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Background: Individuals with trichotillomania (TTM), a disorder characterized by repetitive pulling out of one's own hair, often have co-occurring ADHD, but little is known about this comorbidity. Additionally, there have been intimations in the literature that treatment of ADHD with stimulants may worsen TTM symptoms. This study aims to examine clinical aspects of individuals with TTM and co-occurring ADHD., Methods: 308 adults with a current diagnosis of TTM were assessed for ADHD using the Mini International Neuropsychiatric Interview 7.0.2 and Adult ADHD Self Report Scale. Participants also completed clinical measures related to TTM severity, impulsivity, quality of life, and psychosocial dysfunction. A series of analyses of variance were used to calculate differences in scale scores among subjects with and without co-occurring ADHD., Results: Of the 308 participants, 47 (15.3%) met the clinical threshold for ADHD. Participants with ADHD reported significantly higher scores in all first and second factor traits of impulsivity, including attentional impulsiveness (p < .0001), motor impulsiveness (p < .0001), and non-planning impulsiveness (p < .0001). Interestingly, participants with ADHD did not report significant differences in TTM severity, perceived quality of life, or functional impairment, regardless of medication status., Discussion: The data suggest that ADHD is common in adults with TTM, and the comorbidity is associated with heightened impulsivity. The co-occurrence of ADHD does not affect individuals' quality of life, symptom severity, or functionality. Taking stimulant medications for ADHD also did not appear to affect TTM severity, despite past case reports suggesting these medications may lead to onset or worsening of TTM., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Body-focused repetitive behaviors (BFRBs) are repetitive, ritualized behaviors focused on the body, involving compulsively damaging one's physical appearance or causing physical injury. They include skin picking, hair pulling, nail biting, and lip or cheek biting and chewing. This study sought to examine prevalence, clinical correlates and quality of life (QoL) impairment associated with these conditions in a non-clinical sample of adults., Method: An online survey was completed by N = 1378 participants. Comparisons were made between those self-reporting body-focused repetitive behavior to those without, on a range of clinical correlates (depression, anxiety, obsessive-compulsive symptoms, body dysmorphic symptoms, fear of negative evaluation) and QoL domains., Results: Three-hundred and eighteen participants (23%) reported the presence of a probable BFRB; n = 85 (6%) nail biting, n = 88 (6%) lip or cheek biting/chewing, n = 187 (14%) skin picking, and n = 39 (2%) hair pulling. There were significant differences between those with and without a probable BFRB (pBFRB) across all clinical variables investigated, with the pBFRB group reporting higher levels of symptoms. The BFRB group reported reduced QoL on some domains. Few differences emerged between the BFRB groups, although individuals with probable skin picking reported higher levels of body image concern, than those with other pBFRB conditions, and there was a trend toward probable skin picking to endorse higher levels of OCD symptoms and anxiety. There were no significant differences between the BFRB groups on QoL domains., Conclusion: Although differences were found between those with a pBFRB and those without, there were few differences between the different pBFRB groups, indicating that all BFRB conditions are concerning. Skin picking may be one of the more severe of the BFRB presentations, although the small number of differences between the groups may reflect a single pathological grooming factor underlying the BFRBs. These findings underscore the importance of recognizing that all body-focused behaviors can cause significant distress, impairment, and reduced QoL, and highlights the need for timely and accurate identification of these conditions by health professionals., (Copyright © 2018. Published by Elsevier Inc.)

