Trichotillomania

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

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. Swallowing hair sometimes results in trichobezoars (tightly packed collections of swallowed hair that are unable to exit the gastrointestinal tract), which on occasion lead to medical complications (eg, gastric obstruction or perforation) and which may require surgical removal.

Patients may feel embarrassed or ashamed because of their appearance or their inability to control their behavior. Many try to camouflage the hair loss by covering the bald areas (eg, wearing wigs, hats, or scarves). 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 perhaps for family members. However, individuals with trichotillomania, if asked, typically admit that their alopecia is due to hair pulling.

Some patients pull hair from other people 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 (1). Many also have major depressive disorder.

• Psychiatric assessment

• Sometimes general medical evaluation and medical tests to rule out a medical disorder that can cause hair loss

Clinical criteria for diagnosis of trichotillomania from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR) include the following (1):

• Recurrently removing hair, resulting in hair loss (which may be hidden)

• Making repeated attempts to decrease or stop the hair pulling

• Experiencing significant distress and/or impairment in functioning from the activity

To diagnose trichotillomania, the hair pulling must not be better explained by a general medical condition or by another psychiatric disorder (such as body dysmorphic disorder).

• Cognitive-behavioral therapy (usually habit reversal training)

• N-Acetylcysteine (NAC) or memantine (glutamate modulators/antagonists)-Acetylcysteine (NAC) or memantine (glutamate modulators/antagonists)

• Selective serotonin reuptake inhibitors (SSRIs) or clomipramineSelective serotonin reuptake inhibitors (SSRIs) or clomipramine

Cognitive-behavioral therapy that is tailored to treat the specific symptoms of hair-pulling disorder is the preferred initial therapy (1). Habit reversal training, a predominantly behavioral therapy, is recommended; it includes the following:

• 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)

• Competing response training (teaching patients to substitute other behaviors—such as clenching their fist, knitting, or sitting on their hands—for hair pulling)

In randomized trials, the glutamate modulators/inhibitors N-acetylcysteine (NAC) and memantine were effective for adults (-acetylcysteine (NAC) and memantine were effective for adults (2, 3). However, in a small study in children, N-acetylcysteine was no more effective than placebo (-acetylcysteine was no more effective than placebo (4). There is limited evidence that low-dose neuroleptics such as olanzapine or aripiprazole are effective, but the risk:benefit ratio must be carefully assessed (). There is limited evidence that low-dose neuroleptics such as olanzapine or aripiprazole are effective, but the risk:benefit ratio must be carefully assessed (5).

Clomipramine (a tricyclic antidepressant with potent serotonergic effects) may be useful for reducing severity of symptoms (Clomipramine (a tricyclic antidepressant with potent serotonergic effects) may be useful for reducing severity of symptoms (6). Clomipramine appears to be more effective than desipramine (a tricyclic antidepressant that inhibits reuptake of norepinephrine) (). Clomipramine appears to be more effective than desipramine (a tricyclic antidepressant that inhibits reuptake of norepinephrine) (7). Studies of SSRIs in patients with trichotillomania are limited, but clinical experience suggests that they may be useful for some patients.