NORD is very grateful to Samuel R. Chamberlain, MD PhD MRCPsych, Clinical Lecturer, Department of Psychiatry, University of Cambridge, England, for assistance in the preparation of this report.
Synonyms of Trichotillomania
- hair-pulling syndrome
- pathological hair-pulling
- No subdivisions found.
Trichotillomania is characterized by an overwhelming urge to repeatedly pull out one's own hair, resulting in repetitive hair pulling and noticeable patches of baldness. The hair on the scalp is most often affected. The eyelashes, eyebrows, and beard can also be affected. In some cases, affected individuals chew and/or swallow (ingest) the hair they have pulled out (trichophagy), which can result in gastrointestinal problems. Trichotillomania causes significant emotional distress and often impairs social functioning. The exact cause of the condition is not known. Trichotillomania was previously classified as an impulse control disorder but is now considered an obsessive-compulsive related disorder in the latest version of the psychiatric Diagnostic and Statistical Manual of Mental Disorders (Version 5, American Psychiatric Association).
Individuals with trichotillomania repeatedly experience an overwhelming urge to pull out their hair. According to diagnostic criteria, affected individuals are extremely tense upon feeling such an impulse, and experience relief, gratification or pleasure afterwards. However, many individuals experience problematic repetitive hair pulling, but do not endorse these diagnostic criteria.
The severity and the specific areas of hair on the body that are affected can vary greatly from one individual to another. For some individuals trichotillomania may be mild and manageable, for others it can become a severe and debilitating problem. Trichotillomania may occur chronically, continuously, temporarily (transiently) or it may occur and then disappear for months or years only to recur.
The scalp is the most commonly affected area in trichotillomania. Affected individuals may break off pieces of hair or pull out entire strands. Patches of baldness usually result on the scalp. In most cases, individuals pull out hair from one or two areas, though there may be more. Although the scalp is the most common site involved, the beard, eyelashes, and eyebrows may also be involved. Less commonly, individuals may also pull hair from the armpits, trunk, and/or pubic areas.
There may be a generalized tingling or itching (pruritis) in the involved areas, but affected individuals usually do not typically experience pain after hair plucking, at least once the habit is established. Skin irritation may occur at affected sites. In addition, affected individuals often have an uncontrollable urge to twist their hair or undertake other ritualistic behaviors such as counting hair, ordering it, or playing with the bulb roots.
Some affected individuals may chew or swallow (ingest) their hair, a condition known as trichophagy. In rare cases, ingestion of hair may lead the formation of a hairball in the stomach (trichobezoar) resulting in abdominal pain, nausea and vomiting, anemia and/or bowel obstruction.
Individuals with trichotillomania may deny that their hair-pulling behavior exists and may attempt to conceal the behavior by wearing wigs and false eyelashes and taking similar additional steps to hide hair loss. Affected individuals are often extremely secretive about the behavior as well and may avoid social situations.
In some cases, people with trichotillomania may also engage in other behaviors, such as abrading or wearing off of the skin (excoriation), scratching, gnawing, biting their nails, cracking their knuckles, or playing with pulled out hair. As such, trichotillomania is regarded by some researchers as a ‘body focused repetitive behavior’.
Trichotillomania can occur in conjunction with mood and anxiety disorders such as depression, obsessive compulsive disorder (OCD), general phobias, or attention deficit hyperactivity disorder (ADHD).
The exact cause of trichotillomania is not known and poorly understood. Most likely, trichotillomania results from several factors occurring together including genetic and environmental factors.
Some individuals may have a genetic predisposition to developing trichotillomania, and this notion is supported by the one available twin study conducted in people with this condition available to date. A person who is genetically predisposed to a disorder carries a gene (or genes) for the disease, but it may not be expressed unless it is triggered or "activated" under certain circumstances such as due to particular environmental factors.
In some cases, it is believed that severely stressful situations play a role in causing this disorder. Some cases of trichotillomania have been associated with previous traumatic events.
Researchers have speculated that structural or functional abnormalities of the brain may play a role in the development of trichotillomania in some cases. Such findings include abnormalities of the putamen, cerebellum and cortical regions such as the anterior cingulate and right inferior frontal gyri. The specific structural or functional brain abnormalities associated with trichotillomania and the role that they play in the development of trichotillomania is not understood.
Some scientists believe that trichotillomania is a subcategory of obsessive compulsive disorder (OCD), which may be caused by certain imbalances in brain chemicals (see OCD in related disorders section below).
