Trichotillomania: Symptoms, Diagnosis, and Treatment Explained

Trichotillomania Symptoms Diagnosis Trichotillomania (TTM) is a mental disorder characterized by a recurrent urge that is difficult to resist to pull out one’s hair. It is also known as hair-pulling or compulsive hair-pulling disorder. Trichotillomania was first described in ancient Greece. However, the modern term “trichotillomania” was coined in 1889 (late 19th century) by French dermatologist François-Henri Hallopeau.^[1] Excessive and persistent pulling of hair can result in noticeable hair loss. One can pull hair from any area of the body, but the scalp is the most commonly affected area, followed by the eyebrows and eyelashes. Hair loss resulting from hair pulling can range from subtle, undetectable thinning to complete alopecia.

With both physical and psychosocial implications, the disorder can also occur in early adolescence. The peak prevalence of the disease occurs between the ages of 4 and 17 years.^[2] The lifetime prevalence of TTM is as high as 3.5%. The disorder is more common in females, especially in adults, with ratios ranging from about 3:1 to 9:1 depending on age and study population.^[3]

Etiology & Pathophysiology of Trichotillomania : Trichotillomania Symptoms Diagnosis

The causes of the disease are largely unknown. Both genetic and environmental factors contribute to the development of TTM. The proposed explanations for the onset and maintenance of the hair-pulling behavior can include:

• TTM can occur as a coping mechanism, as people describe it as starting after a particularly stressful time in their lives. Some also describe it as starting because of boredom. They start pulling their hair as a habit.
• It becomes a benign habit that develops from a sensory event (such as an itchy eyelash) or occurs in conjunction with another habitual behavior, like thumbsucking in young children.
• Structural brain abnormalities and abnormal brain metabolism: Individuals may exhibit abnormalities in the subcortical regions responsible for habit formation, affect regulation, and inhibitory control. Individuals with trichotillomania have a high metabolic glucose rate in bilateral, global, cerebellar, and right superior parietal regions.
• Genetic susceptibility plays a role in trichotillomania, as it occurs more in people with obsessive-compulsive disorder (OCD) and their first-degree relatives.
• TTM may also present a disorder of disordered reward processing within the CNS.
• Several psychological factors, such as sensory stimulation, emotional regulation, and stress reduction, can contribute to the development of TTM.
• In older populations, there is a possible link between the neurodegenerative disorders (such as dementia and Parkinson’s disease) and TTM.

From the dermatological point of view, TTM is a form of traumatic alopecia. Trauma to the hair follicles occurs due to the repetitive hair-pulling behavior of the patients. TTM causes variable patterns of hair loss. Ingestion of the pulled hair (trichophagia) is also common in individuals who pull out their hair, which can lead to the formation of trichobezoars (such as hair casts) in the small intestine or stomach. Trichobezoars can cause nausea, vomiting, abdominal pain, bowel obstruction, gastrointestinal bleeding, hematemesis, and obstructive jaundice.^[4]

Symptoms of Trichotillomania

• The apparent symptoms of TTM include repeated, compulsive hair pulling, often from the scalp, eyebrows, and eyelashes. However, it can also sometimes originate from other areas of the body, such as the arms, legs, or pubic area.
• There are visible areas of hair loss (thinning areas and bald patches). People often experience an urge or tension before pulling their hair, and relief, satisfaction, or pleasure after, though this pattern is not universal.
• People can engage in hair-pulling either automatically (without conscious awareness) or intentionally (with conscious awareness).
• Other common manifestations include pulling hairs from pets, lip chewing, nail biting, skin picking, rubbing plucked hairs on the skin, playing with them, biting, eating, or chewing them.
• People with this condition try to stop this habit, but find it difficult, and hence suffer from emotional distress, low self-esteem, social avoidance, and problems in daily functioning.

A girl suffering from trichotillomania. She has a compulsive desire to pull out her hair, intrusive thoughts, and autoaggression.

Diagnosis of Trichotillomania

The history and physical examination are enough for the diagnosis. However, a punch biopsy can also help in diagnosis, but it is not necessary.

History:

In gathering a history, the patient must meet the criteria stated in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The current DSM-5 manual outlines the five criteria necessary for the diagnosis of TTM. ^[5]These criteria include:

• Repeated pulling of the hair can cause hair loss. There may be associated thinning of hair or bald spots.
• Trying multiple times to stop or lessen this hair-pulling behavior.
• Feeling that hair-pulling has a negative impact on your life, particularly in your social or work life.
• The hair loss or hair pulling is not happening due to another medical condition (e.g., dermatological disorder like alopecia areata)
• The hair pulling is not happening due to another mental health condition (such as dysmorphia, in which hair pulling happens due to a person’s belief that there is a problem with the appearance of hair, and they try to fix it).

Physical Examination:

A physical exam assesses the skin, mainly by examining areas of hair loss. Hair loss can be obvious in some cases and barely visible in others. Hair loss, visible in different lengths and various stages of regrowth, can be noticeable. There can also be geometric areas of hair loss. Clinicians examine the skin for scarring at the follicles to assess the potential for regrowth (no scarring means regrowth can occur). Clinicians can also conduct a thorough abdominal examination to assess for pain, faecal impaction, masses, and other signs that may be indicative of a possible trichobezoar.

Other Tests:

In a few cases, a punch biopsy is necessary to confirm the diagnosis of TTM. The healthcare provider takes a skin sample for lab analysis. The test can help in ruling out other skin conditions. In some cases, when the clinician suspects a blockage caused by swallowed hair, you may also undergo additional diagnostic tests, such as blood tests for anemia and imaging tests like a computed tomography scan.

