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Aubree Pereyra

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3/18/2019 11:30:35 PM


Obsessive-compulsive disorders encompass a large portion of diverse disorders and presentations that revolve around the central theme of repeated thoughts and repeated activities. In its most general description, obsessive-compulsive disorder (OCD) is just as the name states, an obsession known as repeated thoughts, or compulsions known as repeated activities. Under this particular spectrum of disorders, there is trichotillomania (TTM) also known as hair-pulling disorder. It was first described in ancient Greece, but its current name was coined in the later part of the 18th century[1]. In these cases the hair is pulled from anywhere on the body repeatedly, appearing as hair loss but is caused by the action of the patient. As this condition can greatly affect the appearance of the patient, it is associated with societal stigma. This stigma creates an environment of underreporting, attempts to conceal the disorder, and often a patient will seek treatment with a dermatologist before or completely in place of a psychiatrist.


Trichotillomania is part of OCD and is thought to be largely related to anxiety disorders. There have been twin studies that have demonstrated genetic anomalies associated with trichotillomania and other OCD-related disorders[2]. Some imaging studies have shown thickening of the right inferior frontal gyrus, and others have shown reduced cerebellar volumes[3][4]. The structural abnormalities had been observed in prior research, but most had low participant numbers, and generally, there has been little robust research in this regard.

The more recent focus has been on the grey and white matter tracts. One study found the reduced integrity of the white matter within the anterior cingulate, pre-supplementary motor area, and the right and left temporal cortex in people with a diagnosis of TTM[5]. Studies have shown a significantly increased diffusivity in the tracts of the frontostriatal-thalamic pathway with more severe and longer cases of TTM[6].  Studies like these demonstrate structural abnormalities may be present in those with TTM. Positron emission tomography (PET), and single photon emission computed tomography (SPECT) studies have shown higher cerebral glucose metabolic rates in the cerebellum and right parietal cortex [3]. SPECT studies have shown decreased perfusion of the temporal lobes [3].

Studies focusing on neurochemistry have shown a relationship with the Serotonin 2A receptor[7]. Most studies that focus on neurotransmitters or neurochemistry are based on the patient's response to therapy that modulates these neurotransmitters. For example, multiple randomized controlled studies look at treatment with selective serotonin reuptake inhibitors (SSRIs). Some have yielded positive results, and some have been equivocal [8][7][9][10]. One meta-analysis that looked at SSRIs showed moderate effects on patient symptoms, compared to more sizeable effects of behavior therapy[11]. Other studies suggest that the dopamine system is also involved. There have been double-blind, placebo-controlled trials that have shown positive effects with olanzapine, and the reversal of TTM has been shown with aripiprazole treatment [12][13][14]. There have been studies that have shown clomipramine also can be effective[15]. Generally, these studies suggest the involvement of the monoamine system with serotonin, norepinephrine, and dopamine receptors. Data in these studies are often not robust and need to be replicated.

Other factors in the etiology are neuropsychology and the cognitive components. Many trichotillomania patients report that there was a stressful situation that occurred before the hair-pulling behavior. Others describe boredom before hair-pulling[16]. These feelings of boredom or stress are negative effects, or internal feelings or emotions, which have been shown in research to correlate to the increased behavior of pulling hair. If we examine the action in behavioral terms, there is a sense of tension that precedes hair-pulling behavior[16][17]. This tension is then relieved by the hair pulling itself. This creates a cycle of learned and reinforced behavioral activity. The negative affect, or emotion, is paired with the behavior which relieves the negative affect and thus is reinforced and repeated[18][8][7]. For example, the patient feels stressed, pulls hair, stress goes away and thus the alleviation of the stress reinforces the behavior of hair pulling. Some patients report an association of depressive symptoms likely resulting in some response of TTM to SSRI treatment. Since the psychiatric and psychological symptomatology is diverse, no single predictor can be named at this time. Currently, it is accepted that behavioral therapy is the mainstay of treatment and that the neuropsychology of TTM is the greater of the etiological components.


Beginning in adolescence, the lifetime prevalence is reported as high as 3.5%[19]. The adolescent patients do not all meet criteria for trichotillomania as described by the DSM-V criteria but they do experience some form of the symptoms. The disorder is reported more commonly in females, the ratio shown to be about 9:1 toward females[7][20][21]. It is thought that the stigma of the disorder creates underreporting in general.


