Anxiety Disorder, Trichotillomania 

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]

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.