Professional Documents
Culture Documents
MEDICAL EDUCATION
Trichotillomania
Giuseppe Hautmann, MD,a Jana Hercogova, MD,b and Torello Lotti, MDa
Florence, Italy, and Prague, Czech Republic
Trichotillomania is a neglected psychiatric disorder with dermatologic expression that has only recently
received research attention. On the basis of clinical data, trichotillomania appears to be far more common
than previously believed. Like obsessive-compulsive disorder, the hair-pulling behavior is recognized as
senseless and undesirable but is performed in response to several emotions and affects, such as increasing
anxiety, or unconscious conflicts with resultant tension relief. The condition may be episodic but is usually
chronic and difficult to treat. On the basis of possible medical and psychiatric complications, it is important
that the diagnosis is exact and early. We describe the comorbidity and the phenomenology of trichotillomania, paying attention to the possible available treatments. (J Am Acad Dermatol 2002;46:807-21.)
Learning objective: At the conclusion of this learning activity, participants should be familiar with clinical
and histologic aspects of trichotillomania and should be able to cope with the risks of medical and
psychiatric complications in these patients. Finally, participants will be able to easily interact with psychiatrists, when needed, to identify the most successful treatment.
EPIDEMIOLOGY
807
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CLINICAL FEATURES
Fig 1. Typical case of adult trichotillomania: tonsural pattern of baldness with hairs of varying length; shortest are
those more recently removed.
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CLINICAL ASSESSMENT
Severity of trichotillomania has been rated with 3
measures, summarized as follows34:
1. The Trichotillomania Symptom Severity Scale
(score range: 0-20), consisting of 5 items evaluating (1) average time spent pulling each day, (2)
average time spent pulling on the previous day,
(3) amount of resistance against the hair-pulling
urge, (4) degree of subjective distress, and (5)
interference with daily activity
2. The Trichotillomania Impairment Scale (score
range: 0-10): assessment of overall impairment
resulting from the trichotillomania, in which 0
represents total lack of symptoms and 10 indicates severe impairment (majority of time each
day spent pulling or resisting the urge to pull out
the hair, and large bald patches or total denudation evident)
3. Physicians Rating of Clinical Progress (score
range: 0-20): assessment of clinical change, in
which 0 represents a total cure, 10 the pretreatment baseline, and 20 the worst possible or total
incapacitation secondary to the trichotillomania.
The relative merits and disadvantages of many
assessment methods and instruments have been reviewed by Winchel, Jones, and Molcho.35 For clinical purposes, one can ask the patient to daily count
the pulled hairs and collect the hairs in envelopes.
However, patients who swallow their plucked hairs
must first stop this behavior. Patients can also be
asked to keep a diary that records each pulling
episode (duration, situation, precipitating factor,
and response), but some find this too time consuming. The National Institute for Mental Healths
(NIMH) Trichotillomania Questionnaire,36 a modified form of the Yale-Brown Obsessive-Compulsive
Scale (Y-BOCS), rates pulling behavior, but not related thoughts. The Psychiatric Institute Trichotillomania Scale allows the clinician to record the sites of
pulling and to rate on a 0-7 scale the quantity of
observable hair loss, time spent pulling and thinking
about pulling, success in resisting the impulse to
pull, distress related to trichotillomania, and the degree to which hair pulling interferes with activities.
The only validated self-rating scale is the Massachusetts General Hospital Hairpulling Scale.37,38 The
patient rates 7 items weekly on a 0-4 scale: the
frequency of urges to pull, their intensity, ability to
control the urges, frequency of hair pulling, attempts
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Fig 2. Histologic characteristics of trichotillomania. Infundibulum appears hyperkeratotic and dilated, in a relatively
noninflammatory dermis. (Hematoxylin-eosin stain; original magnification l00.)
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Fig 4. Histologic characteristics of trichotillomania. Atrophied follicle filled with the products of degeneration of
the hair matrix (hair keratin, pigment casts). Hair appears
dystrophic and separated from the internal epithelial
sheath. (Hematoxylin-eosin stain; original magnification
l00.)
Fig 3. Histologic characteristics of trichotillomania. Fragment of the hair shaft with hyperpigmentation. (Hematoxylin-eosin stain; original magnification 200.)
