Journal name: Neuropsychiatric Disease and Treatment Article Designation: Original Research Year: 2015 Volume: 11 Neuropsychiatric Disease and Treatment Dovepress Running head verso: Özten et al Running head recto: Psychological trauma with trichotillomania and skin picking open access to scientific and medical research DOI: http://dx.doi.org/10.2147/NDT.S79554 Open Access Full Text Article ORIGINAL RESEARCH The relationship of psychological trauma with trichotillomania and skin picking Eylem Özten1 Objective: Interactions between psychological, biological and environmental factors are Gökben Hızlı Sayar1 important in development of trichotillomania and skin picking. The aim of this study is to Gül Eryılmaz1 determine the relationship of traumatic life events, symptoms of post-traumatic stress disorder Gaye Kag˘an2 and dissociation in patients with diagnoses of trichotillomania and skin picking disorder. Sibel Işık3 Methods: The study included patients who was diagnosed with trichotillomania (n=23) or skin Og˘uz Karamustafalıog˘lu4 picking disorder (n=44), and healthy controls (n=37). Beck Depression Inventory, Traumatic Stress Symptoms Scale and Dissociative Experiences Scale were administered. All groups 1 Neuropsychiatry Health, Practice, checked a list of traumatic life events to determine the exposed traumatic events. and Research Center, Üsküdar University, 2Istanbul Neuropsychiatry Results: There was no statistical significance between three groups in terms of Dissociative Hospital, Üsküdar University, 3Turkish Experiences Scale scores (P=0.07). But Beck Depression Inventory and Traumatic Stress Red Crescent Altıntepe Medical Symptoms Scale scores of trichotillomania and skin picking groups were significantly higher Center, 4Department of Psychology, For personal use only. Faculty of Human and Social Sciences, than the control group. Subjects with a diagnosis of trichotillomania and skin picking reported Üsküdar University, Istanbul, Turkey statistically significantly higher numbers of traumatic and negative events in childhood com- pared to healthy subjects. Conclusion: We can conclude that trauma may play a role in development of both trichotilloma- nia and skin picking. Increased duration of trichotillomania or skin picking was correlated with decreased presence of post-traumatic stress symptoms. The reason for the negatively correlation of severity of post-traumatic stress symptoms and self-harming behavior may be speculated as devel- oping trichotillomania or skin picking symptoms helps the patient to cope with intrusive thoughts related to trauma. Future longitudinal research must focus on whether trauma and post-traumatic stress or trichotillomania and skin picking precede the development of mental disorder. Keywords: psychological trauma, trichotillomania, skin picking Introduction Neuropsychiatric Disease and Treatment downloaded from https://www.dovepress.com/ by 137.108.70.13 on 13-May-2019 Trichotillomania (TTM) has been first defined in the 19th century as a syndrome that leads to noticeable hair loss by pulling out one’s own hair. The hair pulling behavior is accompanied by a feeling of distress, and it leads to gratification or relief while pulling the hair.1 TTM is mainly involved in pulling out hair, and less frequently pulling out hairs from different parts of the body.2 The bodily area of pulling out hair is reported as 75% scalp hair, 53% eyelashes, 42% eyebrows, 10% beard, and 17% pubic area, and it is seen in more than one area with increasing age.3 TTM was classified under Correspondence: Eylem Özten the title of “Impulse Control Disorders Not Classified Elsewhere” inDiagnostic and NPİstanbul Hastanesi Alemdağ Caddessi, Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-R) and Siteyolu Sokak No 27, Ümraniye, as “Habit and Impulse Disorder” in International Classification of Diseases, tenth İstanbul, Turkey Tel +90 21 6633 0633 revision (ICD-10).4 Although there are many assumptions about TTM, the etiology Fax +90 21 6634 1250 is not clear.5 While discussing TTM to be classified within the obsessive spectrum Email [email protected]; [email protected] before Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), submit your manuscript | www.dovepress.com Neuropsychiatric Disease and Treatment 2015:11 1203–1210 1203 Dovepress © 2015 Özten et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further http://dx.doi.org/10.2147/NDT.S79554 permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on how to request permission may be found at: http://www.dovepress.com/permissions.php Powered by TCPDF (www.tcpdf.org) 1 / 1 Özten et al Dovepress it has been reported that, in a person suffering from mental The SP is not better explained by symptoms of another trauma, obsessive–compulsive disorder (OCD) symptoms mental disorder (eg, delusions or tactile hallucinations in a might have