Trichotillomania is a potentially disfiguring behavior disorder characterized by the intentional removal of hair from the scalp, eyebrows, eyelashes, beard, axillary area or pubic area. It may be accompanied by trichophagy (the ingestion of hair). If trichotillomania is left untreated, further psychologic complications may develop.
An estimated 4 percent of the population currently are hair pullers, and approximately 10 percent have had the habit at some time in their lives.(1) Most cases of trichotillomania do not come to the attention of physicians. Mild cases often go unnoticed, and denial of hair-pulling behavior frequently is an associated feature. Patients who pull their own hair often seek dermatologic evaluation.
Trichotillomania is more common in children than in adults and occurs more frequently in women than in men. Hair pulling is the chief complaint in about 0.5 percent of all patients who present to children's mental health services., The scalp is the most frequent site of hair pulling Figure 1), followed by the eyebrows, eyelashes, axillary areas and pubic areas. Facial hair pulling has been reported in men.
Patients with trichotillomania may initially rationalize their hair-pulling behavior. There may be a history of attempts to conceal the hair loss. Other self-stimulatory behaviors, such as nail biting, thumb sucking, enuresis and encopresis, may be present. Despite the trauma associated with hair pulling, patients frequently report littleornopain.(3) If trichophagy is also present, patients may report loss of appetite, abdominal pain, diarrhea or constipation.
All patients who present with hair loss should undergo a thorough physical examination. Medical causes of hair loss or skin inflammation, such as medication, endocrinopathy, lymphoma, systemic lupus erythematosus, nutritional deficiency and infection, should be excluded in the diagnostic work-up.
A complete history also should be included in the medical work-up of patients presenting with hair loss. Important historical factors in the assessment of trichotillomania are listed in Table 1. Predisposing factors are listed in Table 2.
Hair pulling may be associated with a variety of intense emotional states. It has been related to disturbance in the motherchild relationship or maternal deprivation during the early developmental years. Threatened loss, through illness, birth of a sibling, divorce or other circumstances, is also frequently involved. It may be possible to observe the patient engaging in hair pulling, usually at times of tension during a family interview, such as a discussion of marital conflicts.
Hair loss from trichotillomania usually follows an ill-defined linear configuration, with the remainder of the scalp appearing normal.(4)In severe cases, complete baldness may be seen. The scalp usually is not inflamed, atrophied or scarred.(5) Scalp examination with a Wood's lamp is negative to fluorescence. Microscopic examination of the scalp is rarely necessary when a careful history has been obtained and a thorough physical examination has been performed. However, several microscopic findings have been reported to be consistent with trichotillomania(4,5) (Table 3).
The criteria listed in the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) for the diagnosis of trichotillomania are presented in Table 4.6 These criteria emphasize the obsessive-compulsive features of the disorder that are found in many cases. The diagnosis of trichotillomania is excluded when there is a preexisting skin disorder or when the behavior results from psychosis.
A variety of psychiatric illnesses frequently underlie hair pulling (Table 5).
Adjustment disorders related to family, school or medical difficulties are probably the most common associated psychiatric problems. Hair-pulling behavior may begin or worsen after stressful life events. It may be one of the restless behaviors in attention-deficit hyperactivity disorder. Anxiety, depression and addictive disorders are common in patients with trichotillomania.(3) Self-destructive behaviors may serve to relieve anxiety in some patients.
In the recent literature, hair pulling has frequently been reported in association with obsessive-compulsive disorder. (7,8) The behaviors of patients with trichotillomania are similar to those of patients with other obsessions and/or compulsions. However, the chief obsessive-compulsive behaviors, such as repetitious checking and washing activities, are not commonly reported in patients with trichotillomania. In addition, the higher prevalence of hair pulling in women is not characteristic of other forms of obsessive-compulsive disorder.
Pathologic hair pulling first presenting in adulthood often results from psychosis or organic brain conditions. The psychosis of schizophrenia, mania, depression or organic brain conditions may cause delusions or hallucinations involving the hair, which may result in hair pulling. However, according to the diagnostic criteria in DSM-III-R, the presence of psychosis excludes the diagnosis of trichotillomania.
Family dynamics may play a role in trichotillomania. The patient is commonly the eldest or only child in the family. Trichotillomania may serve to distract attention from the parents' marital conflict. Siblings of the patient commonly have distant relationships with the rest of the family.
