August 27th, 2013
Is the compulsive urge to pull out (and in some
cases, eat) one's own hair leading to noticeable
hair loss, distress, and social or functional
impairment. It is classified as an impulse control
disorder by DSM-IV and is often chronic and
difficult to treat.
Hair pulling was first described in the literature in
1885, and the term trichotillomania was coined by
the French dermatologist François Henri Hallopeau
It was not until 1987 that trichotillomania was
recognized in the Diagnostic and Statistical Manual
of the American Psychiatric Association, third
INCIDENCE AND PREVALENCE
Trichotillomania’s peak age of onset is from 9 to 13
years of age. It may be triggered by depression or
stress. Owing to social implications the disorder is
often unreported and it is difficult to accurately
predict its prevalence. However, the lifetime
prevalence is estimated to be as high as 1.5% (in
males) to 3.4% (in females).
DIFFICULTIES OF DIAGNOSIS
Trichotillomania includes the criteria of an increasing
sense of tension before pulling the hair and
gratification or relief when pulling the hair.
However, some people with trichotillomania do not
endorse the inclusion of "rising tension and
subsequent pleasure, gratification, or relief" as part of
the criteria because many individuals with
trichotillomania may not realize they are pulling their
hair. Patients presenting for diagnosis may deny the
criteria for tension prior to hair pulling or a sense of
gratification after hair is pulled.
AUTOMATIC VS. FOCUSED
Trichotillomania is often not a focused act, but
rather hair pulling occurs in a "trance-like" state.
Hence, trichotillomania is subdivided into
"automatic" versus "focused" hair pulling.
Children are more often in the automatic, or
unconscious, subtype and may not consciously
remember pulling their hair.
Other individuals may have focused, or conscious,
rituals associated with hair pulling, including
seeking specific types of hairs to pull, pulling until
the hair feels "just right", or pulling in response to a
specific sensation. Knowledge of the subtype is
helpful in determining treatment strategies.
SIGNS AND SYMPTOMS
People who suffer from trichotillomania often pull only
one hair at a time and these hair pull episodes can
last for hours at a time. Trichotillomania can go into
relapse-like states where the individual may not
experience the urge to "pull" for days, weeks,
months, and even years.
Individuals with trichotillomania exhibit hair of
differing lengths. Some are broken hairs with blunt
ends, some new growth with tapered ends, some
broken mid-shaft, or some uneven stubble. Scaling
on the scalp is not present, overall hair density is
normal, and a hair pull test is negative (the hair does
not pull out easily). Individuals with trichotillomania
may be secretive or shameful of the hair pulling
STRESS AND HEALTH
Low self-esteem, often associated with being shunned by
peers and the fear of socializing due to appearance and
negative attention they may receive. Some people with
trichotillomania wear hats, wigs, false eyelashes, eyebrow
pencil, or style their hair in an effort to avoid such
attention. There seems to be a strong stress component.
In low-stress environments, some exhibit no symptoms
(known as "pulling") whatsoever. This "pulling" often
resumes upon leaving this environment.
Other medical complications include infection, permanent
loss of hair, and gastrointestinal obstruction as a result of
trichophagia. In trichophagia, people with trichotillomania
ingest the hair that they pull and in extreme and rare
cases, this can lead to a hair ball (bezoar). Rapunzal’s
Syndrome, an extreme form of trichobezoar in which the
"tail" of the hair ball extends into the intestines, this can be
fatal if misdiagnosed.
Environment is a large factor which affects hair
pulling. Sedentary activities such as being in a
relaxed environment are conducive to hair pulling.
An extreme example of automatic trichotillomania is
found when some patients have been observed to
pull their hair out while asleep. This is called sleep-
Anxiety, depression and obsessive–compulsive
disorder are more frequently encountered in people
with trichotillomania. Trichotillomania has a high
overlap with post traumatic stress disorder.
Differential diagnosis must be pursued before a
dianogsis of trichotillomania can be made with
certainty. The differential diagnosis will include
evaluation for alopecia areata, tinea capitis, traction
alopecia, and loose anagen syndrome.
When it occurs in early childhood (before five years
of age), the condition is typically self-limiting and
intervention is not required. In adults, the onset of
trichotillomania may be secondary to underlying
psychiatric disturbances and symptoms are
generally more long-term.
Secondary infections may occur due to picking and
scratching, but other complications are rare.
Individuals with trichotillomania often find that
support groups are helpful in living with and
overcoming the disorder.
Establishing the diagnosis and raising
awareness of the condition is an important
reassurance for the family and patient.
Non-pharmacological interventions, including
behavior modification programs, may be
considered. Referrals to psychologists or
psychiatrists are considered when other
interventions fail. The hair pulling may resolve
when attributable conditions are treated.
Habit reversal training (HRT) has the highest rate of
success in treating trichotillomania. HRT has been
shown to be a successful adjunct to medication as a
way to treat trichotillomania.
With HRT, the individual is trained to learn to
recognize their impulse to pull and also teach them to
redirect this impulse. In comparisons of behavioral
versus pharmacologic treatment, cognitive behavioral
therapy (including HRT) have shown significant
improvement over medication alone. It has also
proven effective in treating children.
Clomipramine, a tricyclic antidepressant, was shown to
significantly improve symptoms.
Fluoxetine (Prozac) and other selective serotonin reuptake
inhibitors (SSRIs) have limited usefulness in treating
trichotillomania, and can often have significant side effects.
Behavioral therapy has proven more effective when compared to
fluoxetine or control groups. Dual treatment (behavioral therapy
and medication) may provide an advantage in some cases.
Acetylcysteine treatment stemmed from an understanding of
glutamate's role in regulation of impulse control.
HOWEVER, Many medications, depending on individuality, may
actually increase hair pulling, so be aware of potential side
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correlates in trichotillomania--A case-control association study
in the South African Caucasian population". Isr J Psychiatry
Relat Sci 43 (2): 93–101. PMID 16910371. Greer JM,
2) Capecchi MR (January 2002). "Hoxb8 is required for normal
grooming behavior in mice". Neuron 33 (1): 23–34.
doi:10.1016/S0896-6273(01)00564-5. PMID 11779477. James,
3) Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin:
Clinical Dermatology (10th ed.). Saunders. p. 63. ISBN 0-7216-
4) Grant, J. E.; Odlaug, B. L.; Won Kim, S. (2009). "N-
Acetylcysteine, a Glutamate Modulator, in the Treatment of
Trichotillomania: A Double-blind, Placebo-Controlled Study".
Archives of General Psychiatry 66 (7): 756–63.
5) Swedo SE, Leonard HL, Rapoport JL, Lenane MC, Goldberger
EL, Cheslow DL (1989). "A double-blind comparison of
clomipramine and desipramine in the treatment of
trichotillomania (hair pulling)". N. Engl. J. Med. 321 (8): 497–