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Trichotillomania (TTM), also known as hair-pulling disorder or compulsive hair pulling, is a
mental disorder A mental disorder, also referred to as a mental illness or psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. Such features may be persistent, relapsing and remitti ...
characterized by a long-term urge that results in the
pulling out ''Coitus interruptus'', also known as withdrawal, pulling out or the pull-out method, is a method of birth control in which a man, during sexual intercourse, withdraws his penis from a woman's vagina prior to ejaculation and then directs his ej ...
of one's own hair. A brief positive feeling may occur as hair is removed. Efforts to stop pulling hair typically fail. Hair removal may occur anywhere; however, the head and around the eyes are most common. The hair pulling is to such a degree that it results in distress and hair loss can be seen. The disorder may run in families. It occurs more commonly in those with
obsessive compulsive disorder Obsession may refer to: Psychology * Celebrity worship syndrome, obsessive addictive disorder to a celebrity's personal and professional life * Fixation (psychology), a persistent attachment to an object or idea * Idée fixe (psychology), a pr ...
. Episodes of pulling may be triggered by
anxiety Anxiety is an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events. Anxiety is different than fear in that the former is defined as the anticipation of a future threat wh ...
. People usually acknowledge that they pull their hair, and broken hairs may be seen on examination. Other conditions that may present similarly include body dysmorphic disorder; however, in that condition people remove hair to try to improve what they see as a problem in how they look. Treatment is typically with
cognitive behavioral therapy Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. CBT focuses on challenging and changing cognitive distortions (suc ...
. The medication clomipramine may also be helpful, as will keeping fingernails clipped. Trichotillomania is estimated to affect one to four percent of people. Trichotillomania most commonly begins in childhood or adolescence. Women are affected about 10 times more often than men. The name was created by
François Henri Hallopeau __NOTOC__ François Henri Hallopeau (17 January 1842, Paris – 20 March 1919, Paris) was a French dermatologist. He studied medicine under Alfred Vulpian and Sigismond Jaccoud. He co-founded and was secretary general of the ''Société Française ...
in 1889, from the Greek ; (meaning 'hair'), along with ; (meaning 'to pull'), and ; '' mania'' (meaning 'madness').


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, and legs. Some less common areas include the pubic area, underarms, beard, and chest. 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. People with trichotillomania often pull only one hair at a time and these hair-pulling episodes can last for hours at a time. Some individuals may experience more satisfaction after pulling an anagen phase hair with the gel-like
inner root sheath The inner root sheath or internal root sheath of the hair follicle is located between the outer root sheath and the hair shaft.James, William; Berger, Timothy; Elston, Dirk (2005) ''Andrews' Diseases of the Skin: Clinical Dermatology'' (10th ed.). ...
still surrounding the base of the hair. Trichotillomania can go into remission-like states where the individual may not experience the urge to "pull" for days, weeks, months, or even years. 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 is confidence in one's own worth or abilities. Self-esteem encompasses beliefs about oneself (for example, "I am loved", "I am worthy") as well as emotional states, such as triumph, despair, pride, and shame. Smith and Mackie (2007) d ...
, 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, 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. For some people, trichotillomania is a mild problem, merely a frustration. But for many, embarrassment about hair pulling causes isolation and results in a great deal of emotional distress, placing them at risk for a co-occurring psychiatric disorder, such as a mood or anxiety disorder. Hair pulling can lead to tension and strained relationships with family members and friends. Family members may need professional help in coping with this problem. Other medical complications include infection, permanent loss of hair, repetitive stress injury,
carpal tunnel syndrome Carpal tunnel syndrome (CTS) is the collection of symptoms and signs associated with median neuropathy at the carpal tunnel. Most CTS is related to idiopathic compression of the median nerve as it travels through the wrist at the carpal tunn ...
, and gastrointestinal obstruction as a result of
trichophagia Trichophagia is the compulsive eating of hair associated with trichotillomania (hair pulling). In trichophagia, people with trichotillomania also ingest the hair that they pull; in extreme cases this can lead to a hair ball ( trichobezoar). The te ...
. 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 Rapunzel syndrome is an extremely rare intestinal condition in humans resulting from ingesting hair ( trichophagia). The syndrome is named after the long-haired girl Rapunzel in the fairy tale by the Brothers Grimm. Trichophagia is sometimes ass ...
, 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

Anxiety Anxiety is an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events. Anxiety is different than fear in that the former is defined as the anticipation of a future threat wh ...
, depression and obsessive–compulsive disorder are more frequently encountered in people with trichotillomania. Trichotillomania has a high overlap with
post traumatic stress disorder Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on ...
, and some cases of trichotillomania may be triggered by stress. Another school of thought emphasizes hair pulling as addictive or negatively reinforcing, as it is associated with rising tension beforehand and relief afterward. A neurocognitive model — the notion that the
basal ganglia The basal ganglia (BG), or basal nuclei, are a group of subcortical nuclei, of varied origin, in the brains of vertebrates. In humans, and some primates, there are some differences, mainly in the division of the globus pallidus into an ext ...
play a role in habit formation and that the frontal lobes are critical for normally suppressing or inhibiting such habits — sees trichotillomania as a habit disorder. Abnormalities in the
caudate nucleus The caudate nucleus is one of the structures that make up the corpus striatum, which is a component of the basal ganglia in the human brain. While the caudate nucleus has long been associated with motor processes due to its role in Parkinson's d ...
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. In several MRI studies that have been conducted, it has been found that people with trichotillomania have more gray matter in their brains than those who do not have the disorder. It is likely that multiple genes confer vulnerability to trichotillomania. One study identified mutations in the SLITRK1 gene.


