NORD gratefully acknowledges Samuel R. Chamberlain, MB/BChir, PhD, MRCPsych, Professor of Psychiatry, Department of Psychiatry, Faculty of Medicine, University of Southampton, UK, 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 subsequent hair loss. The hair on the scalp is most often affected. The eyelashes, eyebrows, and beard can also be affected. Some 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 and occupational 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 Diagnostic and Statistical Manual of Mental Disorders Version 5 (DS-5, American Psychiatric Association).
The core symptom of trichotillomania is repetitive pulling out of one’s own hair, leading to hair loss and significant distress/impairment. The individual has usually attempted to decrease or stop hair pulling at some point. The previous diagnostic criteria (in version IV of the Diagnostic and Statistical Manual) also included ‘noticeable hair loss’ and ‘tension and subsequent relief from hair pulling’ but these two criteria are no longer required to be met for a diagnosis to be made.
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. Most 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. 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.
Some 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 a variety of conditions including depression, anxiety disorders, obsessive compulsive disorder (OCD), or attention deficit hyperactivity disorder (ADHD).
The exact causal factors in trichotillomania are not known or well-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. It is important to note that although first-degree family members of someone with trichotillomania are at increased risk of developing trichotillomania themselves, the majority of such individuals do not. Anxiety and arousal levels can play a role in trichotillomania – some affected individuals report that they pull hair more when relaxing (such as when watching television), or alternatively during times of stress (such as when work is stressful). The role of anxiety varies across individuals. Early work suggested that childhood trauma might predispose people to develop trichotillomania but there is little robust evidence to support this.
Researchers have suggested that structural or functional abnormalities of the brain may play a role in the development of trichotillomania. Such findings include subtle changes (compared to ‘control’ groups of people without trichotillomania) in the putamen, cerebellum and cortical regions such as the anterior cingulate and right inferior frontal gyri. These brain regions are important in how prone we are to develop habitual behaviors, and how able we are to suppress inappropriate or unwanted habits once they occur. The specific structural or functional brain abnormalities associated with trichotillomania and the role that they play in the development of trichotillomania require more research to understand, because findings differ between studies.
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. Most affected people have never received appropriate treatment.
A diagnosis of trichotillomania may be suspected if characteristic symptoms are present such as 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 may be reluctant to talk about hair pulling behavior due to shame/embarrassment, a diagnosis can often be overlooked.
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 medication 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). Of these options, generally speaking, n-acetyl cysteine appears to be the most well tolerated (the one least likely to cause significant side effects).
In some people, 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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