AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Trichotillomania is an anxiety disorder characterized by the persistent and excessive pulling of one's own hair, resulting in noticeable hair loss. In 1889, Hallopeau, a Greek dermatologist, first used the word trichotillomania to describe a patient who pulled out his hair. Despite this first description of trichotillomania in the late 1800s, little is understood about the disorder in children.

Hair pulling can occur on any part of the body where hair grows. The most common area of hair pulling is the scalp. However, hair pulling also can occur on the eyebrows, eyelashes, pubic region, and any other area of the body with hair. The alopecia that results from hair pulling can range from small undetectable areas of hair loss to total baldness.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) classifies trichotillomania as an impulse-control disorder. The hair-pulling behavior can occur during both relaxed and stressful times, but people with trichotillomania often experience a mounting sense of tension before hair pulling occurs or when attempting to resist the behavior. In addition, as noted in the DSM-IV, a "gratification" or "sense of relief" occurs after the hair is pulled. Therefore, at times, trichotillomania may be described better as a type of obsessive-compulsive disorder (OCD) due to its compulsivelike nature.

In many individuals, adolescent-onset trichotillomania indicates more severe psychopathology as an impulse-control disorder or OCD, whereas preschool-onset trichotillomania often is described as a childhood habit disorder. Trichotillomania in younger children often is mistaken for a short-term habit of hair pulling; therefore, careful analysis of the duration of the behavior is important for making the diagnosis because the behavior must last several months to be considered trichotillomania.

Trichotillomania can cause a child to experience distress and may result in impaired social or family functioning. Many times, children feel ashamed and embarrassed by the hair loss caused by pulling. Additionally, trichotillomania may result in impairment in other important areas of functioning.

The DSM-IV diagnostic criteria for trichotillomania are (1) recurrent pulling out of one's hair, resulting in noticeable hair loss, (2) an increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior, (3) pleasure, gratification, 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 general medical condition (eg, a dermatologic condition), and (5) the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Pathophysiology

Trichotillomania results in highly variable patterns of hair loss. The scalp is the most common area of hair pulling, followed by the eyebrows, eyelashes, pubic and perirectal areas, axilla, limbs, torso, and face. The resulting alopecia can range from thin unnoticeable areas of hair loss to total baldness in the area(s) being plucked. In addition, trichophagia (ie, mouthing and/or ingesting hair) is common in persons who pull out their hair. This chewing or mouthing behavior frequently can lead to the formation of trichobezoars (ie, hair casts) in the stomach or small intestines. Trichobezoars can result in anemia, abdominal pain, hematemesis, nausea and/or vomiting, bowel obstruction, perforation, gastrointestinal (GI) bleeding, acute pancreatitis, and obstructive jaundice.

Frequency

United States

Accurate prevalence rates of trichotillomania are difficult to approximate due to the frequent denial of the disorder and the failure of many individuals with the disorder to seek professional intervention. Therefore, as indicated in the DSM-IV, exact systematic data on prevalence rates of trichotillomania are limited.

Although US epidemiologic studies on the prevalence rate of trichotillomania are rare, estimates indicate that approximately 8 million people have trichotillomania. An accurate prevalence rate is difficult to achieve because of individuals who attempt to hide the disorder. Future studies are needed to confirm the prevalence rates. In a study of college students, approximately 1-2% had past or current symptoms of trichotillomania. Although empiric data are not available, some studies indicate that substantially more children suffer from trichotillomania than adults.

Mortality/Morbidity

Trichotillomania results in highly variable patterns of hair loss, ranging from small undetectable patches of hair loss to total baldness. Ingestion of the pulled hair can result in trichobezoar formation and subsequent anemia, abdominal pain, hematemesis, nausea and/or vomiting, bowel obstruction, perforation, GI bleeding, pancreatitis, and obstructive jaundice.

Race

No prevalence rates of trichotillomania among various racial groups are available.

Sex

In children, trichotillomania typically is observed in equal numbers of males and females. Among adults, more females than males present with the disorder. Exact estimates of sex differences are limited.

Age

Trichotillomania frequently is a chronic disorder (lasting weeks to decades) with a variable age of onset. According to the DSM-IV, the following age data exist:

• The mean age of onset is 13 years with an average duration of 21 years.
• Peaks of onset exist (ie, in children aged 5-8 y, in adolescents aged 13 y).
• Adults with the disorder frequently report onset in childhood. Children as young as 1 year have been diagnosed with trichotillomania.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

The diagnosis of trichotillomania can be difficult to make. Symptoms may include pulling hair (resulting in alopecia), denying hair-pulling behavior, pulling hairs from other objects or people, avoiding social situations, experiencing increased stress and anxiety levels, and experiencing GI complaints related to trichobezoar formation.