Fig 5. Histologic characteristics of trichotillomania. Massive fragmentation of the follicle not readily recognized
and substituted by intense fibrosis. (Hematoxylin-eosin
stain; original magnification 100.)
Trichotillomania entered the American Psychiatric Associations diagnostic classification system with
the 1987 publication of DSM-III-R, where it was
grouped with the Impulse-Control Disorders Not
Elsewhere Classified. DSM-IV48 added the criterion
causes clinically significant distress or impairment
to the 4 criteria contained in DSM-III-R (Table I).
Approximately 20% of individuals who chronically
pull out their hair do not meet DSM-IV criteria for
trichotillomania in that they deny the presence of
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However, the data begin to suggest that the prevalence of comorbid mood and anxiety disorders is
higher in individuals with trichotillomania than in
the general population. In the study by Christenson,
Mackenzie, and Mitchell,21 60 patients aged 18 to 61
years (mean standard deviation, 34 8 years)
were evaluated for hair pulling with a semistructured interview that utilized DSM-III-R criteria. Another set of estimates is provided by a study of 43
older children, adolescents, and adults (mean age,
30 11 years) who responded to advertisements for
drug studies at the NIMH and were evaluated with a
semistructured interview.46 This study utilized modified diagnostic criteria for trichotillomania; neither
gratification nor tension relief was required.
In a methodologically limited study, respondents
to print media materials that sought individuals with
trichotillomania or self-injury were mailed a survey
package.51 Only 16% of 772 individuals surveyed
returned usable questionnaires and recorded their
formally diagnosed disorders on a self-report form.
In addition to trichotillomania, which was reported
by 40% of these 123 respondents, 13% reported a
formal diagnosis of OCD; 14%, depressive disorder;
3%, bipolar disorder; 15%, anxiety disorder; and 7%,
substance abuse.
Case reports and small case series link trichotillomania to a variety of other disorders, but the diagnostic criteria vary widely. Most cases of the literature data reporting behavioral and hypnotic
treatments do not carry additional diagnoses, although patients are usually described as guilty,
ashamed, anxious, depressed, or suffering low selfesteem. Because of ascertainment and reporting
bias, conclusions about comorbid risk cannot be
drawn from these sources.
The prevalence of DSM Axis II personality disorders has been examined in 3 convenience samples,
but again, these figures cannot be generalized. The
limited diagnostic validity of all structured instruments used to evaluate personality disorders52 further complicates the interpretation of these data. In
a study to examine the prevalence of personality
disorders in subjects with trichotillomania and gender-matched patients seeking psychiatric treatment
at the same center, no differences were found between the two groups.49
RELATIONSHIP TO OCD
As anticipated in the abstract, the question is
whether trichotillomania is a syndrome on its own, a
form of OCD, or a symptom observed in various
disorders. It can be present as a major mental retardation symptom,53 in schizophrenia,54 in borderline
personality disorder,11 and in depression.43 Some
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PROGNOSIS
As already stated and observed by other authors,7,10,13,21,24,41 trichotillomania has periods of exacerbation and remission and in most cases is
chronic. According to some authors, there appears
to be both a remitting and a chronic form, which are
related to age at onset and sex distribution, with
older female patients being more susceptible to the
chronic form.21
TREATMENT
Treatment begins with taking a thorough history
of the disorder and its effects and inquiring after
possible comorbid conditions. The data reviewed
earlier suggest that mood and anxiety disorders will
commonly be found. No treatment approach has
been established as effective in a large controlled
trial. Case reports, small series, and a few uncontrolled and controlled trials present a variety of treatment methods that merit exploration. Patients are
often quite relieved to find that others pull out hair
and should be guided to organizations offering educational material and contact with kindred sufferers. Behavior therapy, hypnosis, insight-oriented
psychotherapy, and pharmacologic therapy have
been considered. Obviously, all these nonmedical
treatments require specialized training.
Behavior therapy
The behavior therapy literature shares the shortcomings of the pharmacotherapy literature: mostly
uncontrolled observations, short follow-up periods,
and a publication bias toward favorable outcomes.
