Elsevier

Comprehensive Psychiatry

Volume 72, January 2017, Pages 1-5
Comprehensive Psychiatry

Trichotillomania and co-occurring anxiety

https://doi.org/10.1016/j.comppsych.2016.09.005Get rights and content

Abstract

Background

Trichotillomania appears to be a fairly common disorder, with high rates of co-occurring anxiety disorders. Many individuals with trichotillomania also report that pulling worsens during periods of increased anxiety. Even with these clinical links to anxiety, little research has explored whether trichotillomania with co-occurring anxiety is a meaningful subtype.

Methods

One hundred sixty-five adults with trichotillomania were examined on a variety of clinical measures including symptom severity, functioning, and comorbidity. Participants also underwent cognitive testing assessing motor inhibition and cognitive flexibility. Clinical features and cognitive functioning were compared between those with current co-occurring anxiety disorders (i.e. social anxiety, generalized anxiety disorder, panic disorder, and anxiety disorder NOS) (n = 38) and those with no anxiety disorder (n = 127).

Results

Participants with trichotillomania and co-occurring anxiety reported significantly worse hair pulling symptoms, were more likely to have co-occurring depression, and were more likely to have a first-degree relative with obsessive compulsive disorder. Those with anxiety disorders also exhibited significantly worse motor inhibitory performance on a task of motor inhibition (stop-signal task).

Conclusions

This study suggests that anxiety disorders affect the clinical presentation of hair pulling behavior. Further research is needed to validate our findings and to consider whether treatments should be specially tailored differently for adults with trichotillomania who have co-occurring anxiety disorders, or more pronounced cognitive impairment.

Introduction

Trichotillomania is characterized by repetitive pulling out of one's hair, leading to significant functional impairment [1]. With a lifetime prevalence estimated between 1% and 3% [2], trichotillomania is common and is frequently associated with significant psychosocial impairment [3]. Adults with trichotillomania have elevated rates of co-occurring disorders, most commonly depression (52% to 60%) [4], [5] and anxiety disorders (60%) [6]. Among children with trichotillomania, anxiety disorders are arguably the most common co-occurring mental health issue (24% to 30%) [7], [8].

Trichotillomania's functional impairment has often been attributed, in substantial part, to associated anxiety, but the directional relationship of trichotillomania to anxiety is still unsettled [9]. In fact, one study of 894 individuals with trichotillomania found that 83% reported anxiety associated with pulling [3]. One explanation for its association with anxiety is that trichotillomania is simply a behavioral response to anxiety. Research suggests that hair pulling in some individuals seems to regulate unpleasant or aversive feelings [3]. Adults with trichotillomania frequently report that their pulling worsens during periods of heightened anxiety [9]. Alternatively, hair pulling for many adults leads to avoidance of social activities and results in anxiety during intimate situations [6], [10], [11]. This directional nature of trichotillomania and anxiety is supported by research findings that trichotillomania generally begins at an earlier age than co-occurring anxiety disorders [12]. Of course not all studies have found an association between anxiety disorders and hair pulling severity [5].

Based on the extant literature, we hypothesized the following: 1) because people report stress often worsens pulling behavior [9], that co-occurring anxiety disorders would be associated with worse trichotillomania symptom severity; and 2) because previous research has found that anxiety worsens inhibitory control on a stop-signal task [13], that adults with trichotillomania and co-occurring anxiety disorders would demonstrate greater impairment in inhibiting a prepotent motor response. By examining anxiety disorders within a large sample of adults with trichotillomania who had been systematically evaluated, we hoped to finally determine whether anxiety disorders influence the clinical presentation of trichotillomania and are associated with a unique cognitive presentation.

Section snippets

Subjects

The study included 165 adults (152 [92.1%] females; mean age = 32.0 ± 10.9 years) with current trichotillomania. Subjects were recruited for treatment, neuroimaging, genetic or neurocognitive studies at the University of Minnesota and the University of Chicago from 2007 to 2016. All participants had a primary diagnosis of trichotillomania based on expert clinical assessment. As is customary in trichotillomania research, prior to 2013, the diagnosis was based on DSM-IV criteria with or without the

Results

Of all participants, 38 (23.0%) had at least one current co-occurring anxiety disorder. Those with anxiety disorders did not differ significantly from those without on demographic variables of interest (Table 1).

There were several significant clinical differences in people with trichotillomania based on anxiety disorders. Those with anxiety disorder had more severe trichotillomania symptoms based on both self-report (MGH-HPS) and clinician-administered instruments (NIMH-TSS) assessing past-week

Discussion

In this study, we determined clinical and cognitive associations with anxiety disorders in individuals with a primary diagnosis of trichotillomania. In this large study of adults with trichotillomania, 23% had a co-occurring anxiety disorder. This rate of comorbidity is consistent with rates of anxiety disorders found in many other studies of trichotillomania [21], [22].

In terms of clinical variables, this study demonstrated that adults with anxiety disorders and trichotillomania reported more

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