Trichotillomania
Encyclopedia
Trichotillomania, which is classified as an impulse control disorder
by DSM-IV, is the compulsive urge to pull out one's own hair leading to noticeable hair loss, distress, and social or functional impairment. It is often chronic and difficult to treat.
Trichotillomania may be present in infants, but the peak age of onset is 9 to 13. It may be triggered by depression or stress. Due to social implications the disorder is often unreported and it is difficult to accurately predict its prevalence
; the lifetime prevalence is estimated to be between 0.6% (overall) and may be as high as 1.5% (in males) to 3.4% (in females).
The name, coined by French dermatologist François Henri Hallopeau
, derives from the Greek: trich- (hair), till(en) (to pull), and mania
("an abnormal love for a specific object, place, or action").
with pyromania
, pathological gambling and kleptomania
, and includes the criterion of an increasing sense of tension before pulling the hair and gratification or relief when pulling the hair. However, some people with trichotillomania do not endorse the inclusion of "rising tension and subsequent pleasure, gratification, or relief" as part of the criteria; because many individuals with trichotillomania may not realize they are pulling their hair, patients presenting for diagnosis may deny the criteria for tension prior to hair pulling or a sense of gratification after hair is pulled.
Trichotillomania has been hypothesized to lie on the obsessive–compulsive spectrum, which is proposed to encompass obsessive–compulsive disorder, nail biting (onychophagia) and skin picking (dermatillomania
), tic disorder
s and eating disorder
s. These conditions may share clinical features, genetic contributions, and possibly treatment response; however, differences between trichotillomania and OCD are present in symptoms, neural function and cognitive profile. In the sense that it is associated with irresistible urges to perform unwanted repetitive behavior, trichotillomania is akin to some of these conditions, and rates of trichotillomania among relatives of OCD patients is higher than expected by chance. However, differences between the disorder and OCD have been noted including differing peak ages at onset, rates of comorbidity, gender differences, and neural dysfunction and cognitive profile. When it occurs in early childhood, it can be regarded as a distinct clinical entity.
Because trichotillomania can present in multiple age groups, it is helpful in terms of prognosis and treatment to approach three distinct subgroups by age: preschool age children, preadolescents to young adults, and adults.
Trichotillomania is often not a focused act, but rather hair pulling occurs in a "trance-like" state; hence, trichotillomania is subdivided into "automatic" versus "focused" hair pulling. Children are more often in the automatic, or subconscious, subtype and may not consciously remember pulling their hair. Other individuals may have focused, or conscious, rituals associated with hair pulling, including seeking specific types of hairs to pull, pulling until the hair feels "just right", or pulling in response to a specific sensation. Knowledge of the subtype is helpful in determining treatment strategies.
Individuals with trichotillomania exhibit hair of differing lengths; some are broken hairs with blunt ends, some new growth with tapered ends, some broken mid-shaft, or some uneven stubble. Scaling on the scalp is not present, overall hair density is normal, and a hair pull test is negative (the hair does not pull out easily). Hair is often pulled out leaving an unusual shape; individuals with trichotillomania may be secretive or shameful of the hair pulling behavior.
An additional psychological effect can be low self-esteem
, often associated with being shunned by peers and the fear of socializing due to appearance and negative attention they may receive. Some people with trichotillomania wear hats, wigs, wear false eyelashes, eyebrow pencil, or style their hair in an effort to avoid such attention. There seems to be a strong stress-related component. In low-stress environments, some exhibit no symptoms (known as "pulling") whatsoever. This "pulling" often resumes upon leaving this environment. Some individuals with trichotillomania may feel they are the only person with this problem due to low rates of reporting.
Other medical complications include infection, permanent loss of hair, repetitive stress injury, carpal tunnel syndrome
, and gastrointestinal obstruction as a result of trichophagia
. In trichophagia, people with trichotillomania also ingest the hair that they pull; in extreme (and rare) cases this can lead to a hair ball (trichobezoar
). Rapunzel syndrome
, an extreme form of trichobezoar in which the "tail" of the hair ball extends into the intestines, can be fatal if misdiagnosed.
