders in this study noted the hair-pulling as more distressing and annoying than their other disorder, even with depression. This is huge, as the other disorders the people in this study had are much more well-known and well-researched; if this could bring more awareness to TTM, there could potentially be some sort of cure in the future, rather than just waiting for the hair pulling urges to deplete on their own.
4. Kurien B, Tim G, Hal S (2005) Barbering in mice: a model for trichotillomania, BMJ, 331, 1503-1505.
Barbering is basically trichotillomania but in animals, specifically, mice in this study. Barbering is considered "excessive grooming causing hair loss" and tricho is "uncontrollable hair pulling". Barbering in mice is so similar to trichotillomania that it is considered a useful model of TTM, and can be an advantageous way of looking at the difficult disorder. Humans aren't always the easiest or most willing to study, and animals can be especially raised to live and work well in a lab, so they are more easy to work with, especially in this study. Both barbering in mice and trichotillomania in humans can lead to alopecia, a more serious fur or hair loss disorder. In the mice, barbering is when one mouse pulls out another mouse's whiskers or fur, so it's more involved than human trichotillomania, but is still useful for research into whether TTM is sex-linked, or if there are any brain abnormalities in any of the mice. Removing concentrated areas of hair is a common feature of both barbering and TTM, as well as spontaneous development (most common in puberty), and greater presence in females. In mice, a mutated Hoxb8 gene is associated with TTM; no such mutation has been found in humans. This mutation causes fur removal in the mouse itself, as well as barbering other mice.
5. Chamberlain S, Naomi F, Andrew B, Trevor R, Barbara S (2006) Motor Inhibition and Cognitive Flexibility in Obsessive-Compulsive Disorder and Trichotillomania, American Journal of Psychiatry, 163, 1282-1284.
Obsessive-compulsive disorder has a spectrum of related disorders, each accompanied with their own obsessions and compulsions. Most notable from these are trichotillomania, excoriation (skin-picking disorder), and body dysmorphia. OCD and trichotillomania share concerns with the person's inability to regulate their motor functions. With trichotillomania, this is seen mostly in automatic hair pulling, which is when the person is pulling their hair out without realizing they're doing it; the inability to stop pulling once it has started is also indicated by TTM's association with motor functioning issues. In the DSM-IV, OCD is described with recurring thoughts and actions that carry out those thoughts, usually kept to a strict routine. Theories have been formed about attempting to stop those behaviors with a change of attention--if the person can't focus on their thoughts because they're thinking about or doing other things, then they can't carry out those thoughts through actions, either. The Stop-Signal Task was used in this study: it is supposed to measure how long it takes to mentally block the desire to carry out motor actions. The Stop-Signal Task is a test on the computer in which patients view left/right arrows and hit the corresponding keyboard button, and are supposed to hit no button when an audio prompt is played.
It was found that participants with TTM took the longest time to respond to the "stop" audio prompt, as opposed to the OCD and control groups. The OCD group took the second longest time to respond, and the controls responded the fastest, by not pressing any button. These results imply that trichotillomania is a difficult motor function to attempt to suppress, and people with the disorder struggle to do so.
6. Fine K, Michael W, Jessica J, Jordan R, Emily R, William B, Douglas W (2012) Acceptance-Enhanced Behavior Therapy for Trichotillomania in Adolescents, Cognitive and Behavioral Practice, 19, 463-471.
Most research on trichotillomania has been done with adults, even though the most common demographic for the disorder is adolescents and young adults. Habit Reversal Training (HRT, self-explanatory) is the most common nonpharmacological treatment for TTM. Habit Reversal Training encapsulates 3 steps-awareness, competing response, social support training. HRT has previously been found to reduce trichotillomania symptoms in adults, and typically works best to decrease automatic pulling. Focused pulling is thought to have some sort of emotional component, and HRT doesn't combat those, so it doesn't work as well with focused pulling. Combining HRT & Acceptance and Commitment Therapy (ACT), the Acceptance-Enhanced Behavior Therapy (AEBT) method was formed. AEBT has been proven to work in adults, decreasing the number of hairs pulled, severity of pulling episodes, experiental avoidance, and anxiety & depression symptoms.
