Hair Pulling (AKA Trichotillomania) and Skin Picking Problems – Greater Research Support for Behavior Therapy over Medication

Trichotillomania (or trich for short) is a condition in which people repeatedly pull out their body hair, often leading to bald patches and thinning. The scalp is a common site—as are eyebrows and eyelashes—but some may pick at hair anywhere on the body. A related condition is repetitive skin picking. This condition did not have an official diagnostic name until 2013, when the most recent edition of the DSM psychiatric guide decided on the name excoriation. People with an excoriation disorder pick or scratch at their skin—often at perceived imperfections or blemishes—to the degree that they may cause marks, bleeding, and scarring.

Both are broadly categorized as body-focused repetitive behaviors, and these have recently been more broadly categorized and obsessive-compulsive and related disorders. People with these problems often experience a great deal of shame and embarrassment about their difficulties and have an extremely tough time stopping.

Unfortunately, both conditions are understudied and not well-known. Many people struggle with them without realizing there is even a name for their condition.

The treatment literature is relatively small compared to problems such as depression and anxiety. However, I recently came across a nice summary of treatment options for trichotillomania and skin picking, as well as other conditions more broadly called obsessive-compulsive and related disorders.

Cognitive Behavioral Therapy

For hair pulling, cognitive behavioral therapy has the greatest research support. An intervention called habit reversal training has been the most studied, either by itself or in combination with a more comprehensive cognitive behavioral treatment such as Acceptance and Commitment Therapy (called “act” for short).

With excoriation, there is evidence that treatments that work for hair pulling also work for skin picking. Unfortunately, the treatment evidence for excoriation is more limited. Although it was studied for decades before being given an official diagnosis in 2013, I suspect not having an official diagnosis slowed research interest. Hopefully, we will begin to see more research on skin picking.

Medication

Rigorous research on the use of medication is much less robust than the research on therapy. There’s some evidence that the antidepressant clomipramine may help reduce hair pulling, but controlled studies on the use of SSRI’s—the most common class of antidepressants—have not shown much effectiveness. Of the SSRI’s, fluoxetine has been the most studied, but it’s effectiveness with hair pulling has been very mixed.

There’s some research support for the use of antidepressants in reducing skin picking; however, there have been no large controlled trials.

My Impressions

The research matches my experience as a therapist. Many people I’ve treated for hair pulling or skin picking have tried medication first and have either not found it helpful at all or have been unclear about whether it was effective or not. If someone’s anxiety is contributing to pulling or picking behavior, medication may help reduce the tendency somewhat but is not likely to be a total cure.

I should also acknowledge that behavioral treatment for picking and pulling is hard work. It takes a lot of attention and effort to change these habits, and many people who do well with treatment continue to struggle with it to some degree. For these reasons, it is important to see a specialist in hair pulling and skin picking. Generic talk therapy is unlikely to be of much help.

Summary

In sum, some form of cognitive behavioral treatment—especially with habit reversal training—with an experienced specialist should be the first-line treatment for hair pulling and skin picking.

As I’ve written about before, the Trichotillomania Learning Center is a great grassroots resource for learning more about hair pulling and skin picking.

If you’d like to read the full article yourself, you can download it here.

What Medications are Effective in OCD?

In previous posts, I’ve written about how cognitive behavioral treatment (specifically, CBT with exposure and response prevention) has been shown to be much more effective in treating obsessive compulsive disorder (OCD) than medication. Nevertheless, many people with OCD are still interested in seeing if they can find a medication that will turn down the intensity of the anxiety. I’ve found that this can sometimes be helpful and may allow the person to more fully participate in CBT.

Clients regularly ask me for medication recommendations. Because I am not a medication prescriber, I avoid suggesting particular medications or dosages but will talk to them about the pros and cons of trying medication. I recently deepened my knowledge of the pros and cons of medications for OCD when I attended a training though the International OCD Foundation. At this workshop, Dr. Michele Pato, a psychiatrist at the University of Southern California, discussed the use of medications for OCD. Here’s a chart with her suggestions for medications:

Click here for a list of medications Dr. Pato suggests in treating OCD.

