LEITERS TO THE EDITOR
patient must necessarily be false because the patient and her family form a "tightly knit whole." We observed some exclusive family phenomena that we feel are important for understanding the atmosphere in which an anorectic syndrome develops. I. The fathers of eight patients in our study were emotionally uninvolved with their familie s. They stated that generally speaking they didn 't know what was going on at home and preferred to leave all family responsibilities in the hands of their wives, who assumed the central position within the family constellation. The mothers resorted to sharing their most intimate thought s and feelings with their daughters. In this way the mothers had formed a very special and intimate relationship with their " yet to be" anorectic daughters, thus crossing the intergenerational boundaries. In our opinion, this is an additional aspect of overinvolvement, described by Minuchin et aI. (1978). 2. The appearance of the anorectic symptomatology was preceded by a radical change, which fits in with the breach in .a rigid homeostatic system described by Selvini-Pallazolli (1989) . (a) In three cases , the mother had been diagnosed as suffering from a malignant illnes s in a female organ (e.g., breast, womb ) and was hospitalized for surgery. The patient' s anorectic symptoms appeared simultaneously with the mother's hospitalization. The physical state of the daughter focused the mother's attent ion on her child, helping to deny her own malady, thus alleviating the emotional distress caused by her predicament, which besides the threat of an early death, damaged the image of her own femininity. (b) In six families, the father, formerly an outsider, had returned home, either because of his health problems or occupational changes, creating a significant impact on the family . The father's daily presence at home affected the family balance, particularly with regard to role models. Responsibilities and tasks, previously belonging exclusively to the wife , were now taken over by the father. This dramatic change confused the young anorectic adolescent, exacerbating existing identity problems. It is worthwhile noticing that in four of the above cases the change of the father's place at home went along with a revision of his dietary habits. After having been confronted with cardiac disease, hyperlipidemia, or hypertension, he had become anxious and obsessively concerned with dieting and the fear of gaining weight. 3. Five of the families in our study included siblings suffering from a psychosomatic-type illness : In three of the families where one of the siblings suffered from bronchial asthma, strong feelings of j ealousy were manifested by the anorectic adolescent toward the asthmatic child because of the exaggerated attention and care provided by the mother. In twocases with a child suffering from Coelliac's disease, a special dietaryregimen had been prescribed. As a result, a complex ritual was created by the families around the subject of food . This preoccupation with food evolved into an additional line of communication, enabling the expre ssion of anger, aggression, and je alousy, on the one hand, and means of achieving a central position, control, and attention on the other. 4. Our final observation concerns the anorectic daughter's exposure to the interparental relationship: during the day, the parents in all 10 families acted in a cold and formal manner, demonstrating verbal and nonverbal abuse and criticism. The father, in particular, attacked the mother's external appearance. The nights, according to the parents' descriptions, were marked by warm sexual relations based on tenderness, sensitivity, and mutual satisfaction on both the physical and emotional levels . In the course of the therapy, all the anorectic patients in our sample expressed a marked sensitivity to the atmosphere at home , revealing their anxieties and fears about a possible parental separation. Moreover, intrapsychically, they thought that only through the expression of their anorectic symptoms could the family system J. Am.Acad. Child Adolesc. Psychiatry, 31:5, September 1992
be maintained either by attracting all parental attention to their illness or by shifting their father's criticism from the mother's body and appearance to theirs. The aforementioned findings were reflected in the treatment policy. We encouraged an analysis of the implications of the father 's return home , an acknowledgment of the disruption of the previous homeostasis, and the building of a new, less rigid one. At the same time , we encouraged the father to return home in such a way that he would not be percei ved as a threat to the mother's position. We also helped to define clear boundaries between the parents as a unit and their children . In the course of the treatment, two main "secrets" were broken : the " secret" of the special relationship between the mother and her daughter and the nighttime romantic " secret" of the parents. We hope that the observations presented in this letter, that are consistent with the literature but still have a different emphasis, will serve to widen perspectives and will be of clinical and scientific interest. A. Telerant, M.D. J. Kronenberg, M.D. S. Rab inovitch, Ph.D. I. Elman, M.D. M. Neum ann , M.D. B. Gaoni , M.D. Shalvata Mental Health Cente r Tel-Aviv University, Israel REFERENCES
Laseque, E. C. (1964) , On hysterical anore xia, In: Evolution of Psychosomatic Concepts, eds. M. R. Kaufman & M . Heiman. New York: International University Press , pp. 141-155. Minuchin, S., Bernice, L. & Rosman, B. L. (1978), Psychosomatic Families. London: Cambridge-Harvard University Press. Sel vini-Palazzolli, M. & Viaro, M. (1988 ), The anorectic process in the family: a six-stage model as a guide for individu al therapy. Family Process, 27:129-148.