AEBT is a 10-session program, with psychoeducation about TTM, learning stimulus control and habit reversal training, and learning relapse prevention tips. Each session gets more intense, and it is supposed to make it more difficult for people to pull in between each meeting. The toughest part of this process was making the adolescents understand that the urge to pull hair wasn't the issue, but their attempt to control that urge was. It was found that AEBT works for decreasing adolescents with TTM pulling their hair out, but not as well as it did for the adults. This may be due to the adolescents being unable to repress the urge to pull out hair, or a lack of thorough understanding if the disorder was not simplified enough for their comprehension
7. Keuthen N, Nikos M, John S, Brian M, Cary S, Katherine M, Larry S, Jeremy S, David K, Steven H, Scott R (2007) Evidence for Reduced Cerebellar Volumes in Trichotillomania, Biological Psychiatry, 61, 3, 374-381.
Trichotillomania has a negative impact on aspects of people's psychosocial functions, such as relationship conflicts, social withdrawal, avoidance of liesure activities, and limitations in career choice.
This study focused on the cerebellum because it regulates and coordinates movement and balance. A huge part of TTM is the movement/motor routine that is pulling out hair, and the researchers theorized that there might be a difference in cerebellar size between people with and without trichotillomania. MRI scans were used to see structural differences in the cerebellum between 14 TTM and 12 NC (normal control) participants. As expected, there were differences in the structures--those with TTM had smaller cerebellar and cortical volumes. The emotional/autonomic had a noticably smaller size in people with trichotillomania--this plays into what we already know about the disorder having ties to emotions. People often pull out their hair to alleviate stress (autonomic/emotional), or because they're feeling discomfort with their hair/appearance (emotional). There is typically a sense of relief or satisfaction after an episode of pulling, which also ties into TTM's emotional aspect, as well as tension and discomfort going as far as anger and an inability to control when attempting to deny the urge to pull hair. A correlation was found between a smaller left primary sensorimotor cluster in the cerebellum and more severe TTM symptoms. Does not equal causation though. This correlation is not to be ignored, though, as a huge aspect of trichotillomania is focused pulling, or pulling out hairs because they have a different length or texture. The left primary sensorimotor cluster may come into play here, as it has previously been established with upper limb movement, such as arms and hands. Everyone in this study was right-handed, and all stated that they most commonly pull their hair with their nondominant (left) hand, as to not mess with their dominant hand's actions. There is no established hand dominance for hair pulling in TTM, but this definitely opens opportunities for studies of that kind.
8. O' Sullivan R, Scott R, Hans B, Igor G, Lee B, David K, Nancy K, Cary S, Peter M, Verne C, Michael J (1997) Reduced Basal Ganglia Volumes in Trichotillomania Measured via Morphometric Magnetic Resonance Imaging, Biological Psychiatry, 42, 39-45.
The theories for this study are based on another study on Tourette's Syndrome, in which positive correlations were found in the ventral striatum and the sensorimotor cortex in people with Tourette's, and a negative correlation was found in the control groups. Tourette's, Obsessive-Compulsive Disorder, and trichotillomania have been linked by many previous studies, so the aforementioned Tourette's study provoked these researchers to see if there are other brain structure abnormalities in people with TTM specifically. They took MRIs of 20 women total, 10 with and 10 without tricho. These images showed that the people diagnosed with TTM had significantly smaller left putamen (language and motor control), and left lenticulate. These are both part of the basal ganglia, which largely control motor movement, which ties into the defining characteristic of trichotillomania--hair pulling, a motor movement of the arms, hands, and fingers to remove hair from the body, most commonly scalp hair, eyelashes, and eyebrows. This study also found smaller putamen in people with TTM, which is interesting because the putamen has to do with motor control and reward. Reward comes into play with TTM because some people feel a sense of relief after pulling, as well as reduced anxiety and calmness, which may feel rewarding. Structural differences in the brain are largely telling of the biological underlyings of many disorders, and everything they found for trichotillomania makes sense with the nature of the obsessive-compulsive related disorder.
9. Diefenbach G, David T, Scott H, Johanna C, Patrick W (2005) Trichotillomania: impact on psychosocial functioning and quality of life, Behaviour Research and Therapy, 43, 869-884.
