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Home > Library > Annotated Journal Abstracts > 2014 Q3: Psychodermatology

Annotated Abstracts of Journal Articles
2014, 3rd Quarter


Annotations by J. Jewel Shim, MD, FAPM
September 2014

PUBLICATION #1 — Psychodermatology
Treating trichotillomania: A meta-analysis of treatment effects and moderators for behavior therapy and serotonin reuptake inhibitors
McGuire JF, Ung D, Selles RR, et al
J Psychiatr Res 2014 Nov; 58:76-83

ANNOTATION (J. Jewel Shim)

The Finding:  This is a meta-analysis of studies examining the effects of behavior therapy (BT) or serotonin reuptake inhibitors for the treatment of trichotillomania (TTM) with a designated primary outcome measure of mean improvement in TTM symptom severity. In particular, the study authors identified several potentially important treatment moderators, including participant age, percentage of comorbid anxiety and depressive disorders, the average number of 1-hour therapy sessions, and the intervention subtypes. Included studies were randomized controlled trials that had a comparison treatment. Results demonstrated a large effect size (ES) for BT, with a moderator analysis that indicated greater ES for interventions that had a greater number of therapeutic contact hours and were mood-enhanced versus solely core BT components. However, the investigators pointed out there was potential confounding in that mood-enhanced BT required more therapy hours than core BT. The SRIs had only moderate treatment effects, with clomipramine showing a larger treatment effect than SSRIs, though this was not statistically significant.

Strengths and Weaknesses: Strengths of the study include the careful selection of included studies by three different raters, identification of a primary outcome measure (reduction in TTM symptoms) to better evaluate overall treatment effectiveness, and further delineation of potential moderating factors that could have an impact on a treatment’s effectiveness. The investigators also included several analyses of publication bias and sensitivity analyses. Potential weaknesses are the relatively small number of included studies in this analysis (11), thus making the results less definitively conclusive. Thus, the study authors pointed out that results that were not found to be statistically significant could not necessarily be interpreted as lacking a true association. Additionally, included BT studies did not specify the medication status of the subjects, and results may not have represented the true effects of BT alone. The study authors also suggested that there may be other factors not accounted for in their analysis that could have contributed to the observed treatment effects, for example, medication adherence.

Relevance: This meta-analysis is helpful in supporting current evidence that BT is first-line treatment for TTM and that clomipramine is likely most effective among serotonergic agents.


Few randomized controlled trials (RCTs) exist examining the efficacy of behavior therapy (BT) or serotonin reuptake inhibitors (SRIs) for the treatment of trichotillomania (TTM), with no examination of treatment moderators. The present meta-analysis synthesized the treatment effect sizes (ES) of BT and SRI relative to comparison conditions, and examined moderators of treatment. A comprehensive literature search identified 11 RCTs that met inclusion criteria. Clinical characteristics (e.g., age, comorbidity, therapeutic contact hours), outcome measures, treatment subtypes (e.g., SRI subtype, BT subtype), and ES data were extracted. The standardized mean difference of change in hair pulling severity was the outcome measure. A random effects meta-analysis found a large pooled ES for BT (ES = 1.41, p < 0.001). BT trials with greater therapeutic contact hours exhibited larger ES (p = 0.009). Additionally, BT trials that used mood enhanced therapeutic techniques exhibited greater ES relative to trials including only traditional BT components (p = 0.004). For SRI trials, a random effects meta-analysis identified a moderate pooled ES (ES = 0.41, p = 0.02). Although clomipramine exhibited larger ES relative to selective serotonin reuptake inhibitors, the difference was not statistically significant. Publication bias was not identified for either treatment. BT yields large treatment effects for TTM, with further examination needed to disentangle confounded treatment moderators. SRI trials exhibited a moderate pooled ES, with no treatment moderators identified. Sensitivity analyses highlighted the need for further RCTs of SRIs, especially among youth with TTM.

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PUBLICATION #2 — Psychodermatology
Trichotillomania and emotion regulation: is symptom severity related to alexithymia?
Rufer M, Bamert T, Klaghofer R, Moritz S, Schilling L, Weidt S
Psychiatry Res 2014 Aug 15; 218(1-2):161-5

ANNOTATION (J. Jewel Shim)

This is a descriptive study examining the association between alexithymia and trichotillomania (TTM). Further, the authors hypothesized that the severity of hair pulling would correlate with the degree of alexithymic deficits. The authors described previous research reporting an emotion-regulation function of hair pulling and that emotion regulation may be impaired in such patients. They further posit that because patients with alexithymia have difficulty identifying and expressing emotions, they may have impairment in their ability to tolerate and regulate emotions. 105 patients were enrolled, 95% women.

