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Chapter: Essentials of Psychiatry: Impulse Control Disorders

Trichotillomania: Course, Treatment, Demographical Features

Trichotillomania may be one of the earliest occurring conditions in psychiatry.



The age at onset typically ranges from early childhood to young adulthood. Peak ages at presentation may be bimodal, with an earlier peak about age 5 to 8 years among children in whom it has a self-limited course, whereas among patients who present to clinicians in adulthood the mean age at onset is approximately 13 years (Rothbaum et al., 1993). Initial onset after young adulthood is apparently uncommon. There have been reports of onset as early as 14 months of age and as late as 61 years.


Trichotillomania may be one of the earliest occurring con-ditions in psychiatry. Some parents insist that their child began pulling hair before 1 year of age. When trichotillomania begins before age 6 years it tends to be a milder condition. It often re-sponds to simple interventions and may be self-limited, with a duration of several weeks to several months, even if not treated. It often occurs in association with thumb-sucking. In some cases it remits spontaneously when therapeutic attention is directed at concurrent, severe thumb-sucking. It has been suggested that trichotillomania in childhood may be associated with severe intrapsychic or familial psychiatric conditions. But there is no

. reliable evidence that supports such a conclusion. Indeed, some have suggested that because it may be common and frequently self-limiting, it should be considered a normal behavior among young children.


Some individuals have continuous symptoms for decades. For others, the disorder may come and go for weeks, months, or years at a time. Sites of hair-pulling may vary over time. Circumscribed periods of hair-pulling (weeks to months) fol-lowed by complete remission are reported among children.


Progression of the condition appears to be unpredictable. Waxing and waning of the severity of hair-pulling and number of hair-pulling sites occur in most individuals. It is not known which factors may predict a protracted and unremitting course.




Because of the unavailability of longitudinal studies of tricho-tillomania, generalizations about prognosis cannot be made. Patients who present in research clinics typically have histories of many years (up to decades) of hair-pulling. Presentation after age 40 years appears to be far less common than in the previous three decades of life, suggesting that the condition may eventu-ally remit spontaneously, even when untreated. It is likely that the persistent cases seen in research environments reflect the more severe end of the spectrum. As noted earlier, trichotillomania in children may often be a time-limited phenomenon.




Treatment Goals


Treatment of trichotillomania typically occurs in an outpatient setting. Eradication of hair-pulling behavior is the general focus of treatment. Distress, avoidant behaviors and cosmetic impair-ment are secondary to the hair-pulling behavior and would be likely to remit if the hair-pulling behavior is controlled. However, if sufficient control of hair-pulling cannot be attained, treatment goals should emphasize these associated problems as well. Even if hair-pulling persists, therapeutic interventions may be targeted at reducing secondary avoidance and diminishing distress.

Treatment may be considered in three phases:


Initial Contact The diagnosis is made and the patient and psy-chiatrist agree on a strategy that may incorporate both pharma-cological and psychological interventions. If distress is severe, supportive interventions should be immediately considered in anticipation of incomplete treatment response or of a delay of weeks to months before interventions may be beneficial.


Acute Treatment Even when treatment of hair-pulling behav-ior is optimally successful, there may be a delay of several weeks to months before adequate control is attained. Therefore, the acute treatment phase may be prolonged.


Maintenance It is not known how long patients must maintain active treatment interventions to prevent relapse. It should be anticipated that a substantial number of patients require ongo-ing treatment for an extended time. Pharmacological treatments may need to be maintained for open-ended periods. Behavioral or hypnotic intervention may require periodic “booster shots” to support continuation of benefits.


Psychiatrist–Patient Relationship


It is important to bear in mind the particular nature of embar-rassment that often accompanies this condition. Several factors contribute to feelings of shame for many people with trichotil-lomania. When hair-pulling has had its onset in childhood oradolescence, there is often a history of the hair-pulling being treated as a family secret. Patients have been frequently casti-gated by parents or spouses for lack of self-control. In addition, there may be a feeling that the problem is largely cosmetic, caus-ing some individuals to fear they do not have the “right” to utilize health resources for its treatment. This may also be manifest as fears of having their problem minimized or of being derided for seeking help. It is helpful for the psychiatrist to share with pa-tients an understanding that the problem pervades their daily life and may result in meaningful distress and functional inhibition.


A variety of treatment approaches have been advocated for trichotillomania. However, there have, as yet, been few controlled studies of the efficacy of any treatment approach. A number of in-vestigations of the use of antidepressants with specific inhibition of serotonin reuptake (i.e., fluoxetine and clomipramine) have yielded mixed results. A multimodal approach, simultaneously utilizing several complementary treatment options, may turn out to be the most effective approach for most patients. While a num-ber of treatment options can be currently offered to individuals with trichotillomania, the durability of long-term outcomes is unclear


Stress Management


Before embarking on a course of treatment, the psychiatrist and the patient should first consider the course and severity of the in-dividual’s condition. Because early remission may occur in cases of recent onset, mild trichotillomania of short duration does not necessarily require immediate intervention. In particular, if the hair-pulling first occurred during a period of stress, the behav-ior may spontaneously diminish as the stressful circumstances abate. In such circumstances, therapeutic attention may best be directed toward examining and seeking to diminish the basis for stress. Teaching alternative stress reduction methods may be useful in reducing recent-onset trichotillomania. However, when individuals with trichotillomania present to the psychiatrist, it is often likely to have been a persistent condition and may have been present for many years or decades. Among such patients, stress reduction may also be useful in reducing trichotillomania but complete remission is less likely.




