Trichotillomania Hoarding Disorder and Excoriation Disorder Allison Cowan

Trichotillomania, Hoarding Disorder and Excoriation Disorder Allison Cowan, MD Assistant Professor Department of Psychiatry Boonshoft School of Medicine Wright State University Dayton, OH

Disclosures • Nothing to disclose – Access Ohio • Ohio’s Telepsychiatry Project for Intellectual Disability – Montgomery County Board of Developmental Disabilities Services – Coleman Professional Services

Trichotillomania • Persistent hair pulling leading to hair loss • With repeated attempts to stop • Resulting in significant distress and functional limitations • Cannot be better accounted for by a medical condition

Trichotillomania (TTM) • This is the first time that TTM has been described as its own entity in DSM • Was previously categorized as Impulse Control Disorder Not Otherwise Specified • Now in Obsessive Compulsive Disorderspectrum disorders

Trichotillomania SOURCE: http: //www. cbtspectrum. com/blog-1/2015/10/2/trichotillomania-awareness-week-why-would-i-pull-my-hair

Trichotillomania is NOT SOURCE: http: //www. regionalderm. com/Regional_Derm/Tfiles/tinea_capitis. html

Trichotillomania is NOT SOURCE: https: //www. aad. org/public/diseases/hair-and-scalp-problems/hair-loss#symptoms

Trichotillomania IS SOURCES: https: //www. youtube. com/watch? v=we. Cc. LWgh. Y 2 U http: //www. meddean. luc. edu/lumen/meded/medicine/dermatology/melton/trich 1. htm

Adaptation of Diagnostic Criteria--TTM DSM-5 Criteria Adapted Criteria for Mild to Moderate ID A. Recurrent pulling out of A. No adaptation one’s hair, resulting in hair loss. B. Repeated attempts to B. This criterion may not decrease or stop hair pulling. apply because of the individual’s inability to express feelings. C. The hair pulling causes C. This criterion may not clinically significant distress apply because of the or impairment in social, individual’s inability to occupational, or other express feelings. important areas of functioning. All charts: DM-ID 2, in press. Adapted Criteria for Severe to Profound ID A. No adaptation B. This criterion does not apply. C. This criterion does not apply.

Adaptation D. The hair pulling D. No adaptation or hair loss is not attributable to another medical condition (e. g. , a dermatological condition). D. No adaptation

Adaptation E. The hair pulling is not better explained by the symptoms of another mental disorder (e. g. , attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder). The hair pulling may occur in the presence of other mental disorders, including other types of self-injurious behavior. E. The hair pulling is not better explained by the symptoms of another mental disorder (e. g. , attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder). The hair pulling may occur in the presence of other mental disorders, including other types of self-injurious behavior.

Trichotillomania • Treatment – Bio – Psycho – Social

Trichotillomania • Treatment – Bio • • • clomipramine +/olanzapine + lithium + naltrexone + SSRIs - Checking for bezoars

• Treatment Trichotillomania – Bio – Psychological • Behavioral approaches – Habit Reversal Training – CBT – Relaxation training – Acceptance and Commitment Therapy (ACT) Duke DC, Keeley ML, Geffken GR, Storch EA. Trichotillomania: A current review. Clinical Psychology Review Vol. 30, iss. 2, March 2010, pp. 181 -193.

Trichotillomania • POP QUIZ! • Four methods of psychological treatment for trichotillomania are – Habit Reversal Training – CBT – Relaxation training – Acceptance and Commitment Therapy (ACT)

Trichotillomania • Bio • Psycho • Social – Acceptance – Stress reduction – Education – Social impact

Hoarding Disorder • Persistent difficulty discarding or parting with possessions, regardless of their actual value. • Due to strong urges to save items and/or distress associated with discarding them • As a result, accumulation of a large number of possessions occurs which clutters active living areas of the home/workplace to the extent that the intended use is no longer possible

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Hoarding Disorder is SOURCE: https: //www. flickr. com/photos/carriembecker/6059002713/in/album-

Hoarding • Hoarding—being unable to discard useless items • Collecting—knowing the value of certain items – (Pikachu is rare, but Ratatat is common. )

Hoarding Disorder--Adaptations DSM-5 Criteria A. Persistent difficulty discarding or parting with possessions, regardless of their actual value. Adapted Criteria for Mild to Moderate Intellectual Disability A. No adaptation. Note: Realistic “value” of the possessions to the individual should be interpreted in terms of the objective and subjective functional as well as developmental levels of the individual with intellectual disability Adapted Criteria for Severe to Profound ID A. No adaptation. Note: Realistic “value” of the possessions to the individual should be interpreted in terms of the objective and subjective functional and developmental levels of the individual with intellectual disability

Hoarding Disorder--Adaptations B. This difficulty is due to a perceived need to save the items and to distress associated with discarding them. B. No adaptation. B. Unable to determine in most individuals in this category Note: The individual’s insight Note: Recurrent and persistent into the consequences of thoughts, impulses or images, may accumulating objects or of not be experienced as intrusive or discarding them may be limited. inappropriate nor cause marked Expressions of grief and distress anxiety or distress; delusional may require behavioral beliefs, if present and organized observation in individuals who into a system, may not be possible have limitation with verbal to determine due to cognitive and expression of emotions communicative deficits; distress also may occur when a fixed pattern of arrangement of clutter is altered.