This study looks at trichotillomania's impacts on different aspects of people's social functioning, as well of their qualities of life. Many different interviews were conducted, and surveys and questionnaires given out to obtain data on the participants and how their individual experiences with their trichotillomania effected them and their life. The TTM group reported higher levels of depression than the control group. They also reported lower quality of life, with greater disability and dissatisfaction within their lives. The TTM group also reported lower levels of self-esteem. This most commonly manifests in the TTM sufferers feeling ugly/not feeling pretty. Many of the 28 participants in this study also voiced embarrassment, guilt, shame, and fear of judgement from others when talking about how the disorder affects their emotional states. Some participants said they felt "inept", "unable to control themselves", and saw their inability to control their urges to pull their hair as "internal weaknesses within [themselves]". Daily struggles with things like seeing doctors, work productivity, social interactions, and physical health as well as grooming issues were discussed in many of the interviews.
10. Diefenbach G, David T, Scott H, Johanna C, Patrick W (2005) Trichotillomania: impact on psychosocial functioning and quality of life, Behaviour Research and Therapy, 43, 869-884.
This study looks at trichotillomania's impacts on different aspects of people's social functioning, as well of their qualities of life. Many different interviews were conducted, and surveys and questionnaires given out to obtain data on the participants and how their individual experiences with their trichotillomania effected them and their life. The TTM group reported higher levels of depression than the control group. They also reported lower quality of life, with greater disability and dissatisfaction within their lives. The TTM group also reported lower levels of self-esteem. This most commonly manifests in the TTM sufferers feeling ugly/not feeling pretty. Many of the 28 participants in this study also voiced embarrassment, guilt, shame, and fear of judgement from others when talking about how the disorder affects their emotional states. Some participants said they felt "inept", "unable to control themselves", and saw their inability to control their urges to pull their hair as "internal weaknesses within [themselves]". Daily struggles with things like seeing doctors, work productivity, social interactions, and physical health as well as grooming issues were discussed in many of the interviews.
11. Chamberlain S, Adam H, Lara M, Eleftherios G, Jon G, Brian O, Kevin C, Naomi F, Barbara S (2010) Reduced Brain White Matter Integrity in Trichotillomania, Arch Gen Psychiatry, 67, 965-971.
This study investigates white matter (myelinated axons) differences in the brains of people with and without TTM. MRI scans were used to get pictures of the brains' structures. This study established that the participants had reduced integrity in many white matter tracts across the brain, most importantly in the left frontal lobe and anterior cingulate cortex. These and the other tracts they studied are involved with suppression and generation of motor impulses, the main feature of TTM, and emotional regulation, an important side feature of tricho. This reduction in integrity in these regions, along with reduced gray matter areas they are near which control similar things, may explain why people with trichotillomania struggle to suppress the urges they get to pull their hair.
12. Grant J, Darin D, Samuel C (2020) Prevalence, gender correlates, and co-morbidity of trichotillomania, Psychiatry Research, 288.
Over 10,000 people were given surveys in this study. They found a 2.5% lifetime prevalence of TTM in males, and 2.4% lifetime prevalence in women--tricho has no gender or ethnic preference. Trichotillomania was more present and notable in people under 50 years old. Tricho was found to be comorbid with other disorders such as anxiety, depression, OCD, skin-picking disorder, PTSD, and more. People rated TTM as more annoying than their other disorders about 30% of the time, which is interesting since it's more common and life-disturbing than people think, for a disorder with no treatment. Almost 80% of the people in this study had more than one disorder, including trichotillomania.