The disease is a clinical diagnosis but can be confirmed by punch biopsy of the scalp[8]. Typically the hands are used to pull the hair, but tweezers or other devices can be used. The hair from the head is the most common to be pulled but can be from anywhere. Some individuals exhibit the Friar Tuck sign with hair loss in a distinct area at the crown and maintenance of hair in temporal and occipital regions[8]. There can be a ritualistic manner of choosing the hair and the act of pulling, for example searching for the coarse hair at the beginning of the hairline after combing hands through the hair. After the hair is pulled, some individuals will inspect it and eat all or portions of the hair. If eating the hair is involved, then the patient is at risk for a trichobezoar.  If the patient suffers pain, nausea, vomiting, or constipation, trichobezoar should be sought because they can potentially get large enough to cause bowel obstruction or perforation[22]. Important to note is that the hair pulling may be considered automatic, done when the patient is not aware or focused or completed when the patient is solely focused on the pulling behavior[16].


Punch biopsy will show evidence of traumatic removal of the hair; this step can help with diagnosis but is not required. The slide will show a non-inflammatory non-scarring alopecia  where there is follicular damage secondary to external insult. The anatomy of the hair follicle gets distorted. There can be loss of hair shafts and noticeable trichomalacia of the hair[23]. The number of hair follicles is normal[23]. Important to note is that with chronic traumatic insult, this non-scarring condition eventually results in scarring leading to permanent hair loss.

History and Physical

Generally, as with any patient seeking psychiatric care, start with a semistructured diagnostic interview. There is, unfortunately, no structured interview technique that has been validated for DSM-V. There are some that have been validated for TTM based on DSM-IV-TR criteria. These older structured interviews incorporate the National Institute of Mental Health Trichotillomania Severity Scale and the National Institute of Mental Health Trichotillomania Impairment Scale. Some more recent studies have attempted to use adapted scales that have shown positive interrater reliability in assessing for TTM[7]. When gathering a history, the patient must meet criteria as stated in the Diagnostic and Statistical Manual-V. 

The current DSM-V manual lists 5 criteria necessary for a diagnosis of TTM. The criteria are as follows:

  • Criteria A: The person must be removing hair from a body region. The hairs can be from a concentrated region or a diffuse area. There may be associated bald spots or thinning of the hair.
  • Criteria B: the person must have tried to stop or decrease hair removal.
  • Criteria C: The removal must cause significant distress or impairment in at least one area of functioning.
  • Criteria D: The hair pulling or loss cannot be caused by another medical condition (e.g., alopecia areata, tinea capitis).
  • Criteria E: The hair pulling is not better explained by some other mental disorder and its symptoms.

Other symptoms that are also screened for in a structured interview would include those in other psychiatric disorders.

When patients visit a practitioner that is not a psychiatrist, as usual, complete a History and Physical exam. There should be a high level of suspicion when discussing hair loss. Patients may deny that they are pulling the hair out. They may complain of other psychiatric disorders and their associated symptoms.  They may have somatic gastrointestinal complaints, possibly due to trichobezoar. The patient’s history of hair loss can be varied, and there may be vague answers if they are trying to minimize this stigmatizing behavior.

The physical exam should assess the skin specifically looking at the areas of hair loss which can be obvious in some cases and barely visible in others. The hair can be missing from any area of the body that hair grows. The areas of hair loss will be noted to have hair of differing lengths and various stages of regrowth. There is often an identifiable geometric area of hair loss. Rash or other skin changes should be noted to the site as these can be associated with another diagnosis in the differential. To determine the potential for regrowth, you will need to check for scarring of the skin at the follicles.  If no scarring is present, then regrowth can occur[8]. There should also be a thorough abdominal examination for masses, pain, or fecal impaction because all are indicative of possible trichobezoar.


History and physical are enough for a diagnosis of TTM. Punch biopsy of the scalp can help diagnose but is not necessary. The hairs themselves can be visualized microscopically and will show signs of regrowth. The extent of balding measures the severity of the disorder. Taking pictures to document changes may be useful in evaluating the effectiveness of treatment[8]. The behavioral components of hair-pulling should be evaluated as well. This would include a thorough evaluation of the triggers or antecedents in behavioral terminology and consequences. Antecedents can be cues from the environment like particular situations and also cues from internal factors like emotions[16][17][18][24]. Consequences can be feelings of guilt, poor self-image, or pleasure from the action or the alleviation of negative emotion. Again this is not required for diagnosis but can assist in guiding treatment. Physician and patient rating scales can be used but are not mandatory for diagnosis[7]. These include:

  • NIMH Trichotillomania Scale
  • Yale-Brown Obsessive-Compulsive Scale-Trichotillomania
  • The Psychiatric Institute Trichotillomania Scale.
  • Massachusetts General Hospital Hairpulling Scale
  • Trichotillomania Scale for Children
  • The Milwaukee Inventory for Styles of Trichotillomania- Adult and Child Versions

Treatment / Management

Trichotillomania is a multifaceted disorder that often involves various specialties and cross-specialties as well as multiple treatment modalities. The patient may be seen by a primary care physician, a dermatologist, a psychiatrist, and a licensed clinical psychologist. The treatment will likely include therapy techniques, and there may be the use of medications. The currently studied therapy techniques for the treatment of Trichotillomania include Cognitive Behavioral Therapy and Habit Reversal Training.