Is Hair Pulling Benign? To the Editor: In their recent article (January, 1992; vol. 31:132-138), Reeve et aI. linked hair pulling and comorbidity and used their data to question the assertion that childhood trichotillomania is frequently a benign habit. However, their study has a number of limitations that limit the generality of their conclusion s. The first is sampling bias . The authors excluded children under 6 years old . Other research has shown the likelihood of comorbidity is elevated in older child hair pullers (Swedo and Rappoport, 1991). Additionally, for all the children in the Reeve et aI. sample, at least one course of treatment was unsuccessful (including behavior therapy, hypnosis, and medication). Given the numerous reports of cases successfully treated with these methods (e.g., Friman et al., 1984; Friman and O'Conner, 1984), the habits of those whose treatments were unsuccessful are probably influenced by variables not representative of the general population of hair pullers. Finally, all the children in their sample were brought to a university psychiatric clinic . Given that the child mental health system is structured so that the most intractable problems are referred to psychiatry, the children studied may represent a very select group of children. The second limitation involves method. No attempt to establish the reliability of the assessments or interviews was reported. The first author conducted all the diagnostic interviews, and yet no attempts to control for demand factors were reported. These limitations are
991
LEITERS TO THE EDITOR
especially pertinent because the authors did not employ a control group to establish the divergent validity of their findings. With respect to the data from the diagnostic interview, Reeve et aI. suggest that when hair pulling and anxiety coexist, hair pulling is a symptom of the anxiety. It is just as plausible, however, that anxiety is a symptom of hair pulling, especially in older children. Consider that hair-pulling creates appearance problems that can cause social anxiety, especially in teens and preteens. Public performance of child habits (e.g., hair pulling, thumb sucking) by school-aged children generate peer and parent negati vity (Friman, 1991) that can also cause anxiety. There are other possibilities. The Reeve et aI. study is important because it supports the observation that older hair pulling children, especially those whose treatment is unsuccessful and who present in psychiatric settings, are likely to exhibit comorbidity. Because of its limitations, however, the study does not mitigate the observation that many hair pulling children (perhaps most) have a benign habit easily treated with behavior modification, counseling, or placebo interventions (e.g., Friman et al., 1984; Friman and Hove, 1987). Perhaps there are two (or more) populations of hair pullers, and DSM-lII-R needs to be revised to reflect subtypes. Alternatively, trichotillomania may be a spectrum disorder of graded intensity. In summary, the results of the Reeve et aI. article do not warrant the necessary association between hair pulling, anxiety, and affective disorders. Such an association may have existed in the very select sample studied, but these results should not be generalized to the majority of childhood hair pullers. Additional studies focused on the spectrum of symptomatology, and related problems need to be conducted on broader samples of patients before generalizable scientific conclusions can be drawn. Patrick C. Friman, Ph.D. Father Flanagan's Boys' Home Creighton University School of Medicine Nathan J. Blum, M.D. Anthony Rostain, M.D. University of Pennsylvania School of Medicine REFERENCES
Friman, P. C. (1991), Treatment issues for child habits. Paper presented at the Third Florida Conference on Child Health Psychology, Gainsville. Friman, P. C., Finney, J. W. & Christophersen, E. R. (1984), Behavioral treatment of trichotillomania: An evaluative review. Behav. Ther., 15:249-266. Friman, P. C. & Hove', G. (1987), Apparent covariation between child habit disorders: effects of successful treatment for thumb sucking on untargeted chronic hair pulling. J. Appl. Behav. Anal., 20:421--426. Friman, P. C. & O'Conner, W. A. (1984), The integration of hypnotic and habit reversal techniques in the treatment of trichotillomania. Behav. Ther., 7: 166-167. Swedo, S. E. & Rapoport, J. L. (1991), Annotation: trichotillomania. J. Child. Psychol. Psychiatry, 32:401--409.