The relationship between the patient and one or both parents is often overly intense and ambivalent. There may be much hostility and provocation in the relationship, although there are cases in which trichotillomania has a minimal family component.
Therapeutic approaches that have been reported to be effective in trichotillomania include behavior modification therapy, hypnosis, psychotropic medication, psychotherapy and/or play therapy, and family therapy. A combination of therapies is often used.
Behavior modification therapy is the treatment of choice for patients in whom hair pulling is an isolated problem and who have no other underlying psychiatric disturbance or family problem. Over the past 20 years, effective results have been reported more often for behavioral treatments than for any other form of treatment.
Some type of self-monitoring should be recommended initially, both for determining a baseline and as a form of treatment. Self-monitoring enhances patient awareness of hair-pulling behavior and may serve as a mildly aversive stimulus. Patients who record the number of hairpulling episodes and the time spent pulling hair or saving hair may be able to substantially reduce the frequency of hair pulling.
Relaxation training can also be prescribed. This approach may include progressive muscle relaxation, autogenic training, meditation or metronome-conditioned relaxation. While a reduction in the frequency of hair pulling has been found to occur when relaxation therapy is the only intervention, the effect does not seem to be long-lasting. Thus, relaxation therapy is generally used in combination with other treatments.
Positive reinforcement through verbal praise or token rewards is included in the usual treatment program. In patients with longstanding social isolation resulting from trichotillomania, counseling in social skills facilitates recovery. Negative reinforcing behaviors, such as extra attention following hair-pulling episodes, should be eliminated.
Cognitive-behavioral techniques may control the behavior by changing thought patterns, reframing antecedent events, correcting maladaptive beliefs and encouraging positive self-assessment. Patients can be asked to report the thoughts they had during anxiety-provoking situations. When these thoughts involve self-defeating evaluations of themselves, more adaptive thoughts can be suggested. Habit reversal techniques include awareness training, habit control motivation and learning an incompatible competing response pattern (e.g., grasping objects instead of hair). These techniques have been reported to be successful in the treatment of trichotillomania,(9)but only after the patient's level of anxiety has been reduced through the acquisition of a more effective coping style.
In developmentally disabled persons, facial "screening" and overcorrection have been successful in the treatment of trichotillomania.(10-12) Facial screening involves briefly covering the patient's face with a nonabrasive terry-cloth bib after an episode of hair pulling. Overcorrection involves repeating appropriate grooming behaviors a specified number of times after a hair-pulling episode. Hypnosis may be used alone or in combination with other forms of treatment to encourage constructive behavior. 13 While in the hypnotic trance, the patient is reminded of his or her desire for attractive hair and is given suggestions for good hair grooming. It is also suggested during the trance that the patient will be aware of impending hair-pulling urges in the future and will avoid giving in to these urges by concentrating on a powerful thought.
Medication should be considered when psychiatric illness coexists with trichotillomania. In case studies, the usual therapeutic dosages of the antidepressant medications amitriptyline (Elavil, Endep), fluoxetine (Prozac) and isocarboxazid (Marplan) have been effective in treating cases of trichotillomania with predominantly obsessive-compulsive or depressive features.(7,14,15) In a recent study,(8) clomipramine (Anafranil), a new antidepressant prescribed for obsessive-compulsive disorders, has been reported to be more effective than desipramine (Norpramin, Pertofrane) for the treatment of trichotillomania. Hair pulling that results from underlying psychosis has been relieved by neuroleptic agents. Definitive studies comparing pharmacologic therapy with other treatments for trichotillomania are lacking.
Psychotherapy or play therapy can relieve symptoms through the exploration of underlying, usually multiply-determined conflicts. Enhancing awareness of feelings and challenging negative self images and cognitions may be important components of this therapy. Psychoanalytic psychotherapy has been reported to be successful in the treatment of trichotillomania associated with other psychiatric illness, but the duration of therapy is usually two or three years.
When possible, family therapy should encourage parents to negotiate and resolve marital conflicts in a controlled manner in front of the young patient. In this way, the patient learns that conflict expression and resolution are not necessarily dangerous." If the parent-child relationship is overly dependent, the child should be encouraged to participate in outside activities, and the parents should be encouraged to develop their own relationship. In some adult patients, separation from the family may promote recovery.
COPYRIGHT 1991 American Academy of Family Physicians
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