Habit Reversal Training is grounded in CBT techniques it aims to identify cognitive distortions and thought-action pairings and change them. For example, a patient notes that they have stressful group activities at work and after this, they notice that pulling hair out alleviates this stress. The cognitive distortion/thought of all social interaction creating stress is paired with the hair pulling as a way to alleviate the stress, and so this behavior is negatively reinforced by the alleviation of the stress, and the connection is strengthened. Habit Reversal therapy is a low-risk treatment for TTM that has been shown to be effective[18][24].

The Habit Reversal therapy has three components: awareness, competing for the response, and social support[7]. The person is trained to be aware of hair pulling and of the situations or emotions that cause the hair pulling. They are trained to notice when they are in the act and when they are about to perform the behavior. They are praised for correct awareness and reminded if incorrect. Once this is solidified, then they are taught a competing response which is some action that takes place instead of hair removal. They are to complete this task when they are pulling the hair or if they have the urge to pull. The social support from those around the individual that praise the appropriate use of habit reversal training or remind the patient to use the training when they are not doing so is core to habit reversal training[7].

Current research suggests modest positive effects with Selective Serotonin Reuptake Inhibitors. The effects are more robust in combination with therapy. There have been meta-analysis reviews of more recent research that have shown a moderate positive effect of SSRI medications, but a more pronounced effect was seen with therapy[11].  There are more recent preliminary data that have shown some positive effect with Olanzapine, Aripiprazole, and Quetiapine[12][13][14][25]. The studies with antipsychotics are few and require future studies to replicate results. Past studies using Clomipramine and others in the Tricyclic antidepressant medication class have been studied to treat TTM and efficacy has been found with more research supporting Clomipramine[15]. Other novel treatment case studies using N-acetylcysteine have shown positive results, but there have been no robust studies[26].

Differential Diagnosis

Other forms of hair loss must be placed on the differential diagnosis. Examples include traction alopecia, male pattern baldness, pressure alopecia, alopecia areata, tinea capitis, short-term habit, obsessive-compulsive disorder, and systemic diseases like cancer, lupus, hypothyroidism, and factitious disorder[8][7].


The prognosis is better when the disorder is diagnosed early, and treatment begins early. It is associated with better prognosis the younger the age of occurrence. Long-term complications of the disease include permanent hair loss, and this is seen primarily in people who have been pulling the hair out into adulthood[8].


Psychiatry may be consulted. Dermatology consult may also be sought. Consult with a licensed therapist is also part of treatment.

Pearls and Other Issues

There is a significant stigma surrounding self-inflicted pathological hair loss thus patients may be hesitant to discuss it. Remember to keep a high degree of suspicion.

Often, a multidisciplinary approach to treatment and management will include, dermatology, psychiatry, and psychology.

Enhancing Healthcare Team Outcomes

Trichotillomania often presents to the primary care provider or mental health nurse. However, this is not a trivial disorder and should be managed by a multidisciplinary team that includes a psychiatrist, behavior therapist, psychologist, and a dermatologist. The treatment includes therapy techniques combined with anxiety-relieving medications. The currently studied therapy techniques for the treatment of Trichotillomania include Cognitive Behavioral Therapy and Habit Reversal Training.

Unfortunately, the disorder has no cure and all treatments have limitations. The disorder has relapses and remissions. In the long run, the patient has permanent loss of hair, scarring, and poor cosmesis.[27] (Level V)

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Trichotillomania - Questions

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A 17-year-old female is brought in by her parents for hair loss. The patient herself is not worried. The exam shows the part in her hair is widened with decreased hair density. The hair in the area is coarse and of multiple different lengths. Gentle traction does not pull out any hairs. The skin of the scalp has some light brown scales. The eyelashes show varying lengths. Which of the following would be the most appropriate question?

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A patient is diagnosed with trichotillomania. What laboratory testing is indicated?

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Which of the following is not used in the treatment of trichotillomania?

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What condition is characterized by the Friar Tuck sign?