• Pulling hair: Patients may report hair loss related directly to hair pulling or plucking. However, unexplainable alopecia or hair loss frequently is the complaint because the behavior typically is conducted in private and subsequently denied.
• Denying hair pulling: Children often deny hair pulling. Because the behavior usually is not conducted in the presence of adults or others, it often is difficult to diagnose as self-inflicted hair loss.
• Pulling hairs from other objects or people: Occasionally, patients may engage in hair pulling or plucking from other people, pets, dolls, or other fibrous materials (eg, carpets).
• Avoiding social situations: Some individuals may avoid social situations to maintain the privacy to engage in hair-pulling behavior and to escape the embarrassment such behavior may bring.
• Experiencing increased stress levels and/or anxiety: Although hair pulling can occur during periods of relaxation, increased stress frequently precipitates or exacerbates trichotillomania. Furthermore, patients may present with anxiety, which they may not report, associated with their hair-pulling behavior.
• Experiencing GI complaints: Trichobezoar formation or hair casts can lead to complaints of abdominal pain, nausea and/or vomiting, constipation or other symptoms of bowel obstruction, and GI bleeding.

Physical

Physical signs of trichotillomania may include variable patterns of alopecia or hair thinning, hair abnormalities, and trichobezoar formation.

• Alopecia: The area(s) of alopecia can range from barely noticeable areas of hair loss to total baldness. The scalp is the most common area of hair pulling; however, hairs may be pulled from the eyebrows, eyelashes, pubic and perirectal areas, axilla, limbs, torso, and face. In addition, the absence of eyebrows and eyelashes can indicate a more serious form of trichotillomania.
• • Friar Tuck sign: This common presentation of trichotillomania includes areas of hair loss with broken hairs of varying lengths arranged in a circular pattern. Thus, unaffected hairs surround an area of hair loss.
  • Hair regrowth: Patients may exhibit signs of variable lengths of hair during the regrowing phase.
  • Absence of skin abnormalities or inflammation: Individuals with trichotillomania do not typically exhibit signs of excoriation or other dermatologic pathology that may be common in individuals with tinea capitis.
• Hair abnormalities
• • Empty and/or damaged hair follicles
  • Twisted and/or broken hairs of varying length
  • Wavy, wrinkled, or corkscrew-shaped hair shafts
• Trichobezoars
• • Trichobezoars can develop as a result of the ingestion of plucked hairs.
  • Trichobezoars are hair casts and typically are found in the stomach and intestines of patients who chew or mouth their pulled hairs.
  • As a result, anemia, abdominal pain, hematemesis, nausea and/or vomiting, bowel obstruction, perforation, GI bleeding, pancreatitis, and obstructive jaundice may occur.

Causes

The etiology of trichotillomania continues to be unknown. However, the following explanations are proposed hypotheses for the onset and maintenance of the hair-pulling behavior:

• Serotonin deficiency: A link may exist between a deficiency of the neurotransmitter serotonin (5-hydroxytryptamine [5-HT]) and trichotillomania; this hypothesis is due to the success of selective serotonin reuptake inhibitors (SSRIs) in treating some people with trichotillomania.
• Structural brain abnormalities: Magnetic resonance imaging (MRI) studies have demonstrated that some individuals with trichotillomania have abnormalities of the lenticulate.
• Abnormal brain metabolism: Positron emission tomography (PET) scans have revealed that some individuals with trichotillomania have a high metabolic glucose rate in the global, bilateral, cerebellar, and right superior parietal areas.
• Psychological theories: Several psychological theories, including psychodynamic, behavioral, and ethological theories, have attempted to explain trichotillomania in children.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Tinea capitis
Alopecia areata (Approximately 33% of children who have trichotillomania are misdiagnosed as having alopecia areata. Therefore, a confirmed thorough assessment is important.)
Traction alopecia
Male pattern baldness
Other causes of alopecia (eg, infections, medications, febrile illnesses, crash diets)
Other mental disorders
Systematic diseases (eg, cancer, leukemia, Hodgkin disease, cirrhosis, hypothyroidism, tuberculosis)
Anxiety Disorder: Habit
Stereotypic movement disorder
Factitious disorder with predominately physical signs and symptoms
Short-term habit in children

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Imaging Studies

• Ultrasonography and computed tomography (CT) scans may be useful in detecting trichobezoar formation that can result from swallowing and/or ingesting plucked hairs in children with trichotillomania.

Procedures

• Histologic procedures may aid in the diagnosis of suspected trichotillomania in children.
• Punch biopsy may be used to verify a suspected diagnosis of trichotillomania. The following are positive results of punch biopsies on individuals with trichotillomania:
• • High frequency of telogen hairs
  • High frequency of noninflamed catagen hairs, which may be deformed
  • Melanin pigment casts and granules in the upper hair follicles and infundibulum of hair shaft
• A trichogram (ie, hair pluck) can help verify a diagnosis of trichotillomania. This procedure reveals newly growing anagen hairs with tapered unpigmented distal ends and a low incidence of telogen hairs due to the immediate plucking of hairs when they are long enough to remove.

