essential feature of trichotillomania is the recurrent failure to resist
impulses to pull out one’s own hair. Resulting hair loss may range in severity
from mild (hair loss may be negligible) to severe (complete baldness and
involving multiple sites on the scalp or body). Individuals with this condition
do not want to en-gage in the behavior, but attempts to resist the urge result
in great tension. Thus, hair-pulling is motivated by a desire to reduce this
dysphoric state. In some cases, the hair-pulling results in a plea-surable
sensation, in addition to the relief of tension. Tension may precede the act or
may occur when attempting to stop. Distress over the symptom and the resultant
hair loss may be severe.
etiology of trichotillomania is unknown. The phenom-enological similarities
between trichotillomania and OCD have prompted speculations that the
pathophysiology of the two con-ditions may be related. The apparent association
between altered serotonergic function and OCD has guided attention toward the
possible role of serotonergic function in the underlying cause of trichotillomania.
Thus, interest has been spurred in examining serotonergic function in patients
with trichotillomania. As yet, however, only limited laboratory investigations
In summary, few data are available to support any particu-lar model of the etiological pathophysiology of trichotillomania. Early studies point to some alteration of brain activity. Incon-sistent support has been found in these early explorations for a relationship with OCD.
the person complaining of unwanted hair-pulling is a young adult or the parent
of a child who has been seen pull-ing out hair. Hair-pulling tends to occur in
small bursts that may last minutes to hours. Such episodes may occur once or
many times each day. Hairs are pulled out individually and may be pulled out
rapidly and indiscriminately. Often, however, the hand of the individual may
roam the afflicted area of scalp or body, searching for a shaft of hair that
may feel particularly coarse or thick. Satisfaction with having pulled out a
complete hair (shaft and root) is frequently expressed. Occasionally the
experience of hair-pulling is described as quite pleasurable. Some individuals
experience an itch-like sensation in the scalp that is eased by the act of
pulling. The person may then toss away the hair shaft or inspect it. A
substantial number of people then chew or consume (trichophagia) the hair.
Hair-pulling is most commonly limited to the eyebrows and eyelashes. The scalp
is the next most frequently afflicted site. However, hairs in any location of
the body may be the focus of hair-pulling urges, including facial, axillary,
chest, pubic and even perineal hairs.
is almost always associated with the act of hair-pulling. Such anxiety may
occur in advance of the hair-pulling behavior. A state of tension may occur
spontaneously, driving the person to pull out hair in an attempt to reduce
dysphoric feel-ings. Varying lengths of time must pass before the tension
abates. Consequently, the amount of hair that may be extracted in an epi-sode
varies from episode to episode and from person to person. Frequently,
hair-pulling begins automatically and without con-scious awareness. In such
circumstances, individuals discover themselves pulling out hairs after some
have already been pulled out. In these situations, dysphoric tension is
associated with the attempt to stop the behavior.
that seem to predispose to episodes of hair-pulling include both states of
stress and, paradoxically, mo-ments of particular relaxation. Frequently
hair-pulling occurswhen at-risk individuals are engaged in a relaxing activity
that promotes distraction and ease (e.g., watching television, reading, talking
on the phone). It is common for hair-pullers to report that the behavior does
not occur in the presence of other people. A frequent exception may be that
many pull hair in the presence of members of the nuclear family.
individuals have urges to pull hairs from other peo-ple and may sometimes try
to find opportunities to do so surrepti-tiously (such as initiating bouts of
play fighting). There have been reports of affected individuals pulling hairs
from pets, dolls, and other fibrous materials, such as sweaters or carpets.
distress that usually accompanies trichotillomania varies in severity. Concerns
tend to focus on the social and vo-cational consequences of the behavior.
Themes of worry include fear of exposure, a feeling that “something is wrong
with me”, anxiety about intimate relationships and sometimes inability to
pursue a vocation. Because certain kinds of work, such as read-ing and writing
at a desk, seem to precipitate episodes of hair-pulling, some afflicted
individuals make career choices based on the avoidance of desk work. Leisure activities
that may involve a risk of exposure (ranging from gymnastics class to sexual
inti-macy) may be avoided.
of hair-pulling behavior among children are less well described. Usually, the
parent observes a child pulling out hair and may note patches of hair loss.
Children may sometimes be unaware of the behavior or may, at times, deny it.
Childhood trichotillomania has been reported to be frequently associated with
thumb-sucking or nail-biting. It has been suggested that trichotillomania with onset
in early childhood may occur frequently with spontaneous remissions.
