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Greetings! I am Dr. Bob Hudak, a psychiatrist serving in the OCD Program at the University of Pittsburgh. Today, I wish to discuss the application of memantine in treating trichotillomania and skin-picking disorder; this is a particularly critical subject. Body-focused repetitive behaviors—commonly known as trichotillomania and skin picking disorder, among other body-focused repetitive behaviors—are prevalent in the general population. They may affect 2% or more of patients; regrettably, we possess limited evidence-based pharmacologic treatments for these disorders.
We have established that certain behavioral therapies—for instance, habit-reversal training (HRT)—can assist individuals with trichotillomania and skin-picking disorder; however, locating clinicians trained in HRT is challenging. The scarcity of pharmacologic options further complicates the treatment of these disorders.
Moreover, a significant number of individuals suffering from these disorders do not report them to their psychiatrist or physician. They often perceive their symptoms as habits and fail to recognize an underlying psychiatric disorder. Many people attribute skin-picking or hair-pulling to anxiety; thus, they consult their psychiatrist or physician about an anxiety problem. However, only upon meticulous questioning can you deduce that patients indeed have a skin-picking or hair-pulling problem.
Hence, it is crucial for clinicians to screen for these relatively common disorders, which can be problematic and disfiguring—an impairment that could potentially lead to death. Indeed, I have had patients succumb due to body-focused repetitive behaviors in the past. They can pose serious health risks, leading to infection and osteomyelitis, among others.
This paper examines a double-blind, placebo-controlled study of memantine’s use in treating trichotillomania and skin-picking disorder. Some historical context—the lead author had previously researched N-acetylcysteine’s use in treating trichotillomania and skin-picking disorder; N-acetylcysteine is an over-the-counter supplement. However, it is not regulated, and its exact composition varies. Memantine is a medication used for OCD augmentation. It is safe and familiar to clinicians. Like N-acetylcysteine, it acts on the glutamatergic system. Therefore, there was a hypothesis that patients might respond to it.
In the study, they ended up with a total of 100 patients for a double-blind placebo-controlled study—50% received placebo, and 50% received memantine. Some patients were already on antidepressant medication. Some were undergoing general supportive therapy, whereas others were receiving psychotherapy targeted at trichotillomania or skin-picking disorder. Nevertheless, medication use and psychotherapy rates were equivalent in both groups. One group was assigned 20 mg of memantine, whereas the other received a placebo.
The study yielded significant results. Patients on memantine had a substantial response in comparison with the placebo group—the placebo group showed only an 8.3% response rate vs a 60% response rate for the group on memantine. They focused on patients with severe levels of illness and observed even better responses—no patient in the placebo group with severe illness responded, whereas 6 out of 8 patients deemed severe in the treatment group responded positively. The study did not raise any safety or tolerability problems.
There were some limitations to the study worth mentioning. Participants could continue their antidepressant regimen, but the study does not specify if these were serotonergic antidepressants, clomipramine—which studies have shown could be beneficial—or nonserotonergic-type antidepressants. Furthermore, participants could continue psychotherapy during this period; besides this, there are limited robust scales for skin picking.
The team utilized the Massachusetts General Hospital Hair Pulling Scale and modified it for skin-picking. Clinically, we understand that hair-pulling disorder and skin-picking disorder bear similarities and can be treated similarly, both clinically and medicinally. Modifying an existing scale was a valid approach given the lack of established skin-picking scales;. Validating this skin-picking disorder scale in future studies could lend greater credibility to this current study. The authors note that most patients in this study presented mild–to–moderate severity of hair-pulling or skin-picking disorder. They did, however, analyze more severe cases, as mentioned previously. In the future, it is vital—and the authors concur—that more severe cases be included in further research.
This study’s findings are highly significant. It tackled a serious illness with potentially disfiguring and fatal consequences—hair-pulling and skin-picking disorder—an ailment with limited evidence-based treatment options. It examined a medication commonly used by outpatient psychiatrists—memantine—which is safe, tolerable, and familiar to psychiatrists to ascertain if patients with trichotillomania or skin picking disorder would respond. They indeed found a statistically significant response in a severe disorder with limited pharmacologic solutions. Consequently, this study garnered considerable attention, and rightfully so. Based on this study, using memantine to treat body-focused repetitive behaviors, including trichotillomania and skin-picking disorder, is justified.
I appreciate your attention very much.
Abstract
Double-Blind Placebo-Controlled Study of Memantine in Trichotillomania and Skin-Picking Disorder
Jon E Grant, Eve Chesivoir, Stephanie Valle, Dustin Ehsan, Samuel R Chamberlain
Objective: Trichotillomania and skin-picking disorder are underrecognized and often disabling conditions in which individuals repeatedly pull at their hair or pick at their skin, leading to noticeable hair loss or tissue damage. To date there is a severe paucity of evidence-based treatments for these conditions. In this study, the authors sought to determine whether memantine, a glutamate modulator, is more effective than placebo in reducing hair-pulling and skin-picking behavior.
Methods: One hundred adults with trichotillomania or skin-picking disorder (86 women; mean age, 31.4 years [SD=10.2]) were enrolled in a double-blind trial of memantine (dosing range, 10-20 mg/day) or placebo for 8 weeks. Participants were assessed with measures of pulling and picking severity. Outcomes were examined using a linear mixed-effects model. The prespecified primary outcome measure was treatment-related change on the NIMH Trichotillomania Symptom Severity Scale, modified to include skin picking.
Results: Compared with placebo, memantine treatment was associated with significant improvements in scores on the NIMH scale, Sheehan Disability Scale, and Clinical Global Impressions severity scale in terms of treatment-by-time interactions. At study endpoint, 60.5% of participants in the memantine group were “much or very much improved,” compared with 8.3% in the placebo group (number needed to treat=1.9). Adverse events did not differ significantly between the treatment arms.
Conclusions: This study found that memantine treatment resulted in statistically significant reductions in hair pulling and skin-picking symptoms compared with placebo, with relatively high efficacy (based on number needed to treat), and was well tolerated. The glutamate system may prove to be a beneficial target in the treatment of compulsive behaviors.
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Reference
Grant, J. E., Chesivoir, E., Valle, S., Ehsan, D., & Chamberlain, S. R. (2023). Double-blind placebo-controlled study of memantine in trichotillomania and skin-picking disorder. American Journal of Psychiatry, 180(5), 348-356.
