Basics
Description
Trichotillomania (TTM) is the recurrent pulling out of one 's hair resulting in hair loss. Pulling causes clinically significant distress or functional impairment, is accompanied by repeated efforts to stop, and is not due to another mental disorder or a general medical condition.
- Hair pulling can occur in any region of the body, but the most common sites are the scalp, eyelashes, and eyebrows. Other relatively common sites include the axilla, face, and pubic area. Sites may vary over time.
- Pulling can occur in brief episodes throughout the day or in sustained bouts.
- Automatic pulling is outside the patient 's awareness.
- Focused pulling is in response to identifiable affective triggers.
- Some patients experience tension immediately before pulling or when attempting to resist the behavior, whereas others experience pleasure or relief when pulling.
- Patients may search for and pull hairs with specific qualities (e.g., thick hairs or short hairs).
- More than half of patients engage in a "ritual " with the hair before discarding it.
- TTM does not include habitual hair twirling.
Epidemiology
- Typical onset in childhood or adolescence: often coincides with the onset of puberty
- In childhood, girls and boys are equally affected.
- In adulthood, the ratio of affected females to males is 10:1.
Prevalence
1 " 3% lifetime prevalence
Risk Factors
TTM is more common in individuals with obsessive-compulsive disorder (OCD) and in their 1st-degree relatives.
Genetics
- One study of 34 twin pairs showed concordance in 38% of monozygotic and 0% of dizygotic twins, suggesting heritability.
- No specific genes implicated, although animal models of TTM exist.
Commonly Associated Conditions
- Trichophagia (ingesting hair), which can lead to trichobezoar. It is estimated that between 5 and 18% of patients with TTM ingest their hair.
- Psychiatric comorbidity is common (seen in 1/3 " 2/3 of children with TTM) and includes autism, pervasive developmental disorder (PDD), anxiety, mood, attention deficit, substance use, and eating disorders.
- Patients may also engage in nail-biting, skin-picking, or other pathologic grooming behaviors.
Diagnosis
History
- Patients may present with a complaint of hair loss or with concern regarding pulling behavior.
Physical Exam
- Areas of hair loss do not show complete alopecia; instead, they contain hairs of different lengths, hairs with blunt ends, and remnants of hair bulbs. Hair density is normal in other areas.
- In some cases, pulling is widely distributed and hair loss may not be readily apparent.
- In children, patches of loss may be more prevalent on the side of the patient 's dominant hand.
Diagnostic Tests & Interpretation
Diagnostic Procedures/Other
Several instruments are available for clinical use; the Massachusetts General Hospital Hair Pulling Scale is one tool commonly used to monitor symptom severity and response to treatment.
Differential Diagnosis
- Alopecia areata
- Tinea capitis
- Dermatologic conditions causing pruritus; normative hair removal (e.g., for cosmetic reasons)
- Other obsessive-compulsive or related disorders where pulling is part of a symmetry or other ritual
- Body dysmorphic disorder
Treatment
Medication
- Few placebo-controlled randomized trials have included children or adolescents.
- N-acetylcysteine
- A randomized controlled trial (RCT) of 50 adults demonstrated efficacy of N-acetylcysteine (56% of patients responded to treatment compared to 16% of patients on placebo).
- A similarly designed study of 34 children showed no effect, with clinically modest but statistically significant improvements in symptoms in both treatment and control groups.
- Olanzapine
- Has been shown to be efficacious in a study of 25 adults (85% of treatment group responded as compared to 17% of placebo group)
- However, 84% of treatment group reported undesirable side effects.
- SSRIs do not reduce hairpulling but are efficacious for treating comorbid conditions and are used in some adults with TTM.
Additional Therapies
- For mild cases in young children, reward systems or "home remedies " like a hat or Band-Aids on fingers may help.
- Behavior modification programs, habit reversal training methods, and cognitive behavioral therapy have all been used.
