Trichotillomania (Hair-Pulling Disorder) DSM-5 312. 39 (F63.2)

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Trichotillomania (Hair-pulling disorder)

Trichotillomania is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th ed.) diagnosis assigned to individuals who recurrently pull out their own hair. Individuals with trichotillomania feel compelled to pull hairs, either from their head or elsewhere, resulting in hair loss and other forms of impairment.

Introduction

Trichotillomania is an impulse control psychiatric disorder within the group of conditions known as body-focused repetitive behaviors (BFRBs). Such conditions are characterized by self-grooming through pulling, picking, scraping or biting the hair, nails or skin, often causing damage. (The TLC Foundation for Body-Focused Repetitive Behaviors 2018)

An individual with trichotillomania experiences an irresistible urge to pull out hair from the scalp or other places, such as the eyelashes or eyebrows. People with trichotillomania tend to feel rising tension until they pull out a hair, at which point they experience relief. Some sufferers of trichotillomania pull hairs out as a response to stress; others do it subconsciously. (NHS 2017)

The condition most commonly presents at or following the onset of puberty and is more prevalent among females than males at a ratio of 10:1. In any given year, between one and two per cent of the American population will be affected by trichotillomania. (American Psychiatric Association 2013)

Symptoms

If someone is suffering from trichotillomania, they will usually display various symptoms, including:

  • Constant pulling or twisting hair
  • Bald patches or hair loss
  • Uneven hair appearance
  • Denial of the hair pulling
  • Obstructed bowels if the hair is consumed
  • Tension before hair is pulled and relief or gratification after
  • Other self-injury behaviors
  • Poor self-image
  • Feeling sad, depressed or anxious

(US National Library of Medicine 2016)

Symptoms of trichotillomania usually begin before the age of 17 and many are commonly seen in children and young people.

The majority of people with trichotillomania pull hair from their scalps but others may pull out hair from their eyebrows, eyelashes, genital area, beard or moustache.

Diagnostic criteria for trichotillomania

For a diagnosis of trichotillomania to be made, a medical professional will be looking for the following diagnostic criteria:

  1. The individual pulls their hair out on a recurrent basis, which results in hair loss.
  2. Repeated attempts have been made to reduce or stop the hair pulling altogether.
  3. The hair pulling causes significant distress or impairment in areas of occupational, social or other regions of functioning.
  4. The hair pulling cannot be better attributed to another medical condition.
  5. The hair pulling cannot be better explained as a symptom of another mental disorder.

An individual with trichotillomania will find that the distress caused by the condition affects areas of their life, such as at work or school, during leisure time or learning. They may experience feelings of embarrassment and shame or loss of control, and avoid social situations as a result.

The hair pulling does not usually occur in the presence of others with the exception in some cases for immediate family members. Sufferers may also attempt to pull hair from other people, or from pets or toys.

Some people search out a specific type of hair to pull, or remove hairs in a specific way, such as to keep the root intact. They may break or manipulate the hair afterwards, bite or swallow it. The hair pulling may be accompanied by an emotional state or preceded by an itch-like feeling or tingling that resolves when the hair is pulled.

An individual displaying the symptoms or trichotillomania will usually be given a thorough psychiatric assessment to ensure diagnosis is accurate and to identify any co-occurring disorders. They will also receive a medical evaluation if they admit to ingesting the hair. (American Psychiatric Association 2013)

A diagnostic questionnaire may be used incorporating the National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS) and the National Institute of Mental Health Trichotillomania Impairment Scale (NIMH-TIS). Photographs of the pulling sites may also be used to gauge severity. (Franklin, M. E. et al 2011)

Causes of trichotillomania

There is no single known cause of trichotillomania but research suggests a number of factors may contribute to onset of the disorder.

Scientists have identified that some people may be genetically predisposed to developing trichotillomania, while individuals with obsessive compulsive disorder (OCD) - or whose first-degree relatives have OCD - are more likely to be diagnosed with trichotillomania than other people.

Characterized by recurrent and persistent thoughts, urges or behaviors, obsessive compulsive conditions compel an individual to imagine something recurrently or perform a behavior over and over again, compulsively or obsessively. (American Psychiatric Association 2013)

Other factors that may contribute to the onset of trichotillomania include:

  • A chemical imbalance in the brain
  • Hormonal changes during puberty
  • A coping mechanism for dealing with stress
  • A form of self-harm to relieve distress

(NHS 2017)

Comorbidity

Trichotillomania often occurs alongside another mental condition, commonly major depressive disorder or skin-picking disorder (excoriation).

Many people with trichotillomania will also display other body-focused symptoms alongside hair pulling and skin picking such as nail biting, which may suggest other obsessive-compulsive or body-focused repetitive behaviour disorders may be present. (American Psychiatric Association 2013)

Trichotillomania may also occur with other disorders; studies have shown that among people with trichotillomania, up to a third also have an anxiety disorder, while up to 19 per cent have a co-occurring substance use disorder. (Grant, J. E., & Chamberlain, S. R. 2016)

Differential diagnosis

In some instances, hair may be manipulated or pulled out for cosmetic reasons. Individuals may remove hair to improve their physical appearance, or may twist the hair or even bite it as part of normative behavior - not to be confused with trichotillomania.