Objective: Several compulsive grooming habits such as hair pulling, skin picking, and nail biting are collectively known as body-focused repetitive behaviors (BFRBs). Although subclinical BFRBs are common and benign, more severe and damaging manifestations exist that are difficult to manage. Researchers have suggested that BFRBs are maintained by various cognitive, affective, and sensory contingencies. Although the involvement of cognitive and affective processes in BFRBs has been studied, there is a paucity of research on sensory processes., Methods: The current study tested whether adults with subclinical or clinical BFRBs would report abnormal patterns of sensory processing as compared to a healthy control sample., Results: Adults with clinical BFRBs (n = 26) reported increased sensory sensitivity as compared to persons with subclinical BFRBs (n = 48) and healthy individuals (n = 33). Elevations in sensation avoidance differentiated persons with clinical versus subclinical BFRBs. Sensation seeking patterns were not different between groups. Unexpectedly, BFRB severity was associated with lower registration of sensory stimuli, but this finding may be due to high psychiatric comorbidity rates in the BFRB groups., Conclusions: These findings suggest that several sensory abnormalities may underlie BFRBs. Implications for the etiology and treatment of BFRBs are discussed., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Body-Focused Repetitive Behaviors (BFRBs), including skin-picking, hair-pulling, and nail-biting, commonly occur in youth, even at elevated/problematic levels, and are associated with a number of other psychiatric symptoms. The present study examined the internal consistency of a brief screening tool for BFRBs as well as the prevalence, severity, and correlates of BFRBs in a sample of youth with a primary anxiety or obsessive-compulsive disorder (OCD)., Methods: Ninety-three youth-parent dyads presenting for treatment for anxiety or OCD completed study measures including the Repetitive Body Focused Behavior Scale - Parent (RBFBS), which includes subscales for skin-picking, hair-pulling, and nail-biting, as well as a number of additional clinician-, parent-, and child-rated scales., Results: The RBFBS demonstrated good to excellent internal consistency. BFRBs were endorsed in 55% of youths, with elevated levels in 27%. Skin-picking was the most common BFRB (38%), followed by nail-biting (34%) and hair-pulling (4%). Youth with BFRBs, as compared to those without, were rated as more avoidant by their parents. Among those with BFRBs, more avoidant tendencies, anxiety sensitivity, and child-rated panic, separation, and generalized anxiety symptoms were associated with elevated BFRB severity. BFRBs were equally common but more likely to be elevated among youth with a primary anxiety, than OCD, diagnosis., Discussion: Results provide initial support for the RBFBS as a brief screening tool for the three common BFRBs. In addition, the results suggest avoidant tendencies and physical manifestations of distress may be particularly relevant to the escalation of BFRB symptoms in youth., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Trichotillomania appears to be a fairly common disorder, with high rates of co-occurring anxiety disorders. Many individuals with trichotillomania also report that pulling worsens during periods of increased anxiety. Even with these clinical links to anxiety, little research has explored whether trichotillomania with co-occurring anxiety is a meaningful subtype., Methods: One hundred sixty-five adults with trichotillomania were examined on a variety of clinical measures including symptom severity, functioning, and comorbidity. Participants also underwent cognitive testing assessing motor inhibition and cognitive flexibility. Clinical features and cognitive functioning were compared between those with current co-occurring anxiety disorders (i.e. social anxiety, generalized anxiety disorder, panic disorder, and anxiety disorder NOS) (n=38) and those with no anxiety disorder (n=127)., Results: Participants with trichotillomania and co-occurring anxiety reported significantly worse hair pulling symptoms, were more likely to have co-occurring depression, and were more likely to have a first-degree relative with obsessive compulsive disorder. Those with anxiety disorders also exhibited significantly worse motor inhibitory performance on a task of motor inhibition (stop-signal task)., Conclusions: This study suggests that anxiety disorders affect the clinical presentation of hair pulling behavior. Further research is needed to validate our findings and to consider whether treatments should be specially tailored differently for adults with trichotillomania who have co-occurring anxiety disorders, or more pronounced cognitive impairment., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The significance of family history in body-focused repetitive behavior disorders (BFRBs) (i.e. trichotillomania and skin picking) has received scant research attention. We sought to understand the clinical and cognitive impact of having a first-degree relative with a BFRB or a substance use disorder (SUD)., Methods: 265 participants with BFRBs undertook clinical and neurocognitive evaluations. Those with a first-degree relative with a BFRB or an SUD were compared to those without on a number of clinical and cognitive measures., Results: 77 (29.1%) participants had a first-degree family member with a BFRB and 59 (22.2%) had a first-degree family member with an SUD. In terms of clinical severity, the amount of time spent picking or pulling per day in the past week was higher among those with a first-degree relative with an SUD. There were a higher rate of ADHD and higher HAM-D scores among those with a positive family history of an SUD. There were no significant cognitive differences based on family history., Conclusions: These results indicate that among those with BFRBs, having a first-degree family member with an SUD may be associated with a unique clinical and cognitive presentation. Whether family history also is associated with differential response to treatments awaits further research., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: This study investigated relationship functioning in trichotillomania (TTM) as well as specific interpersonal behaviors that have received little attention in TTM research, including by-proxy pulling, symptom accommodation, and self-disclosure. The objective was to contribute data for future development of components of treatment that focus on interpersonal functioning., Methods: Data were collected through survey about relationships and related difficulties among adults who endorsed criteria consistent with DSM-5 criteria for TTM (n=670)., Results: Consistent with our hypotheses, TTM symptom severity was correlated negatively with relationship satisfaction and perceived social support, positively with perceived criticism, perceived risk in intimacy, and social interaction anxiety, though these correlations were small (absolute values r=.08 to .17). Approximately one-quarter of survey respondents had not told their closest friend about their trichotillomania, and one-fifth had not told their spouse or long-term romantic partner. TTM-by-proxy urges were reported by 54% of participants, and 37% of participants reported having actually pulled hair from other people, with the most common proxies specified as significant others (51%), parents (13%), friends (8%), siblings (8%), children (7%) and pets (5%). Higher levels of TTM-by-proxy urges were associated with "focused" pulling (d=.37) and perfectionistic thinking (d=.16 to .20), yet current by-proxy urges were not associated with, functional impairment. A small minority of individuals (7%) reported having asked other people to pull hair for them (78% of these requests were granted); there was increased endorsement of "focused" pulling among these individuals. The people who participants asked to pull hairs for them included significant others (66%), mothers (20%), siblings (11%), friends (9%) and one's children (9%)., Conclusion: More than one-third of respondents had pulled hair from others, 7% had asked others to pull their hair, and sizable minorities kept TTM secret from their closest friends or even spouse/partners. Clinical levels of social interaction anxiety were endorsed by 51% of the sample. Understanding these interpersonal experiences more fully could improve our understanding of relationship functioning in TTM and guide efforts to individualize treatment for adults with TTM., (Published by Elsevier Inc.)

