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Trichotillomania (Hair-Pulling Disorder)

by Katharine A. Phillips, MD, Dan J. Stein, MD, PhD

Trichotillomania is characterized by recurrent pulling out of one's hair resulting in hair loss.

Patients with trichotillomania repeatedly pull or pluck out their hair for noncosmetic reasons. Most commonly, they pull hair from their scalp, eyebrows, and/or eyelids, but any body hair may be pulled out. Sites of hair pulling may change over time.

For some patients, this activity is somewhat automatic (ie, without full awareness); others are more conscious of the activity. Hair pulling is not triggered by obsessions or concerns about appearance but may be preceded by a feeling of tension or anxiety that is relieved by the hair pulling, which is often then followed by a feeling of gratification.

Hair pulling typically begins just before or after puberty. At any given point in time, about 1 to 2% of people have the disorder. About 90% of them are female.

Symptoms and Signs

Hair pulling is usually chronic, with waxing and waning of symptoms.

Patterns of hair loss vary from patient to patient. Some have areas of complete alopecia or missing eyelashes and/or eyebrows; others merely have thinned hair.

A range of behaviors (rituals) may accompany hair pulling. Patients may search fastidiously for a particular kind of hair to pull; they may try to ensure that hair is pulled out in a particular way. They may roll the hair between their fingers, pull the strands between their teeth, or bite the hair once it is pulled. Many patients swallow their hair.

Patients may feel embarrassed by or ashamed of their appearance. Many try to camouflage the hair loss by covering the bald areas (eg, wearing wigs or scarfs). Some patients pull out hair from widely scattered areas to disguise the loss. They may avoid situations in which other people may see the hair loss; typically, they do not pull hair out in front of others, except for family members.

Some patients pull hair from others or from pets or pull strands from fibrous materials (eg, clothing, blankets). Most patients also have other body-focused repetitive behaviors, such as skin picking or nail biting.

Diagnosis

  • Clinical criteria

Diagnostic criteria typically include the following:

  • Removing hair

  • Making repeated attempts to stop the hair pulling

  • Experiencing significant distress or impairment from the activity

The distress can include feelings of embarrassment or shame (eg, at loss of control of one's behavior, at the cosmetic consequences of the hair loss).

Treatment

  • SSRIs or clomipramine

  • Cognitive-behavioral therapy

SSRIs or clomipramine (a tricyclic antidepressant with potent serotonergic effects) may be useful for coexisting depression or anxiety disorders. For hair pulling, clomipramine appears to be more effective than desipramine (a tricyclic antidepressant that inhibits reuptake of norepinephrine). However, SSRIs have been disappointing. Some evidence suggests that N -acetylcysteine (a partial glutamatergic agonist) is effective. There is also limited evidence that low-dose dopamine blockers are effective, but risk:benefit ratio must be carefully assessed.

Cognitive-behavioral therapy that is tailored to treat the specific symptoms of hair-pulling disorder is currently the psychotherapy of choice. For example, habit reversal, a predominantly behavioral therapy, can be used; it includes awareness training (eg, self-monitoring, identification of triggers for the behavior), stimulus control (modifying situations—eg, avoiding triggers—to reduce the likelihood of initiating pulling), and competing response training (substituting other behaviors for hair pulling).

Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • ANAFRANIL
  • LEVOPHED
  • No US brand name
  • ACETADOTE
  • NORPRAMIN

* This is a professional Version *