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Trichotillomania

Presentation, Etiology, Diagnosis and Therapy

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Abstract

Trichotillomania (TTM) is an impulse disorder, in which patients chronically pull hair from the scalp and/or other sites. Very early onset of hair pulling in children under the age of 6 may be more benign and self-limiting than the more common syndrome of late childhood onset hair pulling. While far more women and adolescent girls appear for treatment, survey studies suggest chronic hair pulling also occurs in males. Diagnosis may be complicated by patient and family denial or ignorance of the hair pulling; accurate scalp examination and biopsy can be critical. Classic scalp biopsies for TTM feature trichomalacia, pigment clumps, peribulbar hemorrhage and hair canal pigment casts, and lack lymphocytic infiltrates seen in alopecia areata. Treatment is difficult: the tricyclic antidepressant clomipramine is the most promising agent, although many patients find it difficult to tolerate at adequate dosages, and treatment response may not be maintained over the long term. More benign medications have not demonstrated efficacy in controlled studies. Augmentation with topical preparations or psychotropic medications may be helpful for patients experiencing limited efficacy or relapse. Specialized psychotherapy, known as habit reversal training, is highly recommended; however, the treatment is intensive and highly specialized. Skilled therapists are difficult to locate.

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References

  1. Diagnostic and Statistical Manual of Mental Disorders. Trichotillomania. 4th ed. Washington, DC: American Psychiatric Association, 1994: 618-21

  2. Christenson G.A., Mackenzie T.B., Mitchell J.E. Characteristics of 60 adult chronic hair pullers. Am J Psychiatry 1991; 148: 365–370

    PubMed  CAS  Google Scholar 

  3. Cohen L.J., Stein D.J., Simeon D., et al. Clinical profile, comorbidity, and treatment history in 123 hair pullers: a survey study. J Clin Psychiatry 1995: 56; 319–326

    PubMed  CAS  Google Scholar 

  4. Christenson G.A., MacKenzie T.B., Mitchell J.E. Adult men and women with trichotillomania a comparison of male and female characteristics. Psychosomatics 1994; 35: 142–149

    Article  PubMed  CAS  Google Scholar 

  5. O’sullivan R.L., Keuthen N.J., Jenike M.A., et al. Trichotillomania and the carpal tunnel syndrome. J Clin Psychiatry 1996: 57: 174

    PubMed  Google Scholar 

  6. Christenson G.A., Ristvedt S.L., Mackenzie T.B. Identification of trichotillomania cue profiles. Behav Res Ther 1993; 31: 315–320

    Article  PubMed  CAS  Google Scholar 

  7. Christenson G.A., Raymond N.C., Faris P.L., et al. Pain thresholds are not elevated in trichotillomania. Biol Psychiatry 1994; 36: 347–349

    Article  PubMed  CAS  Google Scholar 

  8. Stemberger R.M.T., Thomas A.M. Personal toll of trichotillomania: behavioral and interpersonal sequelae. J Anxiety Disord 2000; 14: 97–104

    Article  PubMed  CAS  Google Scholar 

  9. Soriano J.L., O’sullivan R.L., Baer L., et al. Trichotillomania and self-esteem: a surveyof 62 hair-pullers. J Clin Psychiatry 1996; 57: 77–82

    PubMed  CAS  Google Scholar 

  10. Christenson G.A., Pyle R.L., Mitchell J.E. Estimated lifetime prevalence of trichotillomania in college students. J Clin Psychiatry 1991; 52: 415–417

    PubMed  CAS  Google Scholar 

  11. Rothbaum B.O., Shaw L., Morris R., et al. Prevalence of trichotillomania in a college freshman population. J Clin Psychiatry 1993; 54: 72

    PubMed  CAS  Google Scholar 

  12. Muller S.A. Trichotillomania. Dermatol Clinics 1987; 5: 595–601

    CAS  Google Scholar 

  13. Oguchi T., Miura S. Trichotillomania: its psychopathological aspect. Comp Psychiatry 1977: 18; 177–182

    Article  CAS  Google Scholar 

  14. Reeve E.A., Bernstein G.A., Christenson G.A. Clinical characteristics and psychiatric comorbidity in children with trichotillomania. J Am Acad Child Adolesc Psychiatry 1992: 31; 132–138

    Article  PubMed  CAS  Google Scholar 

  15. King R.A., Scahill L., Vitulano L.A., et al. Childhood trichotillomania: clinical phenomenology, comorbidity, and family genetics. J Am Acad Child Adolesc Psychiatry 1995: 34; 1451–459

    Article  PubMed  CAS  Google Scholar 

  16. Hanna G.L. Trichotillomania and related disorders in children and adolescents. Child Psychiatry Human Devel 1997; 27: 255–268

    Article  CAS  Google Scholar 

  17. Lenane M.C., Swedo S.E., Rapoport J.L., et al. Rates of obsessive compulsive disorder in first degree relatives of patients with trichotillomania: a research note. J Child Psychol Psychiat 1992; 33: 925–933

    Article  PubMed  CAS  Google Scholar 

  18. Schlosser S., Black D.W., Blum N., et al. The demography, phenomenology, and family history of 22 persons with compulsive hair pulling. Ann Clin Psychiatry 1994; 6: 147–152

