Psychiatric comorbidity in pedophilic sex offenders.

OBJECTIVE: The primary purpose of this research was to assess the rates of axis I and axis II psychiatric disorders, as defined in DSM-IV, in a group of pedophilic sex offenders. METHOD: Forty-five male subjects with pedophilia who were participating in residential or outpatient sex offender treatment programs were recruited to participate. Subjects were interviewed by using the Structured Clinical Interview for DSM-IV. RESULTS: Ninety-three percent of the subjects (N = 42) met the criteria for an axis I disorder other than pedophilia. The lifetime prevalence of mood disorder in this group was 67%. Sixty-four percent of the subjects met the criteria for an anxiety disorder, 60% for psychoactive substance use disorder, 53% for another paraphilia diagnosis, and 24% for a sexual dysfunction diagnosis. CONCLUSIONS: Axis I and II comorbidity rates are high in this population. Untreated comorbid psychiatric disorders may play a role in treatment failure and recidivism.

The use of pharmacologic pain sensitization in the treatment of repetitive hair-pulling.

A significant problem for many individuals who engage in repetitive hair-pulling is the fact that they experience no discomfort associated with their behavior, and can thus carry on with hair-pulling outside of conscious awareness. The present case study was an attempt to address this problem through the use of a commercially available topical cream which enhances pain sensitivity. A 38-yr-old female applied the cream daily to two affected areas on her scalp. The increased pain sensitization, in conjunction with the habit reversal technique, resulted in markedly decreased hair-pulling.

The characterization and treatment of trichotillomania.

Trichotillomania is an impulse control disorder characterized by chronic self-directed hair pulling. Trichotillomania has additionally been viewed as one of the obsessive-compulsive spectrum disorders. Any body hair may be targeted, and most patients pull from more than one site. In clinical settings the disorder predominantly affects females. Onset is generally in childhood or adolescence, and a chronic course is typical. Depression and anxiety frequently accompany the disorder. An increased incidence of comorbid obsessive-compulsive disorder (OCD) has been noted. Neurobiological investigations have paralleled etiologic studies of OCD and have demonstrated both similarities and differences between these two disorders. Current treatment options include a variety of medications, particularly the serotonin selective reuptake inhibitors, the behavioral technique of habit reversal, and hypnosis.

Impulse control disorders and attention deficit disorder in pathological gamblers.

Little systematic research has been done on psychiatric comorbidity of pathological gambling, an impulse control disorder. This report describes the occurrence of attention deficit disorder and impulse control disorders in 40 pathological gamblers in treatment for gambling problems and 64 controls. Diagnoses were made by structured interviews which utilized operationalized diagnostic criteria. An impulse control disorder other than pathological gambling was noted in 35% of the pathological gamblers, compared to 3% of the controls (p < .001). Compulsive buying (p < .001) and compulsive sexual behavior (p < .05) were significantly higher in pathological gamblers than controls. A strong association was seen among pathological gambling, attention deficit, and other impulse control disorders. Attention deficit disorder was seen in 20% of the pathological gamblers. Rates of impulse control disorders did not differ by gender. Implications of these high rates of comorbidity are discussed.

Identification of cues associated with compulsive, bulimic, and hair-pulling symptoms.

Subjects with obsessive compulsive disorder, bulimia nervosa, or trichotillomania selected cues which elicited or worsened their symptoms from a 339 item list. Principal components analysis suggested a four-component solution. Each disorder was significantly associated with one of these components. Diagnostic assignment based on component scores yielded 85% correct classification. The diagnostic groups did not differ on a negative feeling state component. The results indicate that both disorder-specific and generic components exist. This approach has potential for defining clinical subtypes, studying the interaction of feeling states and environmental cues in evoking symptoms, and designing treatment strategies.

Adult men and women with trichotillomania. A comparison of male and female characteristics.

Trichotillomania (hair pulling) has been considered a disorder that primarily affects women. It is rarely reported in men. Such rarity may reflect distinct clinical features in men that call for different treatment strategies. To investigate potential gender differences in trichotillomania, the authors systematically assessed the descriptive and phenomenological characteristics as well as psychiatric comorbidity of 14 male hair pullers and compared them to 128 female hair pullers who had been similarly assessed. Although a few gender differences existed, male trichotillomania was very similar to that seen in women. These results suggest that gender-specific treatment is not justified at this time; however, a more thorough psychiatric screening should be done with men because they may have additional psychiatric comorbidity.

Compulsive buying: descriptive characteristics and psychiatric comorbidity.

