Trichotillomania

Trichotillomania (hair-pulling disorder (HPD)) is defined as repetitive pulling of one’s hair resulting in hair loss that may be visible to others. This disorder is classified under obsessive-compulsive and related disorders, as there is tension prior to the act that is relieved after the hair-pulling. Diagnosis is made clinically through history taking and physical exam. Treatment is multimodal, using behavioral interventions to recognize and properly respond to the tension and pharmacotherapy, which is beneficial in some cases.

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Overview

Definition

Trichotillomania, also known as hair-pulling disorder, is characterized by a repetitive or deliberate desire to pull one’s hair, done unconsciously.

  • Can cause visible hair loss 
  • Requires clinically significant levels of distress or functional impairment

Most people suffering from trichotillomania tend to pull out hair from their head, eyelashes, eyebrows, legs, arms, face, and pubic region.

Epidemiology

  • Presents in 1%–3% of the population
  • Occurs more often in women than in men
  • Onset: childhood–adolescence, frequently associated with a stressful event
  • Roughly ⅓ of patients also ingest the hair, which can develop into hazardous bezoars (hairballs that can block the GI tract).

Clinical Presentation and Diagnosis

Clinical features

2 types of hair pulling:

  • Focused: where unpleasant personal experiences are addressed via conscious pulling of hair 
  • Automatic: occurs during sedentary activity mostly outside of person’s awareness

Oral manipulation often occurs:

  • Hair nibbling
  • Swallowing of hair
Trichotillomania lesions on scalp

Trichotillomania lesions on the vertex of the scalp

Image: “Trichotillomania lesions on vertex of scalp” by Department of General Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, India. License: CC BY 3.0

Diagnostic approach

  • Diagnostic criteria according to DSM-5:
    • Persistent pulling out of one’s hair leading to visible hair loss
    • Repeated attempts to stop or reduce hair pulling
    • Hair pulling is not due to any other medical condition.
    • Exclude any other mental disorders.
    • Causes significant distress or functional impairment to the patient
  • On exam:
    • Hair-growth pattern is notable by hair with varying lengths and stages of regrowth. 
    • No other abnormalities of skin or scalp 
  • Punch biopsy can confirm the diagnosis but is not required. 
  • If patient is found to ingest the pulled hair, radiologic studies (or even invasive procedures) are needed to visualize the location of a potential bezoar.
Intragastric trichobezoar

Swallowed hair: endoscopic image of an intragastric trichobezoar

Image: “Intragastric trichobezoar” by Department of Surgery, School of Medicine, University of Campinas (Unicamp), Rua Tessália Vieira de Camargo, 126 – Cidade Universitária Zeferino Vaz, Campínas – SP – CEP: 13083-887, Brazil. License: CC BY 3.0

Management

Management usually involves collaborative care between dermatologists and psychiatrists.

Psychotherapy

Cognitive-behavioral therapy (habit-reversal training):

  • Patients are trained to recognize their impulse to pull hair. 
  • Patients are educated to redirect to a healthier coping mechanism (stress-reducing techniques).
  • Social support

Behavioral treatments such as self-monitoring and biofeedback also have exhibited some effectiveness.

Pharmacotherapy

  • No FDA-approved medication therapy at this time 
  • Medication(s) providing some benefit:
    • Tricyclic antidepressants such as clomipramine
    • Selective serotonin reuptake inhibitors such as fluoxetine 
    • Mood stabilizers such as lithium are thought to reduce impulsive behaviors. 
  • Topical steroids and hydroxyzine HCl (an anxiolytic with antihistamine activity) are used to treat psychodermatologic disorders.

Prognosis

  • Onset in early childhood (< age 6) is more self-limiting. 
  • Onset in adulthood or adolescence (> age 13), especially with another psychiatric disorder, has longer-lasting symptoms.

Differential Diagnosis

  • Body dysmorphic disorder (BDD): psychiatric disorder characterized by a patient’s preoccupation with minor or imagined flaws in their physical appearance. The obsession over the perceived defect leads to compulsive behaviors to cover it up, either with cosmetic therapy or social avoidance. Those with trichotillomania are not necessarily pulling their hair because of a perceived defect or flaw in the appearance of their hair. 
  • Alopecia: loss of hair in areas anywhere on the body where hair normally grows. Alopecia may be defined as scarring or nonscarring, localized or diffuse, congenital or acquired, reversible or permanent, or confined to the scalp or universal. Alopecia has several etiologies, such as infectious (fungal infection from tinea capitis), autoimmune (alopecia areata), or traction-related. These conditions must be ruled out prior to the diagnosis of trichotillomania being made. Physical exam will reveal wide variation in lengths of remaining hair in those with trichotillomania. 

References

  1. Sadock, B. J., Sadock, V. A., Ruiz, P. (2014). Obsessive-compulsive and related disorders. Chapter 10 of Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry, 11th ed. Philadelphia: Lippincott Williams and Wilkins, pp. 431–434.
  2. Thomas, E. (2017). Trichotillomania (hair pulling disorder). DeckerMed Medicine. https://pubmed.ncbi.nlm.nih.gov/30745687/
  3. Thompson, J. W., Jr., Winstead D. K. (2019). Impulse-control disorders. Chapter 27 of Ebert M. H., Leckman J. F., Petrakis I. L. (Eds.), Current Diagnosis & Treatment: Psychiatry, 3rd ed. McGraw-Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=2509&sectionid=200806368

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