Trichotillomania

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vatsala Sharma; M.B.B.S[2]

Synonyms and keywords: TTM, hair-pulling, trich, trichophagia, trichobezoar

Overview

Trichotillomania (TTM) is a condition characterized by the repeated irresistible desire to pull out scalp hair, eyelashes, facial hair, pubic hair, nose hair, eyebrows, and/or other body hair. The hair pulling relieves the anxiety preceding the event but leaves behind scars and injuries. The feeling of losing control and fear of pulling out all of the hair leaves the individual in severe frustration. The person very often pulls out a significant amount of hair amounting to hair loss. It also results in enormous distress and functional impairment in several areas of life. Secondary to this behavior, there is a progressive deterioration of self-esteem and eventually, self-isolation. These individuals unsuccessfully try to stop this behavior due to physical and mental stress experienced after the act, or harsh comments from the family and friends. Therefore, trichotillomania is emotionally traumatizing as well as socially stigmatizing.

Historical Perspective

  • The term "trichotillomania" is Greek in origin. It is a compilation of three words- trich, tillo, and mania.
  • "Trich" stands for hair, "tillo" means to pull, and "mania" denotes an unusual fascination towards an object, place, or action. The resulting word "trichotillomania" signifies the irresistible urge to pull hair. [1]
  • It was first mentioned in a published scientific report about hair pulling behavior in 1885. [2]
  • The term, however, was first used by a French dermatologist, Francois Hallopeau, in 1889.[3]
  • Originally, Francois Hallopeau had used this word for alopecia due to the self-traction of hair. It has now evolved to include the syndrome of pathological hair-pulling. [4]
  • A French physician, Baudamant gave details of trichobezoar (mass of undigested hair in the gastrointestinal tract) in a 16 year-old adolescent in the late 18th century.[5]

Classification

  • Among the classification systems, trichotillomania was first mentioned in ICD-9 in the year 1975 under 'the other disorders of impulse control'.
  • In 1987, DSM-III-R included trichotillomania as an 'impulse control disorder, not classified elsewhere'. [6]
  • Trichotillomania was accepted as an independent disorder in ICD-10 in 1990. It has been included under 'the habit and impulse control' category. [7]
  • In DSM-IV, two minimal modifications were made in this disorder's descriptions. Criteria B emphasized more on the stress experienced while resisting to pull the hair. The distress and impairment experienced by the individual were also brought into focus in Criteria E. [8][9]
  • DSM-IV-TR also described trichotillomania as 'an impulse control disorder, not classified elsewhere'.[10]
  • Therefore, it would be appropriate to point out here that DSM had only minor changes until the classification change in DSM-5.
  • DSM-5 moved trichotillomania from 'Impulse Control Disorder' to the category of 'Obsessive-Compulsive and Related Disorders' (OCRD).
  • Unlike DSM-IV, DSM-5 Criteria does not require the hair loss in trichotillomania to be noticeable. The individuals with this condition may pull out the hair from a wider region making it difficult to distinguish.[11]
  • DSM-5 has included a criterion that the individual should have made multiple attempts to stop the hair pulling behavior. This has replaced the DSM-IV criteria of preceding tension and immense gratification following hair pulling, this explains the transition from impulse control disorder to OCRD.[12]
  • It has been further made clear in DSM-5 that the condition should not be secondary to medical (various dermatological conditions) or psychiatric disorders (such as body dysmorphic disorder, psychosis, and obsessive compulsive disorder) .

Pathophysiology

Clinical Features

Differential Diagnosis

Trichotillomania should be differentiated from other medical and psychiatric conditions like-[28][29]

  • Other medical conditions-
  • Neuro-developmental disorder

Epidemiology and Demographics

Prevalence

  • The prevalence of trichotillomania is 1,000-2,000 per 100,000 (1%-2%) of the overall population. The number of reported cases has increased over the years, likely due to a decreased perceived stigma.[28]

Age

  • Patients of all age groups may develop trichotillomania.
  • Based on the age at onset, it is divided predominantly into three types- children of pre-school age, pre-adolescents and adolescents, and adults.[30]
  • Contrary to the popular belief, childhood-onset trichotillomania is common but differs in neurobiology from the adult-onset type. [31]
  • From childhood to adolescence, focused hair pulling increases whereas the automatic hair pulling remains the same.[32]
  • As the children grow older, more frequent urges and decreased ability to resist have been noticed. [33]
  • The post-pubertal onset is associated with greater severity of symptoms. [34]