13. Everett G, Mohammad J (2020) Recent advances in the treatment of trichotillomania, Dermatologic Therapy, 33, 6.
Animal models have pointed us to 3 main genes that may have to do with tricho: Hoxb8, Sapap3, and Slitrk5. Hoxb8 mutant mice exhibited excessive grooming similar to humans, and showed a potential increase in synaptic activity; mice with deleted Sapap3 also exhibited TTMish behavior, and had different postsynaptic functioning at the glutamatergic corticostriatal synapses. A 2009 study showed that a rare heterozygous mutation of Sapap3 was present in about 4% of those diagnosed with TTM. Mice with deleted Slitrk5 genes also show excessive grooming behavior. Different treatments are better than others, depending on the age group being treated: the younger the person is, the more helpful behavioral therapy would be, and the less helpful drug therapy would be, since they are so young. As the people age, they can handle some sorts of drugs, especially if they have co-morbid disorders, as the medicine could knock out two things at once. Nonpharmacological treatments for trichotillomania include habit reversal training (often paired w stimulus control), ACT, exposure and prevention therapy, and more. There are currently no FDA-approved pharmacological treatments for trichotillomania, but they've tried tricyclics, SSRIs, second-gen antipsychotics, and opioid antagonists. The second-generation antipsychotics were the only ones with a stronger impact than "very weak", which ended up being a "moderate" effect on TTM. The study done with the SSRIs was a really bad study ngl so i can replicate that but actually include controls, making it better and more accurate. Newer psychopharmacological methods were also tested with TTM, such as n-acetylcysteine, milk thistle, probiotics, dronabinol, inositol; n-acetylcysteine was the only one not considered "weak" or "very weak", and it also had a "moderate" effect on TTM. NAC has great potential for future research-there haven't been any double-blind or placebo studies using that, so that would prob be good to do, specifically with adults.
14. van Minnen A, Kees H, Ger K, Inge H, Gert-Jan H (2003) Treatment of Trichotillomania With Behavioral Therapy or Fluoxetine, Arch Gen Psychiatry, 60, 517-522.
43 people, diagnosed with TTM: 3 groups of 12-week sessions: Behavioral Therapy (15 ppl), Fluoxetine treatment (13 ppl), or a waitlist (15 ppl). Random assignment to those groups. The behavioral therapy in this study was biweekly 45-minute sessions, designed to teach the participants self-control, and to help them monitor their own progress with trichotillomania. They used stimulus-response interventions and rewards to help the people pull their hair less. The therapist helped the people in the behavioral therapy group monitor their progress and motivate them. For the first session, the participants were instructed to write down how many hairs they pulled out and how much time they spent pulling, as well as to save the hairs to turn in to the therapist. During the second session, the therapist informed the participants on different strategies they could use to lessen the hair pulling-a strong perfume on the wrists to condition them to not pull every time they smell it, or some sort of band-aids on the fingers to prevent pulling, or to wear loud jewelry so the participants were consciously aware every time they were pulling their hair. In the third session, the interventions switched to more engaging activities, like cleaning a room or going for a walk, and only allowing themselves to pull after doing some sort of activity. In the final three sessions, the therapist and participant discussed these interventions and other consequences geared toward preventing TTM urges. The last session included education about relapse prevention. The Fluoxetine group was initially put on a 20mg dose, then over the first two weeks, it was increased to 60mg. They had biweekly meetings with a psychiatrist to discuss the diagnosis and all that that entails, treatment, possible side effects. They were promised alternative treatment if any adverse reactions to Fluoxetine appeared. There were only a few participants who had adverse reactions to the SSRI. The therapist also motivated the participants, but did not give them the same kinds of advice that the behavioral therapy group was given. The drug group was not instructed to monitor/record every time they pulled out their hair. Finally, the waiting list group got no treatment for the 12 weeks.
Behavioral Therapy showed the greates reductions in the immediate severity of TTM symptoms, especially the actual hair pulling. The Fluoxetine treatment was ineffective in reducing TTM symptoms. This indicates that serotonin is probably not the dysfunctional neurotransmitter related to trichotillomania. They found a reduction in hair-pulling in the wait list group, probably because they were told that they were going to be put in either the fluoxetine or BT group after the 12 weeks. All participants in this study were given some literature on the nature of the disorder, and were able to interact with other people with the disorder, so they might have taken advice from others during the process, and reduced their own symptoms.
15. Grant J, Brian O (2009) N-Acetylcysteine, a Glutamate-Modulator, in the Treatment of Trichotillomania, Arch Gen Psychiatry, 66, 756-763.
