Edit concept Question Editor Create issue ticket

Trichotillomania

Trichotillomanias

Trichotillomania is an impulse control disorder marked by the urge to pull out scalp hair, eyelashes, eyebrows and other body hair.


Presentation

The symptoms are generally reported by friends or family members of the person directly plucking of one’s hair, resulting in significant hair loss. Patients usually pluck one hair at a time and the urge is continuous lasting for hours together.

There are phases of remission in between two episodes. This phase of remission can continue for many days or months or even few years. Patients seek solitude while doing this activity. They are affected psychologically and suffer from fear of appearing socially [5] [8]. They manipulate their appearance in order to look appealing. This is done by wearing hair extensions or hats, scarves etc.

Hair pulling is highly prevalent in association with stress and anxiety. The individual feels mentally relieved and his anxiety reduces by pulling his hair. Some people also ingest the plucked hair. This leads to formation of trichobezoar, a hair ball formation in the gut. An extreme form of trichobezoar leads to the hair ball tail extending to the intestine [7]. This condition is called Rapunzel disease. This condition is fatal if not diagnosed. Other factors such as a sedentary lifestyle, lying in bed, idealism can contribute to such activity. Children are especially prone to develop this habit.

Alopecia
  • Differential diagnoses include the most common forms of alopecia such as alopecia areata. It is usually associated with depression and obsessive-compulsive disorder. Trichotillomania treatment standardization is a gap in the medical literature.[ncbi.nlm.nih.gov]
  • Nobody in the family history suffered from alopecia areata, but her father has male androgenetic alopecia (Norwood/Hamilton MAGA C3F3).[ncbi.nlm.nih.gov]
  • Trichotillomania is a relatively common cause of childhood alopecia. We report our observations of 10 children with trichotillomania seen over a 2-year period at Texas Children's Hospital.[ncbi.nlm.nih.gov]
  • Considering the entire stepped care program, participants significantly reduced symptoms, alopecia, and impairment, and increased quality of life. For quality of life and symptom severity, there was some relapse by 3-month follow-up.[ncbi.nlm.nih.gov]
  • Trichotillomania is a form of traction alopecia resulting from repetitive and compulsive hair pulling and plucking. Trichotillomania and patchy alopecia areata may have similar clinical and dermoscopic features in some cases.[ncbi.nlm.nih.gov]
Compulsive Behavior
  • Pharmacologic modulation of the glutamate system may prove to be useful in the control of a range of compulsive behaviors. clinicaltrials.gov Identifier: NCT00354770.[ncbi.nlm.nih.gov]
  • While there are many theories for the cause of Trichotillomania, growing evidence to suggests the compulsive behavior is caused by stress, anxiety, depression and/ or additional mental disorders.[pavlok.com]
  • Interestingly, these feelings aren’t traditionally thought of as triggering compulsive behaviors.[yahoo.com]
  • Decreasing stress can help, because stress may increase compulsive behavior. References Morelli JG. Disorders of the hair. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 19th ed.[web.archive.org]
  • Trichotillomania is a compulsive behavior, which means that it’s difficult to stop. If you have this disorder, you have an overwhelming urge to pull out your hair.[newbeginningsdrugrehab.org]
Cognitive Deficit
  • Abstract Trichotillomania (hair pulling disorder, HPD) is characterized by significant psychological distress, childhood-onset, and, in adults, certain cognitive deficits such as inhibitory control.[ncbi.nlm.nih.gov]
  • In neuropsychological studies, patients with trichotillomania showed deficits on tests of divided attention, 42 response inhibition and working memory. 43, 44 The relationship between grey matter excesses and cognitive deficits in patients with trichotillomania[web.archive.org]

Workup

Microscopic examination of the collected plucked hair helps in the diagnosis of this condition. The pattern of hair suggests the anagen or telogen count. Anagen hair are typical of trichotillomania. Multiple longitudinal and transverse sections are obtained [7] [9]. The hair showing an exclamation mark are typical of alopecia areata. Biopsy from the scalp is the most reliable in achieving the diagnosis.

