Trichotillomania (Hair Pulling Disorder)

Clinical Description

Trichotillomania, also known as Hair Pulling Disorder, is characterized by the repetitive pulling out of one’s hair leading to hair loss and functional impairment. In order to qualify for a diagnosis, the hair loss must not be due to another psychiatric or medical condition. The most common sites pulled include the scalp, eyebrows, and eyelashes although pulling from other areas of the body is frequent. Pulling from multiple sites is common and pulling episodes can last from a few minutes to several hours.

Onset of hair pulling is generally in late childhood or early adolescence although onset of pulling behaviors can occur at any age. In adults, Trichotillomania has a large female preponderance, however in childhood, the sex distribution has been found to be equal. Trichotillomania is associated with reduced self-esteem and avoidance of social situations due to shame and embarrassment from the pulling and its consequences—it has a negative impact on quality of life. Patients often perceive Trichotillomania as nothing more than a “bad habit” rather than being a recognized psychiatric condition, and the majority have never sought treatment or discussed their pulling behaviors with health care professionals. Indeed, patients commonly have never disclosed their symptoms to anyone. Avoidance of activities, such as getting haircuts, swimming, being outside on a windy day, sporting activities, dating, or going out in public more than necessary are quite common. Many individuals conceal areas in which they have pulled hair with hats, scarves, bandanas, make-up or by wearing concealing clothing.

Individuals with Trichotillomania often report significant urges or a “drive” to pull their hair. Triggers to pull vary from person to person. Cues prompting pulling episodes may include stress, boredom, “downtime,” fatigue, or driving. Many patients report not being fully aware of their pulling behaviors, also referred to as “automatic” pulling and comprise a more habitual form of the disorder. Conversely, “focused” pulling generally occurs when the patient sees or feels a hair that is “not right” (e.g., the hair may feel coarse, fine, sharp, rough, oily, or dry, or appear too dark, curly, gray, or “out of place”). Most patients pull with varying degrees of focused and automatic pulling.

Trichotillomania can result in unwanted medical consequences. Pulling of hair can lead to skin damage if sharp instruments, such as tweezers or scissors, are used to pull the hairs. Over 20% of patients eat hair after pulling it out (trichophagia), which can result in gastrointestinal obstruction and the formation of intestinal hair-balls (trichobezoars) requiring surgical intervention.

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