Much of this literature is presented in detail elsewhere.71-74 All reports include at least two treatment
elements and most include at least 4, making it
difficult to identify the essential factors. Placebo effects and the nonspecific elements of supportive
psychotherapy may have contributed to the reported results. The first reported behavioral intervention for trichotillomania consisted of self-monitoring paired with response chain interruption,
whereby patients monitored their hair-pulling attempts and then told their hands to stop.70,75 Other
interventions are counting and recording hair
pulls,70,76 denial of privileges and applying eye
drops to stop pulling,77 aversive self-stimulation
with a rubber band,78-80 and punishment via sit-ups
whenever a pull attempt is made.81 Except for
Sapers study,64 at the end of treatment patients reported hair-pulling rates of zero.
Unfortunately, deriving conclusive evidence from
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proposed by Koran,39 is displayed in Table II; obviously, these guidelines are somewhat idealistic. We
first want to emphasize the relevance of a good
physician-patient relationship and a successful referral to a psychiatrist.
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Answer sheets are bound into the Journal for US, Canadian, and life members. Request additional
answer sheets from American Academy of Dermatology, Member Services Department, PO Box 4014,
Schaumburg, IL 60168-4014. Phone: 847-330-0230; E-mail: tsmith@aad.org
CME examination
Identification No. 802-106
Instructions for Category I CME credit appear in the front advertising section. See last page of Contents for page number.
in
in
in
in
3. In trichotillomania,
a. eyebrows are second in frequency as a hair-pulling site
b. extremities are never involved
c. the pubic region is a very frequent hair-pulling area
d. an itching sensation occurs when the eyelashes
are involved
e. approximately 12% of first-degree relatives of patients have also had it
4. Plucking is
a. diffuse to the scalp
b. confined to a single patch of varying size
c. confined to a single, scaly patch of varying size
d. confined to 2 or 3 patches that are 5 to 7 cm in
diameter
e. diffuse to the scalp that appears erythematous and
scaling
5. Patients with trichotillomania
a. usually present to psychiatrists early
b. always refuse to present to physicians
c. often present to a dermatologist after avoiding
dating for a long period
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e. unlike subjects with OCD, do not present abnormalities of serotonins cerebral spinal fluid metabolite
16. The most successful self-management treatment in
the remediation of hair pulling
a. is habit reversal
b. consists of self-monitoring
c. includes hair collection
d. is stimulus control
17. In the treatment of trichotillomania, the only drug
found to be effective appears to be
a. imipramine
b. fluoxetine
c. clomipramine
d. clomipramine intravenously administered
e. imipramine associated with desipramine
18. In the treatment of trichotillomania, according to a
chart review study, patients with a moderate response
to
a. clomipramine had marked improvement after the
addition of 8 mg/d of pimozide
b. imipramine had marked improvement after the
addition of 2 mg/d of pimozide
c. clomipramine had marked improvement after the
addition of 2 mg/d of pimozide
d. desipramine had marked improvement after the
addition of 2 mg/d of pimozide
19. In the treatment of trichotillomania, according to a
chart review study, patients with a moderate response
to
a. clomipramine had marked improvement after the
addition of 8 mg/d of risperidone
b. fluoxetine had marked improvement after the addition of 1 mg/d of risperidone
c. fluoxetine had marked improvement after the addition of 2 mg/d of risperidone
d. fluoxetine had marked improvement after the addition of 1 mg/kg per day of isotretinoin
e. clomipramine had marked improvement after the
addition of 1 mg/kg per day of isotretinoin
20. Which of the following are the diagnostic criteria of
DSM-IV for trichotillomania?
a. Acute pulling out of ones hair resulting in noticeable hair loss; an increasing sense of tension immediately before pulling out the hair or when
attempting to resist the behavior; pleasure, gratification, or relief when pulling out the hair; the
disturbance is not better accounted for by another
mental disorder and is not due to a general medical condition (eg, a dermatologic condition); the
disturbance causes clinically significant distress or
impairment in social, occupational, or other areas
of functioning
b. Recurrent pulling out of ones hair; an increasing
sense of tension immediately before pulling out
the hair or when attempting to resist the behavior;
pleasure, gratification, or relief when pulling out
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1.
2.
3.
4.
5.
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10.
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c
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826