Trichotillomania, classified as an impulse control disorder by DSM-IV, is the compulsive urge to pull out one's own hair leading to noticeable hair loss, distress, and social or functional impairment, and in some cases one may even consume the hair. It is often chronic and difficult to treat.
DSM-IV diagnostic criteria for trichotillomania include: (A) Recurrent pulling out one's hair resulting in noticeable hair loss, (B) an increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior, (C) pleasure, gratification, or relief when pulling out hair, (D) the disturbance is not better accounted for by another mental disorder and is not due to a general medical condition, and (E) the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
The scalp is the most common site of hair-pulling. Eyebrows and eyelashes are the next most common sites, followed by pubic hair in the majority of people with this condition. Men appear to pull from a greater variety of sites than women do, and are more likely to pull hair from the face, chest, and abdomen.
A person with trichotillomania cannot control or resist the urge to pull out his or her body hair. Other symptoms that might occur with this disorder include: a sense of tension before pulling hair or when trying to resist the urge to pull hair, feeling of relief, satisfaction, and/or pleasure after acting on the impulse to pull hair, presence of bare patches where the hair has been pulled out, and presence of other associated behaviors such as inspecting the hair root, twirling the hair, pulling the hair between the teeth, chewing on the hair, or eating hair (called trichophagia). Many people who have trichotillomania try to deny they have a problem and may attempt to hide their hair loss by wearing hats, scarves, and false eyelashes and eyebrows.
Interestingly, children more often fall in the autonomic category, whereby they do not recall the actual pulling, but may admit to "playing with hair." Christenson and MacKenzie described this state as "trance-like" and 75% of their adult chronic pullers had times where they were unaware of their behavior.
In the focused subtype, patients may have specific rituals regarding hair-pulling activity. They may search out specific hairs to pull (white, kinky, odd texture), they may pluck "until the hair feels just right" or pull in response to a sensation in that area. Still others may use tools such as tweezers or shavers to remove their hair, and some may pick at their skin causing excoriations and secondary infections.
Doctors don't know for certain what causes trichotillomania. Some think it could be related to obsessive-compulsive disorder since OCD and trichotillomania both involve repetitive behaviors.
A variety of treatment approaches have been attempted with this unusual disorder, including psychoanalysis, traditional psychotherapies, hypnotherapy, and a variety of operant and other behavior modification techniques. Generally, the earlier the age of onset, the greater the likelihood of successful treatment (Sorosky & Sticker, 1980). Behavioral techniques appear to be the most successful methods of treating Trichotillomania and trichophagia, particularly when competing responses can be developed, although success has been reported with a variety of techniques and the role of spontaneous remission is not known
Although medications clearly help some people temporarily, symptoms are likely to return when the medication is stopped unless behavioral therapy is incorporated into treatment. Medications may help to reduce the depression and any obsessive-compulsive symptoms the person may be experiencing.Commonly used medications are: fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), paroxetine (Paxil), clomipramine (Anafranil), and valproate (Depakote).
Although trichotillomania may be multidetermined, its onset has been linked to stressful situations in more than 25% of all cases. Disturbances in mother–child relationships, fear of being left alone, and recent object loss are often cited as important contributing factors. Neurobiological investigations show evidence of abnormal patterns of brain neurotransmitters (serotonin) and involvement of the parts of the brain called the basal ganglia and frontal lobes, similar to that seen in people with OCD and Tourette's syndrome. Baseline levels of amino acids in spinal fluid (cerebrol spinal fluid 5-hydroxyindoleacetic acid levels) in individuals with trichotillomania seem to correlate with response to serotonin reuptake inhibitors.
Incidences of Trichotillomania have also been reported in conjunction with episodes of child abuse. Incidence is generally greater in females than males.
Medical complications of trichotillomania can include infection and scarring at the site, change in color or texture of the hair, slowed or stopped hair growth, and indirect complications leading to fear of embarrassment such as avoiding physical examinations, and the like. Repetitive arm and hand movements involved in hair pulling can cause carpal tunnel syndrome and other neuromuscular disorders. Psychiatric comorbidities (conditions occurring at the same time) include major depression, generalized anxiety disorder, eating disorder, Tourette's syndrome, body dysmorphic disorder, alcohol or other substance dependence and abuse, simple or social phobia.
Trichotillomania is a type of compulsive behavior, meaning that people with the condition feel an overwhelming urge to pull their hair. They also may have other compulsive habits, such as nail biting or skin picking. Some also have problems like depression, anxiety, or obsessive-compulsive disorder (OCD). Compulsive behaviors like trichotillomania involve brain chemistry and may be genetic.
Up to 98% of patients with trichotillomania try to resist urges to pull, and may use barriers, such as hats, wigs, mittens, or tape, or alternative activities (knitting, sitting on hands) to decrease pulling. These attempts are generally unsuccessful.