The following is a research paper written by Brittany Meredith who is a Master of Counselling (Psychology) student in her second year of study. She wrote this paper last semester for her Psychology of Addiction class. Her interest in BFRBs was sparked by a youth she currently works with as a youth worker, who lives with trichotillomania. Together, the pair started the BFRB Edmonton support group, although that is now being run by someone else. She feels BFRBs are in dire need of more research and more resources, so she plans to continue to persue this line of research and may use it for her capstone project, which is much like a thesis, which will begin next year.
In this paper, a graduate psychology student explored the conceptualization of trichotillomania (TTM) as a disorder of addiction. In the DSM-5 this hair-pulling disorder is grouped with obsessive compulsive (OCD) and related disorders. It was formerly categorized as an impulse control disorder (ICD). The author discussed differences between OCD and TTM in terms of presentation, and responses to treatments. As well, the similarities between TTM and gambling addiction are identified. The author cited findings from her research review to support her argument that viewing TTM as possibly an addiction disorder may result in better treatment outcomes for some sufferers..
Keywords: trichotillomania, addiction, behaviour, treatment
Conceptualizing Trichotillomania as a Disorder of Addiction
In this paper, a graduate student, enrolled in a psychology of addiction course, examined the hair pulling disorder known as trichotillomania (TTM) as a possible addiction rather than as an impulse control disorder (ICD), or obsessive compulsive disorder (OCD). The author focused on viewing TTM from a different lens, i.e. an addiction perspective, rather than as an ICD or OCD. The author examined TTM, OCD, ICD and addiction disorders in terms of etiology and treatment outcomes.
First, the etiology of TTM as detailed in the 4th revised and 5th editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) (American Psychiatric Association (APA), 2000, 2013) was reviewed. Second, existing models utilized in the understanding of TTM were considered. Finally, perceptions of what constitutes addiction and how TTM may fit with this were discussed.
Formerly defined as an ICD in the DSM-IV-TR, TTM is currently defined as a body-focused repetitive behaviour (BFRB) within a spectrum of OCD’s (APA, 2013). The diagnostic criteria of TTM as defined by DSM 5 include
A). Recurrent pulling out of one’s hair resulting in hair loss. B). Repeated attempts to decrease or stop hair pulling. C). The hair pulling causes clinically significant distress or impairment in social, occupation, or other important areas of functioning. D). The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition). E). The hair pulling is not better explained by the symptoms of another medical disorder (e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder) (APA, 2013, p. 251)
Previous diagnostic criteria included in DSM-IV-TR have been removed, namely the idea that hair loss should be noticeable, as well as criteria B. an increasing sense of tension immediately before pulling out the hair or when attempting to resist the behaviour, and C. pleasure, gratification or relief when pulling out the hair. Duke, Keeley, Geffken and Storch (2009) stated that the criteria of noticeable hair loss was a “highly subjective variable marker of TTM” (p. 182). As such, the diagnostic criteria had not been representative of all individuals with TTM, excluding some from a formal diagnosis (Duke et al. 2009). Duke et al. (2009) emphasized that TTM may lack acknowledgment in the professional community due to a lack of diagnostic recognition of behaviours associated with TTM (p. 182).
Inconsistent diagnostic criteria have made it difficult to pinpoint the prevalence of TTM, however, studies have shown the prevalence to range from 0.6% to 4%, with up to 10% of the general population being personally affected by hair pulling at some point in their lives (Shoenfeld, Rosenberg, Kotler, and Dannon, 2012, p. 125). Duke et al. (2009) reported that the prevalence ranges from 1% to 13.3% amongst college students. Onset of TTM is divided between early onset and later onset. Early onset occurs in children under the age of 8 and generally requires little to no medical intervention, thus Shoenfeld et al. (2012) presented early onset as the benign form of TTM. Early onset TTM does not appear to be characterized by a pattern of tension followed by relief (Shoenfeld et al., 2012, p. 125). Later onset usually occurs in early adolescence, following the onset of puberty (APA, 2013). The majority of individuals who suffer from TTM are female, at a 10:1 ratio in adulthood (APA, 2013). In childhood the rates appear to be equally male and female (APA, 2013).