- One RCT of 24 children showed sustained effect of behavioral therapy (75% in behavioral therapy group were responders as compared with 0% in minimal attention control group at 8 weeks; effect sustained over 8-week maintenance period).
General Measures
- Triggers should be identified and minimized with a focus on stress management strategies.
- Parent and family education about TTM and associated conditions is essential.
- The Trichotillomania Learning Center (www.trich.org) has valuable educational materials for patients, parents, and clinicians as well as a list of mental health providers with experience treating TTM.
Ongoing Care
Follow-up Recommendations
Patients with TTM should be referred to a mental health professional with training in behavioral therapy and, ideally, with experience treating patients with TTM.
Prognosis
TTM often waxes and wanes, with symptoms reemerging at times of stress or transition.
Complications
- TTM can lead to significant academic, social, and developmental impairment.
- 55% of children reported that TTM made it more difficult to study and 35% reported academic impairment as a direct result of pulling.
- 55% of parents of children with TTM reported that their child avoided social events as a direct result of pulling.
- 80% of parents of children with TTM felt that their child 's pulling contributed to another psychiatric problem.
- Trichobezoar resulting from trichophagia can cause serious gastrointestinal complications including obstruction and perforation.
Additional Reading
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.
- Bloch MH, Landeros-Weisenberger A, Dombrowski P, et al. Systematic review: pharmacological and behavioral treatment for trichotillomania. Biol Psychiatry. 2007;62(8):839 " 846. [View Abstract]
- Bloch MH, Panza KE, Grant JE, et al. N-acetylcysteine in the treatment of pediatric trichotillomania: a randomized, double-blind, placebo-controlled add-on trial. J Am Acad Child Adolesc Psychiatry. 2013;52(3):231 " 240. [View Abstract]
- Duke DC, Keeley ML, Geffken GR, et al. Trichotillomania: a current review. Clin Psychol Rev. 2010;30(2):181 " 193. [View Abstract]
- Franklin ME, Flessner CA, Woods DW, et al. The child and adolescent trichotillomania impact project: descriptive psychopathology, comorbidity, functional impairment, and treatment utilization. J Dev Behav Pediatr. 2008;29(6):493 " 500. [View Abstract]
- Franklin ME, Zagrabbe K, Benavides KL. Trichotillomania and its treatment: a review and recommendations. Expert Rev Neurother. 2011;11(8):1165 " 1174. [View Abstract]
- Grant JE, Odlaug BL, Kim SW. N-acetylcysteine, a glutamate modulator, in the treatment of trichotillomania. Arch Gen Psychiatry. 2009;66(7):756 " 763. [View Abstract]
- Novak CE, Keuthen NJ, Stewart SE, et al. A twin concordance study of trichotillomania. Am J Med Genet B Neuropsychiatr Genet. 2009;150B(7):944 " 949. [View Abstract]
- Van Ameringen M, Mancini C, Patterson B, et al. A randomized, double-blind, placebo-controlled trial of olanzapine in the treatment of trichotillomania. J Clin Psychiatry. 2010;71(10):1336 " 1343. [View Abstract]
Codes
ICD09
- 312.39 Other disorders of impulse control
- 307.59 Other disorders of eating
ICD10
- F63.3 Trichotillomania
- F50.8 Other eating disorders
SNOMED
- 17155009 trichotillomania (disorder)
- 5125001 Habitual eating of own hair (finding)
FAQ
- Q: What are signs and symptoms of trichobezoar?
- A: Patients can present with abdominal pain, nausea, vomiting, weight loss, or gastrointestinal bleeding. X-ray shows a characteristic abdominal mass, and hair may be present in the patient 's stool.
- Q: Which patients with hairpulling behaviors should be referred for evaluation and treatment?
- A: Patients with patches of alopecia, distress related to their alopecia or pulling behavior, and those with deliberate pulling should be referred.
- Q: To whom should I refer patients with suspected or diagnosed TTM?
- A: Ideally, a psychologist or other mental health professional with training in behavioral therapy, cognitive behavioral therapy, or exposure-response management therapy.