Information on the following diseases can be found in the Related Disorders section of this report:

• Alopecia Areata
• Monilethrix
• Obsessive Compulsive Disorder

Individuals with trichotillomania repeatedly experience an overwhelming urge to pull out their hair. In most cases, they are extremely tense upon feeling such an impulse and do not experience relief until after they have pulled out the hair. Affected individuals may break off pieces of hair or pull out entire strands. Patches of baldness (alopecia) usually result on the scalp. The beard, eyelashes, and eyebrows are also commonly involved. In some cases, individuals may also pull hair from the armpits, trunk, and/or pubic areas. There may be a generalized tingling or itching (pruritis) in the involved areas, but affected individuals usually do not experience pain after hair plucking. In addition, affected individuals often have an uncontrollable urge to twist their hair. In some cases, affected individuals may chew or swallow (ingest) their hair, a condition known as trichophagy. In rare cases, ingestion of hair may lead the formation of a hairball in the stomach resulting in abdominal pain (trichobezoar).

Individuals with trichotillomania may deny that their hair-pulling behavior exists and may attempt to conceal the behavior by wearing wigs and false eyelashes and taking similar additional steps to hide hair loss.

In some cases, people with trichotillomania may also engage in other self-mutilating behaviors, such as abrading or wearing off of the skin (excoriation), scratching, gnawing, nail biting or banging their heads. Some individuals may also suck their thumbs.
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The exact cause of trichotillomania is not known. In some cases, it is believed that severely stressful situations play a role in causing this disorder. It is also felt that abuse of psychoactive drugs may help cause trichotillomania. Some scientists believe that trichotillomania is a subcategory of obsessive compulsive disorder (OCD), which may be caused by certain imbalances in brain chemicals (see OCD in related disorders section). When trichotillomania occurs in adulthood, it commonly accompanies a psychotic disorder.
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Trichotillomania usually occurs in childhood. However, the disorder has occurred in adults up to approximately 60 years of age. During childhood, the disorder may be more frequent in males; in adolescence and adulthood, females are affected more often. Trichotillomania has been known to affect individuals for a period of several months to more than 20 years. In many cases, symptoms may occur in cycles, with symptoms periodically lessening, then worsening, disappearing, and then recurring.

Because some cases of trichotillomania go unrecognized, the disorder is under-diagnosed, making it difficult to determine its true frequency in the general population.
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Symptoms of the following disorder can be similar to those of trichotillomania. Comparisons may be useful for a differential diagnosis:

Obsessive dompulsive disorder is characterized by recurrent obsessive and compulsive thoughts and actions. Obsessions are persistent ideas, thoughts, impulses or images that the affected individual knows are senseless. Attempts are made to ignore or suppress such thoughts or impulses, or to counteract them with some other thought or action. The individual recognizes that the obsessions are the product of his or her own mind, but they are difficult to resist. Many scientists believe that trichotillomania and obsessive compulsive disorder are caused by related brain chemical abnormalities because they are often responsive to the same drug treatments. (For more information on this disorder, choose "Obsessive Compulsive" as your search term in the Rare Disease Database.)

Monilethrix is a rare inherited disorder characterized by sparse, dry, and/or brittle hair that often breaks before reaching more than a few inches in length. The hair may lack luster, and there may be patchy areas of hair loss (alopecia). Another common symptom may be the appearance of elevated spots (papules) surrounding the hair follicles that may be covered with gray or brown crusts or scales (perifollicular hyperkeratosis). When viewed under a microscope, the hair shaft resembles a string of evenly-spaced beads. In most cases, monilethrix is thought to be inherited as an autosomal dominant trait. (For more information on this disorder, choose “monilethrix” as your search term in the Rare Disease Database.)

Alopecia areata is a rare disorder characterized by the progressive loss of hair. It often begins suddenly with oval or round bald patches appearing on the scalp; however, other areas of hairy skin may also be involved. Gradually, the affected skin becomes white and smooth. The hair may regrow in these areas within weeks; at the same time, additional patches of hair loss may occur elsewhere. In some cases, hair regrowth may occur in one area of the scalp but not in others; in other cases, the loss of hair may be permanent and lead to baldness. In a few rare cases, all body hair may be lost. Cases with onset during childhood tend to be more severe than those with an adult onset. The exact cause of alopecia areata is unknown. (For more information on this disorder, choose "Alopecia Areata" as your search term in the Rare Disease Database.)
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Diagnosis
When an individual exhibits unexplained baldness, a diagnosis of trichotillomania may be suspected. Because many individuals attempt to conceal their hair pulling behavior, a diagnosis may be difficult to obtain. To differentiate trichotillomania from other disorders, surgical removal and microscopic examination of scalp tissue (biopsy) may be used to reveal characteristic results of hair-pulling behavior (e.g., plus of fibrous protein [keratin] and characteristic changes in the structure of the hair follicles [trichomalacia] with no signs of inflammation).