Diagnosis

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 diagnosis In healthcare, a differential diagnosis (abbreviated DDx) is a method of analysis of a patient's history and physical examination to arrive at the correct diagnosis. It involves distinguishing a particular disease or condition from others that p ...
must be pursued. The differential diagnosis will include evaluation for alopecia areata, iron deficiency,
hypothyroidism Hypothyroidism (also called ''underactive thyroid'', ''low thyroid'' or ''hypothyreosis'') is a disorder of the endocrine system in which the thyroid gland does not produce enough thyroid hormone. It can cause a number of symptoms, such as ...
, tinea capitis, traction alopecia,
alopecia mucinosa Alopecia mucinosa (also known as "Follicular mucinosis," "Mucinosis follicularis", "Pinkus' follicular mucinosis," and "Pinkus' follicular mucinosis–benign primary form") is a skin disorder that generally presents, but not exclusively, as erythe ...
,
thallium poisoning Thallium poisoning is poisoning that is due to thallium and its compounds, which are often highly toxic. Contact with skin is dangerous and adequate ventilation should be provided when melting this metal. Many thallium compounds are highly solubl ...
, and loose anagen syndrome. In trichotillomania, a hair pull test is negative. A
biopsy A biopsy is a medical test commonly performed by a surgeon, interventional radiologist, or an interventional cardiologist. The process involves extraction of sample cells or tissues for examination to determine the presence or extent of a dise ...
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. Multiple
catagen The growth of human hair occurs everywhere on the body except for the soles of the feet, the inside of the mouth, the lips, the backs of the ears, the palms of the hands, some external genital areas, the navel, scar tissue, and, apart from eyelas ...
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.


Classification

Trichotillomania is defined as a self-induced and recurrent loss of hair. It 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, and patients presenting for diagnosis may deny the criteria for tension prior to hair pulling or a sense of gratification after hair is pulled. Trichotillomania may lie on the obsessive-compulsive spectrum, also encompassing obsessive-compulsive disorder (OCD), body dysmorphic disorder (BDD), nail biting ( onychophagia) and skin picking ( dermatillomania), tic disorders and
eating disorder An eating disorder is a mental disorder defined by abnormal eating behaviors that negatively affect a person's physical or mental health. Only one eating disorder can be diagnosed at a given time. Types of eating disorders include binge eating d ...
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
comorbid In medicine, comorbidity - from Latin morbus ("sickness"), co ("together"), -ity (as if - several sicknesses together) - is the presence of one or more additional conditions often co-occurring (that is, concomitant or concurrent) with a primary ...
ity, 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 be 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. In preschool age children, trichotillomania is considered benign. For these children, hair-pulling is considered either a means of exploration or something done subconsciously, similar to nail-biting and thumb-sucking, and almost never continues into further ages. The most common age of onset of trichotillomania is between ages 9 and 13. In this age range, trichotillomania is usually chronic, and continues into adulthood. Trichiotillomania that begins in adulthood most commonly arises from underlying psychiatric causes. 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 unconscious, 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.


Treatment

Treatment is based on a person's age. Most pre-school age children outgrow the condition if it 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 modification Behavior modification is an early approach that used respondent and operant conditioning to change behavior. Based on methodological behaviorism, overt behavior was modified with consequences, including positive and negative reinforcement conti ...
programs, may be considered; referrals to psychologists or psychiatrists may be considered when other interventions fail. When trichotillomania begins in adulthood, it is often associated with other
mental disorder A mental disorder, also referred to as a mental illness or psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. Such features may be persistent, relapsing and remitti ...
s, and referral to a psychologist or psychiatrist for evaluation or treatment is considered best. The hair pulling may resolve when other conditions are treated.


Psychotherapy

Habit reversal training Habit reversal training (HRT) is a "multicomponent behavioral treatment package originally developed to address a wide variety of repetitive behavior disorders". Behavioral disorders treated with HRT include tics, trichotillomania, nail biting, ...
(HRT) has the highest rate of success in treating trichotillomania. HRT has also been shown to be a successful adjunct to
medication A medication (also called medicament, medicine, pharmaceutical drug, medicinal drug or simply drug) is a drug used to diagnose, cure, treat, or prevent disease. Drug therapy ( pharmacotherapy) is an important part of the medical field and ...
as a way to treat trichotillomania. With HRT, the individual is trained 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 Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. CBT focuses on challenging and changing cognitive distortions (suc ...
(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.
Acceptance and commitment therapy Acceptance and commitment therapy (ACT, typically pronounced as the word "act") is a form of psychotherapy, as well as a branch of clinical behavior analysis. It is an empirically based psychological intervention that uses acceptance and mind ...
(ACT) is also demonstrating promise in trichotillomania treatment. A systematic review from 2012 found tentative evidence for " movement decoupling".


