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Classification and external resources

An unusual pattern of incomplete hair loss on the scalp of a patient with trichotillomania
ICD-10 F63.3
ICD-9 312.39
DiseasesDB 29681
MedlinePlus 001517
eMedicine derm/433 ped/2298

Trichotillomania (TTM, also known as trichotillosis,[1] or more commonly as trich) is defined as "hair loss from a patient's repetitive self-pulling of hair"[2] and is characterized by the repeated urge to pull out scalp hair, eyelashes, facial hair, nose hair, pubic hair, eyebrows or other body hair, sometimes resulting in noticeable bald patches.[3] Trichotillomania is classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as an impulse control disorder, but there are questions about how it should be classified. It may seem, at times, to resemble a habit, an addiction, a tic disorder or an obsessive–compulsive disorder.

The disorder "leads to noticeable hair loss, distress, and social or functional impairment", and is "often chronic and difficult to treat".[3]

Trichotillomania may be present in infants, but the peak age of onset is 9 to 13. Depression or stress can trigger the trich. Due to social implications the disorder is often unreported and it is difficult to predict accurately prevalence of trichotillomania; the lifetime prevalence of trich is estimated to be between 0.6% (overall) and 1.5% (in males) to 3.4% (in females).

The name, coined by French dermatologist François Henri Hallopeau, derives from the Greek: trich- (hair), till(en) (to pull), and mania ("an abnormal love for a specific object, place, or action").[4]



Trichotillomania, "in the broadest sense ... is self-induced [recurrent] loss of hair".[2] It is classified in DSM-IV as an impulse control disorder with pyromania, pathological gambling and kleptomania, and includes the criterion of an increasing sense of tension before pulling the hair and gratification or relief when pulling the hair.[3] However, some people with trich do not endorse the inclusion of "rising tension and subsequent pleasure, gratification, or relief" as part of the criteria;[3] because many individuals with trich may not realize they are pulling their hair, patients presenting for diagnosis may deny "the criteria for tension prior to hair pulling or a sense of gratification after hair is pulled".[2]

An obsessive–compulsive spectrum disorder—encompassing obsessive–compulsive disorder (OCD), trichotillomania, nail biting and skin picking, tic disorders and eating disorders—has been proposed as it is hypothesized that these conditions may share "clinical features, genetic contributions, and possibly treatment response".[3] In the sense that it is "associated with irresistible urges to perform unwanted repetitive behavior", trich is akin to some of these conditions, and rates of trich among relatives of OCD patients is higher than expected by chance.[3] However, differences between trich and OCD have been noted including differing peak ages at onset, rates of comorbidity, gender differences, and neural dysfunction and cognitive profile.[3] When it occurs in early childhood, it "can be regarded as a distinct clinical entity".[3]

Because trich can present in multiple age groups, it is helpful in terms of prognosis and treatment to approach three distinct subgroups by age: "preschool age children, preadolescents to young adults, and adults".[2]

Trich is also subdivided into "automatic" versus "focused" hair pulling. Children are more often in the automatic, or subconscious, subtype and may not consciously remember pulling their hair. Other individuals may have focused, or conscious, rituals associated with hair pulling, including seeking specific types of hairs to pull, pulling until the hair feels "just right", or pulling in response to a specific sensation. Knowledge of the subtype is helpful in determining treatment strategies.[2]

Signs and symptoms

Trichotillomania is usually "confined to one or two sites",[3] but can involve multiple sites: "the scalp is the most common, then eyebrows, eyelashes, face, arms, legs, and pubic hairs".[2] Children are less likely to pull from areas other than the scalp.[2]

Individuals with trichotillomania exhibit hair of differing lengths; some are broken hairs with blunt ends, some new growth with tapered ends, some broken mid-shaft, or some uneven stubble. Scaling on the scalp is not present, "overall hair density is normal", and a hair pull test is negative (the "hair does not pull out easily"). Hair is often pulled out leaving an unusual shape; individuals with trich may be secretive or shameful of the hair pulling behavior.[2]

