Trichotillomania across the life span.

KEY POINTS • No randomized clinical trials have been conducted in children with trichotillomania. Research examining the clinical course and natural history of childhoodonset trichotillomania is equally sparse. • Behavioral treatments such as habit reversal therapy have demonstrated efficacy in the treatment of adults with trichotillomania. Large uncontrolled trials have suggested similar efficacy of behavioral therapies in children. • Several double-blind, randomized, clinical trials have demonstrated that selective serotonin reuptake inhibitors have no efficacy in treating the primary symptoms of trichotillomania in adults. • Evidence from a recent double-blind, placebo-controlled randomized clinical trial suggests that the glutamatemodulating agent, N-acetylcysteine, may be effective in treating trichotillomania in adults. Trichotillomania (TTM) is a disorder in which patients chronically pull out their hair, producing noticeable hair loss, distress, and impairment. The lifetime prevalence of TTM is estimated to be 1% to 3%. Children with TTM can experience significant impairment because of peer teasing, avoidance of activities (such as swimming and socializing), difficulty concentrating on school work, and medical complications due to pulling behaviors. Trichotillomania has an average age of onset of 11 to 13 years and is considered to have a chronic course, often waxing and waning in severity. 1 The DSM-IV criteria for TTM are depicted in Table 1. One quarter of adult pullers do not report experiencing urges before pulling or relief after pulling and thus do not meet current DSM criteria for TTM. The proportion of children who experience chronic hair-pulling without reporting these sensory phenomena are considerably higher. In recent years, there have been advances in the development of evidence-based treatments for adults with TTM. 2 Despite these advances, only 15% of adults with TTM experience significant improvement with community treatment. More than 55% of adults with TTM felt that their clinician did not have sufficient knowledge of the disorder, and less than half were receiving evidence-based treatments. 3 The evidence base for judging treatment efficacy in pediatric patients is considerably less, and children’s success rate with community treatments is equally discouraging. 4 The lack of controlled clinical trials in children, the secrecy of many children with TTM, and the infrequency with which it reaches psychiatric attention present considerable challenges for clinicians. However, much can be learned by examining the randomized clinical trial data in adults and combining it with the evidence base from Psychopharmacology Perspectives aims to discuss practical approaches to everyday issues in pediatric pharmacotherapy. The discussions may address aspects of clinical care related to psychopharmacology for which we do not have adequate applicable controlled trials. Given the need to address symptoms in youths with often complex, severe, and comorbid disorders, recommendations are likely to be off-label from the perspective of the U.S. Food and Drug Administration. We fully appreciate that for virtually all disorders, medication is only one aspect of comprehensive care. This column focuses primarily on psychopharmacological management. Although it is important that clinicians address psychosocial issues in the evaluation and treatment of their patients, such discussion is beyond the specific scope of this feature. These are not meant to be practice guidelines, but rather examples of the thought process that may go into pharmacotherapy decision making. Accepted April 20, 2009. This article was reviewed under and accepted by Deputy Editor John T. Walkup, M.D. Dr. Bloch is with the Yale Child Study Center, Yale University School of