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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=weCcLWghY2U
http://www.meddean.luc.edu/lumen/meded/medicine/dermatology/melton/trich1.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
or hair loss is not
attributable to
another medical
condition (e.g., a
dermatological
condition).
D. No adaptation
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).
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
Trichotillomania
• Treatment
– 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
Hoarding Disorder is NOT
SOURCE: https://dabidrobinson.files.wordpress.com/2010/01/pokemon-2.jpg
Hoarding Disorder is NOT
SOURCE: http://1.bp.blogspot.com/-51Q2g-rd7WA/U-5Gn4-qwfI/AAAAAAAAARM/M0a75HrlqcE/s1600/5-makeup-collection.jpg
Hoarding Disorder is
SOURCE: https://www.flickr.com/photos/carriembecker/6059002713/in/album-72157627470133958/
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.
Note: The individual’s insight
into the consequences of
accumulating objects or of
discarding them may be limited.
Expressions of grief and distress
may require behavioral
observation in individuals who
have limitation with verbal
expression of emotions
B. Unable to determine in most
individuals in this category
Note: Recurrent and persistent
thoughts, impulses or images, may
not be experienced as intrusive or
inappropriate nor cause marked
anxiety or distress; delusional
beliefs, if present and organized
into a system, may not be possible
to determine due to cognitive and
communicative deficits; distress
also may occur when a fixed
pattern of arrangement of clutter is
altered.
Hoarding Disorder--Adaptations
C. The difficulty discarding
possessions results in the
accumulation of possessions
that congest and clutter active
living areas and substantially
compromises their intended
use. If living areas are
uncluttered, it is only because
of the interventions of third
parties (e.g., family members,
cleaners, authorities).
C. No adaptation.
Note: The individual’s ability to
understand health
consequences of clutter and
storage limitations should be
taken into consideration.
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).
C. No adaptation.
Note: The individual’s ability to
understand health consequences of
clutter and storage limitations
should be taken into consideration.
The individual may not have the
ability to take the initiative to
discard objects.
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
not require an additional
psychotic disorder, cognitive
deficits in major
Hoarding Disorder diagnosis.
neurocognitive 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%20Library/Main%20navigation/Public%20and%20patients/Diseases%20and%20treatments/Itchy%20skin/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.
A. No adaptation.
B. Repeated attempts to
decrease or stop skin picking.
B. No adaptation.
B. No adaptation.
Note: Repeated attempts to
decrease or stop skin picking
may not be possible due to
cognitive and communicative
deficits.
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.
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.
Note: The skin picking 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