Tricho is an obsessive-compulsive related disorder, so things that help with OCD may also help with TTM. Issues with the funciton of glutamate has been associated with OCD. Other studies have promoted the idea of glutamatergic modulators treating compulsive or repititive disorders, so N-acetylcysteine was used in this one. N-acetylcysteine was previously used to help treat acetaminophen poisoning. N-acetylcysteine gets converted to and allows for the uptake of cysteine, which then stimulates metabotorpic glutamate receptors. This causes a decrease in the synaptic release of glutamate in the brain. In the nucleus accumbens, this reintroduction of glutamate seems to halt compulsive actions. A hypothesis associated with using N-acetylcysteine in this way was that it might help with the glutamate dysfunction associated with obsessive-compulsive disorder and OCRDs.
44 participants. Age range 18-65. DSM-IV diagnosed. 12-week study of double-blind N-acetylcysteine or placebo therapy. 1200 mg dose. Halfway in they doubled the dose for the final 6 weeks, unless the hair pulling already stopped.
Found that N-acetylcysteine works better & is safer than the placebo. Started working well within the first 9 weeks. This indicaes that glutamate might be the main neurotransmitter associated with OCD and OCRDs. N-acetylcysteine increased cysteine and glutathione levels in glial cells, which is important bc glial cells are responsible for approving glutamatergic clearance from a synapse. All important to figure out how N-acetylcysteine affects glutamate. This study did not look at how the subtypes of trichotillomania are affected by N-acetylcysteine (automatic vs focused pulling). Could look at that for project. Could also try a longer study bc this one said at the end that longer therapy could help reduce symptoms even more. Also could potentially combine CBT with N-acetylcysteine which would be pretty sick bc like every study has showed how CBT is the best treatment, so combining the best treatment with the best medication could be a sick combo.
16. Bloch M, Kaitlyn P, Jon G, Christopher P, James L (2013) N-Acetylcysteine in the Treatment of Trichotillomania: A Randomized, Double-Blind Placebo Controlled Add-On Trial, Journal of the American Academy of Child & Adolescent Psychiatry, 52, 3, 231-240.
12-week study with children & adolescents ages 8-17 diagnosed w TTM and displaying hair pulling habits for 6 months. N-Acetylcysteine vs placebo in a younger demographic. 600mg dose once a day for the first week, then it was increaced to twice a day for the second week. Then for the remaining 10 weeks they took 1200mg twice a day, which is the same dosage as the adult NAC study. After the 12 weeks, all participants were offered NAC as well. Everyone involved was blind to who was getting what.
They didn't find any benefit to NAC over the placebo in terms of improving hair pulling symptoms. Both groups significantly improved over the course of the study, but it was pretty equal so neither method was better over the other. The main difference between these two studies is the age groups of the participants: the NAC worked well and showed significant improvement in the adults, but had no real improvement in the children/adolescents. Both studies were 12 weeks and had the same dosage of NAC-the ony difference was the ages. Hair-pulling urges and severity increases with age. N-acetylcysteine may reduce the intensity & frequency of the urge to pull hair. If this is true, it makes sense that it doesn't work very well in children, as the majority of their pulling is automatic, and they are less aware of their pulling urges.
17. D Özcan, D Seçkin (2016) N-Acetylcysteine in the treatment of trichotillomania: remarkable results in two patients, Journal of the European Academy of Dermatology & Venerenology, 30, 9, 1606-1608.
Case 1: 30 year old woman with a one-month history of hair pulling and hair loss, located on the top and front of her head. She pulls to relieve anxiety. When given a 1200 mg dose of N-acetylcysteine for two months, hair pulling decreased and got reduced to zero. Within four months, the hair fully regrew and the woman was no longer experiencing urges to pull it out. There were no side effects, and after 7 months total, the woman had no relapses and full regrowth.
Case 2: 14 year old girl with two-month history of head hair loss. She has ADHD and had been on haloperidol for 6 months and methylphenidate hydrochloride for 3 years. She pulled her hair out by habit, and this was intensified with stress. After she got diagnosed with TTM, haloperidol was stopped and she was put on 1200mg of NAC. After two weeks of N-acetylcysteine treatment, her hair pulling habit had greatly decreased, and there were no side effects observed. After 6 months, she had full hair regrowth, and NAC treatment was ended. After 8 months, she had not relapsed.
