Name = Trichotillomania
ICD10 = ICD10|F|63|3|f|60
ICD9 = ICD9|312.39
eMedicineSubj = derm
eMedicineTopic = 433
eMedicine_mult = eMedicine2|ped|2298
DiseasesDB = 29681
MedlinePlus = 001517
Trichotillomania (TTM), or "trich" as it is commonly known, is an impulse control disorder or form of
self-injurycharacterized 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. Trichotillomania is classified in the DSM-IV as an impulse control disorder, but there are still 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. Trichototillomania often begins during the individual's teenage years. Depression or stress can trigger the trich. Due to social implications the disorder is often unreported and it is difficult to predict accurately prevalenceof trichotillomania; 2.5 million in the U.S. may have TTM, with a 1% prevalence rate.cite journal |author=Diefenbach, G.J., Reitman, D. & Williamson, D.A., |title=Trichotillomania: A challenge to research and practice |journal=Clinical Psychology Review |issue=20 |pages=289–309 |year=2000 | volume = 20 | doi = 10.1016/S0272-7358(98)00083-X]
The name derives from Greek: "tricho-" (hair), "till(en)" (to pull), and "
Individuals with trichotillomania live relatively normal lives; however, they may have bald spots on their head, among their eyelashes, pubic hair, or brows. 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, 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.cite journal |author=Christenson GA, Mackenzie TB, Mitchell JE |title=Characteristics of 60 adult chronic hair pullers |journal=The American journal of psychiatry |volume=148 |issue=3 |pages=365–70 |year=1991 |pmid=1992841]
Many clinicians classify TTM as a habit behavior, in the same family as
nail biting(onychophagia) or compulsive skin picking(dermatillomania). These disorders are a cross between mental disorders, such as obsessive compulsive disorder(OCD) because the sight or feel of a body part causes the individual anxiety, and physical disorders such as stereotypic movement disorderbecause the person performs repetitive movements without being bothered by or completely aware of them. The current classification of trich as an impulse disorder with pyromania, pathological gamblingand kleptomania, has been called into question as inadequate and in need of revision.Penzel (2003) "The Hair-Pulling Problem: A Complete Guide to Trichotillomania"; Oxford University Press, p. 3. ISBN 0-19-514942-4] One study showed that individuals with TTM have decreased cerebellar volume.cite journal
author=Keuthen NJ, Makris N, Schlerf JE, "et al" |title=Evidence for reduced cerebellar volumes in trichotillomania |journal=Biol. Psychiatry |volume=61 |issue=3 |pages=374–81 |year=2007 |pmid=16945351 |doi=10.1016/j.biopsych.2006.06.013] Anxiety, depression and OCD are more frequently encountered in people with TTM.cite journal |author=Christenson GA, Crow SJ |title=The characterization and treatment of trichotillomania |journal=The Journal of clinical psychiatry |volume=57 Suppl 8 |pages=42–7; discussion 48–9 |year=1996 |pmid=8698680 ] People with TTM may also eat/chew the roots of the hair that they pull, referred to as
trichophagia. In extreme cases this can lead to Rapunzel syndrome, and even death. [cite journal |author=Ventura DE, Herbella FA, Schettini ST, Delmonte C |title=Rapunzel syndrome with a fatal outcome in a neglected child |journal=J. Pediatr. Surg. |volume=40 |issue=10 |pages=1665–7 |year=2005 |pmid=16227005 |doi=10.1016/j.jpedsurg.2005.06.038] [cite journal |author=Pul N, Pul M |title=The Rapunzel syndrome (trichobezoar) causing gastric perforation in a child: a case report |journal=Eur. J. Pediatr. |volume=155 |issue=1 |pages=18–9 |year=1996 |pmid=8750804] [cite web | url=http://www.keratin.com/ar/ar012.shtml | title=Hairball kills teenager |publisher=hairgrowthnews.com | accessdate=2007-08-11] Some individuals with TTM may feel they are the only person with this problem due to low rates of reportage. [cite journal |author=Christenson GA, MacKenzie TB, Mitchell JE |title=Adult men and women with trichotillomania. A comparison of male and female characteristics |journal=Psychosomatics |volume=35 |issue=2 |pages=142–9 |year=1994 |pmid=8171173]
Habit Reversal Trainingor HRT, has been shown to be a successful adjunct to medicationas a way to treat TTM.cite journal |author=Woods DW, Wetterneck CT, Flessner CA |title=A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania |journal=Behaviour research and therapy |volume=44 |issue=5 |pages=639–56 |year=2006 |pmid=16039603 |doi=10.1016/j.brat.2005.05.006] With Habit Reversal Training, doctors train the individual to learn to recognize their impulse to pull and also teach them to redirect this impulse. As a part of the behavioral record-keeping component of HRT, patients are often instructed to keep a journal of their hair-pulling episodes. They may be asked to record the date, time, location, and number of hairs pulled, as well what they are thinking or feeling at the time. This can help the patient learn to identify situations where they commonly pull out their hair and develop strategies for avoiding episodes.