Hoarding Disorder--Adaptations C. The difficulty discarding C. No adaptation. possessions results in the accumulation of possessions Note: The individual’s ability to that congest and clutter active understand health consequences of living areas and substantially of clutter and storage limitations compromises their intended use. should be taken into consideration. If living areas are uncluttered, it consideration. The individual may not have the is only because of the interventions of third parties ability to take the initiative to (e. g. , family members, cleaners, discard objects. authorities). D. The hoarding causes clinically D. No adaptation. significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others). D. Unable to determine in some individuals in this category. Note: Baseline areas of functioning may already be limited. Changes in behavior need to be interpreted as compared with baseline for the individual.

Hoarding Disorder--Adaptations E. The hoarding is not better E. No adaptation. explained by the symptoms of another mental disorder (e. g. , Note: Prader-Willi, dementia obsessions in obsessiveand other syndromes involving compulsive disorder, decreased hoarding behavior that are energy in major depressive sometimes seen in autism are disorder, delusions in diagnosed elsewhere and do schizophrenia or another psychotic disorder, cognitive not require an additional deficits in major neurocognitive Hoarding Disorder diagnosis. disorder, restricted interests in autism spectrum disorder). E. No adaptation. Note: Prader-Willi, dementia and other syndromes involving hoarding behavior that are sometimes seen in autism are diagnosed elsewhere and do not require an additional Hoarding Disorder diagnosis.

Hoarding Disorder • Treatment – Bio – Psycho – Social

Hoarding Disorder • Treatment – Biological • Lack of evidence (until recently, was incorporated in OCD) and some studies demonstrating poorer outcome with HD+OCD • SSRIs have shown some benefit • Antipsychotic agents Muroff J, Bratiotis C, Steketee G. Treatment for Hoarding Behaviors: A review of the evidence. Clinical Social Work Journal Vol 39 Iss 4, Dec 2011, pp. 406 -423.

Hoarding Disorder • Treatment – Bio – Psychological • • CBT Exposure Response Prevention +/Web-based (n=3) High drop-out rate Muroff J, Bratiotis C, Steketee G. Treatment for Hoarding Behaviors: A review of the evidence. Clinical Social Work Journal Vol 39 Iss 4, Dec 2011, pp. 406 -423.

Hoarding Disorder • Treatment – Bio – Psycho – Social • There is little evidence concerning social interventions • BUT impact of Hoarding Disorder on social life – Housing – Occupational impairment – Social stressors with family (removal of children) and friends Tolin, D. F. , Frost, R. O. , Steketee, G. , & Fitch, K. E. (2008). Family burden of compulsive hoarding: Results of an internet survey. Behaviour Research And Therapy, 46334 -344. doi: 10. 1016/j. brat. 2007. 12. 008 Tolin, D. F. , Frost, R. O. , Steketee, G. , Gray, K. D. , & Fitch, K. E. (2008). The economic and social burden of compulsive hoarding. Psychiatry Research, 160200 -211. doi: 10. 1016/j. psychres. 2007. 08. 008

Hoarding • POP QUIZ! • What is one way to tell hoarding from collecting? – Ability to put a relative value on something – Ability to discard an item

Excoriation (Skin-Picking)Disorder • Recurrent picking of one’s own skin which causes tissue damage • Occurs in individuals with Prader-Willi and Smith-Magenis Syndrome more often.

Excoriation Disorder is NOT SOURCE: https: //www. aad. org/Image%20 Library/Main%20 navigation/Public%20 and%20 patients/Diseases%20 and%20 treatments/Itchy%20 skin/bed_bugs_landing. jpg

Excoriation Disorder

Excoriation Disorder--Adaptations DSM-5 Criteria Adapted Criteria for Mild to Moderate Intellectual Disability Adapted Criteria for Severe to Profound Intellectual Disability A. Recurrent skin picking resulting in skin lesions. A. No adaptation. B. Repeated attempts to decrease or stop skin picking. B. No adaptation. Note: Repeated attempts to decrease or stop skin picking may not be possible due to cognitive and communicative deficits. B. No adaptation. Note: Repeated attempts to decrease or stop skin picking may not be possible due to cognitive and communicative deficits. The individual may make no to decrease or stop skin picking.

