Trichotillomania: current issues in conceptualization and treatment.

Trichotillomania is a little-known disorder with wider prevalence and more significant consequences than previously believed. While sharing similarities with obsessive-compulsive disorder, compelling differences from it have also been noted. This fact, coupled with recognized overlap with other obsessive-compulsive spectrum disorders, has resulted in the ongoing evolution of our conceptualization of this illness. While empirical evidence supports the use of behavioral treatment and pharmacotherapy, considerable research is still needed before we can promise highly effective interventions tailored to the individual hairpuller. This review will summarize the evidence supporting, as well as challenging, a hypothesized link with obsessive-compulsive disorder. Current treatment approaches will be reviewed, as well as evidence for their efficacy. Suggestions will be made for future directions in this field.

Are perinatal complications relevant to the manifestation of ADD? Issues of comorbidity and familiality.

OBJECTIVE: We evaluated the role of pregnancy, delivery, and infancy complications (PDICs) in the etiology of attention deficit disorder (ADD) addressing issues of comorbidity and familiarity by formulating and testing multiple hypotheses. METHOD: Subjects were six to 17-year-old boys with DSM-III attention deficit disorder (ADD, N = 73), psychiatric (N = 26), and normal (N = 26) controls and their relatives. Information on PDICs was obtained from the mothers in a standardized manner blind to the proband's clinical status. RESULTS: Using odds ratio analyses, an association was found between ADD and PDICs that was strongest for the comorbid and nonfamilial subtypes. In contrast, noncomorbid and familial ADD subgroups differed less from normal controls in the risk for PDICs. CONCLUSIONS: The increased risk for PDICs in nonfamilial ADD children and the lack of evidence for increased risk among familial ADD patients suggests that PDICs may be part of nongenetic etiologic mechanisms in this disorder, especially for children who have comorbid disorders.

Efficiency of diagnostic criteria for attention deficit disorder: toward an empirical approach to designing and validating diagnostic algorithms.

Using structured psychiatric interviews, 73 attention deficit disorder (ADD) patients, 26 psychiatric control patients, 26 normal controls, and all available first degree relatives of these index children were examined. ADD subgroups with and without comorbid psychiatric disorders did not differ on rates of specific ADD symptoms. The construct of ADD is internally consistent as measured by Cronbach's alpha. The diagnostic efficiency of individual items is presented. A receiver operating characteristic-based procedure is used to create an ADD diagnostic algorithm that is more efficient in discriminating ADD children from controls than the DSM-III-based clinical diagnosis. Cross-validation with family study data shows this procedure to be superior to the procedure used for the DSM-III-R diagnosis. The results show that proponents of conditional probability and receiver operating characteristic analyses are correct in asserting that the examination of symptom combinations may result in better diagnostic algorithms.

Further evidence for family-genetic risk factors in attention deficit hyperactivity disorder. Patterns of comorbidity in probands and relatives psychiatrically and pediatrically referred samples.

We examined 140 probands with attention deficit hyperactivity disorder, 120 normal controls, and their 822 first-degree relatives using "blind" raters and structured diagnostic interviews. Compared with controls, probands with attention deficit hyperactivity disorder were more likely to have conduct, mood, and anxiety disorders. Compared with relatives of controls, relatives of probands with attention deficit hyperactivity disorder had a higher risk for attention deficit hyperactivity disorder, antisocial disorders, major depressive disorder, substance dependence, and anxiety disorders. Patterns of comorbidity indicate that attention deficit hyperactivity disorder and major depressive disorders may share common familial vulnerabilities, that attention deficit hyperactivity disorder plus conduct disorder may be a distinct subtype, and that attention deficit hyperactivity disorder and anxiety disorders are transmitted independently in families. These results extend previous findings indicating family-genetic influences in attention deficit hyperactivity disorder by using both pediatrically and psychiatrically referred proband samples. The distributions of comorbid illnesses in families provide further validation for subgrouping probands with attention deficit hyperactivity disorder by comorbidity.

Comorbidity between ADDH and learning disability: a review and report in a clinically referred sample.

A widely variable overlap ranging from 10 to 92% has been reported in the literature between attention deficit disorder with hyperactivity (ADDH) and learning disability (LD), most likely a result of inconsistencies in the criteria used to define LD in different studies. The following study seeks to more accurately determine rates of LD in clinically referred children. Using a psychometrically reliable methodological approach, it was expected that the rate of LD in ADDH children would be far more modest than previously reported. Subjects were referred children with ADDH (N = 60), children with academic problems (N = 30), and normal controls (N = 36) of both sexes with available psychological and achievement testing. Using a liberal definition of LD, significant differences were found between the groups (ADDH = 38% versus academic problems = 43% versus normals = 8%; p = 0.002). In contrast, more modest rates were found using two more stringent methods of assessment (23 and 17%; 10 and 3%; 2 and 0%, respectively; p = 0.02). Arithmetic-based LD appears to be equally identified by both stringent methods, whereas the liberal definition overidentified children in all three groups. These findings show that a liberal definition of LD overidentifies LD not only in ADDH children but also in normal children.

Psychiatric comorbidity in attention deficit disorder: impact on the interpretation of Child Behavior Checklist results.

Studies have investigated associations between the Child Behavior Checklist (CBCL) and clinical diagnoses without assessing the impact of comorbidity on these results. This study evaluates associations between parental reports from the CBCL and a structured diagnostic interview in children with attention deficit disorder with hyperactivity (ADDH) stratified by the presence (ADDH+) or absence (ADDH-) of psychiatric comorbidity. Interview-defined ADDH children scored significantly worse on all scales of the CBCL compared with scores from interview-defined non-ill comparisons. However, these findings were accounted for by the subgroup of children with ADDH+. The results indicate a good correspondence between CBCL-based ratings and interview-defined diagnoses. These findings also suggest that the CBCL may be a good screening instrument, not only for ADDH but also for comorbid psychiatric disorders.