The objective of this study was to compare patients with obsessive-compulsive disorder (OCD) associated with pathologic skin picking (PSP) and/or trichotillomania, and patients with OCD without such comorbidities, for demographic and clinical characteristics. We assessed 901 individuals with a primary diagnosis of OCD, using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) Axis I disorders. Diagnoses of PSP and trichotillomania were made in 16.3% and 4.9% of the sample, respectively. After the logistic regression analysis, the following factors retained an association with OCD-PSP/trichotillomania: younger (odds ratio [OR] = 0.979; P = .047), younger at the onset of compulsive symptoms (OR = 0.941; P = .007), woman (OR = 2.538; P < .001), with a higher level of education (OR = 1.055; P = .025), and with comorbid body dysmorphic disorder (OR = 2.363; P = .004). These findings support the idea that OCD accompanied by PSP/trichotillomania characterizes a specific subgroup., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Sex has been postulated as one of the factors mediating heterogeneity in obsessive-compulsive disorder (OCD). This study investigated the sex differences in OCD with respect to sociodemographics, symptom profile, and comorbidity including spectrum disorders. Two hundred thirty-one subjects diagnosed with OCD by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria were included in the study. The subjects were evaluated by extensive clinical and semistructured interviews by expert clinical psychiatrists, and diagnosis was made by consensus. Male (n = 166) and female (n = 65) subjects with OCD were compared with respect to the data obtained. Males with OCD tended to have an earlier onset and had more symmetry/religious obsessions and miscellaneous compulsions. Males also showed a tendency to have attention deficit hyperactivity disorder. Female subjects were more likely to be married, have cleaning compulsions and be associated with trichotillomania. The findings support the hypothesis that there are sex differences in OCD, but the results are only partly comparable with other studies, suggesting that the phenotypic expression of OCD is possibly dependent on a complex interaction among biologic, personal, and cultural factors.