Consequently, some have recommended that trichotillomania in early childhood
may be considered a benign habit with a self-limited course. However, many
individuals who present with chronic trichotillomania in adulthood report onset
in early childhood.
general, the diagnosis of trichotillomania is not complicated. The essential
symptom – recurrently pulling out hair in response to unwanted urges – is
easily described by the patient. When the patient acknowledges the hair-pulling
behavior and areas of patchy hair loss are evident, the diagnosis is not
usually in doubt. Problems in diagnosis may arise when the diagnosis is
suspected but the patient denies it. Such denial may occur in younger
in-dividuals and some adults. When the problem is suspected but denied by the
patient, a skin biopsy from the affected area may aid in making the diagnosis.
psychiatrist should carefully inquire into the nature of the distress and
concerns that may be present in a person with this problem. Although the
cosmetic impact may appear slight, dis-tress may be severe. Concerns about
disclosure, anticipation of social rejection and concerns about limitations in career
choices are frequent and may result in chronic dysphoria. The psychia-trist
should be aware of the embarrassment that may accompany inspection of the hair
loss, particularly when located in regions of the body that are not usually
accessible in the course of a standard psychiatric examination. Because of the
apparent fre-quency of comorbid mood disorders (past or current), the
in-terviewer should pay special attention to the presence of these features.
hair loss can be marked by complete alopecia or can appear diffusely thinned or
“ratty”. Altered scalp appearance can range from small areas of thinned hair to
complete baldness. For unclear reasons, several patterns of scalp loss are
typical. Fre-quently, coin-sized areas of alopecia are noted at the vertex or
at temporal or occipital regions. Among more severely afflicted people a
peculiar pattern, so-called tonsure trichotillomania, may appear: a completely
bald head except for a narrow, circular fringe circumscribing the outer
boundary of the scalp, producing a look reminiscent of medieval friars.
the hair loss, most individuals with this condition have no overtly unusual
appearance on cursory inspection. If the hair loss is not covered by clothing
or accessories, artful comb-ing of hair or use of eyeliner and false eyelashes
may easily hide it. The ease with which the condition may often be hidden may
explain the general underappreciation of its apparent frequency and potential
findings are considered characteristic and may aid diagnosis when it is
suspected despite denial by the individual. Biopsy samples from involved areas
may have the following features. Short and broken hairs are present. The
surface of the scalp usually shows no evidence of excoriation. On histological
examination, normal and damaged follicles are found in the same area, as well
as an increased number of catagen (i.e., nongrow-ing) hairs. Inflammation is
usually minimal or absent. Some hair follicles may show signs of trauma
(wrinkling of the outer root sheath). Involved follicles may be empty or
contain a deeply pig-mented keratinous material. The absence of inflammation
distin-guishes trichotillomania-induced alopecia from alopecia areata, the
principal condition in the differential diagnosis.
avoidance of intimate relationships, which occurs among some individuals with
trichotillomania, may be exac-erbated for women in cultures in which physical
appearance is weighted differently for men and women. Avoidance of sports
activities, in which disguised hair loss can be revealed, may also have
gender-related effects in cultures in which athletic participation has
different social meanings for men and women. Although culture-based
expectations regarding appearance may make hair loss a greater burden for
women, women may have a greater opportunity to hide hair loss through the use
of wigs, hats and scarves. Reliable data regarding sex ratio in the general
population are not yet available. For many women hair-pulling may worsen during
the premenstrual phase.
individuals presenting with alopecia who complain of hair-pulling urges, the
diagnosis is not usually in doubt. When patients deny hair-pulling, other
(dermatological) causes of alopecia should be considered. These include
alopecia bareata, male pattern hair loss, chronic discoid lupus erythematosus,
li-chen planopilaris, folliculitis decalvans, pseudopelade and alo-pecia
is not diagnosed when hair-pulling oc-curs in response to a delusion or
hallucination. Many peopletwist and play with their hair. This may be
exacerbated in states of heightened anxiety but does not qualify for a
diagnosis of trichotillomania.
individuals may present with features of tricho-tillomania but hair damage may
be so slight as to be virtually undetectable, even under close examination. In
such conditions the disorder should be diagnosed only if it results in
significant distress to the individual. Trichotillomania may have a short,
self-limited course among children and may be considered a tem-porary habit.
Therefore, among children the diagnosis should be reserved for situations in
which the behavior has persisted during several months.
was long thought to be an uncommon condition, often accompanied by other
psychiatric conditions. Although de-finitive studies of frequency rates in the
general population are still lacking, three surveys of college-age samples
support the emerging view that trichotillomania is quite common. In two of
these samples, totaling approximately 3000 undergraduate students, a lifetime
incidence of self-identified trichotillomania (reaching full symptom criteria
as described in DSM-III-R) was present in about 1% of the respondents. Some
features of the con-dition – but not meeting full criteria – were identified in
an ad-ditional 1 to 2% (Rothbaum et al.,
addition, because onset may occur later in life than the mean ages of
individuals in these groups, the true lifetime inci-dence would probably be
higher. Moreover, these samples consist of a selected population – largely
first-year college students – and may not reflect the general population.
Nonetheless, these stud-ies indicate that the condition is likely to be far
more common than previously assumed. But definitive, controlled studies of the
prevalence of the condition have not yet been performed.
with trichotillomania have increased risk for mood disorders (major depressive
disorder, dysthymic disorder) and anxiety symptoms. The frequency of specific
anxiety disorders (such as generalized anxiety disorder and panic).