Academic journal article Indian Journal of Psychiatry

Trichotillomania (Hair Pulling Disorder)

Academic journal article Indian Journal of Psychiatry

Trichotillomania (Hair Pulling Disorder)

Article excerpt

Byline: Jon. Grant

Trichotillomania is characterized by the repetitive pulling out of one's own hair leading to hair loss and possibly functional impairment. Trichotillomania has been documented in the medical literature since the 19th century. Prevalence studies suggest that trichotillomania is a common disorder (point prevalence estimates of 0.5%-2.0%). Although grouped with the obsessive-compulsive disorder (OCD) in the diagnostic and statistical manual of mental disorders-5, trichotillomania is distinct from OCD in many respects. For example, the treatment of trichotillomania generally employs habit reversal therapy and medication (n-acetylcysteine or olanzapine), both of which are quite different from those used to treat OCD. Conversely, some first-line treatments used for OCD (e.g., selective serotonin reuptake inhibitors) appear ineffective for trichotillomania. This article presents what is known about trichotillomania and the evidence for a variety of treatment interventions.


Trichotillomania (hair-pulling disorder) is an often debilitating psychiatric condition characterized by recurrent pulling out of one's own hair, leading to hair loss, and marked functional impairment.[1],[2] Although discussed in the medical literature for over a century,[3] trichotillomania was not officially included as a mental health disorder in the American psychiatric association's diagnostic and statistical manual of mental disorders (DSM) until the DSM-III-R (1987) when it was classified as an impulse control disorder not elsewhere classified. In the 5th edition of the DSM (DSM-5),[4] trichotillomania was included in the chapter on obsessive-compulsive and related disorders with obsessive-compulsive disorder (OCD), excoriation disorder, body dysmorphic disorder, and hoarding disorder. The current diagnostic criteria for trichotillomania are as follows: pulling of hair which results in hair loss; attempts to either decrease or stop pulling; significant distress or impairment; and the pulling cannot be attributed to another medical or psychiatric condition.[4]

Epidemiology and Clinical Characteristics

Nationwide epidemiological studies of trichotillomania are lacking, smaller studies, usually conducted in university settings, have found a lifetime prevalence of trichotillomania to be around 0.6%;[1] and point prevalence to be 0.0%-3.9%.[5],[6],[7],[8] Because people with trichotillomania are often ashamed and embarrassed about their condition, these numbers may actually reflect underestimates of the true population prevalence. In adults, trichotillomania appears to have a large female preponderance (4:1 female:male), a sex ratio that is unique among psychiatric disorders.[9] In childhood, sex distribution has been found to be equal.[10]

Hair pulling appears to be quite common and often presents along with a continuum from mild-to-severe. The most common sites pulled include the scalp, eyebrows, and eyelashes; although, pulling from other areas of the body is common.[11] Pulling from multiple sites is not uncommon and pulling episodes can last from a few minutes to several hours.[11]

The onset of hair pulling is generally in late childhood or early adolescence.[11] Due to the developmental period when the disorder begins, trichotillomania is often associated with reduced self-esteem and quality of life and avoidance of social situations (for example, getting haircuts, swimming, being outside on a windy day, sporting activities, or dating).[12],[13] Cues to pulling may include stress, boredom, or 'downtime.' In addition, many people not being fully aware of their pulling behaviors also referred to as 'automatic' pulling and comprise a more habitual form of the disorder.[2] Approximately 10%-20% of people with trichotillomania eat their hair after pulling it ('trichophagia'), which can result in gastrointestinal obstruction and the formation of intestinal hair-balls ('trichobezoars') which can require surgical intervention. …

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