Objective: Little is known about trichophagia in individuals with trichotillomania. Although studies have mentioned the behavior, no previous studies have examined clinical correlates of trichophagia., Method: We examined the clinical correlates of trichophagia in 68 subjects with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, trichotillomania (85.3% females; mean age, 35.0 +/- 12.5). Comorbidity data were obtained with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Trichotillomania severity was assessed with the Psychiatric Institute Trichotillomania Scale and the Massachusetts General Hospital Hairpulling Scale. Social/occupational functioning was examined using the Sheehan Disability Scale. All variables were compared in trichotillomania subjects with and without trichophagia., Results: Of the 68 subjects with trichotillomania, 14 (20.6%; 95% confidence interval, 12.7%-31.6%) reported current trichophagia, and an additional 9 (13.2%) ate their hair or the root episodically. There were far more similarities than differences in trichotillomania subjects with current trichophagia and those without, although those with trichophagia were significantly more likely to be male (P = .013) and have more severe trichotillomania (according to the Massachusetts General Hospital Hairpulling Scale) (P = .010)., Conclusions: These preliminary results suggest that trichophagia is not uncommon in individuals with trichophagia. Subjects with and without trichophagia were similar in most domains that were examined.

To compare impulsivity and compulsivity, we performed a case control study comparing a group of 20 patients with obsessive-compulsive disorder with a group of 20 patients with skin picking and/or trichotillomania (SP/T). The instruments used were Structured Clinical Interview for DSM-IV Axis I Diagnosis, Yale-Brown Obsessive-Compulsive Scale, Schalling Impulsivity Scale, and Hamilton Anxiety and Depression Inventories. A Multidimensional Impulsive-Compulsive Spectrum Assessment Instrument was designed for this particular study. The Yale-Brown Obsessive-Compulsive Scale scores were significantly higher in patients with obsessive-compulsive disorder, compared with patients with SP/T (F = 90.29; P < .001). The Hamilton Inventories and Schalling Impulsivity Scale revealed no significant intergroup differences. The Multidimensional Impulsive-Compulsive Spectrum Assessment Instrument allowed us to find 6 statistically significant differences between groups: the ability or inability to delay an impulse, quick response or action planning, feelings of pleasure or guilt during or after an act, ritualization, and whether the patient believes he/she has losses or benefits if prevented from acting. In conclusion, SP/T should deserve further attention about their classification in future versions of diagnostic manuals because, as in International Classification of Diseases, Tenth Revision, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition includes these disorders in the same chapter as pathological gambling, kleptomania, pyromania and others. Despite their resemblance to compulsions, their classification under the Obsessive-Compulsive Spectrum needs particular phenomenological and neurobiologic investigation.

Trichotillomania, the compulsive urge to pull out one's hair, is a poorly studied chronic condition affecting 2 to 8 million people, 90% of whom are women. Significant gains have been made about the nature and clinical presentation of this disorder, and yet conceptualizations of trichotillomania remain inconsistent and controversial. Consequently, treatments for trichotillomania have proven to be largely ineffective. Anecdotal case studies have provided us with preliminary data about the impact of this condition on emotional, psychological, and social well-being. To date, there are no empirical studies that focus on patients' subjective experiences with their disorder. The purpose of this report is to identify and discuss the concerns of women with trichotillomania. We have also provided clinical examples to highlight how these concerns are evident in the lives of these women. A total of seven women participated in focused interviews which asked them to reflect on their experiences with compulsive hair pulling. The interview transcripts were analyzed for themes using techniques from the constant comparative method. Additionally, women were asked to complete a demographic self-report. Our analysis identified themes pertinent to negative affects, control, and triggering precipitants. We argue that identifying and integrating these themes in current treatment protocols is the first step to improving the efficacy of treatment for trichotillomania.

The present study examines some of the beliefs about trichotillomania such as those concerning the sex and age of afflicted individuals. Information was gathered from an exhaustive literature review and surveys of the general public and college students. Data on such factors as prevalence, sex, age distribution, onset, codiagnosis, and details of the hair-pulling act are presented, and reviews of explanations and treatment are provided.

Pathologic hair-pulling (trichotillomania) has been described in the dermatologic and psychiatric literature for the last century, but has become the focus of increased attention in the last few years. Once thought to be either a wholly benign condition or a symptom of obsessive-compulsive disorder, more recently hair-pulling has been noted in the context of numerous types of psychopathology, and has been reported to respond to several different types of intervention, both psychological and somatic. Estimates of its prevalence have varied widely. Because of the disparate conclusions of the literature on this condition, a more careful assessment of diagnostic validity is recommended.