Trichotillomania

Trichotillomania

National Organization for Rare Disorders, Inc.

Important

It is possible that the main title of the report Trichotillomania is not the name you expected. Please check the synonyms listing to find the alternate name(s) and disorder subdivision(s) covered by this report.

Synonyms

  • hair-pulling syndrome
  • TTM

Disorder Subdivisions

  • None

General Discussion

Trichotillomania is an impulse control disorder characterized by an overwhelming urge to repeatedly pull out one's own hair, resulting in noticeable patches of baldness. The hair on the scalp is most often affected. The eyelashes, eyebrows, and beard can also be affected. In some cases, affected individuals chew and/or swallow (ingest) the hair they have pulled out (trichophagy), which can result in gastrointestinal problems. Trichotillomania causes significant emotional distress and often impairs social functioning. The exact cause of the condition is not known.

Symptoms

Individuals with trichotillomania repeatedly experience an overwhelming urge to pull out their hair. According to diagnostic criteria, affected individuals are extremely tense upon feeling such an impulse, and experience relief, gratification or pleasure afterwards. However, many individuals experience problematic repetitive hair pulling, but do not endorse these diagnostic criteria.



The severity and the specific areas of hair on the body that are affected can vary greatly from one individual to another. For some individuals trichotillomania may be mild and manageable, for others it can become a severe and debilitating problem. Trichotillomania may occur chronically, continuously, temporarily (transiently) or it may occur and then disappear for months or years only to recur.



The scalp is the most commonly affected area in trichotillomania. Affected individuals may break off pieces of hair or pull out entire strands. Patches of baldness usually result on the scalp. In most cases, individuals pull out hair from one or two areas, though there may be more. Although the scalp is the most common site involved, the beard, eyelashes, and eyebrows may also be involved. Less commonly, 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, at least once the habit is established. Skin irritation may occur at affected sites. In addition, affected individuals often have an uncontrollable urge to twist their hair.



Some 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 (trichobezoar) resulting in abdominal pain, nausea and vomiting, anemia or bowel obstruction.



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. Affected individuals are often extremely secretive about the behavior as well and may avoid social situations.



In some cases, people with trichotillomania may also engage in other behaviors, such as abrading or wearing off of the skin (excoriation), scratching, gnawing, biting their nails, cracking their knuckles, or playing with pulled out hair.



Trichotillomania can occur in conjunction with mood and anxiety disorders such as depression, obsessive compulsive disorder (OCD), general phobias, or attention deficit hyperactivity disorder (ADHD).

Causes

The exact cause of trichotillomania is not known and poorly understood. Most likely, trichotillomania results from several factors occurring together including genetic and environmental factors.



Some individuals may have a genetic predisposition to developing trichotillomania. A person who is genetically predisposed to a disorder carries a gene (or genes) for the disease, but it may not be expressed unless it is triggered or "activated" under certain circumstances such as due to particular environmental factors.



In some cases, it is believed that severely stressful situations play a role in causing this disorder. Some cases of trichotillomania have been associated with previous traumatic events.



Researchers have speculated that structural or functional abnormalities of the brain may play a role in the development of trichotillomania in some cases. Such findings include abnormalities of the left putamen, cerebellum and grey or white matter. The specific structural or functional brain abnormalities associated with trichotillomania and the role that they play in the development of trichotillomania is not understood.



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 below).



More research is necessary to determine the exact cause(s) and underlying mechanisms that result in trichotillomania.

Affected Populations

Trichotillomania usually occurs in adolescence in the first instance. However, the disorder has occurred in very young children, through to adults up to approximately 60 years of age. During childhood, the disorder affects males and females in equal numbers; in adulthood, females are affected more often than males. This may not reflect the true ratio of trichotillomania in adulthood, but rather that hair loss is more accepted among adult males than females.



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 or unreported, the disorder is under-diagnosed, making it difficult to determine its true frequency in the general population. It has been estimated that 0.5-1 percent of people will experience the condition at some point during life.

Standard Therapies

Diagnosis

A diagnosis of trichotillomania may be suspected if characteristic symptoms are present such as noticeable patches of hair loss. A diagnosis may be made based upon a thorough clinical evaluation, a detailed patient history and a variety of tests that can rule out other causes of hair loss. Because many individuals attempt to conceal their hair pulling behavior, a diagnosis may be difficult to obtain.



Treatment

The two main forms of treatment for trichotillomania are psychotherapy and pharmacotherapy. There is no universal form of therapy that is effective in all cases.



Psychotherapy is the treatment of disorder by psychological methods. Psychotherapy for trichotillomania may include cognitive behavior therapy, which attempts to identify and alter the thoughts and emotions that lead to certain behaviors such as hair pulling. Types of cognitive behavior therapy used to treat individuals with trichotillomania include habit reversal, awareness training and stimulus control.



Pharmacotherapy refers the use of medications to treat illness. A variety of medications have been used to treat individuals with trichotillomania including serotonin reuptake inhibitors (SRIs). These medications include fluoxetine, fluvoxamine, and sertraline.



Another medication called clomipramine has been studied to treat trichotillomania. This drug is a tricyclic antidepressant and has been shown to be effective in some cases.



In some cases, behavior modification and medications are used together to treat trichotillomania. More research is necessary to determine what specific therapies either alone or in combination provide both efficacy and long-term safety for the treatment of individuals with trichotillomania.