Environment is a large factor which affects hair pulling. Sedentary activities such as being in a relaxed environment are conducive to hair pulling. A common example of a sedentary activity promoting hair pulling is lying in a bed while trying to rest or fall asleep. An extreme example of automatic trichotillomania is found when some patients have been observed to pull their hair out while asleep. This is called sleep-isolated trichotillomania.
, depression
and obsessive–compulsive disorder are more frequently encountered in people with trichotillomania. Trichotillomania has a high overlap with post traumatic stress disorder, and some cases of trichotillomania may be triggered by stress. Another school of thought emphasizes hair pulling as addictive or positively reinforcing as it is associated with rising tension beforehand and relief afterward. A neurocognitive model — the notion that the basal ganglia
plays a role in habit formation and that the frontal lobe
s are critical for normally suppressing or inhibiting such habits —sees trichotillomania as a habit disorder.
Abnormalities in the caudate nucleus
are noted in OCD, but there is no evidence to support that these abnormalities can also be linked to trichotillomania. One study has shown that individuals with trichotillomania have decreased cerebellar
volume. These findings suggest some differences between OCD and trichotillomania. There is a lack of structural MRI studies on trichotillomania.
It is likely that multiple genes confer vulnerability to trichotillomania. One study identified mutations in the SLITRK1
gene, another identified differences in the serotonin 2A receptor genes
, and mice with a mutation on the HOXB8
gene showed abnormal behaviors including hair pulling. These data are preliminary, but could indicate a genetic component in trichotillomania.
must be pursued. The differential diagnosis will include evaluation for alopecia areata
, tinea capitis
, traction alopecia
, and loose anagen syndrome
. In trichotillomania, a hair pull test is negative.
A biopsy
can be performed and may be helpful; it reveals traumatized hair follicles with perifollicular hemorrhage, fragmented hair in the dermis, empty follicles, and deformed hair shafts (trichomalacia). Multiple catagen hairs are typically seen. An alternative technique to biopsy, particularly for children, is to shave a part of the involved area and observe for regrowth of normal hairs.
programs, may be considered; referrals to psychologists or psychiatrists are considered when other interventions fail. When trichotillomania begins in adulthood, it is often associated with other psychiatric disorders, and referral to a psychologist or psychiatrist for evaluation or treatment is considered best. The hair pulling may resolve when other conditions are treated.
(HRT) has the highest rate of success in treating trichotillomania. HRT has been shown to be a successful adjunct to medication
as a way to treat trichotillomania. With HRT, doctors train the individual to learn to recognize their impulse to pull and also teach them to redirect this impulse. In comparisons of behavioral versus pharmacologic treatment, cognitive behavioral therapy (including HRT) have shown significant improvement over medication alone. It has also proven effective in treating children. Biofeedback
, cognitive-behavioral methods, and hypnosis
may improve symptoms.
(Anafranil), a tricyclic antidepressant
, was shown in a small double-blind study to significantly improve symptoms, but results of other studies on clomipramine for treating trichotillomania have been inconsistent. Fluoxetine
(Prozac) and other selective serotonin reuptake inhibitor
s (SSRIs) have limited usefulness in treating trichotillomania, and can often have significant side effects. Behavioral therapy has proven more effective when compared to fluoxetine or control groups. Dual treatment (behavioral therapy and medication) may provide an advantage in some cases, but robust evidence from high-quality studies is lacking. Acetylcysteine treatment stemmed from an understanding of glutamate's role in regulation of impulse control.
Many medications, depending on individuality, may increase hair pulling.
Secondary infections may occur due to picking and scratching, but other complications are rare. Individuals with trichotillomania often find that support groups are helpful in living with and overcoming the disorder.
epidemiologic studies
had been conducted as of 2009, the lifetime prevalence
of trichotillomania is estimated to be between 0.6% (overall) and as high as 1.5% (in males) to 3.4% (in females). With a 1% prevalence rate, 2.5 million people in the U.S. may have trichotillomania at some time during their lifetimes.
Trichotillomania is diagnosed in all age groups; onset is more common during preadolescence and young adulthood, with mean age of onset between 9 and 13 years of age, and a notable peak at 12–13. Among preschool children the genders are equally represented; there appears to be a female predominance among preadolescents to young adults, with between 70% and 93% of patients being female. Among adults, females typically outnumber males by 3 to 1.
