Updated: 11/30/2020

Trichotillomania (Hair-Pulling Disorder)

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Topic
Snapshot
  • A 17-year-old female with a history of generalized anxiety disorder and obsessive compulsive disorder presents to the psychiatry clinic with hair loss. During her final exam period, she started pulling out her hair. She now has several large patches of hair loss and states that pulling out her hair relieves her stress.
Introduction
  • Subclassified under obsessive compulsive and related disorders (DSM V)
  • Epidemiology
    • seen in 1-3% of the population
    • more common in women than in men
    • onset often in childhood or adolescence and associated with a stressful event (25% of cases)
    • increased incidence of comorbid OCD, obsessive-compulsive personality disorder, mood disorders, and borderline personality disorder
Presentation
  • Symptoms
    • recurrent, repetitive, intentional pulling out of one's hair causing visible hair loss 
    • often involves the scalp but can also include eyebrows, eyelashes, facial and pubic hair
    • tension experienced immediately before the pulling behavior - pleasure or relief occurs afterwards
    • causes significant distress and impairment in daily functioning
    • disturbance is not better accounted for by another mental disorder
    • not due to a general medical condition (e.g., a dermatological condition).
Evaluation
  • Diagnosis
    • history to obtain symptoms listed above
    • physical examination useful in documenting hair loss
Treatment
  • Behavioral
    • cognitive behavioral therapy first line
      • habit reversal training 
    • hypnosis, relaxation techniques, and substitution with another behavior
  • Pharmacologic
    • SSRIs, TCAs, antipsychotics, and lithium
      • SSRI's are the classic treatment for impulse control disorders
        • trichotillomania
        • OCD
        • suicide
    • data supports clomipramine but SSRIs are used more often
      • clomipramine is the most serotonergic TCA
Prognosis, Prevention, and Complications
  • Prognosis 
    • may be chronic or remitting
    • onset in adulthood often more difficult to treat
    • positive reinforcement may have therapeutic benefit

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