Transcript Document

Danny Duke &
Mary Keeley
What is Trichotillomania?
Trichotillomania is a disorder
characterized by the chronic compulsion of
pulling out one’s own hair.
The word trichotillomania is derived from
the Greek thrix (trich), hair; tillein (tillo), to
pull; and mania, madness or frenzy (mania).
Trichotillomania has historically been
considered a rare condition.
However, a college survey completed by
Christensen et al (1991) found that 3.4% of
college females and 1.5% of college males
engaged in clinically significant hair pulling
A similar survey by Rothbaum (1993) of
700 college freshmen, found that 11% pulled
their hair on a regular basis for other than
cosmetic reasons. (Rothbaum, 1993)
Researchers have reported various
prevalence rates depending on how strict a
criteria they used to define hair-pulling.
If we consider a conservative 1%, and
given a United States population approaching
300 million, we can estimate that over three
million people experience this condition in
the U.S. alone.
 The manifestation of trichotillomania can
be grouped into three subtypes:
1) A transient form that most often occurs in
young children between 2-6 years of age.
2) A habit form wherein the individual pulls
their hair in an unaware state, usually
while engaged in sedentary activities.
3) A tension-release type akin to obsessive
compulsive disorder. In this type the
individual feels a compulsion to pull that
often leads to seeking out and consciously
pulling hair to relieve a building sense of
tension or anxiety.
In this last form the individual may feel
compelled to engage in an associated ritual.
Common rituals include:
A need to extract an intact hair bulb.
A need to bite or mince the hair or hair bulb.
Tactile stimulation of lips or face with the hair shaft.
A need to pull the hair in a particular manner.
Placing, saving, or discarding hairs in a ritualistic way.
Twirling, rolling, or examination of the hair.
Searching for hairs that don’t feel right (i.e. coarse).
Searching for hairs that don’t look right (i.e. color).
Feel compelled to make their hairline absolutely even.
Swallowing their hair.
Trichophagy (injesting hair) can cause
serious medical complications.
Injesting hair can result in trichobezoars
(hairballs) which can cause intestinal
obstruction or perforation. They often
necessitate surgical removal.
Teeth can become grooved due to the
repeated sliding of hair shafts between them.
Occurs about equally for each gender in young
children, then increasingly higher prevalence rate
for girls as they age.
Average age of onset is about 13 years of age.
Children less often report tension and release,
and more often report pulling during sedentary
activities such as watching television, reading,
and lying in bed before falling asleep.
Children are more likely to pull hair from
another person, pets, or dolls.
Body areas where pulling can occur along with
associated percentages:
Scalp 75%
Eyelashes 53%
Eyebrows 42%
Pubic area 17%
Beard/face 10%
Mustache 7%
Arm 10%,
Leg 7%
Chest 3%
Abdomen 2%.
Most report that pulling of hair does not cause
Some have thought that those who pull their
hair may have a higher pain threshold. Some
work in this area has found that they do not.
However, it is thought that the experience of
pain may act as an anxiety or tension reducer
through satisfying the CNS need for stimulation.
Trichotillomania has also been thought to be
refractory to treatment.
However with the emergence of cognitive
behavioral therapy (CBT) and Habit Reversal
Therapy (HRT), effective treatment for
trichotillomania now exists.
(Azrin & Nunn, 1973, 1977)
An important barrier to treatment is that
those who pull their hair often experience
extreme embarrassment and consequently do
not seek treatment.
Most often they neither realize that
effective treatments exist, nor do they realize
that this condition is not uncommon.
Many individuals with Trichotillomania
will go to great lengths to hide the evidence
of their condition.
Wigs, elaborate hairstyles, creative
cosmetics, hats, avoidance of water and
wind, etc.
Avoidance behaviors can take the form of
not participating in common social situations
such as dating, for fear of being “found out”.
Trichotillomania is commonly associated
with young children and adolescents, yet it
can begin in adulthood or even in the elderly.
Trichotillomania is currently classified as an
impulse control disorder, although some argue
that it does not fit into this classification well.
 Why? What would cause a person to pull
out their hair.
Some theorize that hair pulling is an innate
complex grooming behavior (complex motor
program) that is triggered by stress.
Hair pulling does have similar counterparts in
animals (Moon-Fanelli et al., 1999)
Psychogenic alopecia in cats.
Acral lick dermatitis in dogs
Psychogenic feather picking
Flank biting in horses.
Hair pulling tends to occur more frequently
within families, suggesting it has biological, or
hereditary origins.
Hair pulling is thought to occur due to
dysregulation of neurotransmitters, in
particular, serotonin and dopamine.
Neuroimaging shows that the frontal-basil
ganglia pathway is of particular importance in
hair pulling.
Hair pulling may have behavioral origins.
Thought to begin via a classical
conditioning paradigm and then subsequently
maintained through operant conditioning
It is likely that several of these factors play a
role in the emergence and maintenance of
Puberty is often associated with the age of onset. It’s
thought that neuroendocrine maturational changes may
be related to the development of trichotillomania in
some women.
Premenstrual exacerbation of hair pulling symptoms
has been shown in several studies, suggesting that
hormonal variations, particularly gonadotropin levels
may exacerbate some patient’s symptoms. Occasionally
birth control pills have ameliorated symptoms.
Certain genes may be associated with increased risk of
A study by Duke University Medical Center found
two mutations in genetic marker SLITRK1 in some
family members with Trichotillomania and not in other
family members without Trichotillomania.
This gene is thought to play an important role in the
formation of neuronal connections. Mutations may
disrupt the normal formation of neural connections.
Molecular Psychiatry, October 2006
DSM-IV Criteria
Recurrent pulling out of one's hair
resulting in noticeable hair loss.
An increasing sense of tension
immediately before pulling out the hair or
when attempting to resist the behavior.
Pleasure, gratification, or relief when
pulling out the hair.
DSM-IV Criteria
The disturbance is not better accounted for by
another mental disorder and is not due to a
general medical condition (e.g., a dermatological
The disturbance causes clinically significant
distress or impairment in social, occupational, or
other important areas of functioning.
DSM-IV Criteria
What is wrong with these criteria, based on the
earlier description of trichotillomania symptoms?
Both an increasing sense of tension
immediately before pulling out the hair or when
attempting to resist the behavior, and pleasure,
gratification, or relief when pulling out the hair
are not present in about 40% of those who pull
their hair.
DSM-IV Criteria
These individuals still suffer clinically
significant distress or impairment in social,
occupational, or other important areas of
functioning, which many believe should be
the determining criteria.
Generalized Anxiety Disorder
Simple Phobia
Obsessive Compulsive Disorder
Social Phobia
Alcohol Abuse
Substance Abuse
Christenson, 1995
Other reported habits or rituals that seem to
occur with greater frequency in those who
engage in hair pulling:
Nail biting
Skin picking
Thumb sucking
Knuckle cracking
Nose picking
 Both external and internal factors affect hair
 Five modalities are thought to work together to
maintain hair pulling (Mansueto,1999):
Cognitive (thoughts and beliefs)
Affective (emotional state)
Motoric (physical actions)
Sensory (sight, touch, etc.)
External (environment)
 Any or all of these factors may be pulling cues.