Management & Treatment

Trichotillomania is a multifaceted disease. It involves several specialties and cross-specialities as well as multiple treatment modalities. The treatment likely includes therapeutic techniques, and medications may also be used.

Behavioral Therapies:

Behavioral Therapies for trichotillomania include the following:

Habit Reversal Therapy (HRT)

HRT is the cornerstone of TTM treatment and involves three main components:

• Awareness training
• Developing competing responses
• Social support

It is an effective and low-risk method for reducing the hair-pulling behavior. Traditional HRT appears to be more beneficial in individuals with automatic pulling.^[6]

Cognitive Behavioral Therapy (CBT)

CBT is a type of psychotherapy. It helps individuals to identify and change unhelpful thinking patterns and behavior that contribute to psychological problems. CBT aims to identify and change thought patterns that trigger trichotillomania. Therapists often combine it with HRT.^[7]

Medications:

No medications are specifically approved for TTM; however, the following can help in managing the symptoms:

Antipsychotics

Antipsychotics help in balancing the brain chemistry. They can also treat many conditions such as schizophrenia, bipolar disorder, and dementia. For TTM clinicians, consider atypical antipsychotics like olanzapine, quetiapine, and aripiprazole with careful risk-benefit analysis.^[8]

Antidepressants

Selective serotonin reuptake inhibitors and tricyclic antidepressants (clomipramine) can help in reducing the impulse to pull out hair. A tricyclic antidepressant, clomipramine, shows moderate effectiveness in the case of TTM.

Nutraceuticals:

These are nutritional products such as amino acid supplements (N-acetylsysteine (NAC)) that can help in treating medical conditions.

Supportive & Self-Care Measures:

These measures can include:

• Keep your hair short
• Wear hats
• Squeezing stress balls upon hair-pulling urges
• Using Band-Aids on fingertips.
• Applying other distraction techniques to the urges of hair-pulling.

Prognosis

TTM is not a dangerous ailment for your physical health, but it can be damaging and disruptive for your mental health and quality of life. Prognosis is better when the condition is diagnosed early and treatment begins early. However, people with TTM often feel embarrassed or ashamed of this condition and try to avoid treatment. Hence, people who avoid or delay treatment are more likely to have issues like scarring, mental problems, and hair loss.

Differential Diagnosis & Complications

The differential diagnosis includes:

• Pressure alopecia
• Male pattern baldness
• Traction alopecia
• Alopecia areata
• Tinea capitis
• Obsessive–compulsive disorder is more commonly a comorbidity than a differential, as TTM is classified under obsessive–compulsive and related disorders in DSM-5.^[9]

The long-term complications of the condition include:

• Permanent hair loss
• Emotional Distress
• Trichobezoar

Trichotillomania Vs Attention Deficit Hyperactivity Disorder (ADHD)

TTM and ADHD are distinct conditions but can have overlapping features and co-occur. Trichotillomania is an impulse control disorder categorized under obsessive compulsive disorder, while ADHD is a neurodevelopmental disorder characterized by symptoms of inattention, hyperactivity, and impulsivity that affect focus, concentration, and activity levels. TTM is driven by compulsive urges with anxiety-relieving and sensory regulation aspects, while ADHD involves brain development differences affecting executive function, attention, and impulse control. However, ADHD sensory processing issues can contribute to hair-pulling as a self-soothing behavior. TTM treatment focuses on behavioral therapies, while ADHD can be managed with stimulant and non-stimulant medications and behavioral interventions targeting attention and hyperactivity. Both conditions require tailored multidisciplinary care when they co-occur.

A Quick Review

TTM can have a severe effect on your mental health. Individuals suffering from this disorder usually feel embarrassed, shamed, or guilty. Unfortunately, the treatment has no cure as all treatment methods have some limitations. As the disorder has relapses and remissions, the patient can experience loss of hair, scarring, and poor cosmesis in the long run.

References

[1] Kim, W. B. (2014). On trichotillomania and its hairy history. JAMA dermatology, 150(11), 1179-1179.

[2] Keren, M., Ron-Miara, A., Feldman, R., & Tyano, S. (2006). Some reflections on infancy-onset trichotillomania. The Psychoanalytic study of the child, 61(1), 254-272.

[3] Pereyra, A.D. and A. Saadabadi, Trichotillomania, in StatPearls [Internet]. 2023, StatPearls Publishing.

[4] Hamid, M., Chaoui, Y., Mountasser, M., Sabbah, F., Raiss, M., Hrora, A., … & Ouazzani, H. (2017). Giant gastric trichobezoar in a young female with Rapunzel syndrome: case report. The Pan African Medical Journal, 27, 252.

[5] Lochner, C., Grant, J. E., Odlaug, B. L., Woods, D. W., Keuthen, N. J., & Stein, D. J. (2012). DSM‐5 field survey: hair‐pulling disorder (trichotillomania). Depression and anxiety, 29(12), 1025-1031.

[6] Keuthen, N.J., et al., Replication study of the Milwaukee inventory for subtypes of trichotillomania–adult version in a clinically characterized sample. Behavior modification, 2015. 39(4): p. 580-599.

[7] Lewin, A. B., Wu, M. S., McGuire, J. F., & Storch, E. A. (2014). Cognitive behavior therapy for obsessive-compulsive and related disorders. Psychiatric Clinics, 37(3), 415-445.

[8] Yasui-Furukori, N., & Kaneko, S. (2011). The efficacy of low-dose aripiprazole treatment for trichotillomania. Clinical neuropharmacology, 34(6), 258-259.

[9] Woods, D. W., & Houghton, D. C. (2014). Diagnosis, evaluation, and management of trichotillomania. The Psychiatric Clinics of North America, 37(3), 301.