Other obsessive compulsive disorders may share features of trichotillomiania, with sufferers of OCD sometimes pulling hairs to create a symmetrical appearance. Likewise, those with body dysmorphic disorder may remove hair that they think is ugly. In neither case is the diagnosis trichotillomania.

Some psychotic disorders may incite sufferers to remove hair during delusions or hallucinations, while substance abuse - of stimulants, for example - may also make individuals more prone to pulling hair. Other neurodevelopmental disorders may feature hair pulling as a stereotypy.

Hair pulling and loss may also be attributed to another medical condition, such as dermatological disorders, alopecia and folliculitis decalvans. In these instances, a skin biopsy may be carried out to ensure correct diagnosis. (American Psychiatric Association 2013)

Living with trichotillomania

People affected by trichotillomania can be mildly or severely affected by the condition. While some individuals might find the disorder frustrating or annoying, others may be embarrassed or ashamed of their condition, becoming withdrawn and avoiding social situations out of fear that the disorder should be discovered. Trichotillomania can come and go, lasting for weeks, months or even years at a time.

Sufferers can experience emotional distress and isolation, which increases the risk of co-occurring mental disorders. Trichotillomania can also cause individuals to become tense and put a strain on a person’s relationships with friends and family. (The TLC Foundation for Body-Focused Repetitive Behaviors 2018)

Someone with trichotillomania may also be susceptible to a number of physical effects, including infection, tissue damage and injuries to the muscles or joints as a result of repetitive motion. Other complications include carpal tunnel syndrome, worn or broken teeth, back, shoulder and neck pain, irreversible damage to hair growth and swollen, inflamed eyelids from where hair has been repeatedly pulled out.

Individuals who consume the hair after pulling it out risk developing intestinal blockages, which can be serious and have significant knock-on effects, such as nausea and vomiting, stomach pain, anemia and even bowel perforation. (American Psychiatric Association 2013)

Treatment for trichotillomania

Although trichotillomania is usually a chronic condition, the disorder can be treated to manage and relieve the symptoms. Often, trichotillomania will be treated with therapy and medication but there are numerous ways in which sufferers can support their own recovery.

When the urge arises, instead of pulling out hair, sufferers can try:

  • Using a fidget toy or squeezing a stress ball
  • Relieving stress by taking a hot bath
  • Breathing deeply until the urge has subsided
  • Tensing the arm to form a fist
  • Keeping hair cut short or wearing a tightly-fitting hat
  • Exercising
  • Repeating a phrase out loud until the urge has passed

(NHS 2017)

Treatment for trichotillomania usually involves a combination of medication and therapy. Behavioral therapy is commonly advised, which involves encouraging sufferers to keep track of their symptoms and any associated behaviors, helping them develop techniques to reverse the habit and substitute unhelpful behaviors.

Medication may help provide relief from trichotillomania, treating depressive and obsessive-compulsive symptoms. The most commonly prescribed medications include:

  • fluoxetine (Prozac)
  • sertraline (Zoloft)
  • fluvoxamine (Luvox)
  • paroxetine (Paxil)
  • clomipramine (Anafranil)
  • valproate (Depakote)
  • lithium (Lithobid, Eskalith)

(Mental Health America 2018)


Dr. Kevin Fleming obtained his PhD from Notre Dame and is the Founder of Grey Matters International (www.greymattersintl.com) a neuroscience-based behavior change consulting firm.

References

The TLC Foundation for Body-Focused Repetitive Behaviors (2018) What is Trichotillomania? http://www.bfrb.org/learn-about-bfrbs/trichotillomania Date Accessed: 05/12/2018.

NHS (2017) Trichotillomania (hair pulling disorder) https://www.nhs.uk/conditions/trichotillomania/ Date Accessed: 05/12/2018.

American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

US National Library of Medicine (2016) Trichotillomania https://medlineplus.gov/ency/article/001517.htm Date Accessed: 05/12/2018.

Franklin, M. E., Zagrabbe, K., & Benavides, K. L. (2011). Trichotillomania and its treatment: a review and recommendations. Expert Review of Neurotherapeutics, 11(8), 1165–1174. http://doi.org/10.1586/ern.11.93

Grant, J. E., & Chamberlain, S. R. (2016). Trichotillomania. The American Journal of Psychiatry, 173(9), 868–874. http://doi.org/10.1176/appi.ajp.2016.15111432
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5328413/

Mental Health America (2018) Trichotillomania (Hair Pulling) http://www.mentalhealthamerica.net/conditions/trichotillomania-hair-pulling Date Accessed: 05/12/2018.


Dr. Kevin Fleming obtained his PhD from Notre Dame and is the Founder of Grey Matters International (www.greymattersintl.com) a neuroscience-based behavior change consulting firm.

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