"Automatic" pulling occurs in approximately three-quarters of adult patients with trichotillomania.
in 1889.
A documentary film exploring trichotillomania, Bad Hair Life, was the 2003 winner of the International Health & Medical Media Award for best film in psychiatry and the winner of the 2004 Superfest Film Festival Merit Award.
Impulse control disorder
Impulse control disorder is a set of psychiatric disorders including intermittent explosive disorder, kleptomania, pathological gambling, pyromania , and three body-focused repetitive or compulsive behaviors of trichotillomania , onychophagia and dermatillomania...
by DSM-IV, is the compulsive urge to pull out one's own hair leading to noticeable hair loss, distress, and social or functional impairment. It is often chronic and difficult to treat.
Trichotillomania may be present in infants, but the peak age of onset is 9 to 13. It may be triggered by depression or stress. Due to social implications the disorder is often unreported and it is difficult to accurately predict its prevalence
Prevalence
In epidemiology, the prevalence of a health-related state in a statistical population is defined as the total number of cases of the risk factor in the population at a given time, or the total number of cases in the population, divided by the number of individuals in the population...
; the lifetime prevalence is estimated to be between 0.6% (overall) and may be as high as 1.5% (in males) to 3.4% (in females).
The name, coined by French dermatologist François Henri Hallopeau
François Henri Hallopeau
François Henri Hallopeau was a French dermatologist. He studied medicine under Alfred Vulpian and Sigismond Jaccoud. He co-founded and was secretary general of the Société Française de dermatologie et de syphiligraphie. He became a member of the Académie de Médecine in 1893.He coined the medical...
, derives from the Greek: trich- (hair), till(en) (to pull), and mania
Mania
Mania, the presence of which is a criterion for certain psychiatric diagnoses, is a state of abnormally elevated or irritable mood, arousal, and/ or energy levels. In a sense, it is the opposite of depression...
("an abnormal love for a specific object, place, or action").
Classification
Trichotillomania is defined as a self-induced and recurrent loss of hair. It is classified in DSM-IV as an impulse control disorderImpulse control disorder
Impulse control disorder is a set of psychiatric disorders including intermittent explosive disorder, kleptomania, pathological gambling, pyromania , and three body-focused repetitive or compulsive behaviors of trichotillomania , onychophagia and dermatillomania...
with pyromania
Pyromania
Pyromania in more extreme circumstances can be an impulse control disorder to deliberately start fires to relieve tension or for gratification or relief. The term pyromania comes from the Greek word πῦρ . Pyromania and pyromaniacs are distinct from arson, the pursuit of personal, monetary or...
, pathological gambling and kleptomania
Kleptomania
Kleptomania is an irresistible urge to steal items of trivial value. People with this disorder are compelled to steal things, generally, but not limited to, objects of little or no significant value, such as pens, paper clips, paper and tape...
, and includes the criterion of an increasing sense of tension before pulling the hair and gratification or relief when pulling the hair. However, some people with trichotillomania do not endorse the inclusion of "rising tension and subsequent pleasure, gratification, or relief" as part of the criteria; because many individuals with trichotillomania may not realize they are pulling their hair, patients presenting for diagnosis may deny the criteria for tension prior to hair pulling or a sense of gratification after hair is pulled.
Trichotillomania has been hypothesized to lie on the obsessive–compulsive spectrum, which is proposed to encompass obsessive–compulsive disorder, nail biting (onychophagia) and skin picking (dermatillomania
Dermatillomania
Dermatillomania is an impulse control disorder characterized by the repeated urge to pick at one's own skin, often to the extent that damage is caused...
), tic disorder
Tic disorder
Tic disorders are defined in the Diagnostic and Statistical Manual of Mental Disorders based on type and duration of tics...
s and eating disorder
Eating disorder
Eating disorders refer to a group of conditions defined by abnormal eating habits that may involve either insufficient or excessive food intake to the detriment of an individual's physical and mental health. Bulimia nervosa, anorexia nervosa, and binge eating disorder are the most common specific...
s. These conditions may share clinical features, genetic contributions, and possibly treatment response; however, differences between trichotillomania and OCD are present in symptoms, neural function and cognitive profile. In the sense that it is associated with irresistible urges to perform unwanted repetitive behavior, trichotillomania is akin to some of these conditions, and rates of trichotillomania among relatives of OCD patients is higher than expected by chance. However, differences between the disorder and OCD have been noted including differing peak ages at onset, rates of comorbidity, gender differences, and neural dysfunction and cognitive profile. When it occurs in early childhood, it can be regarded as a distinct clinical entity.
