NORD gratefully acknowledges Samuel R. Chamberlain, MD PhD MRCPsych, Clinical Lecturer, Department of Psychiatry, University of Cambridge, England, for assistance in the preparation of this report.
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.
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.
Treatment
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.
Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. Government funding, and some supported by private industry, are posted on this government web site.
For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:
Tollfree: (800) 411-1222
TTY: (866) 411-1010
Email: prpl@cc.nih.gov
For information about clinical trials sponsored by private sources, contact:
www.centerwatch.com
For information about clinical trials conducted in Europe, contact:
https://www.clinicaltrialsregister.eu/
TEXTBOOKS
Hales RE, Yudofsky SC, Gabbard GO, eds. Textbook of Psychiatry, 5th ed. Arlington, VA, American Psychiatric Publishing;2008: 800-806.
Frances A. Chmn. Bd. Eds. Diagnostic and Statistical Manual of Mental Disorders: DSM IV. 4th ed. American Psychiatric Association. Washington, DC; 1994:618-621.
JOURNAL ARTICLES
Chamberlain SR, Hampshire A, Menzies LA, et al. Reduced brain white matter integrity in trichotillomania: a diffusion tensor imaging study. Arch Gen Psychiatry. 2010;67:965-971.
Franklin ME, Edson AL, Freeman JB. Behavior therapy for pediatric trichotillomania: exploring the effects of age on treatment outcome. Child Adolesc Pyschiatry Ment Health. 2010;4:18.
Chamberlain SR, Menzies LA, Fineberg NA, et al. Grey matter abnormalities in trichotillomania: morphometric magnetic resonance imaging study. Br J Psychiatry. 2008;193:216-221.
Grant JE, Odlaug BL. Clinical characteristics of trichotillomania with trichophagia. Compr Psychiatry. 2008;49:579-584.
Chamber lain SR, Menzies L, Sahakian BJ, Fineberg NA. Lifting the veil on trichotillomania. Am J Psychiatry. 2007;164:568-574.
Fennessy J, Crotty CP. Trichotillomania. Dermatol Nurs. 2008 Feb; 20(1):63.
Ninan PT. Conceptual issues in trichotillomania, a prototypical impulse control disorder. Curr Psychiatry Rep. 2000;2:72-75.
Neziroglu F, et al. Behavioral, cognitive, and family therapy for obsessive-compulsive and related disorders. Psychiatr Clin North Am. 2000;23:657-70.
INTERNET
Ellis CR. Roberts HJ. Schnoes CJ. Pediatric Trichotillomania.Medscape, Updated: Apr 16, 2012. Available at: http://emedicine.medscape.com/article/915057-overview Accessed Feb 12, 2014.
Mayo Clinic for Medical Education and Research. Trichotillomania (Hair-Pulling Disorder). Jan. 24, 2009. Available at: http://www.mayoclinic.com/health/trichotillomania/DS00895 Accessed Feb 12, 2014.
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