A variety of medications have been used in the treatment of trichotillomania. Initial reports appeared demonstrating the ap-parent benefits of fluoxetine and clomipramine. Clomipramine was found to be superior to desipramine (and fluoxetine was re-ported beneficial in open treatment. Although reports for more than 60 patients have subsequently added support for the use of these medications, the two double-blind studies in which fluox-etine has been compared with placebo did not demonstrate any improvement compared with placebo. Fluvoxamine, citalopram and venlafaxine have been reported to be efficacious in open tri-als. Although further controlled studies of SSRIs are needed, the use of such medications would be a prudent first step if a pharma-cological approach has been agreed upon.


Initial evidence of improvement is usually first reported by the patient as greater awareness of the inclination to pull hair. This is usually followed by an ability to abort hair-pulling epi-sodes more quickly than in the past. The ability to resist the urge follows. In cases with a good outcome, the inclination to pull di-minishes and may eventually disappear. Patients who pull from several sites may find that the rate of improvement varies from site to site.

There have been conflicting reports of early relapse of symptoms in some patients treated with clomipramine or fluox-etine. Although good maintenance of benefit has been reported for some patients 6 months and longer after the initiation of treatment, early relapse after several weeks to months has been reported as well. Keuthen and coworkers (2001) have provided long-term data on maintenance of response over time. Following a group of individuals who had varying forms of treatment (phar-macologic and psychological) for several years after an index evaluation, the authors concluded that initial improvement was common, but over time there was an increase in symptom scores and self-esteem scores worsened in the group over time. This problem remains to be further evaluated in long-term treatment studies. If early relapse does turn out to be common, it would distinguish trichotillomania from depression and OCD, in which, once established, medication benefits are often well maintained as long as medication is continued. Optimal duration of treatment for well-treated individuals is also still unknown. In accordance with standards developed for the treatment of other conditions, it would be reasonable to continue medication for at least 6 months before tapering. Reinitiation of treatment may be necessary


Other Medications


There have been reports of successful treatment with lithium. Ad-junctive treatment with pimozide, a neuroleptic agent, has been advocated for some patients who are refractory to other medica-tions. The potential benefits of neuroleptics has been reported and individuals have been described for whom SSRIs provided insufficient benefits. The addition of atypical neuroleptics much improved their outcomes. The greater margin of safety and tol-erability associated with atypical neuroleptics have made this a more viable treatment option.


Van Ameringen and colleagues (1999) described the use of haloperidol in nine patients with trichotillomania. Six had previously failed treatment with SSRIs. Eight of nine patients responded to the haloperidol. The possible superiority of neu-roleptics prompted these authors to speculate that trichotilloma-nia may be similar to Tourette’s syndrome (TS), which responds preferentially to neuroleptics.


Psychosocial Treatments


Behavioral Treatment Various behavioral techniques have been tried. The most successful technique, habit reversal, is based on designing competitive behaviors that should inhibit the behavior of hair-pulling. For example, if hair-pulling requires raising the arm to the scalp and contracting the muscles of the hand to grasp a hair, the behaviorist may design a behavioral program in which the patient is taught to lower the arm and extend the muscles of the hand. As with behavioral techniques in general, these inter-ventions are most successful when the patient is strongly moti-vated and compliant. In addition, the treating psychiatrist should be experienced in the use of such techniques. If necessary, a re-ferral should be made to such an experienced individual. Modi-fied behavioral approaches have been described for children and adolescents.


Cognitive Behavioral Therapy (CBT) CBT has been devel-oped for, and applied to, individuals with trichotillomania. At this time, the potential for the efficacy of this treatment approach appears good. Ninan and colleagues (2000) compared CBT with clomipramine in the treatment of trichotillomania. The authors reported that CBT had a dramatic effect in reducing symptomsof trichotillomania and was significantly more effective than clomipramine (P 5 0.016) or placebo (P 5 0.026). Clomipramine resulted in symptom reduction greater than that with placebo, but the difference fell short of statistical significance. Placebo response was minimal.


Hypnotherapy There are no formal studies of the use of hypno-sis for trichotillomania, but there are many published reports of beneficial treatment. Benefits may be variable. Some patients may have dramatic improvement. For some who improve, the benefits may be short-lived. As with behavioral interventions, the benefits of this approach are sometimes dependent on a highly motivated patient who can regularly carry out self-hypnotic measures as in-structed by the psychiatrist. Some patients who have obtained partial benefits from either hypnosis or medication do well when both treatments are combined. Successful use of hypnotherapy for children with trichotillomania has also been reported.


