Diagnosis, Evaluation, and Management of Trichotillomania

Abstract

Synopsis Trichotillomania, or chronic hairpulling, is a common condition that affects primarily women. The disorder can cause significant psychosocial impairment and is associated with elevated rates of psychiatric comorbidity. In the current paper, the phenomenology, etiology, assessment and treatment of the disorder is discussed.

Autism and trichotillomania in an adolescent boy

“…In the latest DSM’s ‘Obsessive Compulsive and Related Disorders (OCRD)’ chapter, the condition requires the presence of increasing sense of anxiety right before pulling hair or on resisting the urge to pull, followed by a sense of relief after the hair is pulled 1. Similar to the illustrated case, it is an interesting fact that trichotillomania may be followed by postpulling rituals like disposing, biting or even ingesting the pulled hair 2. Another interesting associated clinical feature is the two pulling styles, that is, ‘automatic’ during which trichotillomania is performed out of conscious awareness and ‘focused’ when there is a purposeful process leading to hair pulling.…”

“…Unfortunately, the lack of understanding of the pathophysiology of trichotillomania interferes with its proper classification and treatment of the disorder,3 especially when its conceptualisation under the umbrella of OCRD makes it hard to distinguish it from obsessive compulsive disorder 2. Hence, making diagnosis is very challenging particularly in children, in whom multiple sources of information are necessary.…”

“…Another possible therapy involves identifying and teaching the patient to eliminate the triggering factors, a technique known as stimulus control. Patients’ sensory stimuli might be reduced through a simple effort like putting bandages on the fingers they use to pull, in order to reduce the sensory stimulation produced by rolling fingers after the hair pulling 2. In the illustrated case, it was hard to depend on behaviour modification alone as the patient may not be that cooperative.…”

Trichotilomania and Request for Hair Transplantation

“…The most common approach includes combination of pharmacotherapy and psychotherapy. Choice of the drugs in adults are SSRIs [13]. Clomipramine, has shown moderate effectiveness over placebo, N-acetylcysteine (NAC) has strongest empirical support in adults with TTM [12].…”

Trichotillomania and Traction Alopecia

“…Trichotillomania is classified under the obsessive-compulsive and related disorders along with hoarding disorder, skin-picking disorder (excoriation) and body dysmorphic disorder in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5; American Psychiatric Association, May 2013) [2] (Table 1). It is also grouped under obsessive-compulsive disorders in the eleventh revision of the World Health Organization's International Classification of Diseases and Related Health Problems (ICD-11) [3].…”