Histologic Findings

See Procedures.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

After a diagnosis of trichotillomania is confirmed through a workup, take the following actions:

• Determine whether the symptomology represents a short-term childhood habit.
• Determine whether the symptoms are indicative of a more serious psychological problem through consultation and collaboration with a psychiatrist, developmental-behavioral pediatrician, or licensed clinical psychologist. Consultation is recommended and may be required for choosing various treatment options.
• Recognize that children with presenting symptoms of trichobezoars may require further evaluation through ultrasonography and/or MRI and/or CT scan.

Surgical Care

Consider removal of trichobezoars in the stomach and intestines.

Consultations

Consult with psychiatry, psychology, or developmental-behavioral pediatrics specialists.

• As suggested by several studies, the first line of treatment in children who present with hair pulling is behavioral treatment and intervention.
• Effective behavioral strategies in the treatment of trichotillomania in children include the following:
• • Habit reversal - This is a set of procedures taught to a child, which include the following components: increasing the child's awareness of the habit; teaching the child a competing response to practice when they feel the urge to engage in the habit, in situations where the habit historically occurs or for 1 minute following the occurrence of the habit; practicing stress/anxiety reduction procedures on a daily basis; and support and encouragement from parents.
  • Self-monitoring - Self-monitoring involves systematically observing and discriminating when the behavior occurs, recording the responses, and evaluating one's own behavior.
  • Competing reaction training - Competing response or reaction training is one component of habit reversal, which is occasionally used alone. A child is taught a socially appropriate alternative behavior or response, which they are encouraged to practice on a daily basis when they feel the urge to engage in the habit, in situations where the habit historically occurs or for 1 minute following the occurrence of the habit.
  • Relaxation training - Relaxation training involves helping children to identify their own bodily sensations associated with tension and then to use procedures designed to induce relaxation. Typically this approach is individualized and may include such procedures as deep-breathing strategies and systematic muscle tensing and relaxation.
  • Psychotherapy - Psychotherapy is a process that involves direct communication between a therapist and a child, mainly in the form of talking, using various techniques to help solve behavioral and other psychological problems. One of the most popular forms of psychotherapy is cognitive behavioral therapy.
  • Hypnosis - Hypnosis is a process of controlling physiologic responses by focusing attention on specific mental images for therapeutic purposes, typically to gain more control over behavior, emotions, or physical well-being. Hypnotic procedures often involve having the child visualize an experience to facilitate induction, during which time they concentrate intensely on a specific thought, memory, feeling, or sensation while blocking out distractions. In this state, the child is more open than usual to suggestions (provided by the hypnotist) for subsequent changes in behavior.
  • Elimination of a comorbid behavior - In cases where two seemingly different behaviors occur together (eg, trichotillomania and thumb sucking), a treatment to reduce or change one behavior may also result in a change or reduction in the comorbid behavior.

Diet

A child with trichotillomania requires no special diet.

Activity

No activity limitations are suggested for a child with trichotillomania. However, if the hair-pulling behavior is associated with a specific activity, that specific activity may require close monitoring. As indicated in a study of individuals with trichotillomania, the following are possible activities during which patients with trichotillomania may engage in hair pulling:

• Watching television
• Reading
• Talking on the phone
• Lying in bed
• Driving
• Writing or doing paperwork

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Few drug studies on trichotillomania in children and adults exist. However, SSRIs have demonstrated a degree of effectiveness in some patients with trichotillomania. In children, SSRIs (eg, fluoxetine, sertraline, fluvoxamine) may be more advantageous as a medication choice than tricyclic antidepressants (TCAs) because of their milder adverse effects.

Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with antidepressants in the pediatric population.

In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients treated with antidepressant medications. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed, because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.

However, a recent study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declines, not rises, with the use of antidepressants. This is the largest study to date to address this issue.

Currently, evidence does not exist to associate OCD and other anxiety disorders treated with SSRIs with an increased risk of suicide.

Drug Category: Selective serotonin reuptake inhibitors (SSRIs)

Antidepressant agents chemically unrelated to tricyclic, tetracyclic, or other available antidepressants. Inhibits CNS neuronal uptake of serotonin (5-HT). May also have weak effect on norepinephrine and dopamine neuronal reuptake.

SSRIs are greatly preferred over the other classes of antidepressants. Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with mood disorder.