Because trichotillomania can present in multiple age groups, it is helpful in terms of prognosis and treatment to approach three distinct subgroups by age: preschool age children, preadolescents to young adults, and adults.
Trichotillomania is often not a focused act, but rather hair pulling occurs in a "trance-like" state; hence, trichotillomania is subdivided into "automatic" versus "focused" hair pulling. Children are more often in the automatic, or subconscious, subtype and may not consciously remember pulling their hair. Other individuals may have focused, or conscious, rituals associated with hair pulling, including seeking specific types of hairs to pull, pulling until the hair feels "just right", or pulling in response to a specific sensation. Knowledge of the subtype is helpful in determining treatment strategies.
Signs and symptoms
Trichotillomania is usually confined to one or two sites, but can involve multiple sites. The scalp is the most common pulling site, followed by the eyebrows, eyelashes, face, arms, legs. The classic presentation is the "Friar Tuck" form of vertex and crown alopecia. Children are less likely to pull from areas other than the scalp.Individuals with trichotillomania exhibit hair of differing lengths; some are broken hairs with blunt ends, some new growth with tapered ends, some broken mid-shaft, or some uneven stubble. Scaling on the scalp is not present, overall hair density is normal, and a hair pull test is negative (the hair does not pull out easily). Hair is often pulled out leaving an unusual shape; individuals with trichotillomania may be secretive or shameful of the hair pulling behavior.
An additional psychological effect can be low self-esteem
Self-esteem
Self-esteem is a term in psychology to reflect a person's overall evaluation or appraisal of his or her own worth. Self-esteem encompasses beliefs and emotions such as triumph, despair, pride and shame: some would distinguish how 'the self-concept is what we think about the self; self-esteem, the...
, often associated with being shunned by peers and the fear of socializing due to appearance and negative attention they may receive. Some people with trichotillomania wear hats, wigs, wear false eyelashes, eyebrow pencil, or style their hair in an effort to avoid such attention. There seems to be a strong stress-related component. In low-stress environments, some exhibit no symptoms (known as "pulling") whatsoever. This "pulling" often resumes upon leaving this environment. Some individuals with trichotillomania may feel they are the only person with this problem due to low rates of reporting.
Other medical complications include infection, permanent loss of hair, repetitive stress injury, carpal tunnel syndrome
Carpal tunnel syndrome
Carpal Tunnel Syndrome is an entrapment idiopathic median neuropathy, causing paresthesia, pain, and other symptoms in the distribution of the median nerve due to its compression at the wrist in the carpal tunnel. The pathophysiology is not completely understood but can be considered compression...
, and gastrointestinal obstruction as a result of trichophagia
Trichophagia
Trichophagia is the compulsive eating of hair associated with trichotillomania . In trichophagia, people with trichotillomania also ingest the hair that they pull; in extreme cases this can lead to a hair ball ....
. In trichophagia, people with trichotillomania also ingest the hair that they pull; in extreme (and rare) cases this can lead to a hair ball (trichobezoar
Trichobezoar
A trichobezoar is a bezoar formed from the ingestion of hair. Trichobezoars are often associated with trichotillomania , are rare, and can be fatal if undetected. Surgical intervention is often required....
). Rapunzel syndrome
Rapunzel syndrome
The Rapunzel syndrome is an extremely rare intestinal condition in humans resulting from eating hair . The syndrome is named after the long-haired girl Rapunzel in the fairy tale by the Brothers Grimm...
, an extreme form of trichobezoar in which the "tail" of the hair ball extends into the intestines, can be fatal if misdiagnosed.