The authors reply: Drs. Friman, Blum, and Rostain raise several concerns about the methodology and subsequent conclusions of our study. We would like to clarify that children under the age of 6 years were excluded so that all subjects could participate in the structured interviews and rating scales, which are not normed to ages less than 6 years. Although these children presented to a tertiary care setting and a sampling bias may certainly have occurred, to the best of our knowledge, no other child and adolescent clinic offered assessment and treatment for trichotillomania in our community. Families typically reported that they had made numerous phone calls to other clinics before locating our re-
992
search program. Subjects reported previous treatment, but excluding the subject whose treatment by hypnosis failed and the subject whose treatment with clomipramine and subsequently f1uoxetine failed, all other subjects had only tried "home remedies," including wearing hats and gloves and taping fingers together. Subjects had not received formal behavioral treatment. The majority of subjects, therefore, did not appear to reflect a bias ofthe most intractable cases presenting to our psychiatric clinic. We readily acknowledge in our article and agree with Friman and colleagues that the use of a control group would clarify the validity of our findings. Friman and colleagues suggest the we concluded that anxiety, when present, predates and results in hair pulling. As stated in our article, however, the hair pulling may (not must) be a manifestation of the anxiety, and we agree that anxiety may be a symptom of hair pulling. Our increasing sample size supports the trend we have noted in our preliminary report-that is, that childhood hair pulling may be associated with symptoms of anxiety (unpublished data). Whatever the etiological relationship, a careful assessment for anxiety disorders should be considered in children with hair pulling. We agree with Friman and associates that hair pulling may in some children be a time-limited, benign habit. Our recent success in treatment using behavioral approaches suggests that hair pulling in children is likely a treatable entity that may not be predictive of a lifetime of hair pulling. Elizabeth A. Reeve, M.D. St. Paul Ramsey Medical Center Gail A. Bernstein, M.D. Gary A. Christenson, M.D. University of Minnesota
Control Groups in Research To the Editor: Many findings relating biological variables to psychiatric disorders are open to question because of a critical methodological flaw in most research designs. The flaw is in the selection of control or comparison groups. Typically, studies involving a particular biological process investigate differences between a psychiatric disorder group and a normal control group and/or other psychiatric disorder groups. At the same time, it is generally recognized that differences in motor, language, cognitive, and sensory processing capacities accompany many psychiatric disorders (e.g., Vitiello et aI., 1989). Many of the functional CNS differences seen with specific psychiatric disorders (hypothesized to be part of the disorder), however, are also found in nonpsychiatrically impaired individuals (less frequently than impaired individuals). Yet, in explaining a particular biological marker, rarely are the "associated CNS patterns" hypothesized as possible explanatory factors, independent of the psychiatric disorder under study. The fact that the associated CNS variations are found in nonpsychiatrically impaired individuals mandates that these associated CNS findings be controlled for in studies investigating biological correlates of a psychiatric disorder. Only a control group of individuals with the associated or accompanying CNS features, but without the psychiatric illness, can rule out the possibility that the associated CNS irregularities, rather than the psychiatric illness's defining characteristics, are responsible for a given biological marker (e.g., children with excellent attention, but with sensory processing, language, and motor irregularities as a comparison group, in addition to "normals," in studies of attention deficit disorder. A review of the recent studies (the most recent 35 articles from three major psychiatric journals, including 10 from the Journal of the American Academy of Child and Adolescent Psychiatry) involving biological variables in psychiatric disorders revealed that none used
J.Am. Acad. Child Adolesc. Psychiatry, 31:5, September 1992