    Article  PubMed  CAS  Google Scholar 

  19. Winchel R.M., Jones J.S., Stanley B., et al. Clinical characteristics of trichotillomania and its response to fluoxetine. J Clin Psychiatry 1992; 53: 304–308

    PubMed  CAS  Google Scholar 

  20. Stein D.J., Mullen L., Islam M.N., et al. Compulsive and impulsive symptomatology in trichotillomania. Psychopathology 1995; 28: 208–213

    Article  PubMed  CAS  Google Scholar 

  21. O’sullivan R.L., Rauch S.L., Breiter H.C., et al. Reduced basal ganglia volumes in trichotillomania measured via morphometric magnetic resonance imaging. Biol Psychiatry 1997; 42: 39–45

    Article  PubMed  Google Scholar 

  22. Robinson D., Wu H., Munne R.A., et al. Reduced caudate nucleus volume in obsessive-compulsive disorder. Arch Gen Psychiatry 1995; 393–398

    Google Scholar 

  23. Jenike M.A., Breiter H.C., Baer L., et al. Cerebral structural abnormalities in obsessivecompulsive disorder: a quantitative morphometric magnetic resonance imaging study. Arch Gen Psychiatry 1996; 53: 625–632

    Article  PubMed  CAS  Google Scholar 

  24. Breiter H.C.R., Filipek P.A., Kennedy D.N., et al. Retrocallosal white matter abnormalities in patients with obsessive-compulsive disorder. Arch Gen Psychiatry 1996; 51: 663–664

    Google Scholar 

  25. Swedo S.E., Rapoport J.L., Leonard H.L., et al. Regional cerebral glucose metabolism of women with trichotillomania. Arch Gen Psychiatry 1991; 48: 828–833

    Article  PubMed  CAS  Google Scholar 

  26. Sullivan J.R., Kossard S. Acquired scalp alopecia: part I: a review. Australasian J Dermatol 1998; 59: 207–221

    Article  Google Scholar 

  27. Trueb R.M., Cavegn B. Trichotillomania in connection with alopecia areata. Cutis 1996; 58: 67–70

    PubMed  CAS  Google Scholar 

  28. Ihm C.W., Han J.H. Diagnostic value of exclamation mark hairs. Dermatology 1993; 186: 99–102

    Article  PubMed  CAS  Google Scholar 

  29. Muller S.A. Trichotillomania: a histopathologic study in sixty-six patients. J Am Acad Dermatol 1990; 25: 56–62

    Article  Google Scholar 

  30. Thoren P., Asberg M., Cronholm B., et al. Clomipramine treatment of obsessivecompulsive disorder. I. A clinical trial. Archives General Psychiatry 1980; 37: 1281–1285

    Article  CAS  Google Scholar 

  31. Swedo S.E., Leonard H.L., Rapoport J.L., et al. A double-blind comparison of clomipramine and desiparamine in the treatment of trichotillomania (hair pulling). N Eng J Med 1989; 321: 497–501

    Article  CAS  Google Scholar 

  32. Pollard C.A., Ibe I.O., Krojanker D.N., et al. Clomipramine treatment of trichotillomania: a follow-up report on four cases. J Clin Psychiatry 1991; 52: 128–130

    PubMed  CAS  Google Scholar 

  33. Iancu I., Weizman A., Kindler S., et al. Serotonergic drugs in trichotillomania: treatment results in 12 patients. J Nerv Mental Dis 1996; 184: 641–644

    Article  CAS  Google Scholar 

  34. Ninan P.T., Rothbaum B.O., Marsteller F.A., et al. A placebo-controlled trial of cognitivebehavioral therapy and clomipramine in Trichotillomania. J Clin Psychiatry 2000; 61: 47–50

    Article  PubMed  CAS  Google Scholar 

  35. Swedo S.E., Lenane M.C., Leonard H.L., et al. Long-term treatment of trichotillomania (hair pulling). N Engl J Med 1993; 329: 141–142

    Article  PubMed  CAS  Google Scholar 

  36. Greist J.H., Jefferson J.W., Kobak K.A., et al. Efficacy and tolerability of serotonin transport inhibitors in obsessive-compulsive disorder. Arch Gen Psychiatry 1995; 52: 53–60

    Article  PubMed  CAS  Google Scholar 

  37. Stanley M.A., Bowers T.C., Swann A.C., et al. Treatment of trichotillomania with fluoxetine. J Clin Psychiatry 1991; 52: 282

    PubMed  CAS  Google Scholar 

  38. Christenson G.A., Mackenzie T.B., Mitchell J.E., et al. A placebo-controlled, doubleblind crossover study of fluoxetine in trichotillomania. Am J Psychiatry 1991; 148: 1566–1571

    PubMed  CAS  Google Scholar 

  39. Streichenwein S.M., Thornby J.I. A long-term, double-blind, placebo-controlled crossover trial of the efficacy of fluoxetine for trichotillomania. Am J Psychiatry 1995; 152: 1192–1196