An additional psychological effect can be low self-esteem, often associated with being shunned by peers and the fear of socializing due to appearance and negative attention they may receive. Some people with TTM wear hats, wigs, wear false eyelashes, eyebrow pencil, or style their hair in an effort to avoid such attention. There seems to be a strong stress-related component. In low-stress environments, some exhibit no symptoms (known as "pulling") whatsoever. This "pulling" often resumes upon leaving this environment.[5] Some individuals with TTM may feel they are the only person with this problem due to low rates of reporting.[6]

Other medical complications include "infection, permanent loss of hair, repetitive stress injury, carpal tunnel syndrome, and gastrointestinal obstruction ... as a result of trichophagia".[3] In trichophagia, people with trich also ingest the hair that they pull; in extreme (and rare) cases this can lead to a hair ball (trichobezoar).[2] Rapunzel syndrome, an extreme form of trichobezoar in which the "tail" of the hair ball extends into the intestines, can be fatal if misdiagnosed.[2][7][8][9]

Causes and pathophysiology

Anxiety, depression and obsessive–compulsive disorder are more frequently encountered in people with TTM.[3][10] Trichotillomania has a high overlap with post traumatic stress disorder, and some cases of trich may be triggered by stress. "Another school of thought emphasizes hair pulling as addictive or positively reinforcing insofar as it is associated with rising tension beforehand and relief afterward."[3] A neurocognitive model—"the notion that the basal ganglia play[s] a role in habit formation and that the frontal lobes are critical for normally suppressing or inhibiting such habits"—sees trichotillomania as a habit disorder.[3]

Abnormalities in the caudate nucleus are noted in OCD, but there is "no evidence to support the existence of volumetric caudate abnormalities in ... trichotillomania".[3] One study showed that individuals with TTM have decreased cerebellar volume.[3][11] These findings suggest some differences between OCD and trichotillomania.[3] There is a lack of structural MRI studies on trichotillomania.[3]

It is likely that multiple genes confer vulnerability to trichotillomania.[3] One study identified mutations in the SLITRK1 gene,[3][12] another identified differences in the serotonin 2A receptor genes,[3][13] and mice with a mutation on the HOXB8 gene showed abnormal behaviors including hair pulling. These data are preliminary, but could indicate a genetic component in trichotillomania.[3][14]

Diagnosis and screening

Patients may be ashamed or "actively disguise their symptoms to avoid disclosure; clinicians should be vigilant when patients present with inappropriate or unusual head coverings".[3] If the patient admits to hair pulling, diagnosis is not difficult; if patients deny hair pulling, a differential diagnosis must be pursued.[2] The differential diagnosis will include evaluation for alopecia areata, tinea capitis, traction alopecia, and loose anagen syndrome.[2] In trichotillomania, a hair pull test is negative.[2]


Treatment is approached based on the age of the patient. Parents are counseled to ignore the behaviors in pre-school age children, as these children frequently outgrow it. In preadolescents to young adults, establishing the diagnosis and raising awareness of the condition is an important reassurance for the family and patient. Non-pharmacological interventions, including behavior modification programs, may be considered; referrals to psychologists or psychiatrists are considered when other interventions fail. When trichotillomania begins in adulthood, it is often associated with other psychiatric disorders, and referral to a psychologist or psychiatrist for evaluation or treatment is considered best. The hair pulling may resolve when other conditions are treated.[2]

Habit Reversal Training (HRT) has the highest rate of success in treating trichotillomania.[2] HRT has been shown to be a successful adjunct to medication as a way to treat TTM.[3][15] With HRT, doctors train the individual to learn to recognize their impulse to pull and also teach them to redirect this impulse. In comparisons of behavioral versus pharmacologic treatment, cognitive behavioral therapy (including HRT) have shown significant improvement over medication alone.[2][3] It has also proven effective in treating children.[2]