Relevance of NAC: Dysfunction in the glutamatergic system in the brain has been greatly associated repetitive and reward-seeking behaviors, especially those associated with OCD and OCRDs. Glutamate is the main neurotransmitter in the OCD brain circuit (cortico-striato-thalamo-cortical), and high levels are correlated with the severity of OCD symptoms. Once NAC gets through the brain-blood barrier, cysteine is converted into cystine, which leads to an increase in glutamate outside of cells. Then, metabotropic glutamate receptors are activated, and extra production of the neurotransmitter is inhibited. It is thought that through this process, N-acetylcysteine can reduce the frequency and intensity of trichotillomania's urges to pull out hair.
18. Arabatzoudis T, Imogen R, Maja N, Richard M (2017) Emotion regulation in individuals with and without trichotillomania, Journal of Obsessive-Compulsive Related Disorders, 12, 87-94.
This study looks at the relationship between emotional regulation and trichotillomania. 63 total adults, 43 without and 20 with self-reported TTM symptoms. They controlled for depression so that was not present in any of the participants. The people who had reported similar habitual patterns to those that define trichotillomania struggle more with emotions. They had higher levels of difficulty with regulating their own emotions. They also struggle more with tolerating change and distress (don't tolerate it well). Automatic hair pulling was not associated with any issues with regulating emotions, but focused hair pulling had some correlations with emotional regulation issues. Future research could look into how comorbid depression would impact different treatments for TTM, and if there is a way to treat specifically for focused or automatic hair pulling.
*Can tie this in with all of the previous & upcoming drug papers--maybe my project can look into the specifics of NAC on treating automatic over focused, or the opposite*
19. Züchner S, JR W, AE A, AL C, KN T, K Q, KC T, ML C, MA P, DC S, KR K, G F, DL M (2008) Multiple rare SAPAP3 missense variants in trichotillomania and OCD, Molecular Psychiatry.
Mice with deficient postsynaptic synapse-associated protein 90/postsynaptic density-95-associated protein 3 (SAPAP3) end up developing a very similar phenotype to Obsessive-Compulsive Disorder in humans. They compulsively groom and have a high level of anxiety, very similar to TTM. SAPAP3 knockout mice typically lessen the compulsive grooming if given SSRIs. This study was the basis for many similar studies done with humans--one of the other papers I read & summarized here was about Fluoxetine and its effect on TTM (not really any) and without the knowledge of SAPAP3 in mice and how SSRIs effect that, those studies never would have been done with people.
20. Grant J, Brian O, Liana S, Kim S (2014) The Opiate Antagonist, Naltrexone, in the Treatment of Trichotillomania, Journal of CLinical Psychopharmacology, 134-138.
Naltrexone is typically used to help people addicted to opioids get off of the dangerous drugs. Opioid antagonists bind to the opioid receptors in the brain, ensuring that the actual opioids cannot attach there and the person can wean themselves off of the addictive substances. This study looked at 51 adults with TTM. They were randomized to either a naltrexone group or a placebo group for an 8-week, double-blind trial. Before the study, the participants' severity of TTM was evaluated and they had to perform some basic tasks to measure cognitive ability. Throughout the 8 weeks, the participants repeated those tasks, to see if cognitive flexibility was also impacted by the naltrexone, along with the trichotillomania. It was found that cognitive flexibility did increase with the naltrexone, but it did not have a great effect on the participants hair pulling. Those who had family history of addiction decreased their pulling urges, but not enough to be statistically significant.
21. Grant J, Samuel C (2023) Monoamine Oxidase Inhibitors for Trichotillomania, Journal of Clinical Psychopharmacology, 149-151.
Monoamine Oxidase Inhibitors were the earliest antidepressants, which inhibit the activity of monoamine oxidase enzymes which break down the monoamines. MAOIs allow the monoamine neurotransmitters (DA, NE, 5-HT) to accumulate at synapses, and have been associated with mood improvement. MAOIs have helped people with depression in the past, and have potential to help with OCD as well, so they also tested it with TTM, an OCRD. MAOIs were tested in 5 people, diagnosed with trichotillomania, which no other treatment had worked. They tried cognitive behavioral therapy at least once, they tried SSRIs, they tried NAC/antipsychotics. Many different strategies had previously been tried with all five of these people, and none of them had helped them. Two of the five people in this study still showed no improvement with the MAOIs. Two of them showed good improvement with phenelzine, and one showed improvement on tranylcypromine. Two of those three success stories were with people who also had depression, so that most likely influenced that a bit. There are no large-scale randomized control studies to date involving MAOIs, so that's an option for further research.