TTM is commonly divided into two subcategories, automatic and focused TTM (Shoenfeld et al., 2012). Automatic hair pulling is thought to occur without the individual’s conscious awareness/ knowledge and may occur while the individual is engaged in other activities (Shoenfeld et al., 2012). In contrast, focused hair pulling is believed to occupy the individual’s full attention and appears to be characterized by increasing urges and thoughts about hair pulling (Shoenfeld et al., 2012).
Impairment from hair pulling may be represented in various ways from physical harm to emotional and psychological dysfunction (APA, 2013) . Physical harm from TTM may be represented by infections and irritation at the sites of hair pulling, as well as dental erosion from orally manipulating the hair, or hair balls (trichobezoars) in the stomach from ingestion (APA, 2013). Shoenfeld et al. (2012) noted that sucking and chewing of the hair after it has been pulled is seen in nearly half of TTM sufferers, and 5-18% of TTM sufferers report ingesting pulled hair (p. 126). Socially, 22-63% of patients with TTM report having avoided common activities (Shoenfeld et al., 2012, p.126). Emotional and psychological dysfunction can be widespread and may include social anxiety, depression, and feelings of loneliness, as well, shame and embarrassment are common in individuals with TTM (Shoenfeld et al., 2012, p. 126). Odlaug et al. (2010) as cited in McDonald (2012) stated that individuals with TTM have a lower quality of life than do control groups (p. 424), and all of the proposed symptomatology of TTM should be examined in order to improve the wellness of individuals living with this disorder.
Views of Trichotillomania
As previously stated, TTM is now thought to be best represented within the spectrum of OCD disorders. Shoenfeld et al. (2012) reported that although there are similarities between TTM and OCD, there are also major discrepancies between these disorders. Shoenfeld et al. (2012) declared that TTM is distinct from OCD in that the hair pulling behaviour seen in TTM is not a result of an obsessive thought but rather a response to an overwhelming urge, to be gratified following hair pulling (p. 126). That is, Shoenfeld et al. (2012) emphasized that obsessions do not precede compulsions recognized in TTM (p. 126). Viewing TTM differently, Shoenfeld et al. (2012) suggested that TTM may resemble addiction more than OCD. Shoenfeld et al. (2012) noted that repetitive engagement in hair pulling despite undesirable consequences is reflective of the nature of addiction (p. 127). In support of the notion of TTM as an addiction, Shoenfeld (2012) suggested that similar to other types of addiction, TTM sufferers show a gradual loss of control, increases in cravings leading to the behaviour, and pleasure during and following engagement in the behaviour (p. 127). Further, criteria B in the DSM 5 states that the hair pulling is characterized by repeated attempts to stop pulling (APA, 2013). Repeated attempts to stop are also characteristic of some substance related disorders (i.e. alcohol use disorder, opioid use disorder) (APA, 2013). Grant, Odlaug, and Potenza (2007) stated that although OCD offers a reasonable explanation, TTM has just as much in common with addictive disorders as it does with OCD (p.80). Grant et al. (2007) pointed to differences in urges with OCD and addictions, stating that while urges associated with addiction are often in seeking a pleasurable and/or rewarding feelings, urges associated with OCD pertain to the desire to eliminate anxiety. According to Grant et al. (2007) little research has been devoted to examining TTM as an addiction. Grant et al. (2007) questioned, “might conceptualizing trichotillomania in some individuals as an addiction improve treatment outcome?” (p.80).
Due to the lack of consensus with TTM, Grant et al. (2007) proposed that TTM may be understood to have different subtypes, one of them being similar to OCD and another more similar to addictions, as suggested by clinical data (p. 81). One of the reasons that Grant et al. (2007) saw some subtypes of TTM as being separate from OCD is that sufferers of TTM have failed to respond favourably in many cases to OCD focused treatment (p. 81). This lack of treatment response resulted in their questioning whether a different understanding of TTM should be considered (p. 81). Furthermore Grant et al. (2007) suggested that explaining at least one subtype with an addiction model might improve treatment outcomes for TTM (p. 81). Treatment approaches have focused on TTM as an ICD or OCD in concurrence with its diagnostic criteria in the DSM-IV-TR and DSM 5. A discussion of some of these treatment approaches follows.