Medication

The United States
Food and Drug Administration The United States Food and Drug Administration (FDA or US FDA) is a federal agency of the Department of Health and Human Services. The FDA is responsible for protecting and promoting public health through the control and supervision of food ...
(FDA) has not approved any medications for trichotillomania treatment. However, some medications have been used to treat trichotillomania, with mixed results. Treatment with clomipramine, a
tricyclic antidepressant Tricyclic antidepressants (TCAs) are a class of medications that are used primarily as antidepressants, which is important for the management of depression. They are second-line drugs next to SSRIs. TCAs were discovered in the early 1950s and wer ...
, was shown in a small double-blind study to improve symptoms, but results of other studies on clomipramine for treating trichotillomania have been inconsistent. Naltrexone may be a viable treatment.
Fluoxetine Fluoxetine, sold under the brand names Prozac and Sarafem, among others, is an antidepressant of the selective serotonin reuptake inhibitor (SSRI) class. It is used for the treatment of major depressive disorder, obsessive–compulsive diso ...
and other selective serotonin reuptake inhibitors (SSRIs) have limited usefulness in treating trichotillomania, and can often have significant side effects. Behavioral therapy has proven more effective when compared to fluoxetine. There is little research on the effectiveness of behavioral therapy combined with medication, and robust evidence from high-quality studies is lacking.
Acetylcysteine Acetylcysteine, also known as ''N''-acetylcysteine (NAC), is a medication that is used to treat paracetamol overdose and to loosen thick mucus in individuals with chronic bronchopulmonary disorders like pneumonia and bronchitis. It has been us ...
treatment stemmed from an understanding of glutamate's role in regulation of impulse control. Different medications, depending on the individual, may increase hair pulling.


Devices

Technology can be used to augment habit reversal training or behavioral therapy. Several mobile apps exist to help log behavior and focus on treatment strategies. There are also wearable devices that track the position of a user's hands. They produce sound or vibrating notifications so that users can track rates of these events over time.


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 population epidemiologic studies had been conducted as of 2009, the lifetime prevalence of trichotillomania is estimated to be between 0.6% and 4.0% of the overall population. 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 mentioned by
Aristotle Aristotle (; grc-gre, Ἀριστοτέλης ''Aristotélēs'', ; 384–322 BC) was a Greek philosopher and polymath during the Classical period in Ancient Greece. Taught by Plato, he was the founder of the Peripatetic school of ...
in the fourth century B.C., was first described in modern literature in 1885, and the term ''trichotillomania'' was coined by the French dermatologist
François Henri Hallopeau __NOTOC__ François Henri Hallopeau (17 January 1842, Paris – 20 March 1919, Paris) was a French dermatologist. He studied medicine under Alfred Vulpian and Sigismond Jaccoud. He co-founded and was secretary general of the ''Société Française ...
in 1889. In 1987, trichotillomania was recognized in the Diagnostic and Statistical Manual of the
American Psychiatric Association The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the largest psychiatric organization in the world. It has more than 37,000 members are invo ...
, third edition-revised (DSM-III-R).


Society and culture

Support groups and internet sites can provide recommended educational material and help persons with trichotillomania in maintaining a positive attitude and overcoming the fear of being alone with the disorder.


Media

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. Trichster is a 2016 documentary that follows seven individuals living with trichotillomania, as they navigate the complicated emotions surrounding the disorder, and the effect it has on their daily lives.


Fiction

The trichotillomania of a prominent character is a key plot element in the 1999 novel ''Whatever Love Means'' by David Baddiel. In the superhero fiction series The Boys character Ashley Barret, portrayed by Colby Minifie is shown suffering from it.


Music

On the 2017 album, ''20s a Difficult Age'' by Marcus Orelias, there is a song called "Trichotillomania".


See also

* Feather-plucking *
Noncicatricial alopecia Non scarring hair loss, also known as noncicatricial alopecia is the loss of hair without any scarring being present.James, William; Berger, Timothy; Elston, Dirk (2005). ''Andrews' Diseases of the Skin: Clinical Dermatology''. (10th ed.). Saunder ...
*
Psychogenic alopecia Psychogenic alopecia, also called ''over-grooming'' or ''psychological baldness,'' is a compulsive behavior that affects domestic cats. Generally, psychogenic alopecia does not lead to serious health consequences or a decreased lifespan. Causes ...
, a form of baldness that is caused by excessive grooming in cats * Self-harm


References

{{Authority control Body-focused repetitive behavior Conditions of the skin appendages Hair diseases Hair removal Human hair Mania Neurocutaneous conditions Self-harm Wikipedia medicine articles ready to translate Wikipedia neurology articles ready to translate