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Diagnostic Features

The essential feature of Trichotillomania is the recurrent pulling out of one's own hair that results in noticeable hair loss (Criterion A). Sites of hair pulling may include any region of the body in which hair may grow (including axillary, pubic, and perirectal regions), with the most common sites being the scalp, eyebrows, and eyelashes. Hair pulling may occur in brief episodes scattered throughout the day or in less frequent but more sustained periods that can continue for hours. Stressful circumstances frequently increase hair-pulling behavior, but increased hair pulling also occurs in states of relaxation and distraction (e.g., when reading a book or watching television). An increased sense of tension is present immediately before pulling out the hair (Criterion B). For some, tension does not necessarily precede the act but is associated with attempts to resist the urge. There is gratification, pleasure, or a sense of relief when pulling out the hair (Criterion C). Some individuals experience an "itchlike" sensation in the scalp that is eased by the act of pulling hair. The diagnosis is not given if the hair pulling is better accounted for by another mental disorder (e.g., in response to a delusion or a hallucination) or is due to a general medial condition (e.g., inflammation of the skin or other dermatological conditions) (Criterion D). The disturbance must cause significant distress or impairment in social, occupational, or other important areas of functioning (Criterion E).

Associated Features and Disorders

Associated discriptive features and mental disorders. Examining the hair root, twirling it off, pulling the strand between the teeth, or trichophagia (eating hairs) may occur with Trichotillomania. Hair pulling does not usually occur in the presence of other people (except immediate family members), and social situations may be avoided. Individuals commonly deny their hair-pulling behavior and conceal or camouflage the resulgint alopecia. Some individuals have urges to pull hairs from other people and may sometimes try to find opportunities to do so surreptitiously. They may pull hairs from pets, dolls, and other fibrous materials (e.g., sweaters or carpets). Nail biting, scratching, gnawing, and excoriation may be associated with Trichotillomania. Individuals with Trichotillomania may also have Mood Disorders, Anxiety Disorders, or Mental Retardation.

Associated laboratory findings. Certain histological findings are considered characteristic and may aid diagnosis when Trichotillomania is suspected and the affected individual denies symptoms. Biopsy samples from involved areas may reveal short and broken hairs. Histological examination will reveal normal and damaged follicles in the same area, as well as an increased number of catagen hairs. Some hair follicles may show signs of trauma (wrinkling of the outer root sheath). Involved follicles may be empty or may contain a deeply pigmented keratinous material. The absence of inflammation distinguishes Trichotillomania-induced alopecia from alopecia areata.



Associated physical examination findings and general medical condiitons. Pain is not routinely reported to accompany the hair pulling; pruritus and tingling in the involved areas may be present. The patterns of hair loss are highly variable. Areas of complete alopecia are common, as well as areas of noticeably thinned hair density. When the scalp is involved, there may be a predilection for the crown or parietal regions. The surface of the scalp usually shows no evidence of excoriation. There may be a pattern of nearly complete baldness except for a narrow perimeter around the outer margins of the scalp, particularly at the nape of the neck ("tonsure trichotillomania"). Eyebrows and eyelashes may be completely absent. Thinning of pubic hairs may be apparent on inspection. There may be areas of absent hair on the limbs or torso. Trichophagia may result in bezoars (hair balls) that may lead to anemia, abdominal pain, hematemesis, nausea and vomiting, and bowel obstruction and even perforation.

Specific Culture, Age, and Gender Features

Among children with Trichotillomania, males and females are equally represented. Among adults, Trichotillomania appears to be much more common among females than among males. This may reflect the true gender ratio of the condition or it may reflect differential treatment seeking based on cultural or gender-based attitudes regarding appearance (e.g., acceptance of normative hair loss among males).

Prevalence

No systematic data are available on the prevalence of Trichotillomania. Although Trichotillomania was previously thought to be an uncommon condition, it is now believed to occur more frequently. Recent surveys of college samples suggest that 1%-2% of students have a past or current history of Trichotillomania.

Course

Transient periods of hair pulling in early childhood may be considered a benign "habit" with a self-limiting course. However, many individuals who present with chronic Trhichtillomania in adulthood report onset in early childhood. The age at onset is usually before young adulthood, with peaks at around ages 5-8 years and age 13 years. Some individuals have continuous symptoms for decades. For others, the disorder may come and go for weeks, months, or years at a time. Sites of hair pulling may vary over time.

Differential Diagnosis

Other causes of alopecia should be considered in individuals who deny hair pulling (e.g., alopecia areata, male-pattern baldness, chronic discoid lupus erythematosus, lichen planopilaris, folliculitis, decalvans, pseudopelade, and alopecia mucinosa). A separate diagnosis of Trichotillomania is not given if the behavior is better accounted for by another mental disorder (e.g., in response to a delusion or a hallucination in Schizophrenia). The repetitive hair pulling in Trichotillomania must be distinguished from a compulsion, as in Obsessive-Compulsive Disorder. In Obsessive-Compulsive Disorder, the repetitive behaviors are performed in response to an obsession, or according to rules that must be applied rigidly. An additional diagnosis of Stereotypic Movement Disorder is not made if the repetitive behavior is limited to hair pulling. The self-induced alopecia in Trichotillomania must be distinguished from Factitious Disorder With Predominantly Physical Signs and Symptoms, in which the motivation for the behavior is assuming the sick role.



Many individuals twist and play with hair, especially during states of heightened anxiety, but this behavior does not usually qualify for a diagnosis of Trichotillomania. Some individuals may present with features of Trichotillomania, but the resulting hair damage may be so slight as to be virtually undetectable. In such situations, the diagnosis should only be considered if the individual experiences significant distress. In children, self-limiting periods of hair pulling are common and may be considered a temporary "habit." Therefore, among children, the diagnosis should be reserved for situations in which the behavior has persisted for several months.


Diagnostic criteria for Trichotillomania

A. Recurrent pulling out of one's hair resulting in noticeable hair loss.

B. An increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior.

C. Pleasure, gratification, or relief when pulling out the hair.

D. The disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (e.g., a dermatological condition).

E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.


Taken from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, American Psychiatric Association, 1994.


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