Dynamic Psychotherapy Many psychoanalytically oriented descriptions of individuals with trichotillomania have been published. These reports generally describe the psychodynamic formulations of individual cases and should not be the basis for generalizations about most individuals with trichotillomania. Al-though patients with trichotillomania may benefit from explora-tion and attempts to reduce intrapsychic conflict, the literature does not provide persuasive evidence of the efficacy of this ap-proach in reducing hair-pulling.


Self-help and Other Groups Self-help groups for patients with trichotillomania have appeared. Some are based in the structure of other 12-step programs. Some patients appear to experience meaningful reduction in hair-pulling symptoms after begin-ning participation in such a group. Although the efficacy of such groups in reducing symptoms remains to be established, most patients with trichotillomania can benefit from meeting other individuals with similar symptoms. Because of the lack of gen-eral awareness of trichotillomania, these individuals frequently believe that they are “oddball” individuals with a behavior that is unique. Many have experienced parental condemnation for the behavior and have been frequently castigated for a “habit” that may be viewed by others as under their voluntary control. The experience of meeting others with the condition is extremely supportive for such individuals and may help to reduce the at-tendant stress while supporting self-esteem. Where programs specifically oriented toward trichotillomania may not be gener-ally available, these individuals may benefit from groups oriented toward OCD.


Treatment of Comorbid Conditions


Depression, dysthymic disorder and anxiety symptoms occur frequently in patients with trichotillomania. Successful treat-ment of depression may not be associated with reduction in trichotillomania. If depression or dysthymic disorder is present and independently provides an indication for medication, one of the antidepressants discussed earlier should be chosen. If fluox-etine is used, the psychiatrist should be aware that a dose that is sufficient for reduction of the depressive symptoms may not be sufficient for reduction of trichotillomania. If panic disorder is present, either medication may still be used, but fluoxetine may initially exacerbate panic attacks in such patients and initiation of treatment at low doses (2.5–5 mg/day) should be considered. With slow titration upward, the patient should generally be able to tolerate usual doses with concomitant amelioration of the panic disorder. Combined treatment with anxiolytics may be use-ful for some and may contribute to the reduction in symptoms of trichotillomania. Other conditions that may be present, such as OCD or eating disorders, may require special attention. Although fluoxetine may be useful for patients with eating disorders, medi-cation treatment alone is unlikely to be adequate and the usual multimodal approaches for the treatment of bulimia nervosa or anorexia are appropriate. OCD may respond to treatment di-rected at trichotillomania, but adjunctive behavioral treatment of symptoms of OCD may be desirable.


Demographical Features


When trichotillomania presents in early childhood, the condi-tion may be likely to be inherently self-limited. Often, all that may be necessary is to draw the child’s attention to the behavior in some systematic way and to clarify for the child that the be-havior is undesirable. Such methods include daily application of a nonmedicinal ointment to the affected region and reminding the child that the purpose is elimination of the hair-pulling habit. Some suggest that the child be given the responsibility of apply-ing the ointment with parental supervision. Others suggest that parents should monitor the child as much as possible and respond with reminders that the hair should not be pulled and rewards with verbal encouragement for ceasing to pull hair. There have been no systematic studies of the benefits of such interventions, but dermatologists who specialize in the treatment of children have noted that hair-pulling behavior may frequently disappear within a few weeks of initiating such an approach. In circum-stances in which childhood trichotillomania is more persistent, the parent and psychiatrist are faced with a dilemma. More elabo-rate behavioral interventions, such as habit reversal, should be tried. This, however, may be difficult with a child. Hypnosis has been also used in the treatment of habit disorders in children. Medication should be cautiously considered in the treatment of childhood trichotillomania. Although medication may be useful, the absence of data supporting the benefits of such treatments in children indicates a conservative approach. If medication is con-sidered, the use of medication in the treatment of childhood OCD should serve as a guideline.


Should the psychiatrist be presented with trichotillomania in a person of advanced age, special attention should be paid to usual concerns regarding the use of these medications in the el-derly. Lower doses of medication should be considered because of potential altered pharmacokinetics in older persons. Medications with anticholinergic side effects (such as clomipramine) may present greater hazards for the older person. Sedative-hypnotic anxiolytics should be used sparingly because of greater vulner-ability to cognitive side effects and the increased risk of falling.


Women of childbearing potential (perhaps the majority of individuals who may present for treatment) should be advised re-garding the potential risks of these medications to a developing fetus. If the patient is pregnant or considering pregnancy, behav-ioral treatments may be favored.


The psychiatrist should be sensitive to the interaction be-tween cultural values and trichotillomania. Women of certain cultures may be more prone to distress if trichotillomania is per-ceived as a hindrance to achieving valued goals, such as mar-riage. It should also be noted that in some communities, wigs and other hair accessories are generally acceptable and may present a comfortable means of diminishing the cosmetic impact of hair loss. In other communities, such accoutrements may themselves draw undesired attention.


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