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Anxiety Disorder, Trichotillomania: Differential Diagnoses & Workup

Author: Cynthia R Ellis, MD, Director of Developmental Medicine, Associate Professor, Department of Pediatrics and Psychiatry, Munroe Meyer Institute for Genetics and Rehabilitation, University of Nebraska Medical Center
Coauthor(s): Holly Jean Roberts, PhD, Assistant Professor, Pediatrics, Munroe-Meyer Institute, University of Nebraska Medical Center; Connie J Schnoes, MA, PhD, Psychologist, Director of Training, Supervising Practitioner, Father Flanagan's Boys' Home, Boys Town
Contributor Information and Disclosures

Updated: Sep 23, 2009

Differential Diagnoses

Anxiety Disorder: Obsessive-Compulsive Disorder

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

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.

Other Tests

  • The Trichotillomania Scale for Children (TSC) is a newly developed child and parent report used to assess symptom severity and impairment.7

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 in 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.

More on Anxiety Disorder, Trichotillomania

Overview: Anxiety Disorder, Trichotillomania
Differential Diagnoses & Workup: Anxiety Disorder, Trichotillomania
Treatment & Medication: Anxiety Disorder, Trichotillomania
Follow-up: Anxiety Disorder, Trichotillomania
Multimedia: Anxiety Disorder, Trichotillomania
References
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References

  1. Hallopeau M. Alopecie par grottage (trichomanie ou trichotillomani). Ann de Dermatolofie et Venerologie. 1889;10:440-41.

  2. Franklin ME, Flessner CA, Woods DW, Keuthen NJ, Piacentini JC, Moore P, et al. The child and adolescent trichotillomania impact project: descriptive psychopathology, comorbidity, functional impairment, and treatment utilization. J Dev Behav Pediatr. Dec 2008;29(6):493-500. [Medline].

  3. American Psychiatric Association. DSM-IV: Diagnostic & Statistical Manual of Mental Disorders. 4th ed. 2000:674-7.

  4. Christenson GA, Pyle RL, Mitchell JE. Estimated lifetime prevalence of trichotillomania in college students. J Clin Psychiatry. Oct 1991;52(10):415-7. [Medline].

  5. Diefenbach GJ, Tolin DF, Meunier S, Worhunsky P. Emotion regulation and trichotillomania: a comparison of clinical and nonclinical hair pulling. J Behav Ther Exp Psychiatry. Mar 2008;39(1):32-41. [Medline].

  6. Meunier SA, Tolin DF, Franklin M. Affective and Sensory Correlates of Hair Pulling in Pediatric Trichotillomania. Behav Modif. Jan 12 2009;[Medline].

  7. Tolin DF, Diefenbach GJ, Flessner CA, Franklin ME, Keuthen NJ, Moore P, et al. The trichotillomania scale for children: development and validation. Child Psychiatry Hum Dev. Sep 2008;39(3):331-49. [Medline].

  8. 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].

  9. American Academy of Child and Adolescent Psychiatry. Textbook of Child and Adolescent Psychiatry. 2nd ed. American Psychiatric Press; 1997.

  10. Bordnick PS. Trichotillomania: a social worker's guide to practice. Research on Social Work Practice. 1997;7(2):216-28.

  11. 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].

  12. Clore ER, Corey A. Hair loss in children and adolescents. J Pediatr Health Care. Sep-Oct 1991;5(5):245-50. [Medline].

  13. Dimino-Emme L, Camisa C. Trichotillomania associated with the "Friar Tuck sign" and nail-biting. Cutis. Feb 1991;47(2):107-10. [Medline].

  14. 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.

  15. 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].

  16. Kuzma JM, Black DW. Compulsive disorders. Curr Psychiatry Rep. Feb 2004;6(1):58-65. [Medline].

  17. Muller SA. Trichotillomania. Dermatol Clin. Jul 1987;5(3):595-601. [Medline].

  18. Nuss MA, Carlisle D, Hall M. Trichotillomania: a review and case report. Cutis. Sep 2003;72(3):191-6. [Medline].

  19. Penzel FI. Trichotillomania: Recognition and treatment. 2000;Available at: http://www.medscape.com. [Full Text].

  20. 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].

  21. Rothbaum BO, Ninan PT. The assessment of trichotillomania. Behav Res Ther. Jul 1994;32(6):651-62. [Medline].

  22. Stroud JD. Hair loss in children. Pediatr Clin North Am. Aug 1983;30(4):641-57. [Medline].

  23. 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].

  24. Walsh KH, McDougle CJ. Pharmacological strategies for trichotillomania. Expert Opin Pharmacother. Jun 2005;6(6):975-84. [Medline].

  25. 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].

  26. Wright HH, Holmes GR. Trichotillomania (hair pulling) in toddlers. Psychol Rep. Feb 2003;92(1):228-30. [Medline].

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Further Reading

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Keywords

trichotillomania, childhood habit disorder, impulse-control disorder, hair pulling, obsessive-compulsive disorder, OCD, trichophagia, trichobezoars

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Contributor Information and Disclosures

Author

Cynthia R Ellis, MD, Director of Developmental Medicine, Associate Professor, Department of Pediatrics and Psychiatry, Munroe Meyer Institute for Genetics and Rehabilitation, University of Nebraska Medical Center
Cynthia R Ellis, MD is a member of the following medical societies: Nebraska Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Holly Jean Roberts, PhD, Assistant Professor, Pediatrics, Munroe-Meyer Institute, University of Nebraska Medical Center
Holly Jean Roberts, PhD is a member of the following medical societies: Autism Society of America, National Association of School Psychologists, and Psi Chi
Disclosure: Nothing to disclose.

Connie J Schnoes, MA, PhD, Psychologist, Director of Training, Supervising Practitioner, Father Flanagan's Boys' Home, Boys Town
Disclosure: Nothing to disclose.

Medical Editor

Chet Johnson, MD, Medical Director, Child Development Unit, Department of Pediatrics, Professor, University of Kansas Medical Center
Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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