Medications may also be used. Treatment with clomipramine (Anafranil), a tricyclic antidepressant, was shown in a small double-blind study to significantly improve symptoms,[16] but results of other studies on clomipramine for treating trich have been inconsistent.[2] Fluoxetine (Prozac) and other selective serotonin reuptake inhibitors (SSRIs) have limited usefulness in treating TTM, and can often have significant side effects.[17] Behavioral therapy has proven more effective when compared to fluoxetine or control groups.[2] Dual treatment (behavioral therapy and medication) may provide an advantage in some cases, but robust evidence from high-quality studies is lacking.[3]

Reports that hypnotherapy may improve the effects obtained by other treatments were published in the 1980s.[18]

N-acetyl-L-cysteine (NAC) taken as a supplement has shown suppression of the urge to pull hair in a small clinical study.[19]


When it occurs in early childhood (before five years of age), the condition is typically self-limiting and intervention is not required.[3] In adults, the onset of trichotillomania "may be secondary to underlying psychiatric disturbances and has a more protracted course".[2]

Secondary infections may occur due to picking and scratching, but other complications are rare.[2] Individuals with trich often find that support groups are helpful in living with and overcoming the disorder.[2]


Although no broad-based population epidemiologic studies had been conducted as of 2007, the lifetime prevalence of trich is estimated to be between 0.6% (overall) and 1.5% (in males) to 3.4% (in females).[3] With a 1% prevalence rate, 2.5 million people in the U.S. may have TTM at some time during their lifetimes.[20]

TTM is diagnosed in all age groups; onset is more common during preadolescence and young adulthood, with mean age of onset between 9 and 13 years of age,[2] and a notable peak at 12–13.[3] Among preschool children the genders are equally represented; there appears to be a female predominance among preadolescents to young adults, with between 70% and 93% of patients being female.[2] Among adults, females typically outnumber males by 3 to 1.[3]


Hair pulling was first described in the literature in 1885,[4] and the term trichotillomania was coined by the French dermatologist François Henri Hallopeau in 1889.[3][4]

Society and culture

Support groups and internet sites such as the Trichotillomania Learning Center ( can provide recommended educational material and help persons with trich in "maintaining a positive attitude" and overcoming the "fear of being alone with the disease".[2][3]

A documentary film exploring trichotillomania, Bad Hair Life, was the 2003 winner of the International Health & Medical Media Award for best film in psychiatry and the winner of the 2004 Superfest Film Festival Merit Award.[21][22][23]