    PubMed  CAS  Google Scholar 

  40. Stanley M.A., Breckenridge J.K., Swann A.C., et al. Fluvoxamine treatment of trichotillomania. J Clin Psychopharm 1997; 17: 278–283

    Article  CAS  Google Scholar 

  41. Ravindran A.V., Lapierre Y.D., Anisman H. Obsessive-compulsive spectrum disorders: effective treatment with paroxetine. Can J Psychiatry 1999; 44: 805–807

    PubMed  CAS  Google Scholar 

  42. Block C., West S.A., Baharoglu B. Paroxetine treatment of trichotillomania in an adolescent. J Child Adolesc Psychopharm 1998; 8: 69–71

    Article  CAS  Google Scholar 

  43. Reid T.L., Treatment of resistant trichotillomania with paroxetine. American J Psychiat 1994; 151: 290

    CAS  Google Scholar 

  44. Ninan P.T., Knight B., Kirk L., et al. Beyond panic: medication effects in anxiety disorders: a controlled trial of venlafaxine in trichotillomania: interim phase I results. Psychopharmacol Bull 1998; 34: 221–224

    PubMed  CAS  Google Scholar 

  45. White S.D. Naltrexone for treatment of acral lick dermatitis in dogs. Am J Vet Med Assoc 1990; 196 (7): 1073–1076

    CAS  Google Scholar 

  46. Christenson G.A., Crow S.J., Mackenzie T.B., et al. A placebo-controlled double-blind study of naltrexone for trichotillomania [abstract no. 597]. Am Psychiatr Ass New Res Prog 1994: 212

    Google Scholar 

  47. Keuthen N.J., O’sullivan R.L., Goodchild P., et al. Retrospective review of treatment outcome for 63 patients with trichotillomania. Am J Psychiatry 1998; 155: 560–561

    PubMed  CAS  Google Scholar 

  48. Van Ameringen M., Mancini C., Oakman J.M., et al. The potential role of haloperidol in the treatment of trichotillomania. J Affective Disorders 1999; 56: 219–226

    Article  Google Scholar 

  49. Stein D.J., Bouewer C., Hawkridge S., et al. Risperidone Augmentation of serotonin reuptake inhibitors in obsessive-compulsive and related disorders. J Clin Psychiatry 1997; 58: 119–122

    Article  PubMed  CAS  Google Scholar 

  50. Stein D.J., Hollander E. Low-dose pimozide augmentation of serotonin reuptake blockers in the treatment of trichotillomania. J Clin Psychiatry 1992; 53: 123–126

    PubMed  CAS  Google Scholar 

  51. Epperson C.N., Fasula D., Wasylink S., et al. Risperidone addition in serotonin reuptake inhibitor-resistant trichotillomania: three cases. J Child Adolesc Psychopharmacol 1999; 9 (1): 43–49

    Article  PubMed  CAS  Google Scholar 

  52. Carrion V.G. Naltrexone for the treatment of trichotillomania: a case report. J Clin Psychopharmacol 1995; 15: 444–445

    Article  PubMed  CAS  Google Scholar 

  53. Black D.W., Blum N. Trichotillomania treated with clomipramine and a topical steroid. Am J Psychiatry 1992; 149: 842–843

    PubMed  CAS  Google Scholar 

  54. Gupta S., Freimer M. Trichotillomania, clomipramine, topical steroids. Am J Psychiatry 1993; 150: 524

    PubMed  CAS  Google Scholar 

  55. Ristvedt S.L., Christenson G.A. The use of pharmacologic pain sensitization in the treatment of repetitive hair-pulling. Behav Res Ther 1996; 34: 647–648

    Article  PubMed  CAS  Google Scholar 

  56. Azrin N.H., Nunn R.G., Frantz S.E. Treatment of hair pulling (trichotillomania): a comparative study of habit reversal and negative practice training. Behav Ther Exp Psychiatry 1980; 11: 13–20

    Article  Google Scholar 

  57. Rothbaum B.O. The behavioral treatment of trichotillomania. Behav Psychother 1992; 20: 85–90

    Article  Google Scholar 

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Acknowledgements

The authors wish to acknowledge the support, in part, of the Clarian Values Fund for Research (Dr Walsh) and the State of Indiana Division of Mental Health (Drs Walsh and McDougle) for this work. Dr McDougle is a member of the speaker’s bureau of Pfizer Inc and Janssen Pharmaceutica. He is a consultant for Pzifer Inc, Janssen Pharmaceutica, and Eli Lilly and Co. Dr Walsh has research support from Pzifer Inc and Wyeth-Ayrest Research.

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  1. Riley Child and Adolescent Psychiatry Clinic, Indiana University School of Medicine, Riley Hospital for Children, 702 Barnhill Drive, Room 3701, Indianapolis, Indiana, IN 46202-5200, USA

    Kelda H. Walsh & Christopher J. McDougle

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  1. Kelda H. Walsh
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  2. Christopher J. McDougle
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Correspondence to Kelda H. Walsh.

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Walsh, K.H., McDougle, C.J. Trichotillomania. Am J Clin Dermatol 2, 327–333 (2001). https://doi.org/10.2165/00128071-200102050-00007

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