More research is necessary to determine the exact cause(s) and underlying mechanisms that result in trichotillomania.
Trichotillomania usually occurs in adolescence in the first instance. However, the disorder has occurred in very young children, through to adults up to approximately 60 years of age. During childhood, the disorder affects males and females in equal numbers; in adulthood, females are affected more often than males. This may not reflect the true ratio of trichotillomania in adulthood, but rather that hair loss is more accepted among adult males than females.
Trichotillomania has been known to affect individuals for a period of several months to more than 20 years. In many cases, symptoms may occur in cycles, with symptoms periodically lessening, then worsening, disappearing, and then recurring.
Because some cases of trichotillomania go unrecognized or unreported, the disorder is under-diagnosed, making it difficult to determine its true frequency in the general population. It has been estimated that 0.5-3 percent of people will experience the condition at some point during life.
Symptoms of the following disorder can be similar to those of trichotillomania. Comparisons may be useful for a differential diagnosis:
OCD is characterized by recurrent obsessive and/or compulsive thoughts and actions. Obsessions are persistent ideas, thoughts, impulses or images that the affected individual knows are senseless. Attempts are made to ignore or suppress such thoughts or impulses, or to counteract them with some other thought or action. The individual recognizes that the obsessions are the product of his or her own mind, but they are difficult to resist. Many scientists believe that trichotillomania and OCD are related to similar brain chemical abnormalities because they are said to be responsive to the same drug treatments; however, recent meta-analysis of pharmacological treatment studies suggests that this is not the case. (For more information on this disorder, choose "Obsessive Compulsive" as your search term in the Rare Disease Database.)
Monilethrix is a rare inherited disorder characterized by sparse, dry, and/or brittle hair that often breaks before reaching more than a few inches in length. The hair may lack luster, and there may be patchy areas of hair loss (alopecia). Another common symptom may be the appearance of elevated spots (papules) surrounding the hair follicles that may be covered with gray or brown crusts or scales (perifollicular hyperkeratosis). When viewed under a microscope, the hair shaft resembles a string of evenly-spaced beads. In most cases, monilethrix is thought to be inherited as an autosomal dominant trait. (For more information on this disorder, choose "monilethrix" as your search term in the Rare Disease Database.)
Alopecia areata is a rare disorder characterized by the progressive loss of hair. It often begins suddenly with oval or round bald patches appearing on the scalp; however, other areas of hairy skin may also be involved. Gradually, the affected skin becomes white and smooth. The hair may regrow in these areas within weeks; at the same time, additional patches of hair loss may occur elsewhere. In some cases, hair regrowth may occur in one area of the scalp but not in others; in other cases, the loss of hair may be permanent and lead to baldness. In a few rare cases, all body hair may be lost. Cases with onset during childhood tend to be more severe than those with an adult onset. The exact cause of alopecia areata is unknown. (For more information on this disorder, choose "Alopecia Areata" as your search term in the Rare Disease Database.)
A diagnosis of trichotillomania may be suspected if characteristic symptoms are present such as noticeable patches of hair loss. A diagnosis may be made based upon a thorough clinical evaluation, a detailed patient history and a variety of tests that can rule out other causes of hair loss. Because many individuals attempt to conceal their hair pulling behavior, a diagnosis may be difficult to obtain.
The two main forms of treatment for trichotillomania are psychotherapy and pharmacotherapy. There is no universal form of therapy that is effective in all cases.
Psychotherapy is the treatment of disorder by psychological methods. Psychotherapy for trichotillomania may include cognitive behavior therapy, which attempts to identify and alter the thoughts and emotions that lead to certain behaviors such as hair pulling. Types of cognitive behavior therapy used to treat individuals with trichotillomania include habit reversal, awareness training and stimulus control.
Pharmacotherapy refers the use of medications to treat illness. A variety of medications have been used to treat individuals with trichotillomania, however there have been few carefully conducted clinical trials. In a recent Cochrane Systematic Review, it was concluded that preliminary evidence shows beneficial treatment effects in trichotillomania with clomipramine (a tricyclic with serotonergic effects), n-acetyl cysteine (an amino acid compound thought to influence glutamate transmission), and olanzapine (an antipsychotic medication primarily acting on the dopamine system).
In some cases, behavior modification and medications are used together to treat trichotillomania. More research is necessary to determine what specific therapies either alone or in combination provide both efficacy and long-term safety for the treatment of individuals with trichotillomania.
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