been developed in order to cope with anxiety psychotic disorder, attempts to improve a perceived defect or and intrusive thoughts associated with trauma.6 flaw in appearance in body dysmorphic disorder, stereotyp- People with TTM might shift their focus from traumatic ies in stereotypic movement disorder, or intention to harm material to pulling out hair in order to reduce their anxiety. oneself in nonsuicidal self-injury). Owing to phenomenological and neurobiological similarities Personality allegedly plays a role in the development with OCD, several researchers have suggested that TTM might of TTM and SP.14 Emotionality and emotional regulation be better conceptualized as an obsessive–compulsive spectrum difficulties, reward dependence and harm avoidance, have disorder, and it has been classified under obsessive–compulsive been reported among the personality traits in both disorders.15 and related disorders title in DSM-5.7,8 Skin picking (SP) is an Environmental factors, boredom, and lack of stimulation have irresistible scratching and picking urge to the extent that skin been reported being possible triggers of hair pulling and SP lesions are caused by the patients due to excessive excoriation. episodes.14 TTM development has been considered to be a Frequency of SP is reported to be 2% in patients admitted to a behavioral response to stress in order to reduce anxiety or to dermatology clinic,9 4% in university students,10 and 5.4% in a cope with anxiety.16,17 Various researchers reported the high nonclinical population.11 SP disorder is mostly accompanied by frequency of traumatic events in the past history of patients major depressive disorder and OCD. It is reported to be more with SP18,19 and TTM6,20 compared to healthy population. frequent in women. Although SP has been recommended to be In a study on young women, it has been reported that classified in impulse control disorders not otherwise specified history of sexual abuse and rape in childhood was one of the in DSM-IV-TR,12 it was classified in obsessive–compulsive predictors of SP, but not of TTM.21 Although trauma history is disorder and related disorders section in DSM-5.13 not reported in all patients with a diagnosis of TTM, childhood 1. TTM diagnostic criteria are as follows according to trauma is reported to be higher when compared to patients DSM-513: without any psychiatric diagnoses.20,22 Exposure to interper- For personal use only. a. Trichotillomania sonal violence is reported to be high during the initial phase i. recurrent pulling out of one’s hair, resulting in of the TTM.20 Approximately 76% of patients with TTM have hair loss; been found to have a history of at least one traumatic life event, ii. repeated attempts to decrease or stop hair and 19% have a lifetime diagnosis of post-traumatic stress pulling; disorder (PTSD).23 Results of research suggest that in patients iii. the hair pulling causes clinically significant dis- with TTM, PTSD prevalence was found to be higher than the tress or impairment in social, occupational, or general population but lower than psychiatric sample.23 It is other important areas of functioning; interesting that the number of pulled hairs and duration of hair iv. the hair pulling or hair loss is not attributable to pulling are negatively correlated with the severity of comorbid another medical condition (eg, a dermatological PTSD in TTM patients.6 Regarding the relation between TTT, condition); and SP, and dissociative symptoms, it has been reported that one- v. the hair pulling is not better explained by the third of SP patients have a feeling of trance or a feeling of Neuropsychiatric Disease and Treatment downloaded from https://www.dovepress.com/ by 137.108.70.13 on 13-May-2019 symptoms of another mental disorder (eg, mesmerized during SP.24,25 In a study, 21.3% of the patients attempts to improve a perceived defect or flaw with TTM had reported depersonalization during pulling out in appearance in body dysmorphic disorder). hair.26 Despite the high frequency of dissociative symptoms 2. SP diagnostic criteria are as follows according to in TTM and SP, the number of studies is limited. DSM-513: This study was aimed to search for the relationship of a. SP disorder psychological trauma with TTM and SP. A secondary aim i. recurrent SP resulting in skin lesion; was to investigate the presence of dissociative symptoms ii. repeated attempts to decrease or stop SP; with TTM or SP. iii. the SP causes clinically significant distress or impairment in social, occupational, or other Methods important areas of functioning; and The study included 67 outpatients who had been admitted iv. the SP is not attributable to the physiological to the Neuropsychiatry Istanbul Hospital between January effects of a substance (eg, cocaine) or another 2012 and March 2014 and who were diagnosed with TTM medical condition.