Although TTM is estimated to affect 1.7% to 3.4% of the general US population, there are still many gaps in our understanding of why TTM occurs and how best to treat it.
Previous research has suggested that most individuals with TTM have one or more comorbid mental health disorders. In these cases, we say that TTM ‘co-occurs’ with other mental health issues. For example, Christenson and colleagues found that 49 of the 60 (81.7%) participants in a study of chronic hair pullers, met criteria for a co-occurring current or lifetime psychiatric disorder. A recent survey of 175 adults with TTM by Grant et al found that 53% of respondents with TTM had a co- morbid anxiety disorder, 45% had comorbid depression, and 29% had comorbid ADHD.
Although TTM research has taught us that TTM often co-occurs with other psychiatric disorders, it is still largely unknown how the presence of these comorbid disorders may affect TTM symptom severity, functional impairment, quality of life, and the overall clinical picture of TTM.
Knowledge pertaining to ADHD is extremely relevant to the care with give patients with TTM. First, it is know that some patients with TTM can have co-occurring ADHD. In addition, we have now come to recognise that some ADHD medications have been suggested to carry a risk of triggering TTM.
Chesivoir et al 2022
Authors of a new study set out to determine how commonly ADHD occurs in patients with TTM. The researchers assessed 308 adults with a current diagnosis of TTM. Patients were assessed for ADHD using various validated scales the Mini International Neuropsychiatric Interview 7.0.2 and Adult ADHD Self Report Scale. Participants also were evaluated for certain measures of trichotillomania including severity, impulsivity, quality of life, and psychosocial dysfunction.
Of the 308 participants, 47 (15.3%) met the clinical threshold for ADHD.
Those with and without ADHD did not significantly differ in terms of age, gender, race/ethnicity, or education. Of the participants with current ADHD, 16 (36.4%) were currently taking a stimulant ADHD medication.
Patients with TTM +ADHD do not have Altered Severity or Quality of Life
Compared to patients who did not have ADHD, participants with ADHD did not report significant differences in TTM severity, perceived quality of life, or functional impairment, regardless of medication status. In addition, there were no significant differences in TTM severity, BIS, QOLI, or SDS scores between subjects with ADHD currently taking stimulant medications and subjects with ADHD not taking stimulant medications
This is interesting study. It highlights that about 1 in 7 adult patients with TTM can have ADHD. This is similar to a prior study by Grant and colleagues that suggested a number closer to 29 %. Given that the prevalence of ADHD in the general adult population is around 2.5 %, ADHD appears to be about 10 times more common in those with TTM.
As hair specialists, we probably need to do a better job keeping this in mind when we evaluate patients. There are likely many adult patients with TTM who have ADHD and we need to make sure that patients with ADHD are given proper diagnosis and support.
It was interesting that patients with ADHD and those using ADHD medications did not have worse TTM. There has been some thought that ADHD medications can trigger TTM particularly in children. More studies are needed to determine if the ability of ADHD medications to trigger TTM is more relevant to children than adults
It is interesting that patients with ADHD don’t seem to have a worse type of TTM or more impaired quality of life. Other research on co-occurring ADHD in other psychiatric disorders suggests that the presence of co- morbid ADHD leads to worse impairment, greater treatment resistance, and poorer clinical outcomes due to the additive clinical effects of comorbidity. Fortunately for TTM this does not appear to be the case.
Further studies should continue to explore this relationship between TTM an ADHD. Does ADHD in childhood increase risk of developing TTM later in life? Does treating ADHD reduce the risk? Does TTM increase the risk of having ADHD? Further studies are need to understand the relationship between AHDD medications and TTM. Do ADHD medication truly increase the risk? Is the risk less than previous thought?
Chesivoir EK et al. Comorbid trichotillomania and attention deficit hyperactivity disorder in adults.Psychiatry. 2022 Jul;
Grant JE, Dougherty DD, Chamberlain SR. Prevalence, gender correlates, and co- morbidity of trichotillomania. Psychiatry Res 2020;288:112948. https://doi.org/ 10.1016/j.psychres.2020.112948.
ChristensonGA,MackenzieTB,MitchellJE.Characteristicsof60adultchronichair pullers. Am J Psychiatry 1991;148:284–5