Excoriation Disorder--Adaptations C. The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. No adaptation. Note: The skin picking may or may not cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Distress may not occur or may not be ascertainable. Consider occupational limitations like an individual not being able to work due to open sores or inability to keep from picking. Also consider medical complications such as infection, scarring, and irritation.

Excoriation Disorder--Adaptations D. The skin picking is not D. No adaptation. attributable to the physiological effects of a substance (e. g. , cocaine) or another medical condition (e. g. , scabies). E. The skin picking is not E. No adaptation. better explained by symptoms of another mental disorder (e. g. , delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder, stereotypies in stereotypic movement disorder, or intention to harm oneself in a non-suicidal self-injury. D. No adaptation. E. No adaptation.

Excoriation Disorder • Treatment – Bio – Psycho – Social

Excoriation Disorder • Treatment – Bio: • SSRIs • Naltrexone • N-Acetylcysteine • Low-dose antipsychotic augmentation – Olanzapine – Haloperidol

Excoriation Disorder • Treatment – Bio – Psychological • CBT • Habit Reversal Training • Acceptance and Commitment Therapy • Differential Reinforcement of Incompatible Beh (DRI) Stargell, N. A. , Kress, V. E. , Paylo, M. J. , & Zins, A. (2016). Excoriation Disorder: Assessment, Diagnosis and Treatment. Lang R, Didden R, Machalicek W, et al. (2010). "Behavioral treatment of chronic skin-picking in individuals with developmental disabilities: a systematic review". Res Dev Disabil. 31 (2): 304– 15. doi: 10. 1016/j. ridd. 2009. 10. 017

Excoriation Disorder • Treatment – Bio – Psycho – Social • • Occupational impairment Academic impairment Social impairment Connection between skin-picking severity and symptoms of depression, anxiety, and experiential avoidance Flessner, C. A. , & Woods, D. W. (2006). Phenomenological characteristics, social problems, and the economic impact associated with chronic skin picking. Behavior Modification, 30(6), 944 -963.

LAST POP QUIZ • Excoriation Disorder occurs more often in people with what genetic disorders? – Smith-Magenis – Prader-Willi

Thank you! • Questions?

References • Duke DC, Keeley ML, Geffken GR, Storch EA. Trichotillomania: A current review. Clinical Psychology Review Vol. 30, iss. 2, March 2010, pp. 181 -193. • Muroff J, Bratiotis C, Steketee G. Treatment for Hoarding Behaviors: A review of the evidence. Clinical Social Work Journal Vol 39 Iss 4, Dec 2011, pp. 406 -423. • Tolin, D. F. , Frost, R. O. , Steketee, G. , & Fitch, K. E. (2008). Family burden of compulsive hoarding: Results of an internet survey. Behaviour Research And Therapy, 46334 -344. doi: 10. 1016/j. brat. 2007. 12. 008 • Tolin, D. F. , Frost, R. O. , Steketee, G. , Gray, K. D. , & Fitch, K. E. (2008). The economic and social burden of compulsive hoarding. Psychiatry Research, 160200 -211. doi: 10. 1016/j. psychres. 2007. 08. 008 • Grant, J. E. , Odlaug, B. L. , Chamberlain, S. R. , Keuthen, N. J. , Lochner, C. , & Stein, D. J. (2012). Skin picking disorder. American Journal of Psychiatry, 169(11), 1143 -1149.

References • Christensen, R. C. (2004). Olanzapine augmentation of fluoxetine in the treatment of pathological skin picking. Canadian journal of psychiatry, 49(11), 788. • Bloch, M. R. , Elliott, M. , Thompson, H. , & Koran, L. M. (2001). Fluoxetine in pathologic skin-picking: open-label and double-blind results. Psychosomatics, 42(4), 314 -319. • Keuthen, N. J. , Jameson, M. , Loh, R. , Deckersbach, T. , Wilhelm, S. , & Dougherty, D. D. (2007). Open-label escitalopram treatment for pathological skin picking. International clinical psychopharmacology, 22(5), 268 -274. • Bohne, A. , Keuthen, N. , & Wilhelm, S. (2005). Pathologic hairpulling, skin picking, and nail biting. Annals of Clinical Psychiatry, 17(4), 227232. • Stargell, N. A. , Kress, V. E. , Paylo, M. J. , & Zins, A. (2016). Excoriation Disorder: Assessment, Diagnosis and Treatment.

References • Flessner, C. A. , & Woods, D. W. (2006). Phenomenological characteristics, social problems, and the economic impact associated with chronic skin picking. Behavior Modification, 30(6), 944 -963. • Lang R, Didden R, Machalicek W, et al. (2010). "Behavioral treatment of chronic skin-picking in individuals with developmental disabilities: a systematic review". Res Dev Disabil. 31 (2): 304– 15. doi: 10. 1016/j. ridd. 2009. 10. 017