BACKGROUND: Compulsive buying is infrequently described in the psychiatric literature despite suggestions that it may be prevalent. The authors investigated the demographics and phenomenology of this syndrome and assessed psychiatric comorbidity via interviews of both compulsive buyers and normal buyers. METHOD: Twenty-four compulsive buyers were compared with 24 age- and sex-matched normal buyers using (1) a semistructured interview for compulsive buying and impulse control disorders, (2) a modified version of the Structured Clinical Interview for DSM-III-R, and (3) scales measuring compulsiveness, depression, and anxiety. RESULTS: The typical compulsive buyer was a 36-year-old female who had developed compulsive buying at age 17 1/2 and whose buying had resulted in adverse psychosocial consequences. Purchases were usually of clothes, shoes, jewelry, or makeup, which frequently went unused. Compared with normal buyers, compulsive buyers had a higher lifetime prevalence of anxiety disorders, substance use disorders, and eating disorders and were more depressed, anxious, and compulsive. Among compulsive buyers, 16 (66.7%) described buying that resembled obsessive compulsive disorder, whereas 23 (95.8%) described buying that resembled an impulse control disorder. CONCLUSION: Compulsive buying is a definable clinical syndrome that can result in significant psychosocial impairment and which displays features of both obsessive compulsive disorder and the impulse control disorders.

Cues to obsessive-compulsive symptoms: relationships with other patient characteristics.

The waxing and waning of symptoms in obsessive-compulsive disorder (OCD) suggests that environmental cues may impact on exacerbations of this disorder. Eighty-one Ss with OCD completed the Cues Checklist (CCL; Mackenzie, Ristvedt, Christenson, Lebow & Mitchell, 1992), a 339-item checklist of rationally-derived cues and circumstances that might be expected to elicit or worsen symptoms. Principal components analysis revealed four components: household order and organization, contamination and cleaning, negative affect, and prevention of harm and checking. Total number of cues endorsed and component scores were correlated with other characteristics of the disorder, and with the presence of other Axis I and II disorders. Patterns of cue endorsement related to standard measures of obsessive-compulsive content but not to symptom severity. Early-onset Ss endorsed a greater number of cues. History of depression, anxiety disorders and Axis II pathology related most strongly to scores on the negative affect component. The values and limitations of this approach are discussed.

Identification of trichotillomania cue profiles.

To explore the usefulness of emotional and environmental cues in distinguishing different patterns and potential subtypes of hair pulling in trichotillomania, we looked at the responses of 75 chronic hair pullers who had identified relevant cues for hair pulling from a 339 item list. Principal components analysis suggested two independent components which were important to hair pulling, one distinguished by negative affective states (NA), and the other by sedentary activities and contemplative attitudes (S). High NA scores were related to hair pulling which was the focus of the Ss' attention, as well as with increased prevalence of lifetime obsessive compulsive disorder, other anxiety disorders, current and past depression, and obsessive compulsive personality disorder. High SA scores were related to a history of major depression only. Weighted scores on these components may be useful in further elaborating the phenomenology of trichotillomania and designing appropriate treatment interventions.

Personality and clinical characteristics in patients with trichotillomania.

BACKGROUND: Trichotillomania, a disorder of self-directed hair pulling, has been the subject of few systematic studies. Although personality characteristics and disorders are often noted to coexist with trichotillomania, no thorough assessment of comorbidity with DSM-III-R Axis II disorders has been published. The present study was conducted to evaluate personality disorders and other personality characteristics in a large outpatient population of trichotillomanics and to compare these findings with those in a nontrichotillomanic comparison group. METHOD: Forty-eight outpatient female trichotillomanics were evaluated with the Structured Interview for DSM-III-R Personality Disorders (SIDP-R) and the revised version of the Minnesota Multiphasic Personality Inventory (MMPI-2). Personality disorders and personality cluster symptom scores from the SIDP-R and MMPI-2 scales were compared with those derived from a comparison group of 48 age-matched female outpatient psychiatric patients. RESULTS: Forty-two percent of the trichotillomanic group met criteria for a personality disorder. The only statistically significant difference in frequency of diagnoses between the trichotillomanic and comparison groups was a greater frequency of borderline personality disorder in the comparison group. Trichotillomanics demonstrated significantly less SIDP-R cluster A personality symptoms as well as less depression and better psychological adjustment on the MMPI-2. CONCLUSION: Our study suggests that no particular personality disorder or trait characterizes female trichotillomanics. Female trichotillomanics seeking psychiatric intervention appear to have better psychological adjustment and less psychopathology in general than other psychiatric outpatients.

Clinical characteristics and psychiatric comorbidity in children with trichotillomania.

Ten children with trichotillomania (hair pulling) were systematically evaluated with structured psychiatric interviews and rating scales assessing anxiety, depression, life events, self-esteem, and family functioning. Six of the subjects met diagnostic criteria for overanxious disorder on the Diagnostic Interview for Children and Adolescents--Revised--Child or Adolescent Version and/or Diagnostic Interview for Children and Adolescents--Revised--Parent Version. Two met the criteria for dysthymia, including one of the subjects with overanxious disorder. No children reported associated obsessions or compulsions. Only one subject experienced tension before hair pulling and relief associated with hair pulling. The DSM-III-R criteria for trichotillomania, which currently require an increasing sense of tension before hair pulling and gratification with hair pulling, may be overly restrictive and in need of redefinition. Additional research with increased sample size is necessary to define diagnostic criteria for trichotillomania and clarify its relationship with other psychiatric diagnoses.

