eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Anxiety Disorder, Trichotillomania

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

Introduction

Background

Trichotillomania is 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.¹ Despite this first description of trichotillomania in the late 1800s, little is understood about the disorder in children.

Hair pulling in trichotillomania can occur on any part of the body where hair grows. The most common area of hair pulling is the scalp, followed by the eyelashes and eyebrows.² However, hair pulling also can occur in the 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-TR) classifies trichotillomania as an impulse-control disorder.³ 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-TR, 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) because of its compulsivelike nature.

In many individuals, adolescent-onset trichotillomania indicates more severe psychopathology as an impulse-control disorder or OCD, whereas preschool-onset trichotillomania is often described as a childhood habit disorder. Trichotillomania in younger children is often 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 moderate impairment in social or academic functioning.² Additionally, trichotillomania may result in impairment in other important areas of functioning, such as family relationships.

The DSM-IV-TR diagnostic criteria for trichotillomania include (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.³

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 can frequently 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-TR, 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.⁴ 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 is typically 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 is frequently a chronic disorder (lasting weeks to decades), with a variable age of onset. According to the DSM-IV-TR, 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 trichotillomania frequently report onset in childhood. Children as young as 1 year have been diagnosed with the disorder.

Clinical

History

Trichotillomania can be difficult to diagnose. 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 is frequently the complaint, as the behavior is typically conducted in private and subsequently denied.
• Denying hair pulling: Children often deny hair pulling. Because the behavior is usually not conducted in the presence of adults or others, it is often 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 result from the ingestion of plucked hairs.
  • Trichobezoars are hair casts and are typically 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. Such theories include stress reduction, emotional regulation, and sensory stimulation.^5,6

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