Diagnostic Features

Trichotillomania is stereotyped recurrent pulling of hair. The sites of hair pulling include scalp, eyelashes, eyebrows, axillary, body, or pubic. Hair pulling tends to occur in episodes, exacerbated by stress, or conversely sometimes worsened by relaxation (e.g., when reading a book or watching television). The person generally feels tension before pulling hair, which is relieved by the pulling. All other causes of hair loss, including medical and dermatological must be considered and ruled out before the diagnosis of trichotillomania is confirmed.

Associated Features and Disorders

Associated features of trichotillomania include: examining the hair root; twirling it off; pulling the strand between the teeth, or trichophagia (eating hairs). Nail biting, scratching, gnawing, and excoriation may be associated with trichotillomania. Persons with trichotillomania may also have mood disorders (depression), anxiety disorders, or developmental disorders.

There can be histological findings. Biopsy samples may reveal short and broken hairs. Histological examination will reveal normal and damaged follicles. There should be inflammation in the affected area.

The person may have such serious hair pulling that all hair is pulled, except a small rim of hair (Friar Tuck sign). Abdominal pain may result from trichophagia and a hair bezoar.

Specific Culture, Age, and Gender Features

Children with trichotillomania demonstrate a male to female ratio of 1:1. Adults show a female predominance.

Prevalence

Trichotillomania was thought to be an uncommon condition, it is now believed to occur more frequently than previously thought. Surveys of college samples suggest that 1%-2% of students have a past or current history of trichotillomania.

Course

Some children with trichotillomania show complete resolution of symptoms. In adults the course may be chronic or episodic.

Differential Diagnosis

• Trichotillomania (as a syndrome)
• Obsessive-Compulsive Disorder
• Tourette's Syndrome
• Pervasive Developmental Disorder (Infantile Autism)
• Stereotypy Disorder
• Factitious Disorder (Munchausen Syndrome)

• Depression
• Generalized Anxiety Disorder
• Obsessive-Compulsive Disorder
• Personality Disorder

1. Behavior modification: substitution, positive/negative reinforcement
2. Medications: (see following text)

Medicines for Trichotillomania:

Selective Serotonin Reuptake Inhibitors:

• Prozac
• Luvox
• Paxil
• Zoloft

• Anafranil

• Orap
• Risperidone

• Li₂CO₃ (lithium compounds)

1. Recurrent pulling out of one's hair
2. An increasing sense of tension immediately before pulling out the hair
3. Pleasure or relief when pulling out the hair
4. The disturbance is not better accounted for by another mental disorder and is not due to a dermatological condition
5. The disturbance causes clinically significant distress