Treatments (non OCD) + Other

Question 1

what is first line therapy for excoriation (skin picking) disorder

Answer 1

CBT –> including habit reversal and acceptance enhanced therapy

Question 2

what is the main treatment for people with excoriation disorder

Answer 2

habit reversal training (i.e as part of CBT) is main treatment

Question 3

What pharmacological treatment is available for excoriation disorders

Answer 3

SSRIs may be helpful but with limited effects

N-acetylcysteine may be helpful

naltrexone may be helpful

Question 4

what is the approach to treatment of hoarding disorder

Answer 4

current approach = attempt trial of SSRIs or CBT

SSRIs likely to not be as helpful as for people with OCD for example

Question 5

which SSRIs have been investigated in the treatment of hoarding disorder

Answer 5

citalopram, escitalopram, venlafaxine

effectiveness in hoarding disorder remains controversial

Question 6

is CBT effective for hoarding disorder

Answer 6

yes can be

specialized topics for hoarding disorder include:
-psychoeducation
-skills training (organizing, decision making, problem solving)
-behavioural exposures (discarding, non-acquiring)
-cognitive strategies

Question 7

what other resources can be helpful for hoarding disorder

Answer 7

support services like the Toronto Hoarding Support Services Network

Question 8

what must be taken into account in safety planning for people with hoarding disorder

Answer 8

at very high risk for fires in home and for falls

high risk for infestations like bed bugs

consider persons frailty, mobility, medical conditions and visual/hearing impairments as part of safety planning

hygiene, risk of infection, air quality = major issues

make sure can enter and exit home, bathrooms, fire escapes

make sure people have access to emergency services

a forced “clean out” is last resort–> i.e when serious fire or health hazards–> build rapport and consider risk management if possible

Question 9

what psychotherapeutic interventions are there for BDD

Answer 9

CBT

-exposure to social situations

-identification of safety behaviours

-resisting compulsions (i.e mirror checking, reassurance seeking)

there is a treatment manual “CBT for BDD” and “the broken mirror”

Question 10

BDD tends to me generally more responsive to which two pharmacologic agents?

Answer 10

fluoxetine

clomipramine

*also potential role for antipsychotics

Question 11

how does dosing and titration tend to differ when starting medications in someone with BDD

Answer 11

trial of meds may need 12-16 weeks and SSRI doses are usually higher in BDD (just like in OCD) than those required to treat depression

Question 12

other than psychotherapy and pharmacotherapy, are there any other treatments for BDD

Answer 12

very small case report on ECT for BDD–> typically in context of comorbid depression

Question 13

are approaches used to treat trichotillomania similar or different to those for OCD

Answer 13

quite different

Question 14

what % of those with trichotillomania engage in trichophagia

Answer 14

about 5-20%
unclear how many of these develop bezoars

Question 15

which patients who have trichotillomania and engage in trichophagia should be more closely monitored for medical complications of the hair eating

Answer 15

really for anyone eating their hair

particularly those with:
abdominal or epigastric pain

chest discomfort

change in stool color to dark green-to-black color

vomiting

unexplained weight loss or diarrhea or constipation

Question 16

what physical exam should be done if person has trichotillomania and bezoar is suspected/possible?

Answer 16

abdo exam–> check for LUQ mass

bloos test to assess for anemia

consider abdo CT–> diagnostic in 97% of trichobezoar cases

Question 17

why do people with trichotillomania avoid seeking medical care

Answer 17

social embarrassment

belief condition just a “bad habit” or is not treatable

Question 18

does trichotillomania go away on its own

Answer 18

not really–> only 14% rate of spontaneous remission

*with treatment, 50% may experience symptom reduciton

Question 19

what psychotherapy has evidence in treating trichotillomania (is first line psychotherapy for trichotillomania)

Answer 19

behavioural therapy–> HABIT REVERSAL THERAPY

sometimes includes components of acceptance and committment therapy and DBT as well

Question 20

what are the main aspects of habit reversal therapy

Answer 20

self monitoring (track his her tics or hair pulling)

awareness training

competing response training

stimulus control procedures (i.e modifying environment to reduce cues for hair pulling, skin picking, tics)

Question 21

what are the pharmacological options for treating trichotillomania

Answer 21

no current pharmacotherapies that would be universally accepted as first line
Cochrane review–> SSRIS do NOT have strong evidence

Cochrane review–> CLOMIPRAMINE has some benefit

Other meds:
N-ACETYLCYSTEINE

OLANZAPINE

DRONABINOL may be future treatment option (cannabinoid)

Question 22

Based on article from 2016 in American Journal of Psychiatry, what is recommended as the initial pharmacological treatment

Answer 22

N-acetylcysteine

(though recommendation is to do habit reversal therapy first)

Question 23

should you offer pharamcotherapy, psychotherapy, or both for BDD

Answer 23

NICE guidelines recommend CBT for BDD for mild to moderate functional impairment, either SSRI or more intensive individual CBT for moderate functional impairment and combination of SSRI + CBT including ERP for severe functional impairment