Based on Dr. Pato’s advice, here are a few things to consider in choosing a medication:

  1. It’s common to start with a class of antidepressants known as Selective Serotonin Reuptake Inhibitors (SSRI’s). Dr. Pato mentioned she typically starts with Sertraline (known as Zoloft commercially).
  2. The dose needed for OCD is typically higher than the dose used for depression.
  3. If SSRI’s aren’t effective, there’s also evidence that an older Antidepressant called Clomipramine may work. However, it is important to be cautious when taking Clomipramine because—unlike the SSRI’s—it can kill someone when the dosage is too high. Additionally, Clomipramine can interact badly with another SSRI Fluoxetine (Prozac), making it toxic even in smaller doses.
  4. Side effects are common with taking antidepressants, but the side effects often fade over time.
  5. With OCD, it may take 8-12 weeks before there’s any noticeable improvement, so it’s usually a good idea to give the medication enough time to be effective.
  6. There’s a high risk that OCD symptoms will increase when stopping an antidepressant medication, but this risk can be reduced if the individual has had a successful course of CBT + ERP. Dr. Pato mentioned that she frequently tapers people off medication after they successfully complete treatment.

Please note: As I mentioned, I am not a prescriber and am passing on information I learned from a reputable source. As many people with OCD do not have access to a specialist in pharmacology for OCD and often turn to a general practitioner, I offer this is a guide that may be of some use.

Here’s an informational page from the International OCD Foundation on the use of medications in treating OCD.

Anxiety Treatment at Portland Psychotherapy

Are Antipsychotic Medications a Helpful Adjunct for Treating Obsessive-Compulsive Disorder?

Among people with whom I work, a practice that’s grown more common in the last few years but with iffy research support is the addition of an antipsychotic medication when an antidepressant medication doesn’t seem to be working. This is done in an attempt to augment the effect of the antidepressant. The practice concerns me because there’s a lot of research evidence showing that the side effects of antipsychotics can be pretty awful (e.g., weight gain, high blood pressure). It concerned me enough that I wrote an editorial about it that the Oregonian published in 2012.

Now new data has been published that clearly suggests antipsychotics should not be added to antidepressants for people with OCD.

Another study showing that CBT does the best with OCD

As I’ve written before, the most effective treatment for OCD is cognitive behavioral therapy (CBT) with exposure and response (or ritual) prevention (ERP).

A 2013 study examined a group of people with moderate to severe OCD who were already taking an antidepressant. They were divided into three groups.

  1. One group received psychotherapy—cognitive behavioral therapy with ERP.
  2. One group was prescribed an antipsychotic—Risperidone—in addition to the antidepressant.
  3. One group was prescribed a placebo (i.e., inactive) pill.

What did they find?—CBT was much more effective

The results are pretty striking. For those that were given an antipsychotic, only 23% of people showed improvement. This might suggest there is some benefit to adding an antipsychotic; however, this finding is not very impressive because those given the placebo (e.g., sugar pill) showed a 15% improvement. Moreover, the researcher found no statistically significant different between the effectiveness of the antipsychotic and that of the placebo. What this means is that, statistically speaking, the antipsychotic was no better than the placebo; that is, the 23% improvement (i.e., antipsychotic) is not more meaningful than the 15% improvement (i.e., placebo).

By contrast to those who received a pill, 80% of people who received cognitive behavioral therapy with ERP showed improvement! This is 3-4x the rate of improvement compared to those taking an antipsychotic—and without the extensive side effects that are common with antipsychotics.

Antipsychotic medication should not be considered for people with OCD

I think this is an important study because it makes it clear that adding antipsychotic medication is unlikely to really benefit someone with OCD. However, that cognitive behavioral therapy with ERP is more effective than medication for OCD is not a new finding

There’s already a solid base of research that suggests the ERP is superior to antidepressant medication for OCD. Giving an antidepressant to someone receiving EX/RP for OCD neither helps nor hinders treatment. This study is evidence that antipsychotics should not be considered for people with OCD.

Anxiety Treatment at Portland Psychotherapy

Psychotherapy vs. Medication for OCD – Which is More Effective?

Obsessive-Compulsive Disorder (OCD) is a serious and disabling problem for many people. Understandably, many people seek out medication to help with this problem, and research is shown that medication can be helpful some people. However, research is also very clear that particular proven forms of psychotherapy work much better than medication for OCD. A newly published review paper provides further evidence that psychotherapy outperforms medication for OCD.