Environment is a large factor which affects hair pulling. Sedentary activities such as being in a relaxed environment are conducive to hair pulling. A common example of a sedentary activity promoting hair pulling is lying in a bed while trying to rest or fall asleep. An extreme example of automatic trichotillomania is found when some patients have been observed to pull their hair out while asleep. This is called sleep-isolated trichotillomania.
Causes and pathophysiology
AnxietyAnxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
, depression
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
and obsessive–compulsive disorder are more frequently encountered in people with trichotillomania. Trichotillomania has a high overlap with post traumatic stress disorder, and some cases of trichotillomania may be triggered by stress. Another school of thought emphasizes hair pulling as addictive or positively reinforcing as it is associated with rising tension beforehand and relief afterward. A neurocognitive model — the notion that the basal ganglia
Basal ganglia
The basal ganglia are a group of nuclei of varied origin in the brains of vertebrates that act as a cohesive functional unit. They are situated at the base of the forebrain and are strongly connected with the cerebral cortex, thalamus and other brain areas...
plays a role in habit formation and that the frontal lobe
Frontal lobe
The frontal lobe is an area in the brain of humans and other mammals, located at the front of each cerebral hemisphere and positioned anterior to the parietal lobe and superior and anterior to the temporal lobes...
s are critical for normally suppressing or inhibiting such habits —sees trichotillomania as a habit disorder.
Abnormalities in the caudate nucleus
Caudate nucleus
The caudate nucleus is a nucleus located within the basal ganglia of the brains of many animal species. The caudate nucleus is an important part of the brain's learning and memory system.-Anatomy:...
are noted in OCD, but there is no evidence to support that these abnormalities can also be linked to trichotillomania. One study has shown that individuals with trichotillomania have decreased cerebellar
Cerebellum
The cerebellum is a region of the brain that plays an important role in motor control. It may also be involved in some cognitive functions such as attention and language, and in regulating fear and pleasure responses, but its movement-related functions are the most solidly established...
volume. These findings suggest some differences between OCD and trichotillomania. There is a lack of structural MRI studies on trichotillomania.
It is likely that multiple genes confer vulnerability to trichotillomania. One study identified mutations in the SLITRK1
SLITRK1
SLITRK1 is a human gene on chromosome 13q31.1. In 2005, medical researchers observed a de novo chromosomal abnormality in a patient with Tourette syndrome which broke the patient's chromosome near SLITRK1...
gene, another identified differences in the serotonin 2A receptor genes
5-HT2A receptor
The mammalian 5-HT2A receptor is a subtype of the 5-HT2 receptor that belongs to the serotonin receptor family and is a G protein-coupled receptor . This is the main excitatory receptor subtype among the GPCRs for serotonin , although 5-HT2A may also have an inhibitory effect on certain areas such...
, and mice with a mutation on the HOXB8
HOXB8
Homeobox protein Hox-B8 is a protein that in humans is encoded by the HOXB8 gene.Transplantation of normal bone marrow into a Hoxb8 mutant mouse results is a reduction of compulsive grooming....
gene showed abnormal behaviors including hair pulling. These data are preliminary, but could indicate a genetic component in trichotillomania.
Diagnosis and screening
Patients may be ashamed or actively attempt to disguise their symptoms. This can make diagnosis difficult as symptoms are not always immediately obvious, or have been deliberately hidden to avoid disclosure. If the patient admits to hair pulling, diagnosis is not difficult; if patients deny hair pulling, a differential diagnosisDifferential diagnosis
A differential diagnosis is a systematic diagnostic method used to identify the presence of an entity where multiple alternatives are possible , and may also refer to any of the included candidate alternatives A differential diagnosis (sometimes abbreviated DDx, ddx, DD, D/Dx, or ΔΔ) is a...
must be pursued. The differential diagnosis will include evaluation for alopecia areata
Alopecia areata
Alopecia areata is a medical condition in which hair is lost from some or all areas of the body, usually from the scalp. Because it causes bald spots on the scalp, especially in the first stages, it is sometimes called spot baldness. In 1–2% of cases, the condition can spread to the entire scalp ...
, tinea capitis
Tinea capitis
Tinea capitis is a superficial fungal infection of the scalp. The disease is primarily caused by dermatophytes in the Trichophyton and Microsporum genera that invade the hair shaft...