Clomipramine, a tricyclic antidepressant, was shown in a small double-blind study to significantly improve symptoms.cite journal |author=Swedo SE, Leonard HL, Rapoport JL, Lenane MC, Goldberger EL, Cheslow DL |title=A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling) |journal=N. Engl. J. Med. |volume=321 |issue=8 |pages=497–501 |year=1989 |pmid=2761586 |doi=] Fluoxetine(Prozac) and other similar SSRI drugs have limited usefulness in treating TTM, and can often have significant side effects.cite journal |author=Christenson GA, Mackenzie TB, Mitchell JE, Callies AL |title=A placebo-controlled, double-blind crossover study of fluoxetine in trichotillomania |journal=Am J Psychiatry |volume=148 |issue=11 |pages=1566–71 |year=1991 |month=November |pmid=1928474 |doi= |url=http://ajp.psychiatryonline.org/cgi/pmidlookup?view=long&pmid=1928474] According to F. Penzel, antidepressants can even increase the severity of the TTM.
TTM is diagnosed in all age groups; it is more common during the first two decades of life, with mean age of onset usually reported between 9 and 13 years of age. 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. [cite journal |journal= Dermatol Ther |date=2008 |volume=21 |issue=1 |pages=13–21 |title= Trichotillomania |author= Sah DE, Koo J, Price VH |doi=10.1111/j.1529-8019.2008.00165.x |pmid=18318881] Evidence now points to a genetic predisposition.cite web | publisher =
National Center for Biotechnology Information|date= August 12 2006| title= Entrez Gene: HOXB8 homeobox B8 [ Homo sapiens ] |url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=gene&cmd=Retrieve&dopt=Graphics&list_uids=3218 |accessdate=2007-11-13 ] cite web | publisher=BBC News |url= http://news.bbc.co.uk/1/hi/health/5381232.stm | title= Hair pulling disorder gene found | date= 29 September 2006| accessdate=2007-05-01]
The number of reported trichotillomania cases has increased throughout the years, possibly due to a reduced stigma associated with the condition. Estimates of the number of persons with TTM range from 1–3%cite journal | author=Christenson GA, Mackenzie TB, Mitchell JE | title=Characteristics of 60 adult chronic hair pullers| journal=Am J Psychiatry. | year=1991 | volume=148 | issue=3 | pages=365–70] up to 5% of the world's population.
When genes that were suspected to cause trichotillomania were injected into laboratory mice in one study, the mice obsessively pulled out their fur and the fur of other mice in the cage.cite press release|title=Gene Targeting, Homeobox Genes, Development, and Behavior|publisher=
Howard Hughes Medical Institute|date=2008-05-01|url=http://www.hhmi.org/research/investigators/capecchi.html|accessdate=2008-07-12]
* Keuthen, Stein, Christensen & Christenson (2001) "Help for Hair Pullers: Understanding and Coping With Trichotillomania"; New Harbinger Publications, ISBN 1-57224-232-9
* Parker (Ed.) (2004) "Trichotillomania - A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References" ; Icon Health Publications, ISBN 0-597-84664-2
* Stein (Ed.), Christenson (Ed.) & Hollander (Ed.) (1999) "Trichotillomania"; American Psychiatric Press, ISBN 0-88048-759-3
* [http://www.trich.org Trichotillomania Learning Center]
* [http://www.psychiatrictimes.com/p971150.html Psychiatric Times article]
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