Treatment Approaches and Hypotheses
According to the Trichotillomania Learning Centre (TLC), behaviour therapy is the treatment of choice for TTM (Golomb, Franklin, Grant, Keuthen, Mansueto, Mouton-Odum, Novak, and Woods, 2011). Habit reversal training (HRT) is the most consistently validated behavioural treatment for TTM, while acceptance and commitment therapy (ACT) and dialectical behaviour therapy (DBT) have also shown promise (Golomb et al., 2011). Chamberlain et al. (2009) also concluded from their literature review that HRT shows the most promise in treating individuals with TTM. In contrast, the front line treatment recommended for OCD is exposure and response prevention (APA, 2012). This involves exposure to anxiety inducing events so that individuals may learn to stop anxiety, thus not engaging in ritualistic behaviour (APA, 2012).
Many ideas of how to define TTM stem from treatment trials of TTM with various psychopharmacological treatments and psychological treatments. Psychopharmacological trials offer differing views of TTM based on the efficacy of treatment outcomes. The idea of TTM as a disorder on the OCD spectrum has led researchers to employ similar anti depressant medications used in OCD for the treatment of TTM. The results have been mixed.
Chamberlain et al. (2009) noted that serotonin reuptake inhibitors (SRI) show promise in the treatment of OCD but have not found to be consistently efficacious in the treatment of TTM. Research has found clomipramine a tricyclic antidepressant (TCA) showed greater efficacy over desipramine, also a TCA (Swedo et al., 1989 as cited in Chamberlain et al. 2009). Fluoxetine, an SRI, showed no efficacy over a placebo (Christenson et al., 1991 as cited in Chamberlain et al., 2009). Likewise, although Steichenwein and Thornby (1995) hypothesized that fluoxetine would show superiority over placebo, they came to conclude that fluoxetine was not efficacious over placebo in the treatment of TTM.
Given the lack of treatment effect in TTM using antidepressants, researchers have turned to other options. Grant et al. (2007) suggested that there is evidence that opioid antagonists utilized in the treatment of addictions have had some success in treating TTM, leading them to state that some sufferers may be appropriately seen as having an addiction. Along this vein, O’Sullivan and Christenson (1999) as cited in Chamberlain et al. (2009) found the opioid antagonist naltrexone effective on at least one measure of trichotillomania. Frong et al. (2008) as cited in Chamberlain et al (2009) found glutamatergic agents to have some success in the treatment of behavioural addictions, prompting Frong et al. (2008) as cited in Chamberlain et al. (2009) to suggest investigation of glutamatergic agents for TTM. Grant, Odlaug, Chamberlain, and Kim (2011) utilized dronabinol, a cannabinoid agonist, and concluded that dronabinol may “reduce the compulsive motoric aspect of trichotillomania” (p. 499). Their study claimed to support the manipulation of the cannabinoid system for behaviours such as trichotillomania. The authors hypothesized that manipulation of the cannabinoid system effects the glutamate and dopamine system and supports the addiction hypothesis (Grant et al. 2011).
Seemingly similar treatment outcomes are present in some research with regard to TTM and substance disorders. Similar to outcomes with TTM, SRIs appear to have differential affects on alcoholic subgroups (Pettinati, 2001 as cited in Lowengrub, 2006, p. 71). Anton (2001) found naltrexone reduced cravings and promoted abstinence in alcohol and opioid dependent participants (as cited in Lowengrub, 2006). Further, naltrexone is approved by American FDA for use with some substance related disorders (Anton, 2001 as cited in Lowengrub, 2006, p. 71). With this information, the author will now discuss currently accepted definitions of addiction and how these may be challenged.