, traction alopecia
Traction alopecia
Traction alopecia is a form of alopecia, or gradual hair loss, caused primarily by pulling force being applied to the hair. This commonly results from the sufferer frequently wearing his/her hair in a particularly tight ponytail, pigtails, or braids...
, and loose anagen syndrome
Loose anagen syndrome
Loose anagen syndrome is primarily described in fair-haired children who have easily dislodgable hair....
. In trichotillomania, a hair pull test is negative.
A biopsy
Biopsy
A biopsy is a medical test involving sampling of cells or tissues for examination. It is the medical removal of tissue from a living subject to determine the presence or extent of a disease. The tissue is generally examined under a microscope by a pathologist, and can also be analyzed chemically...
can be performed and may be helpful; it reveals traumatized hair follicles with perifollicular hemorrhage, fragmented hair in the dermis, empty follicles, and deformed hair shafts (trichomalacia). Multiple catagen hairs are typically seen. An alternative technique to biopsy, particularly for children, is to shave a part of the involved area and observe for regrowth of normal hairs.
Treatment
Treatment is based on a person's age. Most pre-school age children outgrow it if the condition is managed conservatively. In young adults, establishing the diagnosis and raising awareness of the condition is an important reassurance for the family and patient. Non-pharmacological interventions, including behavior modificationBehavior modification
Behavior modification is the use of empirically demonstrated behavior change techniques to increase or decrease the frequency of behaviors, such as altering an individual's behaviors and reactions to stimuli through positive and negative reinforcement of adaptive behavior and/or the reduction of...
programs, may be considered; referrals to psychologists or psychiatrists are considered when other interventions fail. When trichotillomania begins in adulthood, it is often associated with other psychiatric disorders, and referral to a psychologist or psychiatrist for evaluation or treatment is considered best. The hair pulling may resolve when other conditions are treated.
Psychosocial
Habit Reversal TrainingHabit reversal training
Habit reversal training is a "multicomponent behavioral treatment package originally developed to address a wide variety of repetitive behavior disorders"....
(HRT) has the highest rate of success in treating trichotillomania. HRT has been shown to be a successful adjunct to medication
Medication
A pharmaceutical drug, also referred to as medicine, medication or medicament, can be loosely defined as any chemical substance intended for use in the medical diagnosis, cure, treatment, or prevention of disease.- Classification :...
as a way to treat trichotillomania. With HRT, doctors train the individual to learn to recognize their impulse to pull and also teach them to redirect this impulse. In comparisons of behavioral versus pharmacologic treatment, cognitive behavioral therapy (including HRT) have shown significant improvement over medication alone. It has also proven effective in treating children. Biofeedback
Biofeedback
Biofeedback is the process of becoming aware of various physiological functions using instruments that provide information on the activity of those same systems, with a goal of being able to manipulate them at will...
, cognitive-behavioral methods, and hypnosis
Hypnosis
Hypnosis is "a trance state characterized by extreme suggestibility, relaxation and heightened imagination."It is a mental state or imaginative role-enactment . It is usually induced by a procedure known as a hypnotic induction, which is commonly composed of a long series of preliminary...
may improve symptoms.
Medication
Medications can be used. Treatment with clomipramineClomipramine
Clomipramine is a tricyclic antidepressant . It was developed in the 1960s by the Swiss drug manufacturer Geigy and has been in clinical use worldwide ever since.- Indications :...
(Anafranil), a tricyclic antidepressant
Tricyclic antidepressant
Tricyclic antidepressants are heterocyclic chemical compounds used primarily as antidepressants. The TCAs were first discovered in the early 1950s and were subsequently introduced later in the decade; they are named after their chemical structure, which contains three rings of atoms...
, was shown in a small double-blind study to significantly improve symptoms, but results of other studies on clomipramine for treating trichotillomania have been inconsistent. Fluoxetine
Fluoxetine
Fluoxetine is an antidepressant of the selective serotonin reuptake inhibitor class. It is manufactured and marketed by Eli Lilly and Company...