Some background about the paper

Published in 2013 in World Psychiatry, Cuijpers and colleagues collected 67 studies where medication and psychotherapy were directly compared against each other for depression and anxiety-related problems. The researchers conducted what is called a meta-analysis, a way of converting the data from separate studies into a computation that allow for a direct comparison across studies.

The researchers determined that for OCD, psychotherapy is “clearly more efficacious” than medication. Specifically, psychotherapy was found to be more effective than antidepressants, the most well-research pharmacological treatment for OCD

One caveat

One point I’d like to make clear is that we’re not talking about generic talk therapy but some form of OCD-specific cognitive-behavior therapy (CBT), typically with what is called exposure and response (or ritual) prevention (ERP). Although mild to moderate anxiety and depression may respond to generic talk therapy, OCD generally does not, and usually requires a structured approach such as CBT with ERP.

What this research adds to what we currently know

This study contributes to a body of literature suggesting that psychotherapy is the treatment of choice for OCD. Previous research has found that medication does not interfere with evidence-based psychotherapy for OCD, but neither does it enhance treatment. In sum, although some people with OCD may benefit from medication, particularly if they are also depressed, medication alone for OCD is a substandard treatment. Cognitive behavior therapy with exposure and response/ritual prevention is the gold standard. There is also newer evidence that Acceptance and Commitment Therapy (ACT), even without ERP, is an effective treatment for OCD.

Don’t take my word for it, though: you can read the Cuijpers and colleagues study yourself here.

Ketamine for OCD, Too?

I’ve written in the past about the use of a pharmaceutical version of the drug ketamine (known as the party drug, “Special K”) in studies with depression and with bipolar disorder. Recently, I learned researchers have published a new study looking at the impact of ketamine on obsessive compulsive disorder (OCD).

I was on the phone with someone interested in OCD treatment, and she mentioned she had read some promising work at Yale about an experimental treatment that involved increasing glutamate levels in people with OCD. Glutamate is a neurotransmitter in the brain. Ketamine affects NMDA, an important receptor for glutamate, leading to lower levels of glutamate in the brain. I told the caller I wasn’t familiar with this line of research, and she kindly sent me a few links, including the one below.

The IOCDF article
The International OCD Foundation (IOCDF) has an article on their website about the potential role of glutamate in understanding OCD, under the subheading, “Cutting Edge Research on New Medication Options.” It’s written by three doctors associated with Yale University. The authors summarize some research finding higher levels of glutamate in the brain in people with OCD. Although they acknowledge important caveats about what is known about glutamate so far, the authors end the article with pointing to ketamine as a possible treatment for OCD.

The article is reasonably balanced, but at the time it was written, there was no published research on the use of ketamine in people with OCD. A study from 2012 suggests these speculations may have been overly optimistic.

A 2012 research study
I haven’t been able to track down a copy of the full article, so my comments are taken strictly from the abstract. Two of three authors from the IOCDF article are authors on the study. The details are a little unclear but the take-away message is pretty explicit:

“Ketamine effects on OCD symptoms…did not seem to persist or progress after the acute effects of ketamine had dissipated.”

It appears that the effect of ketamine on OCD was very small, and it didn’t last very long. It looks like the enthusiasm in the IOCDF article could use some updating.

Some concluding thoughts
I’d like to be clear that I think the authors of the IOCDF articles are well-intentioned, honest, and excellent researchers. What’s important to keep in mind is that the history of science is littered with ideas that seemed sound or were based on preliminary research, but which were disappointing when studied through controlled research.

As I’ve noted in my other writings on ketamine, I don’t object to ketamine being studied; however, I think researchers should be more cautious about their enthusiasm when talking to the public. Science is a slow progress of trial-and-error, and truly revolutionary treatments are few and far between. Ketamine may yet emerge as useful for depression, but if this study is any indication, its role for OCD doesn’t look very promising.

That said, there’s some exciting research on improving psychotherapeutic approaches for OCD. Cognitive behavioral therapy isn’t as exciting as the promise of a fast-acting drug, but it is effective and the best thing we have for OCD, particularly exposure therapy, something I’ve written about in our therapist blog.

PLEASE NOTE: PORTLAND PSYCHOTHERAPY IS NOT INVOLVED IN KETAMINE TREATMENT.

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