1. Depression Research Program, Massachusetts General Hospital/Harvard Medical School, Boston, MA
2. Psychiatric Neuroscience Program, Massachusetts General Hospital/Harvard Medical School, Boston, MA
3. Pfzizer, Inc., New York, NY


EDITORS NOTE: I know this is a very technical article for many of our readers, and I am sorry for the complexity of the layout, but it contains some very interesting data that you may wish to share with a treatment provider. I have tried to add definitions that may help! This particular study was presented as a poster session at this year's American Psychiatric Association's annual meeting in Washington, D.C. by Dr. Richard O'Sullivan. It was the only presentation on TTM at the meeting, and I was glad it was entered and accepted. I hope next year there will be more coverage at the APA for us. I found it very interesting to note the Body Dysmorphic ratings for those with TTM, as I have always felt TTM was for certain people an expression of Body Dysmorphic Disorder. I was also surprised not to see Generalized Anxiety Disorder at a higher rate in those with TTM, but there are actually only 15 individuals with TTM in this study, so perhaps with a larger pool it would emerge as a factor. Interesting, though, huh?

ABSTRACT:
Trichotillomania was systematically assessed among a cohort of 303 adult outpatients with major depression. Overall, 1.3% of these subjects met full DSM-III-R (DSM-III-R: Diagnostic and Statistical Manual of Mental Disorders 3rd Edition, Revised) criteria for trichotillomania, while as many as 5% endorsed symptoms of trichotillomania. Depressed subjects with hair-pulling were distinguished from other depressed patients by a greater prevalence of anxiety and somatoform disorders while rates of Axis II (Axis II: personality disorders and mental retardation) disorders were similar. We conclude that the prevalence of trichotillomania symptoms among a depressed sample is appreciable and is associated with a specific pattern of elevated Axis I (AXIS I: Clinical Disorders and Other Disorders That May Be a Focus of Clinical Attention) comorbidity (this word indicates the coesistence of two or more disorders or disease processes).

INTRODUCTION:
Trichotillomania (TTM), classified as an impulsive control disorder in DSM-IV (DSM IV: Diagnostic and Statistical Manual of Mental Disorders Fourth edition), is characterized by distressing repetitive hair-pulling associated with premonitory urges and tension reduction post pulling. Trichotillomania (TTM) is rarely screened for in clinical or research settings and often goes unrecognized due to the secretive nature of the disorder. TTM and subsyndromal TTM are estimated to occur in 0.6% - 3.4% of non-clinical populations (Christensen et al 1991). High rates of comorbid mood and anxiety disorders have been found among patients presenting for TTM treatment (Christensen and Mansueto 1999; Swedo et al 1992), while high rates of TTM have been observed among individuals with tic disorders and OCD (O'Sullivan et al 1998, Swerdlow et al 1999). There are no studies to date systematically assessing a large cohort of patients with major depressive disorder (MDD) for the presence of TTM. Our aim was to characterize the prevalence and Axis I and II comorbidity of DSM-III-R defined trichotillomania amongst a cohort of adults presenting with MDD (major depressive disorder).

METHODS:
We assessed symptoms of TTM as defined by DSM-III-R among 303 depressed adults, ages 18 - 64 (55.4% female; mean age 39.8+/- 10.6 years who were enrolled in an antidepressant treatment trial. Subjects were administered the Structured Clinical Interview for DSM-III-R-Patient Edition (SCID-I/P) at baseline, a diagnostic module for body dismorphic disorder (BDD) and the SCID for Personality Disorders (SCID II). Inclusion criteria included a current episode of MDD and a 17-item Hamilton Depression Rating Scale (HAM-D-17) score of > 16. Patients were administered a four question TTM module to assess: 1) impulses to pull hair resulting in noticeable hair loss; 2) tension preceding hair pulling; 3) gratification or relief during or after hair pulling; and 4) absence of any association with preexisting skin inflammation or with hallucinations or delusions. Patients who endorsed any of the symptoms of hair pulling were included within the broad definition of trichotillomania for purposes of this analysis. Mann-Whitney U was applied as a non-parametric test for differences in the means of continuous variables while Chi square was used to assess differences in the frequency of dichotomous variables.

RESULTS:
Prevalence of TTM: Fifteen subjects, constituting 5% of the total sample, reported clinically significant hair pulling. Among those, four (1.3%) met full DSM-III-R criteria for TTM.
Relationship to MDD: There were no significant differences in demographic or depression-related variables between subjects with and without TTM (see Table 1).

DISCUSSION:
TTM symptoms appear to be more common than generally appreciated among patients presenting with MDD and are associated with a particular pattern of Axis I comorbidity. DSM-III-R defined TTM was observed in 1.3% of our depressed sample. Using a broader definition of TTM approximately 5% of individuals presenting for depression treatment reported hair pulling. TTM was associated with a significantly greater prevalence of anxiety and somatoform disorders. We anticipate that growing knowledge about the prevalence and comorbid associations with TTM will lead to a greater understanding of the pathophysiology and treatment implications of this previously under-recognized disorder.

REFERENCES:
Christensen, G.A., and Mansueto, C.S.,: Trichotillomania: Descriptive characteristics and phenomenology, In Stein, D., Christensen, G., and Hollander,E., (Eds) Trichotillomania: Current Concepts, 1-41, Washington, D.C., American Psychiatric Press, 1999 Christensen, G.A., Pyle, R.L., Mitchell, J.E.,: Estimated lifetime prevalence of trichotillomania in college students. Journal of Clinical Psychiatry 52:415-417, 1991 O'Sullivan, R.L., Miguel, E.C., Coffey, B., Rauch, S.L., Savage, C., Keuthen, N.J., Baer, L., Jenike, M.A.,: Trichotillomania, Obsessive-Compulsive Disorder and Tourette Syndrome: Comorbid relationships and risks for expression. CNS Spectrums, The International Journal of Neurospsychiatric Medicine Vol. 3, #10 October 1998 Swedo, S.E., Leonard, H.L., Lenane, M.C., Rettew, D.C.,: Trichotillomania: A profile of the disorder from infancy through adulthood. International Pediatrics 7:144-150, 1992 Swerdlow, N.R., Zinner, S., Farber, R., Searist, C., Hartson, H.: Symptoms in Obsessive-Compulsive Disorder and Tourette Syndrome: A spectrum. CNS Spectrums 4:21-26, 1999