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). 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 May be chronic or remitting onset in adulthood often more difficult to treat Positive reinforcement may have therapeutic benefit