Pharmacological and Behavioral Systematic Review: Pharmacological and Behavioral Treatment for Trichotillomania BIOL PSYCHIATRY 2007;62:839–846 KAUH TEAM

INTRODUCTION: Trichotillomania (TTM) is a psychiatric condition characterized by compulsive hair pulling. Despite often being quite impairing and affecting approximately .6% to 1% of the population , trichotillomania has been rather sparsely studied.

MODALITIES OF TREATMENT : pharmacotherapy with (SSRI). pharmacotherapy with clomipramine. habit-reversal therapy (HRT).

AIM OF THIS REVIEW : to evaluate the evidence supporting the efficacy of these three interventions compared with placebo and to compare the efficacy of these treatment modalities with each other.

Criteria for Considering Studies for This Review: randomized, controlled, clinical trials published in scientific literature with blinded assessment of clinical outcome. Types of Participants: older than age 16 and have a primary psychiatric diagnosis of trichotillomania or chronic hair pulling by DSM-IV criteria.

Habit-reversal therapy: Self-monitoring. Awareness Training. Stimulus Control. Stimulus-Response Intervention or Competing Response Intervention.

Acceptable control interventions for pharmacological interventions in this review were either placebo or an active control condition . ACTIVE CONTROLS ! 1ry outcome is :improvement in a clinical scale measuring trichotillomania severity.

National Institute of Mental Health Trichotillomania Severity Scale or Trichotillomania Impairment Scale. Clinical Global Impressions Improvement Scale. Massachusetts General Hospital Hairpulling Scale (MGH-HS)

Selection of studies : 1)randomized clinical trials with a control group. 2) blinded assessment of clinical outcome 3) patient population with a primary psychiatric diagnosis of trichotillomania or chronic hair pulling 4) comparison of SSRI, clomipramine, and habit-reversal therapy to each other or a control condition.

Excluded studies : Three open-label SSRI studies examining fluoxetine,fluvoxamine , and citalopram were excluded from this review because they lacked a placebo comparison group and blinded clinical ratings of outcome. One behavioral therapy trial that compared HRT with negative practice (no clinical rating)

Results : Outcome 1: Selective Serotonin Reuptake Inhibitors Versus Control Condition: 4 studies ,72 pts ,used : fluoxetine , sertraline . No significant difference between control &SSRI group.

Outcome 2: Clomipramine Versus Control Condition: Two studies ,24 pts ,used for 5 weeks up to 250 mg Vs desipramine 250 mg for 5 weeks (active control) The other one:11 pts, 9weeks clomipramie Vs placebo. significant treatment effect favoring clomipramine compared with the control condition

Outcome 3: Habit-Reversal Therapy Versus Control Condition 3 trails ,59 pts : Woods et al. 12 pts, the control (waiting list) Van Minnen et al .14 pts ,6 sessions biweekly. Ninan et al. compared five completers of HRT who received nine weekly sessions with five completers who received double-blind placebo treatment.

overall meta-analysis demonstrated a significant benefit of HRT compared with wait-list/placebo control conditions. Blinded rating of hair loss was used as the primary outcome in this systematic review. No randomized controlled studies were excluded from this meta-analysis because the therapy studied failed to meet criteria of HRT.

Outcome 4: Habit-Reversal Therapy Versus Selective Serotonin Reuptake Inhibitors One study,11 pts ,used fluoxetine for 12 weeks ,VS: 14 pts with HRT for 6 sessions . The main outcome measure of this study, the MGH-HS, a subject self-report measure rather than a rating by blinded clinician. larger and significant treatment effect.

Outcome 5: Habit-Reversal Therapy Versus Clomipramine Only one study 6 pts of clomipramine for 9 weeks Vs 5 pts of HRT who received 9 sessions weekly. This study found a statistically significant benefit of HRT compared with clomipramine (ES
-1.74, 95% CI =
-3.23,-.25).

Outcome 6: Clomipramine Versus Selective SerotoninReuptake Inhibitors There was one scientific abstract presented on this subject in 1993 24-week, double-blind, randomized study in 12 trichotillomania patients comparing 10 weeks of clomipramine treatment (mean dosage 200 +\- 15 mg) with 10 weeks of fluoxetine (mean dosage 75 +\- 5 mg) with a 4-week placebo. no significant difference !!

Discussion: HRT,when practiced by experienced clinicia, is the most effective intervention for trichotillomania. HRT demonstrated superiority in individual study trials when compared with the two most prevalent pharmacological interventions for trichotillomania: clomipramine and SSRI

Although recent studies suggest SSRI 1ST line ,in this review considered clomipramine more effective may be due to additional NA activity BUT : Initial benefit from it may not maintained with long term therapy.

Limitation: No single clinical rating instrument was used consistently to assess severity and improvement of trichotillomania symptoms. Comorbid OCD. Drop outs.

SSRIs :type & length of usage . About HRT: does HRT demonstrate efficacy when comparedwith control conditions that account for the nonspecific effects of therapy such as time spent with the therapist (i.e., supportive psychotherapy and psychoeducation)?

Other modalities :antipsychotics ! As monotherapy or augmentation.