A placebo-controlled, double-blind crossover study of fluoxetine in trichotillomania.

OBJECTIVE: It has been proposed by some investigators that trichotillomania, a disorder of chronic hair pulling, is a variant of obsessive-compulsive disorder, and some studies have suggested that the antiobessional agents clomipramine and fluoxetine are useful in treating this disorder. The authors investigated the efficacy of fluoxetine in the treatment of trichotillomania. METHOD: Twenty-one adult chronic hair pullers were recruited into an 18-week placebo-controlled, double-blind crossover study of fluoxetine, in doses up to 80 mg/day. The fluoxetine and placebo treatment phases consisted of 6-week trials of each agent separated by a 5-week washout period. Fifteen subjects (14 female and one male) completed the study; an additional female subject dropped out at 16 weeks after developing a drug reaction. RESULTS: No significant Drug by Period interactions were found in weekly subject ratings of hair pulling, weekly subject ratings of the urge to pull hair, weekly assessments of the number of hair-pulling episodes, or the estimated amount of hair pulled per week. CONCLUSIONS: The short-term efficacy of fluoxetine in the treatment of trichotillomania was not demonstrated in this study.

Estimated lifetime prevalence of trichotillomania in college students.

BACKGROUND: Trichotillomania, a disorder of hair pulling, has been considered a rare condition. Estimations of the prevalence of this disorder have been based largely on clinical experience, and there have been no estimates of its prevalence based on data collected from a large, nonclinical population. METHOD: 2579 freshman college students at two state universities and one liberal arts college were asked to provide written responses to questions designed to practically apply DSM-III-R criteria for trichotillomania and estimate the prevalence of trichotillomania in this population. RESULTS: 2534 students (97.9% of the study population) responded. We found a 0.6% lifetime prevalence of DSM-III-R trichotillomania for both male and female respondents. Hair pulling resulting in visible hair loss, but failing to meet full DSM-III-R criteria, was identified in 1.5% of males and 3.4% of females. CONCLUSION: Trichotillomania may not be as rare as previously suspected and may affect males as often as females.

Characteristics of 60 adult chronic hair pullers.

OBJECTIVE: This study was constructed to detail the demographic and phenomenological features of chronic hair pullers as well as to assess psychiatric comorbidity in a sizable study group. METHOD: Subjects were drawn from an outpatient population of chronic hair pullers who had been referred to a trichotillomania clinic or had responded to a newspaper advertisement announcing a treatment study of adults who pull out their hair. Sixty adult chronic hair pullers completed a semistructured interview that focused on their hair-pulling behavior and demographic characteristics and that incorporated screening questions for DSM-III-R axis I disorders. The data were tabulated to derive a comprehensive picture of this group. RESULTS: The typical subject was a 34-year-old woman who had pulled hair from two or more sites for 21 years. All subjects described either tension before or relief/gratification after pulling hair from the primary site, but 17% (N = 10) failed to describe both of these characteristics and thus failed to fulfill the DMS-III-R criteria for trichotillomania. Forty-nine subjects (82%) qualified for past or current axis I diagnoses other than trichotillomania. Several characteristics of the study group suggested phenomenological differences between obsessive-compulsive disorder and trichotillomania. CONCLUSIONS: Adult trichotillomania is a chronic disorder, frequently involving multiple hair sites, and is associated with high rates of psychiatric comorbidity. Its relation to obsessive-compulsive disorder requires further clarification. The tension-reduction requirement in DSM-III-R for the diagnosis of trichotillomania may be overly restrictive.

Lithium treatment of chronic hair pulling.

Ten patients with chronic hair pulling received trials of lithium carbonate of 2 to 14 months' duration. Eight patients demonstrated decreased hair pulling and mild to marked hair regrowth. Three responders experienced increased hair pulling subsequent to discontinuation of lithium treatment. Lithium's effect on hair pulling may be related to its observed benefits in treating aggressivity, impulsivity, and mood instability.

Social phobia. Recognizing the distress signals.

Social phobia is a distinct clinical entity that accounts for significant morbidity. It is often linked to depression and other anxiety disorders and may be a risk factor for alcohol abuse. Primary care physicians can more easily recognize the disorder if they carefully question patients about anxiety in social situations. Effective behavioral and pharmacologic therapies for social phobia are available. However, primary care physicians may prefer to refer patients to a specialist because of inherent difficulties in treatment that may require the experience of a clinician more familiar with the disorder.