Note from TLC: The following post was written by Lisa Zakhary, who received the Medical Student Scholarship to the 2011 Conference on Hair Pulling and Skin Picking Disorders. In this essay, Dr. Zakhary relays her experience at the national conference.
I am currently an outpatient psychiatrist at the Massachusetts General Hospital Obsessive Compulsive Disorder (OCD) and Related Disorders Program in Boston, Massachusetts which provides clinical care for people with OCD, body dysmorphic disorder (BDD), trichotillomania (TTM), skin picking and tic disorders. As a psychiatry resident, I had the distinct pleasure of attending the 2011 National Conference on Hair Pulling and Skin Picking with generous support from the Trichotillomania Learning Center (TLC) Student Travel Grant. It was an incredible combination of the latest basic and clinical research, psychopharmacologic and therapy practice guidelines, sharing of personal experiences, and making new professional contacts and friends. I am deeply grateful for the opportunity to have been included and wanted to summarize some of the key points that I came away with.
Research is abundant. Some of the most recent findings in body-focused repetitive behaviors (BRFB) were presented during the conference. Dr. Samuel Chamberlain reviewed various approaches to identifying brain regions responsible for TTM including neuroimaging patients with TTM or patients with traumatic brain injury with impaired impulse control. The amygdala, putamen, and right inferior frontal gyrus were implicated in these studies.
Dr. Jon Grant also reviewed some of the neurotransmitters believed to be involved in BFRBs including serotonin, dopamine, and glutamate. While drugs that increase serotonin levels such as selective serotonin reuptake inhibitors can improve BFRBs, he cautioned that drugs such which increase dopamine levels such as stimulants can worsen picking. N-acetylcysteine (NAC), a glutamate modulator, has been shown to reduce hair-pulling. Dr. Grant also described ongoing and unpublished clinical trials of dronabinol. Dronabinol is an FDA-approved legal cannabinoid agonist which is thought to suppress damage from excess glutamate. Interestingly, 2/3 of study participants taking dronabinol showed a decrease in hair pulling. Final results are pending.
Other ongoing research studies were presented at the poster session. Topics included a controlled trial of habit reveral training in youth, styles of hair-pulling in adolescents, developmental factors and comorbidities of TTM, validity of diagnostic criteria in TTM, attentional bias in TTM, impulsivity in skin picking, tirchodagomania (hair biting), outpatient dermatologist knowledge of psychodermatology, and assessment of 2010 TLC conference attendee experiences.
BFRBs can lead to serious physical, emotional, and social consequences which are often overlooked. In a talk entitled “Picking and Pulling 101,” Dr. Fred Penzel presented a comprehensive summary of not only the basics, but some of the finer points of hair pulling and skin picking that may go unnoticed. He encouraged clinicians to inquire about specific sites of picking/pulling including eyelashes, eyebrows, and pubic regions as well as avoided situations such haircuts, swimming, wind, sexual intimacy, and lighted areas. He recommended inquiring about the medical complications of picking and pulling like repetitive strain injuries, tendonitis, skin infections, gastrointestinal blockage due to eating hair, eye irritation, and medical conditions caused by avoiding medical visits. He urged practioners to also assess the emotional consequences of BFRBs such as low self esteem, shame, secrecy, isolation, and loneliness. Co-occurring psychiatric illnesses are common among patients with TTM. In fact, 26% of people with TTM have OCD, 23% have major depression, and 23% have generalized anxiety disorder.
BDD is common and deadly. Dr. Scott Granet described the clinical features and treatment approaches of BDD in a talk entitled “Understanding and Treating Body Dysmorphic Disorder.” It is surprisingly common affecting 11.9-15.8% of patients in a general dermatologic setting (~3.5 million people in the U.S.) and is defined by having a preoccupation with an imagined or slight defect in appearance which causes significant impairment. Associated behaviors include frequently checking mirrors, camouflaging the area, comparing disliked body part to others, touching the area, skin picking and seeking reassurance from friends and family about the perceived flaw. It can lead to social isolation, strained relationships, poor self-esteem, and suicidal ideation. In fact, 80% of people with BDD consider suicide and 25-30% attempt suicide. Dr. Granet bravely shared his own struggles with BDD, providing a genuine perspective of life with BDD. He warned practioners to always closely assess for suicide and educate sufferers of BDD about this common and deadly problem.
BFRBs are common, yet treatment options have historically been limited. Dr. Penzel presented staggering prevalence data about the BFRBs. Large studies of a non-clinical representative college student sample, showed that 1.5% of male students report hair pulling, 3.6% of female students report hair pulling, and 4.6 % of students suffer with skin picking. Despite these numbers, Dr. Penzel presented the TIP-A study by Woods et al. in 2006 which showed that 53% of health-care providers were either not knowledgeable about TTM or had only “heard” of TTM. This is not surprising since psychiatrists and psychologists receive little if any training in the diagnosis and management of BFRBs. Similarly, dermatologists who frequently encounter patients with BFRBs receive little instruction in psychopharmacology or therapy leaving the newest generation of dermatologists, psychologists, and psychiatrists largely underprepared to treat this population.
To accommodate this need, TLC recently created a series of training DVDs for healthcare professionals wishing to treat BFRBs. The course is lead by expert Drs. Charles Mansueto, Fred Penzel, Ruth Gold-finger-Golomb, and Dr. Suzanne Mouton-Odum. Practioners completing the course will receive certification and will be listed for referral on the TLC site. In addition, several multidisciplinary psychiatry-dermatology clinics have cropped up throughout the country- including but not limited to San Francisco (University of California in San Francisco, Dr. John Koo), New York City (St. Luke’s Roosevelt Hospital, Dr. Carmen Grau), and Saginaw, Michigan (Dr. Mohammad Jafferany). Dr. Jafferany presented an overview of psychodermatology at the TLC Conference which broadly includes the skin conditions at the interface of psychiatry and dermatology, ranging from primary psychiatric conditions with skin manifestations (e.g. compulsive skin picking, TTM) to dermatologic conditions with secondary psychiatric symptoms (e.g. depression from a disfiguring skin condition). We have also recently established a psychodermatology clinic at MGH in Boston.
Despite these advances, it may still be difficult to find a provider. Many speakers at the conference provided potential sources of help- including the Trichotillomania Learning Center which lists providers by state, Obsessive Compulsive Foundation, International OCD Foundation, Anxiety Disorders Association of America, BDDCentral.com, Association for Behavioral and Cognitive Therapy, Local TTM/OCD support group, local OCD/Anxiety Clinic. In addition, Drs. Jon Grant, Nancy Keuthen, Daniel Stein, and Douglas Woods recently published a book entitled Trichotillomania, Skin Picking, and Other Body-Focused Repetitive Behaviors which has a wealth of clinical, research, and resource information.
BFRBs are a family affair. Although I have attended many conferences, never have I witnessed such an outpouring of family involvement and support. I was pleased to meet siblings, parents, and spouses of sufferers. I was struck by the enormous bravery and courage not only of those who presented their painful and poignant histories to an audience of hundreds like director Christina Pearson, but for those who quietly put up with multiple treatments until finding the right combination, for those who have been diligently searching for treaters, for those who keep their eye on the latest advances, and for the families who continue to support their family member unconditionally through treatment.
And so, while there may not be a simple “cure,” there are an increasing number of therapeutic and psychopharmacologic options, bolstered by rapidly evolving research, and I have come away from this conference with hope, looking very much forward to the next.