Microcytic Anemia
  • Laboratory tests revealed hypochromic microcytic anemia. Ultrasonographic study demonstrated intense sonic shadowing posterior to the gastric area.[ncbi.nlm.nih.gov]

Treatment

Before initiating any treatment, evaluation of the case is necessary. First determine whether the symptoms represent more of a habit than a real disorder. Secondly, one must evaluate whether the patient requires further investigations such as MRI or a CT scan to rule out further pathology such as trichobezoars syndrome. Thirdly, its necessary to evaluate the level to which the patient is affected psychologically [7] [10]. This is achieved with the help of a psychiatrist or a clinical psychologist.

The treatment is mainly with behavioral correction. This includes ways to reduce and deal with stress. Observing and evaluating one’s own behavior before and after the episodes. Training the patient by teaching them forms of alternative behavior during the time he feels the urge to start pulling hair. This alternative activity should be socially sound. They are encouraged to practice it regularly and frequently. Certain relaxation techniques are advised to help in relaxing the mind.

In general, for reversing this habit, the role of parents is very important. Initial aid needs parent’s attention and care [11]. They should support them socially and personally and communicate with them frequently.

Medications include antidepressants to reduce mental disturbance. These are mainly tricyclic antidepressants that act to interfere with the serotonin uptake by the neurons. Fluoxetine and sertraline are commonly used and they are found to be safe for children aged 8 to 17 years [7] [11].

Prognosis

Younger children show excellent prognosis as in them this disorder is more like a habit. As age increases the prognosis is usually fair. In older age group, the prognosis deteriorates and cure is rare. This illness causes more morbidity than mortality.

There is social and occupational distress especially in the adult age group. The illness usually lasts from weeks to many years; hence, a planned treatment under an excellent psychiatrist is very important. Eating of the pulled out hair leads to conditions such as anemia, gastric complaints, intestinal obstruction and also icterus [6] [7]. It must be immediately attended to.

Etiology

Theories suggest that an individual releases his or her stress and anxiety by pulling his hair. It like a coping mechanism for stress and is often to be present together with thumbsucking in younger patients [2]. It is related to compulsive disorders as changes are observed in certain neurotransmitters like serotonin, leading to obsessive compulsive disorder [3].

This is an inherited disorder and often runs in families. There are changes in a particular gene leading to trichotillomania. In some individuals, this disorder helps in easing out one’s emotional distress; hence, in a way they harm themselves to seek relief from anxiety and mental stress. Certain degenerative neurological disorders such as Parkinson’s and dementia are also associated with trichotillomania.

Epidemiology

Many individuals deny of suffering from this disorder. In the US, about 8 million people are estimated to be suffering from this illness. Trichotillomania is prevalent in all age groups, most commonly between 12-13 years. Females are more common and female to male ratio is 3 by 1 [4] [5].

Hair pulling areas differ with age. Those who are young are found to pull more of eyelashes and eyebrows and those with a significantly older age pull more of pubic hair [5].

Sex distribution
Age distribution

Pathophysiology

As trichotillomania is a psychiatric disorder, its neurobiological studies are inadequately conclusive. Certain studies reveal that changes in the basal ganglia lead to this habit forming disorder. After studying the MRI scans of about 18 patients of trichotillomania and other 18 normal healthy subjects, it was concluded that decrease in the cerebellar volume and increase in the amount of the gray matter were important findings noted with individuals suffering from trichotillomania. [7]

Prevention

Many individuals do not accept or want to be aware of the problem of hair plucking they suffer from until it’s too late. Hence, in order to stop its further progress firstly the person should be committed; he should accept his illness and increase his willingness to overcome the disorder. This can be achieved by noticing triggers, urges, feelings when he gets the desire.

The next step is to use obstacles such as wearing gloves, or clipping the hair together, shaving that part of hair to a very short size or even putting straps on fingers. This interrupts the activity and helps the person to become conscious before he attempts such an unwanted activity [12]. This repulsion of desire could lasts for few minutes or hours.