Results showed a significant correlation between hair pulling and alexithymia and a significant association between one facet of alexithymia (as measured by the Toronto Alexithymia Scale), difficulty identifying emotions, and the severity of TTM. There was a trend toward significance in the association between depression (as measured by the Hamilton Depression Rating Scale) and TTM.

While a small study, it identifies alexithymia as a possible contributor to the etiology of TTM and may help inform a treatment approach for those suffering from this disorder.


Previous research on trichotillomania (TTM) has demonstrated an emotion regulation function of hair pulling behavior. One condition that can impede the regulation of emotions is alexithymia. The present study aimed to explore the relationship between the degree of alexithymia and the severity of hair pulling behavior in individuals with TTM. Multiple strategies were used to recruit a sample of 105 participants via the internet. All participants were diagnosed with TTM by an experienced clinician via a subsequent phone-interview. Multiple linear regression analysis was performed to test the potential predictive value of the different facets of alexithymia (20-item Toronto Alexithymia Scale) on the severity of TTM (Massachusetts General Hospital Hair-Pulling Scale). Both the difficulty in identifying feelings (DIF) facet of alexithymia (p=0.045) and depression (p=0.049) were significant predictors of the severity of TTM. In conclusion, alexithymia seems to play a role in hair pulling behavior in individuals with TTM. However, the significant association was small in terms of the overall variance explained, thus warranting further research. If replicated in prospective studies, then these results indicate that therapeutic approaches aimed at supporting patients in recognizing and differentiating feelings might be useful for the treatment of TTM.

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PUBLICATION #3 — Psychodermatology
Psychopathology and eating disorders in patients with psoriasis
Crosta ML, Caldarola G, Fraietta S, et al
G Ital Dermatol Venereol 2014 Jun; 149(3):355-61

ANNOTATION (J. Jewel Shim)

This is an observational study examining the association between psoriasis, eating disorders, and psychiatric disorders. As a basis for this investigation, the authors highlight the increased prevalence of obesity in patients with psoriasis compared to the general population, and posit a possible association between eating disorders and psoriasis. They also cite a number of studies reporting a significant degree of psychiatric comorbidity in patients with psoriasis. 100 patients with psoriasis and 100 control subjects without psoriasis were enrolled in the study.

Overall they found no significant correlation between eating disorders and the severity of psoriasis, nor was there a significant association between disease severity and psychopathology. Interestingly, they found that there was no corresponding increase in psychopathology despite worsening eating disorder symptoms in the psoriasis group.

In general, this study was limited by poor methodology and small sample size. However, it raises an interesting question regarding the association between eating disorders and psoriasis and psychiatric disorders.


: Psoriasis is a multifactorial chronic inflammatory skin disease that often occurs in patients who are overweight or obese. In literature the connections between obesity and eating disorders are well known, but few studies have investigated the link between eating disorders and psoriasis. We hypothesized that Eating Disorders (ED) can be considered a psychogenic cofactors, which contribute to the development of obesity and metabolic syndrome in psoriatic patients, who are frequently prone to psychiatric comorbidity.

Methods: From January to April 2011 we enrolled 100 consecutive psoriatic outpatients and a control group of 100 selected non-psoriatic outpatients, matched by age, gender, and BMI to the study group. The assessment battery was composed by the Psoriasis Area Severity Index (PASI) score, the Eating Disorder Inventory (EDI) and the Symptom Checklist-90 Revised (SCL-90-R®).

Results: Our data showed that most of EDI and SCL-90R subscales was mostly altered in psoriatic population compared to patients without psoriasis. Moreover, we noticed in patients with psoriasis an association between the progressive weight increase and an impairment on most of EDI subscales.

Conclusion: Psoriasis is associated with psychopathological traits, which are frequently found in EDs. Since obesity makes psoriasis less susceptible to therapy and weight loss improves drug response, dermatologists should be alert to suspect the presence of this condition.

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