Diagnosis of Trichotillomania

The criteria for Trichotillomania in DSM-5 can be summarized as follows:

  • • Pulling of hair which results in hair loss
  • • The person endorses trying to either stop pulling or cut down on pulling
  • • The patient experiences distress as a result of pulling or some aspect of social, work, or other area of functioning is impaired
  • • Another medical condition is not responsible for the pulling
  • • Another mental health condition (such as pulling to improve one’s appearance or a perceived defect as seen in Body Dysmorphic Disorder) is not the main prompt for pulling

[Note: there are two key differences between DSM-5 and its predecessor in DSM-IV-TR, in terms of diagnostic criteria for Trichotillomania. Firstly, in DSM-IV-TR, hair loss needed to be “noticeable” for a diagnosis; for DSM-5, hair loss need not be noticeable. This diagnostic change recognizes that hair loss is often masked by patients, e.g., by using wigs or cosmetics. Secondly, DSM-5 does not require pleasure, gratification, or relief resulting from pulling, while DSM-IV-TR did. This diagnostic change stems from the recognition that at least 10% of people with hair pulling do not endorse these feelings, which in any event are quite subjective.]

The ICD-10 classifies Trichotillomania (or hair plucking or pulling) as an impulse disorder. The ICD criteria for a diagnosis of Trichotillomania include:

  • 1) Excessive pulling of one’s own hair resulting in noticeable hair-loss;
  • 2) Hair-pulling is usually preceded by mounting tension;
  • 3) Pulling is followed by a sense of relief or gratification

ICD-10, like the DSM system, denotes that a diagnosis of Trichotillomania should not be made if there is a pre-existing inflammation of the skin due to other causes. ICD-10 also highlights the need to exclude stereotyped movement disorder and hair pulling undertaken in response to delusions or hallucinations.

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