patient must necessarily be false because the patient and her family form a "tightly knit whole." We observed some exclusive family phenomena that we feel are important for understanding the atmosphere in which an anorectic syndrome develops. I. The fathers of eight patients in our study were emotionally uninvolved with their familie s. They stated that generally speaking they didn 't know what was going on at home and preferred to leave all family responsibilities in the hands of their wives, who assumed the central position within the family constellation. The mothers resorted to sharing their most intimate thought s and feelings with their daughters. In this way the mothers had formed a very special and intimate relationship with their " yet to be" anorectic daughters, thus crossing the intergenerational boundaries. In our opinion, this is an additional aspect of overinvolvement, described by Minuchin et aI. (1978). 2. The appearance of the anorectic symptomatology was preceded by a radical change, which fits in with the breach in .a rigid homeostatic system described by Selvini-Pallazolli (1989) . (a) In three cases , the mother had been diagnosed as suffering from a malignant illnes s in a female organ (e.g., breast, womb ) and was hospitalized for surgery. The patient' s anorectic symptoms appeared simultaneously with the mother's hospitalization. The physical state of the daughter focused the mother's attent ion on her child, helping to deny her own malady, thus alleviating the emotional distress caused by her predicament, which besides the threat of an early death, damaged the image of her own femininity. (b) In six families, the father, formerly an outsider, had returned home, either because of his health problems or occupational changes, creating a significant impact on the family . The father's daily presence at home affected the family balance, particularly with regard to role models. Responsibilities and tasks, previously belonging exclusively to the wife , were now taken over by the father. This dramatic change confused the young anorectic adolescent, exacerbating existing identity problems. It is worthwhile noticing that in four of the above cases the change of the father's place at home went along with a revision of his dietary habits. After having been confronted with cardiac disease, hyperlipidemia, or hypertension, he had become anxious and obsessively concerned with dieting and the fear of gaining weight. 3. Five of the families in our study included siblings suffering from a psychosomatic-type illness : In three of the families where one of the siblings suffered from bronchial asthma, strong feelings of j ealousy were manifested by the anorectic adolescent toward the asthmatic child because of the exaggerated attention and care provided by the mother. In twocases with a child suffering from Coelliac's disease, a special dietaryregimen had been prescribed. As a result, a complex ritual was created by the families around the subject of food . This preoccupation with food evolved into an additional line of communication, enabling the expre ssion of anger, aggression, and je alousy, on the one hand, and means of achieving a central position, control, and attention on the other. 4. Our final observation concerns the anorectic daughter's exposure to the interparental relationship: during the day, the parents in all 10 families acted in a cold and formal manner, demonstrating verbal and nonverbal abuse and criticism. The father, in particular, attacked the mother's external appearance. The nights, according to the parents' descriptions, were marked by warm sexual relations based on tenderness, sensitivity, and mutual satisfaction on both the physical and emotional levels . In the course of the therapy, all the anorectic patients in our sample expressed a marked sensitivity to the atmosphere at home , revealing their anxieties and fears about a possible parental separation. Moreover, intrapsychically, they thought that only through the expression of their anorectic symptoms could the family system J. Am.Acad. Child Adolesc. Psychiatry, 31:5, September 1992
be maintained either by attracting all parental attention to their illness or by shifting their father's criticism from the mother's body and appearance to theirs. The aforementioned findings were reflected in the treatment policy. We encouraged an analysis of the implications of the father 's return home , an acknowledgment of the disruption of the previous homeostasis, and the building of a new, less rigid one. At the same time , we encouraged the father to return home in such a way that he would not be percei ved as a threat to the mother's position. We also helped to define clear boundaries between the parents as a unit and their children . In the course of the treatment, two main "secrets" were broken : the " secret" of the special relationship between the mother and her daughter and the nighttime romantic " secret" of the parents. We hope that the observations presented in this letter, that are consistent with the literature but still have a different emphasis, will serve to widen perspectives and will be of clinical and scientific interest. A. Telerant, M.D. J. Kronenberg, M.D. S. Rab inovitch, Ph.D. I. Elman, M.D. M. Neum ann , M.D. B. Gaoni , M.D. Shalvata Mental Health Cente r Tel-Aviv University, Israel REFERENCES
Laseque, E. C. (1964) , On hysterical anore xia, In: Evolution of Psychosomatic Concepts, eds. M. R. Kaufman & M . Heiman. New York: International University Press , pp. 141-155. Minuchin, S., Bernice, L. & Rosman, B. L. (1978), Psychosomatic Families. London: Cambridge-Harvard University Press. Sel vini-Palazzolli, M. & Viaro, M. (1988 ), The anorectic process in the family: a six-stage model as a guide for individu al therapy. Family Process, 27:129-148.