22. Grant J, Sarah R, Samuel C (2019) Milk Thistle reatment for Children and Adults with Trichotillomania, Journal of Clinical Psychopharmacology, 129-134.
Milk thistle has antioxidant properties, meaning it can delay cell damage. This study looks at its effects in children and adults. 20 people went into a 12-week, double-blind, plavebo-controlled crossover study. This means there were 6 wees with milk thistle, and 6 weeks of the placebo with a 1-week cleansing period in the middle. Each person had different doses of milk thistle depending on their needs, but overall dosage ranged from 150mg twice a day to 300mg twice a day. They found no statistically significant difference in treatment type--milk thistle was no more effective than the placebo. There were some side improvements with the milk thistle, such as a reduction in the time spent pulling each day over a week.
23. Swedo S, Henrietta L, Judith R, Marge L, Erica G, Deborah C (1989) A Double-Blind Comparison of Clomipramine and Desipramine in the Treatment of Trichotillomania, The New England Journal of Medicine, 497-501.
Both clomipramine and desipramine are tricyclics--they are antidepressants. They can also help with chronic pain & insomnia. This study was with 13 women with TTM over a 10-week period. It was double-blind so no one knew what anyone was getting. Clomipramine has selective antiobsessive effects, while desipramine is a typical tricyclic medication. Over the 10 weeks, they found that clomipramine had significantly better effects in reducing hair pulling severity than desipramine. After the 10 weeks, the participants gave self-reports of their pulling habits, and those who took clomipramine reported that the medication helped them resist the urge to pull their hair.
24. Van Ameringen M, Catherine M, Beth P, Mark B, Jonathan O (2010) A Randomized, Double-Blind, Placebo-Controlled Trial of Olanzapine in the Treatment of Trichotillomania, Journal of Clinical Psychiatry.
Olanzapine is a medication previously used with tic disorders and Tourette's Syndrome as a dopaminergic treatment style. It is an antipsychotic medication used with schizophrenia as well. Due to the similarities in the brain with TTM and the tic disorders/Tourette's, the researchers thought a similar medication could work on all of the disorders. 25 people, DSM-IV diagnosed, 12-week, randomized, placebo-controlled, double-blind study with a flexible dosage of olanzapine. Seems like they used self-reports to measure how things changed over the 12 weeks, and the participants weren't talking to a therapist, which could help. They found that olanzapine was more useful in decreasing TTM symptoms than the placebo.
25. McGuire J, Nicholas M, Adam L, Eric S, Omar R (2020) The Influence of Hair Pulling Styles in the Treatment of Trichotillomania, Behavior Therapy, 51, 6, 895-904.
This study was done with 40 children and adolescents, between the ages of 7-17. 8-week study. Participants were randomized into one of two groups: HRT (habit reversal training) or TAU (treatment as usual). Habit reversal training consisted of weekly 50-minute therapy sessions, in which the therapist tells the kids strategies to use to reduce their hair pulling. The family may also be involved in the therapy, learning how to support and assist their kid with the struggle of getting in control of the hair pulling. The treatment as usual group continued with whatever treatment they were getting before this study, whether that was nothing, help at school, or therapy; they didn't change what they were already doing before the study started.
Over the course of the 8 weeks, there was no reduction in automatic hair pulling in any of the participants, regardless of which group they were assigned to. Focused pulling had a reduction in the habit reversal training group. There was no significant reduction in focused pulling in the treatment as usual group. Increasing awareness around the pulling would probably lead to a decrease in automatic pulling. Automatic pulling is not associated with any sort of attention/mood/focusing issues, but focused pulling is associated with anxiety and depression, as well as ADHD. Future research could focus on specific treatments for the individual pulling styles, and attempt to help with automatic pulling.