Treatment
Psychoanalysis, intensive psychotherapy, and behavior-modification therapy such as habit reversal may be helpful for some individuals with trichotillomania. In some cases, medications, specifically anti-depressants known as serotonin reuptake inhibitors (SRIs), may be used to treat individuals with trichotillomania. Such medications include chlorpromazine isocarboxazid, amitriptyline and imiprimine. In some cases, behavior modification and medications are used together to treat the disorder.
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The drug clomipramine, an antidepressant, has been approved by the Food and Drug Administration (FDA) for treating obsessive compulsive disorders. The drug is being investigated as a treatment for trichotillomania. Clomipramine works by enhancing levels of the chemical serotonin in the brain. (Serotonin transmits messages between nerve cells). The drug is manufactured by Ciba-Geigy.

The National Institutes of Health (NIH) is looking for males from ages six to sixty for a study on trichotillomania. If persons of this age group want to get information concerning the study on the compulsion to pull out hair from the head, eyelashes, eyebrows, or any other place on their body, they should call Marge Lenane at (301) 496-6081 for information.

Ongoing research is underway at the trichotillomania clinic at Massachusetts General Hospital to study brain activity of people with trichotillomania using magnetic-resonance imaging (MRI) techniques. The study is being led by Dr. Richard L. O'Sullivan and it is hoped that this research will lead to a better understanding of the relationship between obsessive compulsive disorders and trichotillomania. People with trichotillomania who are between the ages of eight and 20 may also participate in another research study being conducted by Dr. O'Sullivan. For more information on this project, contact:

Richard L. O'Sullivan, M.D.
Obsessive Compulsive Disorders and Trichotillomania Clinic
Massachusetts General Hospital
Boston, MA 02115
(617) 726-4075

Research is being done on individuals affected by trichotillomania at Mount Sinai Medical Center. Individuals interested participating or finding more information about this study, should contact:

Elizabeth Spadaccini, Research Assistant
BDD Program
Mount Sinai Medical Center
New York, NY
(212) 241-2994

The neuroleptic drug, haloperidol, has been studied as a possible treatment option for individuals with trichotillomania. Initial studies have shown that haloperidol, either alone or in conjunction with SRIs, may be effective in treating affected individuals. More research is needed to determine the long-term safety and effectiveness of this treatment for individuals with trichotillomania.

NORD does not promote, endorse, or encourage participation in any specific medical research study. This information is presented to further scientific understanding that could lead to the prevention, treatment, and/or cure of rare disorders. NORD recommends that anyone interested in participating in a clinical research program seek the advice or counsel of his or her own personal physician(s).

TEXTBOOKS
Behrman RE, ed. Nelson Textbook of Pediatrics, 15th ed. Philadelphia, PA: W.B. Saunders Company; 1996:1884.

Kaplan HI & Sadock BJ, eds. Comprehensive Textbook of Psychiatry. 5th Ed.: Baltimore, MD: Williams & Wilkins; 1989:1149-52.

JOURNAL ARTICLES
Ninan PT. Conceptual issues in trichotillomania, a prototypical impulse control disorder. Curr Psychiatry Rep. 2000;2:72-75.

Casati J, et al. Psychosocial issues for women with trichotillomania. Compr Psychiatry. 2000;41:344-51.

Neziroglu F, et al. Behavioral, cognitive, and family therapy for obsessive-compulsive and related disorders. Psychiatr Clin North Am. 2000;23:657-70.

O’Sullivan RL, et al. Characterization of trichotillomania. A phenomenological model with clinical relevance to obsessive-compulsive spectrum disorders. Psychiatr Clin North Am. 2000;23:587-604.

Sharma NL, et al. Trichotillomania and trichophagia leading to trichobezoar. J Dermatol. 2000;27:24-26.

Van Ameringen M, et al. The potential role of haloperidol in the treatment of trichotillomania. J Affect Disord. 1999;56:219-26.

Ko SM, et al. Under-diagnosed psychiatric syndrome. I: Trichotillomania. Ann Acad Med Singapore. 1999;28:279-81.

Schulte-Markwort M, et al. Trichobezoar in a 16-year-old girl. Case report and review of the literature. Nervenarzt. 2000;71:584-87.

Pato MT, et al. Return of symptoms after discontinuation of clomipramine in patients with obsessive compulsive disorder. AM J Psychiatry. 1988;145:1521-25.

Muller SA. Tricotillomania. Dermatol Clin. 1987;5:595-601.

Oranje AP, et al. Trichotillomania in childhood. J Am Acad Dermatol. 1986;15:614-19.