Investigational Therapies

Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. Government funding, and some supported by private industry, are posted on this government web site.



For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:



Tollfree: (800) 411-1222

TTY: (866) 411-1010

Email: prpl@cc.nih.gov



For information about clinical trials sponsored by private sources, contact:

www.centerwatch.com

References

TEXTBOOKS

Hales RE, Yudofsky SC, Gabbard GO, eds. Textbook of Psychiatry, 5th ed. Arlington, VA, American Psychiatric Publishing;2008: 800-806.



Frances A. Chmn. Bd. Eds. Diagnostic and Statistical Manual of Mental Disorders: DSM IV. 4th ed. American Psychiatric Association. Washington, DC; 1994:618-621.



JOURNAL ARTICLES

Chamberlain SR, Hampshire A, Menzies LA, et al. Reduced brain white matter integrity in trichotillomania: a diffusion tensor imaging study. Arch Gen Psychiatry. 2010;67:965-971.



Franklin ME, Edson AL, Freeman JB. Behavior therapy for pediatric trichotillomania: exploring the effects of age on treatment outcome. Child Adolesc Pyschiatry Ment Health. 2010;4:18.



Chamberlain SR, Menzies LA, Fineberg NA, et al. Grey matter abnormalities in trichotillomania: morphometric magnetic resonance imaging study. Br J Psychiatry. 2008;193:216-221.



Grant JE, Odlaug BL. Clinical characteristics of trichotillomania with trichophagia. Compr Psychiatry. 2008;49:579-584.



Chamber lain SR, Menzies L, Sahakian BJ, Fineberg NA. Lifting the veil on trichotillomania. Am J Psychiatry. 2007;164:568-574.



Fennessy J, Crotty CP. Trichotillomania. Dermatol Nurs. 2008 Feb; 20(1):63.



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



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



FROM THE INTERNET

Ellis CR. Roberts HJ. Schnoes CJ. Anxiety Disorder, Trichotillomania. Emedicine Journal, Sept. 23, 2009. Available at: http://emedicine.medscape.com/article/915057-overview Accessed: October 29, 2010.



Mayo Clinic for Medical Education and Research. Trichotillomania (Hair-Pulling Disorder). Jan. 24, 2009. Available at: http://www.mayoclinic.com/health/trichotillomania/DS00895 Accessed: October 29, 2010.

Resources

International OCD Foundation

PO Box 961029

Boston, MA 02196

Tel: (617)973-5801

Fax: (617)973-5803

Email: info@ocfoundation.org

Internet: http://www.ocfoundation.org



National Federation of Families for Children's Mental Health

Attn: Marion Mealing

9605 Medical Center Drive

Rockville, MD 20850

USA

Tel: (240)403-1901

Fax: (240)403-1909

Email: ffcmh@ffcmh.org

Internet: http://www.ffcmh.org



National Mental Health Consumers' Self-Help Clearinghouse

1211 Chestnut Street

Suite 1207

Philadelphia, PA 19107-6312

USA

Tel: (215)751-1810

Fax: (215)636-6312

Tel: (800)553-4539

Email: info@mhselfhelp.org

Internet: http://www.mhselfhelp.org



Mental Health America

2000 N. Beauregard Street, 6th Floor

Alexandria, VA 22314-2971

USA

Tel: (703)684-7722

Fax: (703)684-5968

Tel: (800)969-6642

TDD: (800)433-5959

Email: infoctr@mentalhealthamerica.net

Internet: http://www.mentalhealthamerica.net/



National Alliance on Mental Illness

3803 N. Fairfax Drive

Suite 100

Arlington, VA 22203-

Tel: (703)524-7600

Fax: (703)524-9094

Tel: (800)999-6264

TDD: (703)516-7227

Email: membership@nami.org

Internet: http://www.nami.org



NIH/National Institute of Mental Health

Health Science Writing, Press and Dissemination Branch

6001 Executive Boulevard

Room 8184, MSC 9663

Bethesda, MD 20892-9663

Tel: (301)443-4513

Fax: (301)443-4279

Tel: (866)615-6464

TDD: (301)443-8431

Email: nimhinfo@nih.gov

Internet: http://www.nimh.nih.gov/index.shtml



Trichotillomania Learning Center

207 McPherson Street,

Suite H

Santa Cruz, CA 95060-5863

USA

Tel: (831)457-1004

Fax: (831)426-4383

Email: info@trich.org

Internet: http://www.trich.org/index.html



Genetic and Rare Diseases (GARD) Information Center

PO Box 8126

Gaithersburg, MD 20898-8126

Tel: (301)251-4925

Fax: (301)251-4911

Tel: (888)205-2311

TDD: (888)205-3223

Internet: http://rarediseases.info.nih.gov/GARD/



Locks of Love

234 Southern Blvd.

West Palm Beach, FL 33405-3099

Tel: (561)833-7332

Fax: (561)833-7962

Tel: (888)896-1588

TDD: (561)833-7332

Email: info@locksoflove.org

Internet: http://www.locksoflove.org



North American Hair Research Society

Dept. of Dermatology Medical Center Blvd.

Walke University School of Medicine

Winston-Salem, NC 27157

Tel: (336)776-2768

Fax: (336)776-7732

Email: amcmicha@wfubmc.edu

Internet: http://www.nahrs.org/home/



For a Complete Report

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