Within the spectrum of obsessive-compulsive disorders (OCD), distinctive behaviors exist that do not respond to typical OCD treatments, including skin picking and trichotillomania (TRIC). Awareness of these disorders is not widespread, but Jon Grant, JD, MD, University of Minnesota, Minneapolis, MN, emphasized that their prevalence is not insignificant. He reported that 11.8% of adolescent inpatients he surveyed were identified as actively skin picking. “Importantly, this is not a behavior to be confused with body dysmorphic disorder: This is not picking to improve appearance. This is more like nail biting – most patients are not even aware that they're doing it.” The number of individuals with TRIC also is higher than might be expected; a study of several thousand college students reported an incidence of 5% overall.

Onset for both disorders is early—10 to 15 years of age—and unlike the behaviors that are typical of OCD, these tend to involve pleasure or gratification. “Historically, people always thought of these as OCD problems, but they don't respond at all—or not as robustly—to the same treatments.” To identify the TRIC patient, look for recurrent pulling of hair that results in noticeable hair loss, a sense of tension before pulling, pleasure or relief at the time of pulling, and often, with men, eating of the hair. TRIC also is often seen with comorbid nail biting.

Diagnostic criteria for skin picking include recurrent picking at or manipulating of the skin (anywhere on the body) that results in noticeable damage, picking of the skin using any tool (nails, tweezers, etc), many hours of picking, and additional picking at night. To emphasize the seriousness of this condition, consider that 45% of such patients have scarring, 30% experiences infections, and 3% actually requires grafts to restore skin integrity.

“From a treatment perspective, what has befuddled clinicians about these diagnoses is ‘How do we characterize them?’” said Dr. Grant. “Are these really just variants of OCD?” Clinical studies say no. SSRIs that are effective in OCD have few responders among TRIC patients. On the other hand, TRIC may respond to naltrexone and other anti-addictive medications, while OCD does not. This last observation is suggestive of certain correlations; comorbid substance abuse is higher for TRIC than OCD, and rates are higher still for skin picking relative to TRIC. “Perhaps an addiction model might be useful to look at for these behaviors.”

Dr. Grant reported an ongoing study using N-acetyl cysteine to treat TRIC. “We actually use this amino acid in gambling addiction.” In his current blinded investigation, 50 patients were enrolled and randomized to 2400 mg of active agent or placebo. Though interim results are still blinded, some patients have reported having stopped picking for the first time in their lives, an outcome that is so profound that Dr. Grant doubts that it could be merely a placebo effect.

Dr. Grant also reported recent data for lamotrigine (median dose, 200 mg/day), which demonstrated a reduction in skin picking from an average of 2 hours a day to just one hour a day (n=24). Though there are no on-label therapies for either disorder, other treatment options that might be considered are naltrexone, acamprosate, baclofen, isradipine, or ondansetron. Dr. Grant stresses, however, that these interventions may have little or no effect for the patient who does not report pleasure or urges that are related to the dysfunctional activity. “You need to really take a close look at the family history and all of the comorbidities to get at what's really driving the behavior.”

For more information on trichotillomania, please visit www.trich.org.