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Anxiety Disorder, Trichotillomania: Treatment & Medication
Updated: Sep 23, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
After a diagnosis of trichotillomania is confirmed through a workup, take the following actions:
- Determine whether symptoms represent a short-term childhood habit.
- Determine whether the symptoms indicate a more serious psychological problem through consultation and collaboration with a psychiatrist, developmental-behavioral pediatrician, or licensed clinical psychologist. Consultation is recommended and may be required for choosing various treatment options.
- Recognize that children with presenting symptoms of trichobezoars may require further evaluation via ultrasonography and/or MRI and/or CT scanning.
Surgical Care
Consider removal of trichobezoars in the stomach and intestines.
Consultations
Consult with psychiatry, psychology, or developmental-behavioral pediatrics specialists.
- As suggested by several studies, the first line of treatment in children who present with hair pulling is behavioral treatment and intervention.
- Effective behavioral strategies in the treatment of trichotillomania in children include the following:
- Habit reversal: This is a set of procedures taught to a child, which include the following components: increasing the child's awareness of the habit; teaching the child a competing response to practice when they feel the urge to engage in the habit, in situations where the habit historically occurs or for 1 minute following the occurrence of the habit; practicing stress/anxiety reduction procedures on a daily basis; and support and encouragement from parents.
- Self-monitoring: Self-monitoring involves systematically observing and discriminating when the behavior occurs, recording the responses, and evaluating one's own behavior.
- Competing reaction training: Competing response or reaction training is one component of habit reversal, which is occasionally used alone. A child is taught a socially appropriate alternative behavior or response, which they are encouraged to practice on a daily basis when they feel the urge to engage in the habit, in situations where the habit historically occurs or for 1 minute following the occurrence of the habit.
- Relaxation training: Relaxation training involves helping children to identify their own bodily sensations associated with tension and then to use procedures designed to induce relaxation. Typically, this approach is individualized and may include such procedures as deep-breathing strategies and systematic muscle tensing and relaxation.
- Psychotherapy: Psychotherapy is a process that involves direct communication between a therapist and a child, mainly in the form of talking, using various techniques to help solve behavioral and other psychological problems. One of the most popular forms of psychotherapy is cognitive behavioral therapy.
- Hypnosis: Hypnosis is a process of controlling physiologic responses by focusing attention on specific mental images for therapeutic purposes, typically to gain more control over behavior, emotions, or physical well-being. Hypnotic procedures often involve having the child visualize an experience to facilitate induction, during which time they concentrate intensely on a specific thought, memory, feeling, or sensation while blocking out distractions. In this state, the child is more open than usual to suggestions (provided by the hypnotist) for subsequent changes in behavior.
- Elimination of a comorbid behavior: In cases where two seemingly different behaviors occur together (eg, trichotillomania and thumb sucking), a treatment to reduce or change one behavior may also result in a change or reduction in the comorbid behavior.
Diet
A child with trichotillomania requires no special diet.
Activity
No activity limitations are suggested for a child with trichotillomania. However, if the hair-pulling behavior is associated with a specific activity, that specific activity may require close monitoring. As indicated in a study of individuals with trichotillomania, the following are possible activities during which patients with trichotillomania may engage in hair pulling:
- Watching television
- Reading
- Talking on the phone
- Lying in bed
- Driving
- Writing or doing paperwork
Medication
Few drug studies on trichotillomania in children and adults exist. However, SSRIs have demonstrated a degree of effectiveness in some patients with trichotillomania. In children, SSRIs (eg, fluoxetine, sertraline, fluvoxamine) may be more advantageous as a medication choice than tricyclic antidepressants (TCAs) because of their milder adverse effects.
Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with antidepressants in the pediatric population.
In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.
In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients treated with antidepressant medications. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed, because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.
However, a recent study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declines, not rises, with the use of antidepressants. This is the largest study to date to address this issue.8
Currently, evidence does not exist to associate OCD and other anxiety disorders treated with SSRIs with an increased risk of suicide.
Selective serotonin reuptake inhibitors (SSRIs)
Antidepressant agents chemically unrelated to tricyclic, tetracyclic, or other available antidepressants. Inhibits CNS neuronal uptake of serotonin (5-HT). May also have weak effect on norepinephrine and dopamine neuronal reuptake.
SSRIs are greatly preferred over the other classes of antidepressants. Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with mood disorder.
Fluoxetine (Prozac)
Selectively inhibits presynaptic serotonin reuptake with minimal or no effect in reuptake of norepinephrine or dopamine. Approved in children aged 8-18 y for major depressive disorder and in children aged 7-17 y for obsessive compulsive disorder.