Is Hair Pulling Benign? To the Editor: In their recent article (January, 1992; vol. 31:132-138), Reeve et aI. linked hair pulling and comorbidity and used their data to question the assertion that childhood trichotillomania is frequently a benign habit. However, their study has a number of limitations that limit the generality of their conclusion s. The first is sampling bias . The authors excluded children under 6 years old . Other research has shown the likelihood of comorbidity is elevated in older child hair pullers (Swedo and Rappoport, 1991). Additionally, for all the children in the Reeve et aI. sample, at least one course of treatment was unsuccessful (including behavior therapy, hypnosis, and medication). Given the numerous reports of cases successfully treated with these methods (e.g., Friman et al., 1984; Friman and O'Conner, 1984), the habits of those whose treatments were unsuccessful are probably influenced by variables not representative of the general population of hair pullers. Finally, all the children in their sample were brought to a university psychiatric clinic . Given that the child mental health system is structured so that the most intractable problems are referred to psychiatry, the children studied may represent a very select group of children. The second limitation involves method. No attempt to establish the reliability of the assessments or interviews was reported. The first author conducted all the diagnostic interviews, and yet no attempts to control for demand factors were reported. These limitations are
991
LEITERS TO THE EDITOR
especially pertinent because the authors did not employ a control group to establish the divergent validity of their findings. With respect to the data from the diagnostic interview, Reeve et aI. suggest that when hair pulling and anxiety coexist, hair pulling is a symptom of the anxiety. It is just as plausible, however, that anxiety is a symptom of hair pulling, especially in older children. Consider that hair-pulling creates appearance problems that can cause social anxiety, especially in teens and preteens. Public performance of child habits (e.g., hair pulling, thumb sucking) by school-aged children generate peer and parent negati vity (Friman, 1991) that can also cause anxiety. There are other possibilities. The Reeve et aI. study is important because it supports the observation that older hair pulling children, especially those whose treatment is unsuccessful and who present in psychiatric settings, are likely to exhibit comorbidity. Because of its limitations, however, the study does not mitigate the observation that many hair pulling children (perhaps most) have a benign habit easily treated with behavior modification, counseling, or placebo interventions (e.g., Friman et al., 1984; Friman and Hove, 1987). Perhaps there are two (or more) populations of hair pullers, and DSM-lII-R needs to be revised to reflect subtypes. Alternatively, trichotillomania may be a spectrum disorder of graded intensity. In summary, the results of the Reeve et aI. article do not warrant the necessary association between hair pulling, anxiety, and affective disorders. Such an association may have existed in the very select sample studied, but these results should not be generalized to the majority of childhood hair pullers. Additional studies focused on the spectrum of symptomatology, and related problems need to be conducted on broader samples of patients before generalizable scientific conclusions can be drawn. Patrick C. Friman, Ph.D. Father Flanagan's Boys' Home Creighton University School of Medicine Nathan J. Blum, M.D. Anthony Rostain, M.D. University of Pennsylvania School of Medicine REFERENCES
Friman, P. C. (1991), Treatment issues for child habits. Paper presented at the Third Florida Conference on Child Health Psychology, Gainsville. Friman, P. C., Finney, J. W. & Christophersen, E. R. (1984), Behavioral treatment of trichotillomania: An evaluative review. Behav. Ther., 15:249-266. Friman, P. C. & Hove', G. (1987), Apparent covariation between child habit disorders: effects of successful treatment for thumb sucking on untargeted chronic hair pulling. J. Appl. Behav. Anal., 20:421--426. Friman, P. C. & O'Conner, W. A. (1984), The integration of hypnotic and habit reversal techniques in the treatment of trichotillomania. Behav. Ther., 7: 166-167. Swedo, S. E. & Rapoport, J. L. (1991), Annotation: trichotillomania. J. Child. Psychol. Psychiatry, 32:401--409.
