Trichotillomania

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Trichotillomania
Synonyms	Hair-pulling disorder
Pronounce	N/A
Specialty	N/A
Symptoms	Recurrent, irresistible urges to pull out hair
Complications	Hair loss, skin damage, infection
Onset	Typically in adolescence
Duration	Long-term
Types	N/A
Causes	Unknown, possibly genetic and environmental factors
Risks	Family history, stress, anxiety
Diagnosis	Based on clinical history and DSM-5 criteria
Differential diagnosis	Alopecia areata, obsessive-compulsive disorder, dermatitis
Prevention	N/A
Treatment	Cognitive behavioral therapy, habit reversal training, medication
Medication	Selective serotonin reuptake inhibitors, clomipramine
Prognosis	N/A
Frequency	~1% of the population
Deaths	None directly

Other Names: Hair-pulling syndrome;Trichotillosis; Compulsive hair pulling Trichotillomania is a disorder characterized by an overwhelming urge to repeatedly pull out one's own hair, resulting in hair loss (alopecia). It is classified under the obsessive-compulsive and related disorders category. Trichotillomania results in highly variable patterns of hair loss. The scalp is the most common area of hair pulling, followed by the eyebrows, eyelashes, pubic and perirectal areas, axillae, limbs, torso, and face. The resulting alopecia can range from thin unnoticeable areas of hair loss to total baldness. Some people chew or swallow the hair they pull out (trichophagy), which can result in gastrointestinal problems or develop a trichobezoar (hairball in the intestines or stomach). In many cases, people with this disorder feel extreme tension when they feel an impulse, followed by relief, gratification or pleasure afterwards. The disorder may be mild and manageable, or severe and debilitating.

Causes

Trichotillomania is a type of impulsive control disorder. Its causes are not clearly understood. It may affect as much as 4% of the population. Women are 4 times more likely to be affected than men.

Symptoms

Symptoms most often begin before age 17. The hair may come out in round patches or across the scalp. The effect is an uneven appearance. The person may pluck other hairy areas, such as the eyebrows, eyelashes, or body hair. These symptoms are most often seen in children:

• An uneven appearance to the hair
• Bare patches or all around (diffuse) loss of hair
• Bowel blockage (obstruction) if people eat the hair they pull out
• Constant tugging, pulling, or twisting of hair
• Denying the hair pulling
• Hair regrowth that feels like stubble in the bare spots
• Increasing sense of tension before the hair pulling
• Other self-injury behaviors
• Sense of relief, pleasure, or gratification after the hair pulling

Most people with this disorder also have problems with:

• Feeling sad or depressed
• Anxiety
• Poor self-image

Diagnosis

Your health care provider will examine your skin, hair, and scalp. A piece of tissue may be removed (biopsy) to find other causes, such as a scalp infection, and to explain the hair loss. A biopsy can be performed and may be helpful; it reveals traumatized hair follicles with perifollicular hemorrhage, fragmented hair in the dermis, empty follicles, and deformed hair shafts. Multiple catagen hairs are typically seen. An alternative technique to biopsy, particularly for children, is to shave a part of the involved area and observe for regrowth of normal hairs.

Treatment

Behavioral treatment seems to be the most powerful treatment for trichotillomania. Parental involvement is important and should include enough support so that affected children grow well intellectually, physically, and socially. Shaving or clipping hair close to the scalp may be helpful to stop the behavior. Professional cognitive behavior therapy (CBT) is recommended if initial approaches are unsuccessful. CBT typically involves self monitoring (keeping records of the behavior); habit-reversal training; and stimulus control (organizing the environment). CBT is typically effective in highly motivated and compliant patients. The success of therapy may depend on firm understanding of the illness and the cooperation of the family members to help the affected individual comply with treatment. Several courses of CBT may be needed. No medication has been approved for the treatment of trichotillomania, and medications used have not been consistently effective. Selective serotonin reuptake inhibitors have been utilized but responses to treatment have not been consistent. Fortunately, several recent studies regarding drug therapy for trichotillomania show promise. While drug therapy alone is currently generally not effective, combination therapy and other treatments may be helpful.

Prognosis

Trichotillomania that begins in younger children (less than 6 years old) may go away without treatment. For most people, the hair pulling ends within 12 months. For others, trichotillomania is a lifelong disorder. However, treatment often improves the hair pulling and the feelings of depression, anxiety, or poor self-image. People can have complications when they eat the pulled-out hair (trichophagia). This can cause a blockage in the intestines or lead to poor nutrition.

Prevention

Early detection is the best form of prevention because it leads to early treatment. Decreasing stress can help, because stress may increase compulsive behavior.

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