Aim should be made to increase the amount of plucking-free time. Patients should be encouraged and rewarded for every effort put by them in this process. Their emotions anxiety should be inquired and an appropriate counseling treatment should be initiated.

Summary

Trichotillomania is also called as trichotillosis. It’s an obsessive compulsive disorder where a person has a compulsive desire to pull out his hair resulting in mild to significant hair loss [1].

Most often, the person pulls scalp hair, but it can be from any other body part also such as eyebrows, eyelashes, beard or pubic area. This can result in baldness of that area. It has been categorized as a mental and behavioral abnormality. Any dermatologic link does not exist [1].

Patient Information

Trichotillomania is a psychological disorder in which the person gets a compulsive desire to pluck out his or her own hair. This desire is mainly from the scalp, but it can also include eyelashes, eyebrows, beard or hair from genital region. It affects all individuals. In kids it represents mostly a habit disorder but as it becomes more chronic it can transform into a serious illness. Teenage children are common victims of this disorder.

The cause is mainly mental disturbance, anxiety, depression, emotional trauma etc. they also suffer from social withdrawal due to embarrassment.

Treatment includes exclusive psychological counseling from an expert psychiatrist. Besides this, parents play a very important role. They need to understand their child’s problem and help him out. Motivation, encouragement and love help a child in overcoming his or her difficulties. They should teach their kids an alternative activity whenever the child gets the desire to perform the undesired hair pulling activity. This alternative method should be socially appropriate. The child should record his behavior and timing when he gets the urge. Certain mental easing out techniques helps the child in overcoming his anxieties and fears. Physically certain obstacles such as clipping the hair together or cutting the hair very short helps in reducing the urge.

References

Article

  1. Chamberlain SR, Odlaug BL, Boulougouris V, Fineberg NA, Grant JE. Trichotillomania: neurobiology and treatment. Neurosci Biobehav Rev. 2009 Jun;33(6):831-42.
  2. Watson TS, Allen KD. Elimination of thumb-sucking as a treatment for severe trichotillomania. J Am Acad Child Adolesc Psychiatry. Jul 1993;32(4):830-4
  3. Harrison JP, Franklin ME. Pediatric trichotillomania. Curr Psychiatry Rep. 2012 Jun;14(3):188-96..
  4. Franklin ME, Zagrabbe K, Benavides KL. Trichotillomania and its treatment: a review and recommendations. Expert Rev Neurother. 2011 Aug;11(8):1165-74
  5. Franklin ME, Flessner CA, Woods DW, Keuthen NJ, et al. The child and adolescent trichotillomania impact project: descriptive psychopathology, comorbidity, functional impairment, and treatment utilization. J Dev Behav Pediatr. 2008 Dec;29(6):493-500
  6. Keren M, Ron-Miara A, Feldman R, Tyano S. Some reflections on infancy-onset trichotillomania. Psychoanal Study Child. 2006;61:254-72
  7. Walsh KH, McDougle CJ. Trichotillomania. Presentation, etiology, diagnosis and therapy. Am J Clin Dermatol. 2001;2(5):327-33
  8. Chamberlain SR, Hampshire A, Menzies LA, Garyfallidis E, et al. Reduced brain white matter integrity in trichotillomania: a diffusion tensor imaging study. Arch Gen Psychiatry. 2010 Sep;67(9):965-71.
  9. Sachdeva A. Managing a case of trichotillomania with trichobezoar. Int J Trichology. 2013 Oct;5(4):228-30.
  10. Leombruni P, Gastaldi F. Oxcarbazepine for the treatment of trichotillomania. Clin Neuropharmacol. 2010 Mar-Apr;33(2):107-8.
  11. Virit O, Selek S, Savas HA, Kokaçya H. Improvement of restless legs syndrome and trichotillomania with aripiprazole. J Clin Pharm Ther. 2009 Dec;34(6):723-5.
  12. Peabody T, Reitz S, Smith J, Teti B. Clinical management of trichotillomania with bimatoprost. Optom Vis Sci. 2013 Jun;90(6):e167-71.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2019-07-11 21:42