Defining and Redefining Addiction
The notion of addiction has changed throughout history and has involved substance use as well as other habits that may come to constitute addiction (Alexander, 2008). In his book, ‘ The Globalization of Addiction: A Study in Poverty of the Spirit’ Alexander (2008) proposed a variety of definitions of addiction as they have changed throughout time. Best represented by the medical model, and thus the DSM 5, is the traditional idea of addiction as it relates to substances. However, Alexander (2008) proposed that the best definition of addiction in the 21st century revolves around addiction not only to substances, but also to habits. Alexander (2008) suggested that addictions that do not revolve around drugs or alcohol are more prevalent than those that do and that they can be just as detrimental (p. 37). In line with this, Karim and Chaudhri (2012) asserted that “the use of repetitive actions, initiated by an impulse that can’t be stopped, causing an individual to escape, numb, soothe, release tension, lessen anxiety or feel euphoric, may redefine the term addiction to include experience and not just substance” (p. 5). Karim and Chaudhri (2012) and Alexander’s (2008) definitions of addiction, as not only representative of substance use, may better encompass TTM. Although broader definitions of addiction may be warranted, a medical and substance related model of addiction continues to be endorsed more than other models. As stated in the DSM-5, there is not enough research in the area of behavioural addiction to establish diagnostic criteria (APA, 2013). As such, criteria for addiction includes a range of substance-related disorders as well as gambling disorder as the single non-substance related disorder. Alexander (2008) proposed that overwhelming adherence to habits can be seen as a form of addiction. This definition of addiction appears to fit well with the epidemiology of TTM, as does the idea of a continuum of addiction as proposed by Alexander (2008). The continuum of addiction in this sense can be seen as very severe on one end, meaning the addiction “can be totally overwhelming and unconcealable” (Alexander, 2008, p. 35) to not severe on the other end, i.e. manageable and concealable.
Karim and Chaudhri (2012) caution that including behaviours in the criteria of addiction may medicalize bad behaviour and blur lines between addictions and bad behaviours. Hair pulling, however, as this author see’s it, has already been medicalized, and viewing it as a behavioural addiction may allow for more efficacious treatment approaches (McDonald, 2012). Further, gambling disorder has been moved from impulse control disorders into a category of addictive disorders in DSM 5. Indeed, according to DSM 5 there is sufficient evidence to suggest that gambling disorder belongs in the realm of addiction (APA, 2013). Further, gambling disorder was formerly grouped with TTM as an impulse control disorder in DSM-IV-TR. Given that gambling disorder and TTM have been viewed as impulse control disorders, it seems logical to note similarities in the two and hypothesize that they may both be forms of behavioural addiction. Further, the rationale for adding gambling to substance related and addictive disorders is that gambling behaviours activate reward systems similar to those activated by drugs of abuse and similar behavioural symptoms (APA, 2013).
Karim and Chaudhri (2012) proposed that behavioural addiction may share similar neural pathways to those implicated in addiction. According to Karim and Chaudhri (2012), dopamine dysregulation is common in both substance use and behavioural addictions (p. 7). Recently, White, Shirer, Molfino, Tenison, Damoiseaux and Greicius (2013) found TTM to share some neurobiological features with addiction with regard to reward systems. White et al. (2013) cautioned that seeing TTM as an addiction might oversimplify a disorder which is actually very complex. Within the current view of addiction, this may be true, however, a view of behavioural addiction as discussed by Alexander (2008) and Karim and Chaudhri (2012) might be well suited to at least some subtypes of TTM. At the core of both behavioural addictions and substance use disorders, Karim and Chaudhri (2012) suggested, is impulsivity.
More research is needed to validate different treatment options and to determine the neural pathways and systems involved in TTM. The APA has grouped TTM with OCD and related disorders in the DSM 5. It appears that a view of TTM as an addictive disorder is worthy of further consideration and research. Some research findings are not consistent with the view of TTM as strictly an ICD or OCD. The classification of TTM as a disorder of impulse or OCD might be premature given research findings that appear to support the possibility that TTM, or at least subtypes of TTM might be better conceptualized as a disorder of behavioural addiction.
As Karim and Chaudhri (2012) stated, redefining our understanding of addiction to include more behavioural addictions may lead us to a better understanding of the overall mechanisms of addiction. Additionally, redefining our understanding of TTM, with at least a subtype of addiction, may allow for more treatment options and better outcomes for some individuals affected with this disorder. Considering TTM has had inconsistent treatment outcomes so far, a new perspective on TTM and on addictions, may open windows to better treatment alternatives.
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