Gender

  • Most studies support the female predominance but there are some studies show mixed results. [35][36]
  • With the male and female subjects having the same severity of symptoms, the females experience more distress and functional impairment due to hair pulling. [37]
  • It has been observed that men have a later age of onset of trichotillomania and are significantly affected by the coexisting anxiety.[38]
  • In females with trichotillomania, the symptoms exacerbate during menstruation. The condition may start during pregnancy or soon after the child birth. [39]

Race

  • African American females mostly pull their hair from the scalp region.[40]
  • Before hair pulling, anxiety has been the predominant feature observed in African American adults. [41]
  • Caucasians report pulling hair predominantly from eyebrows and eyelashes, more tension before hair pulling, higher interruption in their academic life, and greater stress experienced on a day-to-day basis as compared to their minority counterparts.[42]

Risk Factors

The risk factors associated with trichotillomania are[43]

Natural History, Complications and Prognosis

Diagnosis

DSM-5 Diagnostic Criteria


According to DSM-5, to diagnose trichotillomania all the following criteria (A to E) should be fulfilled-

DSM-5 Diagnostic Criteria for Trichotillomania (Hair-Pulling Disorder)
A. Recurrent pulling out of one's own hair leading to hair loss
B. Repeated attempts to reduce or stop pulling hair
C. Clinically significant distress or impairment in social and occupational functioning
D. The hair pulling is not secondary to another medical condition
E. The hair pulling is not better explained by another psychiatric condition


Physical Examination

Trichotillomania of the scalp

Treatment

  • Trichotillomania is a chronic condition where hair pulling is self-directed and irresistible. It is often difficult to treat but can be controlled with repeated attempts.
  • Psychotherapy and to some extent pharmacotherapy are useful. Behavioral therapy has shown better results than pharmacotherapy in most studies.[51] [52]
  • Contrary to this, some studies suggest a combination of the two.[53]

Psychotherapy

Pharmacotherapy

References

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  2. Salaam, Karriem; Carr, Joel; Grewal, Harsh; Sholevar, Ellen; Baron, David (2005). "Untreated Trichotillomania and Trichophagia: Surgical Emergency in a Teenage Girl". Psychosomatics. 46 (4): 362–366. doi:10.1176/appi.psy.46.4.362. ISSN 0033-3182.
  3. Hallopeau M (1889). "Alopicie par grattage (trichomanie ou trichotillomanie)". Ann Dermatol Venereol. 10: 440–441.
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  6. Grant, Jon E.; Stein, Dan J. (2014). "Body-focused repetitive behavior disorders in ICD-11". Revista Brasileira de Psiquiatria. 36 (suppl 1): 59–64. doi:10.1590/1516-4446-2013-1228. ISSN 1516-4446.
  7. Grant, Jon E.; Stein, Dan J. (2014). "Body-focused repetitive behavior disorders in ICD-11". Revista Brasileira de Psiquiatria. 36 (suppl 1): 59–64. doi:10.1590/1516-4446-2013-1228. ISSN 1516-4446.
  8. Grant, Jon E.; Stein, Dan J. (2014). "Body-focused repetitive behavior disorders in ICD-11". Revista Brasileira de Psiquiatria. 36 (suppl 1): 59–64. doi:10.1590/1516-4446-2013-1228. ISSN 1516-4446.
  9. Lochner, Christine; Stein, Dan J.; Woods, Douglas; Pauls, David L.; Franklin, Martin E.; Loerke, Elizabeth H.; Keuthen, Nancy J. (2011). "The validity of DSM-IV-TR criteria B and C of hair-pulling disorder (trichotillomania): Evidence from a clinical study". Psychiatry Research. 189 (2): 276–280. doi:10.1016/j.psychres.2011.07.022. ISSN 0165-1781.
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  13. Özcan, D.; Seçkin, D. (2016). "N-Acetylcysteine in the treatment of trichotillomania: remarkable results in two patients". Journal of the European Academy of Dermatology and Venereology. 30 (9): 1606–1608. doi:10.1111/jdv.13690. ISSN 0926-9959.
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