The authors reply: Drs. Friman, Blum, and Rostain raise several concerns about the methodology and subsequent conclusions of our study. We would like to clarify that children under the age of 6 years were excluded so that all subjects could participate in the structured interviews and rating scales, which are not normed to ages less than 6 years. Although these children presented to a tertiary care setting and a sampling bias may certainly have occurred, to the best of our knowledge, no other child and adolescent clinic offered assessment and treatment for trichotillomania in our community. Families typically reported that they had made numerous phone calls to other clinics before locating our re-
992
search program. Subjects reported previous treatment, but excluding the subject whose treatment by hypnosis failed and the subject whose treatment with clomipramine and subsequently f1uoxetine failed, all other subjects had only tried "home remedies," including wearing hats and gloves and taping fingers together. Subjects had not received formal behavioral treatment. The majority of subjects, therefore, did not appear to reflect a bias ofthe most intractable cases presenting to our psychiatric clinic. We readily acknowledge in our article and agree with Friman and colleagues that the use of a control group would clarify the validity of our findings. Friman and colleagues suggest the we concluded that anxiety, when present, predates and results in hair pulling. As stated in our article, however, the hair pulling may (not must) be a manifestation of the anxiety, and we agree that anxiety may be a symptom of hair pulling. Our increasing sample size supports the trend we have noted in our preliminary report-that is, that childhood hair pulling may be associated with symptoms of anxiety (unpublished data). Whatever the etiological relationship, a careful assessment for anxiety disorders should be considered in children with hair pulling. We agree with Friman and associates that hair pulling may in some children be a time-limited, benign habit. Our recent success in treatment using behavioral approaches suggests that hair pulling in children is likely a treatable entity that may not be predictive of a lifetime of hair pulling. Elizabeth A. Reeve, M.D. St. Paul Ramsey Medical Center Gail A. Bernstein, M.D. Gary A. Christenson, M.D. University of Minnesota
Control Groups in Research To the Editor: Many findings relating biological variables to psychiatric disorders are open to question because of a critical methodological flaw in most research designs. The flaw is in the selection of control or comparison groups. Typically, studies involving a particular biological process investigate differences between a psychiatric disorder group and a normal control group and/or other psychiatric disorder groups. At the same time, it is generally recognized that differences in motor, language, cognitive, and sensory processing capacities accompany many psychiatric disorders (e.g., Vitiello et aI., 1989). Many of the functional CNS differences seen with specific psychiatric disorders (hypothesized to be part of the disorder), however, are also found in nonpsychiatrically impaired individuals (less frequently than impaired individuals). Yet, in explaining a particular biological marker, rarely are the "associated CNS patterns" hypothesized as possible explanatory factors, independent of the psychiatric disorder under study. The fact that the associated CNS variations are found in nonpsychiatrically impaired individuals mandates that these associated CNS findings be controlled for in studies investigating biological correlates of a psychiatric disorder. Only a control group of individuals with the associated or accompanying CNS features, but without the psychiatric illness, can rule out the possibility that the associated CNS irregularities, rather than the psychiatric illness's defining characteristics, are responsible for a given biological marker (e.g., children with excellent attention, but with sensory processing, language, and motor irregularities as a comparison group, in addition to "normals," in studies of attention deficit disorder. A review of the recent studies (the most recent 35 articles from three major psychiatric journals, including 10 from the Journal of the American Academy of Child and Adolescent Psychiatry) involving biological variables in psychiatric disorders revealed that none used
J.Am. Acad. Child Adolesc. Psychiatry, 31:5, September 1992