Drug Category: Tricyclic antidepressants (TCAs)

These antidepressants are structurally related to phenothiazine antipsychotic agents. They exhibit 3 major pharmacologic actions in varying degrees (ie, amine pump inhibition, sedation, anticholinergic action [peripheral and central]). They also inhibit reuptake of norepinephrine or serotonin (ie, 5-hydroxytryptamine, 5-HT) at the presynaptic neuron.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Consult mental health professionals for further assessment and possible treatment modalities.
• A record of hair pulling and/or the saving of plucked hairs may be required to confirm a diagnosis of trichotillomania. However, use caution when depending on patient self-reporting and/or records from children, because some may engage in trichophagia and consume pulled hairs or pluck hairs in privacy to hide the severity of the disorder.

Complications

• Treating trichotillomania in children may be difficult due to the low reliability and validity of self-report.
• Children often pull their hair in private.
• Trichotillomania can result in alopecia, hair abnormalities, and, if the pulled hair is ingested, trichobezoar formation with associated medical complications (see Clinical).

Prognosis

• Trichotillomania can become a chronic and persistent condition of hair pulling. Specifically, symptoms of trichotillomania can persist for weeks to decades. Therefore, comprehensive treatment planning is critical and may require consultations with mental health professionals.
• Hair pulling that occurs in young children may be described more accurately as a short-term habit disorder.

Patient Education

• For excellent patient education resources, visit eMedicine's Anxiety Center. Also, see eMedicine's patient education articles, Anxiety, Panic Attacks, and Hyperventilation.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Special Concerns

• Assess symptoms of trichotillomania in children throughout a period of several months to confirm a correct diagnosis. Children can acquire a short-term habit of hair pulling that closely resembles trichotillomania. Therefore, several visits may be required to confirm a true trichotillomania diagnosis.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• American Academy of Child and Adolescent Psychiatry. Textbook of Child and Adolescent Psychiatry. 2nd ed. American Psychiatric Press;1997.
• American Psychiatric Association. DSM-IV: Diagnostic & Statistical Manual of Mental Disorders. 4th ed. American Psychiatric Association;1994.
• Bordnick PS. Trichotillomania: a social worker's guide to practice. Research on Social Work Practice. 1997;7(2):216-28.
• Christenson GA, Pyle RL, Mitchell JE. Estimated lifetime prevalence of trichotillomania in college students. J Clin Psychiatry. Oct 1991;52(10):415-7. [Medline].
• Christenson GA, Mackenzie TB, Mitchell JE, Callies AL. A placebo-controlled, double-blind crossover study of fluoxetine in trichotillomania. Am J Psychiatry. Nov 1991;148(11):1566-71. [Medline].
• Clore ER, Corey A. Hair loss in children and adolescents. J Pediatr Health Care. Sep-Oct 1991;5(5):245-50. [Medline].
• Dimino-Emme L, Camisa C. Trichotillomania associated with the "Friar Tuck sign" and nail-biting. Cutis. Feb 1991;47(2):107-10. [Medline].
• Hallopeau M. Alopecie par grottage (trichomanie ou trichotillomani). Ann de Dermatolofie et Venerologie. 1889;10:440-41.
• Jacobs C, Piacentini J, McCracken J. Childhood trichotillomania: Presentation of 8 cases using habit reversal training. Presented at: the Annual Conference of the Association for Advancement of Behavior. November 1997.
• King RA, Scahill L, Vitulano LA, et al. Childhood trichotillomania: clinical phenomenology, comorbidity, and family genetics. J Am Acad Child Adolesc Psychiatry. Nov 1995;34(11):1451-9. [Medline].
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• Penzel FI. Trichotillomania: Recognition and treatment. 2000;Available at: http://www.medscape.com. [Full Text].
• Reeve EA, Bernstein GA, Christenson GA. Clinical characteristics and psychiatric comorbidity in children with trichotillomania. J Am Acad Child Adolesc Psychiatry. Jan 1992;31(1):132-8. [Medline].
• Rothbaum BO, Ninan PT. The assessment of trichotillomania. Behav Res Ther. Jul 1994;32(6):651-62. [Medline].
• Simon GE, Savarino J, Operskalski B, Wang PS. Suicide risk during antidepressant treatment. Am J Psychiatry. Jan 2006;163(1):41-7. [Medline]. [Full Text].
• Stroud JD. Hair loss in children. Pediatr Clin North Am. Aug 1983;30(4):641-57. [Medline].
• Vitulano LA, King RA, Scahill L, Cohen DJ. Behavioral treatment of children and adolescents with trichotillomania. J Am Acad Child Adolesc Psychiatry. Jan 1992;31(1):139-46. [Medline].
• Walsh KH, McDougle CJ. Pharmacological strategies for trichotillomania. Expert Opin Pharmacother. Jun 2005;6(6):975-84. [Medline].
• 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. [Medline].
• Wright HH, Holmes GR. Trichotillomania (hair pulling) in toddlers. Psychol Rep. Feb 2003;92(1):228-30. [Medline].

Article Last Updated: May 23, 2006