See also


  1. ^ James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. ISBN 0721629210.
  2. ^ a b c d e f g h i j k l m n o p q r s t u v w x y Sah DE, Koo J, Price VH (2008). "Trichotillomania" (PDF). Dermatol Ther 21 (1): 13–21. doi:10.1111/j.1529-8019.2008.00165.x. PMID 18318881. 
  3. ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad ae Chamberlain SR, Menzies L, Sahakian BJ, Fineberg NA (April 2007). "Lifting the veil on trichotillomania". Am J Psychiatry 164 (4): 568–74. doi:10.1176/appi.ajp.164.4.568. PMID 17403968. 
  4. ^ a b c Salaam K, Carr J, Grewal H, Sholevar E, Baron D (2005). "Untreated trichotillomania and trichophagia: surgical emergency in a teenage girl". Psychosomatics 46 (4): 362–6. doi:10.1176/appi.psy.46.4.362. PMID 16000680. 
  5. ^ Christenson GA, Mackenzie TB, Mitchell JE (1991). "Characteristics of 60 adult chronic hair pullers". The American journal of psychiatry 148 (3): 365–70. PMID 1992841. 
  6. ^ Christenson GA, MacKenzie TB, Mitchell JE (1994). "Adult men and women with trichotillomania. A comparison of male and female characteristics". Psychosomatics 35 (2): 142–9. PMID 8171173. 
  7. ^ Ventura DE, Herbella FA, Schettini ST, Delmonte C (2005). "Rapunzel syndrome with a fatal outcome in a neglected child". J. Pediatr. Surg. 40 (10): 1665–7. doi:10.1016/j.jpedsurg.2005.06.038. PMID 16227005. 
  8. ^ Pul N, Pul M (1996). "The Rapunzel syndrome (trichobezoar) causing gastric perforation in a child: a case report". Eur. J. Pediatr. 155 (1): 18–9. PMID 8750804. 
  9. ^ Matejů E, Duchanová S, Kovac P, Moravanský N, Spitz DJ (September 2009). "Fatal case of Rapunzel syndrome in neglected child". Forensic Sci. Int. 190 (1-3): e5–7. doi:10.1016/j.forsciint.2009.05.008. PMID 19505779. 
  10. ^ Christenson GA, Crow SJ (1996). "The characterization and treatment of trichotillomania". The Journal of clinical psychiatry 57 Suppl 8: 42–7; discussion 48–9. PMID 8698680. 
  11. ^ Keuthen NJ, Makris N, Schlerf JE, et al. (2007). "Evidence for reduced cerebellar volumes in trichotillomania". Biol. Psychiatry 61 (3): 374–81. doi:10.1016/j.biopsych.2006.06.013. PMID 16945351. 
  12. ^ Zuchner S, Cuccaro ML, Tran-Viet KN, et al. (October 2006). "SLITRK1 mutations in trichotillomania". Mol. Psychiatry 11 (10): 887–9. doi:10.1038/ PMID 17003809. Lay summary – BBC News (September 29, 2006). 
  13. ^ Hemmings SM, Kinnear CJ, Lochner C, et al. (2006). "Genetic correlates in trichotillomania--A case-control association study in the South African Caucasian population". Isr J Psychiatry Relat Sci 43 (2): 93–101. PMID 16910371. 
  14. ^ Greer JM, Capecchi MR (January 2002). "Hoxb8 is required for normal grooming behavior in mice". Neuron 33 (1): 23–34. PMID 11779477. 
  15. ^ Woods DW, Wetterneck CT, Flessner CA (2006). "A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania". Behaviour research and therapy 44 (5): 639–56. doi:10.1016/j.brat.2005.05.006. PMID 16039603. 
  16. ^ Swedo SE, Leonard HL, Rapoport JL, Lenane MC, Goldberger EL, Cheslow DL (1989). "A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling)". N. Engl. J. Med. 321 (8): 497–501. PMID 2761586. 
  17. ^ Christenson GA, Mackenzie TB, Mitchell JE, Callies AL (November 1991). "A placebo-controlled, double-blind crossover study of fluoxetine in trichotillomania". Am J Psychiatry 148 (11): 1566–71. PMID 1928474. 
  18. ^ Shenefelt PD (2003). "Biofeedback, cognitive-behavioral methods, and hypnosis in dermatology: is it all in your mind?". Dermatol Ther 16 (2): 114–22. PMID 12919113. 
  19. ^ Grant JE, Odlaug BL, Kim SW (July 2009). "N-acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: a double-blind, placebo-controlled study". Arch. Gen. Psychiatry 66 (7): 756–63. doi:10.1001/archgenpsychiatry.2009.60. PMID 19581567. 
  20. ^ Diefenbach GJ, Reitman D, Williamson DA (April 2000). "Trichotillomania: a challenge to research and practice". Clin Psychol Rev 20 (3): 289–309. PMID 10779896. 
  21. ^ "Bad Hair Life: A Documentary". Trichotillomania Learning Center. Retrieved November 27, 2009. 
  22. ^ "Superfest XXIV Winners". CDT Inc.. Retrieved November 27, 2009. 
  23. ^ "Hannah Sussman’s Art Imitates Life Join Her For a Screening October 3rd". Century City News. September 28, 2009. Retrieved November 27, 2009. 

Further reading

  • Parker (Ed.) (2004) Trichotillomania - A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References ; Icon Health Publications, ISBN 0-597-84664-2

External links

Simple English

Trichotillomania (TTM), or "trich" as it is commonly known, is a disorder causing a person to take out hair from anywhere on the body, sometimes ending in notable areas without hair. Trichotillomania is listed in the Diagnostic and Statistical Manual of Mental Disorders as an "impulse control disorder", but there are questions about how it should be listed. At different times, it may seem to be a habit, an addiction, a tic disorder, or an obsessive-compulsive disorder.

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