Adult
20-80 mg/d PO
Pediatric
<7 years: Not established
≥7 years: Initial doses of 10-20 mg/d have been used
Adolescents: Administer as in adults
Increases toxicity of diazepam and trazodone by decreasing clearance; also increases toxicity of MAOIs and highly protein-bound drugs
Documented hypersensitivity; MAOIs concurrently or within previous 14 d
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hepatic impairment and history of seizures; discontinue MAOIs at least 14 d before initiating therapy; recently, the FDA has urged that all antidepressants should be used with caution in children and adolescents, as their use has been associated with increased suicidal ideation
Sertraline (Zoloft)
Selectively inhibits presynaptic serotonin reuptake. Approved for children aged 6-17 y with OCD.
Adult
50-200 mg/d PO
Pediatric
<6 years: Not established
6-12 years: 25 mg/d PO initially; may gradually increase dose if needed, not to exceed 100 mg/d
13-17 years: 50 mg PO qd; may gradually increase dose if needed; not to exceed 200 mg/d
Increases toxicity of MAOIs, diazepam, tolbutamide, and warfarin
Documented hypersensitivity; MAOIs concurrently or within previous 14 d
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in preexisting seizure disorders, recent myocardial infarction, unstable heart disease, and hepatic or renal impairment; recently, the FDA has urged that all antidepressants should be used with caution in children and adolescents, as their use has been associated with increased suicidal ideation
Fluvoxamine (Luvox)
Potent selective inhibitor of neuronal serotonin reuptake. Does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors and, thus, has fewer adverse effects than TCAs. Approved for OCD in children aged 8 y or older.
Adult
50-300 mg/d PO
Pediatric
<8 years: Not established
≥8 years: 25 mg PO qhs initially; in controlled clinical trials, typical dosage range was 50-200 mg/d, not to exceed 200 mg/d for children ≤11 y and 300 mg/d for adolescents
Risk of hypertensive crisis increases with coadministration with MAOIs; fluvoxamine potentiates effect of triazolam and alprazolam and, thus, when taking concurrently, reduce dose by at least 50%; reduce dose of theophylline by one third, and monitor plasma levels if taking concurrently; alcohol, cimetidine, sertraline, phenothiazines, and warfarin increase toxicity
Documented hypersensitivity; MAOIs concurrently or within previous 14 d
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in liver dysfunction, cardiovascular disease, and history of seizures or suicidal tendencies; recently, the FDA has urged that all antidepressants should be used with caution in children and adolescents, as their use has been associated with increased suicidal ideation
Tricyclic antidepressants (TCAs)
These antidepressants are structurally related to phenothiazine antipsychotic agents. They exhibit 3 major pharmacologic actions in varying degrees (ie, amine pump inhibition, sedation, anticholinergic action [peripheral and central]). They also inhibit reuptake of norepinephrine or serotonin (ie, 5-hydroxytryptamine, 5-HT) at the presynaptic neuron.
Clomipramine (Anafranil)
Inhibits reuptake of norepinephrine or serotonin (5-HT) at presynaptic neuron. Approved for children aged 10-17 y for OCD.
Adult
<10 years: Not established
10-17 years: 25 mg/d PO qd or in divided doses with meals for 2 wk initially; may increase if needed, not to exceed 3 mg/kg or 100 mg/d, whichever is the smaller dose
Pediatric
25-100 mg/d PO; approved for OCD in children >10 y
May increase effects of CNS stimulants, CNS depressants, MAOIs, sympathomimetics, alcohol, antipsychotics, benzodiazepines, barbiturates, anticholinergic agents, and thyroid medications (cardiac effects); TCAs may decrease effects of clonidine and guanethidine; effects of TCAs may be increased by phenothiazines, methylphenidate, oral contraceptives (estrogen), and marijuana; effects of TCAs may be decreased by lithium, barbiturates, chloral hydrate, and smoking
Documented hypersensitivity; narrow-angle glaucoma; in acute recovery phase following myocardial infarction; current use of MAOI or fluoxetine or use within previous 14 d
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May impair mental or physical abilities required for performance of potentially hazardous tasks; caution in cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, hyperthyroidism, and in those receiving thyroid replacement therapy; recently, the FDA has urged that all antidepressants should be used with caution in children and adolescents, as their use has been associated with increased suicidal ideation
More on Anxiety Disorder, Trichotillomania |
| Overview: Anxiety Disorder, Trichotillomania |
| Differential Diagnoses & Workup: Anxiety Disorder, Trichotillomania |
 Treatment & Medication: Anxiety Disorder, Trichotillomania |
| Follow-up: Anxiety Disorder, Trichotillomania |
| Multimedia: Anxiety Disorder, Trichotillomania |
| References |
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References
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Further Reading
Keywords
trichotillomania, childhood habit disorder, impulse-control disorder, hair pulling, obsessive-compulsive disorder, OCD, trichophagia, trichobezoars