(Prozac) and other selective serotonin reuptake inhibitor
Selective serotonin reuptake inhibitor
Selective serotonin re-uptake inhibitors or serotonin-specific reuptake inhibitor are a class of compounds typically used as antidepressants in the treatment of depression, anxiety disorders, and some personality disorders. The efficacy of SSRIs is disputed...
s (SSRIs) have limited usefulness in treating trichotillomania, and can often have significant side effects. Behavioral therapy has proven more effective when compared to fluoxetine or control groups. Dual treatment (behavioral therapy and medication) may provide an advantage in some cases, but robust evidence from high-quality studies is lacking. Acetylcysteine treatment stemmed from an understanding of glutamate's role in regulation of impulse control.
Many medications, depending on individuality, may increase hair pulling.
Prognosis
When it occurs in early childhood (before five years of age), the condition is typically self-limiting and intervention is not required. In adults, the onset of trichotillomania may be secondary to underlying psychiatric disturbances and symptoms are generally more long-term.Secondary infections may occur due to picking and scratching, but other complications are rare. Individuals with trichotillomania often find that support groups are helpful in living with and overcoming the disorder.
Epidemiology
Although no broad-based populationPopulation study
In the various fields of healthcare, a population study is a study of a group of individuals taken from the general population who share a common characteristic, such as age, sex, or health condition...
epidemiologic studies
Epidemiology
Epidemiology is the study of health-event, health-characteristic, or health-determinant patterns in a population. It is the cornerstone method of public health research, and helps inform policy decisions and evidence-based medicine by identifying risk factors for disease and targets for preventive...
had been conducted as of 2009, the lifetime prevalence
Prevalence
In epidemiology, the prevalence of a health-related state in a statistical population is defined as the total number of cases of the risk factor in the population at a given time, or the total number of cases in the population, divided by the number of individuals in the population...
of trichotillomania is estimated to be between 0.6% (overall) and as high as 1.5% (in males) to 3.4% (in females). With a 1% prevalence rate, 2.5 million people in the U.S. may have trichotillomania at some time during their lifetimes.
Trichotillomania is diagnosed in all age groups; onset is more common during preadolescence and young adulthood, with mean age of onset between 9 and 13 years of age, and a notable peak at 12–13. Among preschool children the genders are equally represented; there appears to be a female predominance among preadolescents to young adults, with between 70% and 93% of patients being female. Among adults, females typically outnumber males by 3 to 1.
"Automatic" pulling occurs in approximately three-quarters of adult patients with trichotillomania.
History
Hair pulling was first described in the literature in 1885, and the term trichotillomania was coined by the French dermatologist François Henri HallopeauFrançois Henri Hallopeau
François Henri Hallopeau was a French dermatologist. He studied medicine under Alfred Vulpian and Sigismond Jaccoud. He co-founded and was secretary general of the Société Française de dermatologie et de syphiligraphie. He became a member of the Académie de Médecine in 1893.He coined the medical...
in 1889.
Society and culture
Support groups and internet sites such as the Trichotillomania Learning Center can provide recommended educational material and help persons with trich in maintaining a positive attitude and overcoming the fear of being alone with the disease.A documentary film exploring trichotillomania, Bad Hair Life, was the 2003 winner of the International Health & Medical Media Award for best film in psychiatry and the winner of the 2004 Superfest Film Festival Merit Award.
See also
- Body-focused repetitive behaviorBody-focused repetitive behaviorBody-Focused Repetitive Behavior is an umbrella name for impulse control behaviors involving compulsively damaging one's physical appearance or causing physical injury.The main BFRB disorders are:*Trichotillomania, compulsive hair pulling...
- DermatillomaniaDermatillomaniaDermatillomania is an impulse control disorder characterized by the repeated urge to pick at one's own skin, often to the extent that damage is caused...
(compulsive skin picking) - Onychophagia (compulsive nail biting)
- DermatophagiaDermatophagiaDermatophagia is a form of obsessive-compulsive disorder wherein a sufferer compulsively bites their own skin. Sufferers typically bite the skin around the nails, leading to bleeding and discoloration over time....
(compulsive biting of the skin, particularly around the fingernails) - Noncicatricial alopeciaNoncicatricial alopecia-Causes:Causes of noncicatricial alopecia include:*Alopecia areata*Anagen effluvium*Androgenetic alopecia*Dermatopathia pigmentosa reticularis*Telogen effluvium*Trichotillomania...