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Trichotillomania - References


On trichotillomania and its hairy history., Kim WB,, JAMA dermatology, 2014 Nov     [PubMed]
A Preliminary Investigation of Metacognitive Therapy and Habit Reversal as a Treatment for Trichotillomania., Shareh H,, Behavioural and cognitive psychotherapy, 2018 Jan     [PubMed]
The structure of genetic and environmental risk factors for dimensional representations of DSM-5 obsessive-compulsive spectrum disorders., Monzani B,Rijsdijk F,Harris J,Mataix-Cols D,, JAMA psychiatry, 2014 Feb     [PubMed]
Giant gastric trichobezoar in a young female with Rapunzel syndrome: case report., Hamid M,Chaoui Y,Mountasser M,Sabbah F,Raiss M,Hrora A,Alaoui M,Ahallat M,Chaouch S,Ouazzani H,, The Pan African medical journal, 2017     [PubMed]
Systematic Review of Published Primary Studies of Neuropsychology and Neuroimaging in Trichotillomania., Slikboer R,Reser MP,Nedeljkovic M,Castle DJ,Rossell SL,, Journal of the International Neuropsychological Society : JINS, 2018 Feb     [PubMed]
Cortical thickness abnormalities in trichotillomania: international multi-site analysis., Chamberlain SR,Harries M,Redden SA,Keuthen NJ,Stein DJ,Lochner C,Grant JE,, Brain imaging and behavior, 2017 Jun 29     [PubMed]
Review of epidemiology, clinical presentation, diagnosis, and treatment of common primary psychiatric causes of cutaneous disease., Krooks JA,Weatherall AG,Holland PJ,, The Journal of dermatological treatment, 2017 Nov 5     [PubMed]
Trichotillomania Among Young Adults: Prevalence and Comorbidity., Grzesiak M,Reich A,Szepietowski JC,Hadryś T,Pacan P,, Acta dermato-venereologica, 2017 Apr 6     [PubMed]
Diagnosis, evaluation, and management of trichotillomania., Woods DW,Houghton DC,, The Psychiatric clinics of North America, 2014 Sep     [PubMed]
Grey matter abnormalities in trichotillomania: morphometric magnetic resonance imaging study., Chamberlain SR,Menzies LA,Fineberg NA,Del Campo N,Suckling J,Craig K,Müller U,Robbins TW,Bullmore ET,Sahakian BJ,, The British journal of psychiatry : the journal of mental science, 2008 Sep     [PubMed]
White matter integrity in hair-pulling disorder (trichotillomania)., Roos A,Fouche JP,Stein DJ,Lochner C,, Psychiatry research, 2013 Mar 30     [PubMed]
DSM-5 field survey: hair-pulling disorder (trichotillomania)., Lochner C,Grant JE,Odlaug BL,Woods DW,Keuthen NJ,Stein DJ,, Depression and anxiety, 2012 Dec     [PubMed]
Trichotillomania: Demographic and Clinical Features From a Nationally Representative US Sample., Gupta MA,Gupta AK,Knapp K,, Skinmed, 2015     [PubMed]
Pharmacotherapy of trichotillomania (hair pulling disorder): an updated systematic review., Rothbart R,Stein DJ,, Expert opinion on pharmacotherapy, 2014 Dec     [PubMed]
Pharmacotherapy for trichotillomania., Rothbart R,Amos T,Siegfried N,Ipser JC,Fineberg N,Chamberlain SR,Stein DJ,, The Cochrane database of systematic reviews, 2013 Nov 8     [PubMed]
A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling), Swedo SE,Leonard HL,Rapoport JL,Lenane MC,Goldberger EL,Cheslow DL,, The New England journal of medicine, 1989 Aug 24     [PubMed]
Treating trichotillomania: a meta-analysis of treatment effects and moderators for behavior therapy and serotonin reuptake inhibitors., McGuire JF,Ung D,Selles RR,Rahman O,Lewin AB,Murphy TK,Storch EA,, Journal of psychiatric research, 2014 Nov     [PubMed]
The efficacy of low-dose aripiprazole treatment for trichotillomania., Yasui-Furukori N,Kaneko S,, Clinical neuropharmacology, 2011 Nov-Dec     [PubMed]
A randomized, double-blind, placebo-controlled trial of olanzapine in the treatment of trichotillomania., Van Ameringen M,Mancini C,Patterson B,Bennett M,Oakman J,, The Journal of clinical psychiatry, 2010 Oct     [PubMed]
Reversal of trichotillomania with aripiprazole., Jefferys D,Burrows G,, Depression and anxiety, 2008     [PubMed]
Quetiapine for the treatment of trichotillomania., Crescente Junior JA,Guzman CS,Tavares H,, Revista brasileira de psiquiatria (Sao Paulo, Brazil : 1999), 2008 Dec     [PubMed]
The neuropsychology of trichotillomania., Stanley MA,Hannay HJ,Breckenridge JK,, Journal of anxiety disorders, 1997 Sep-Oct     [PubMed]
Disordered reward processing and functional connectivity in trichotillomania: a pilot study., White MP,Shirer WR,Molfino MJ,Tenison C,Damoiseaux JS,Greicius MD,, Journal of psychiatric research, 2013 Sep     [PubMed]
Histopathology of alopecia: a clinicopathological approach to diagnosis., Stefanato CM,, Histopathology, 2010 Jan     [PubMed]
Cognitive behavior therapy for obsessive-compulsive and related disorders., Lewin AB,Wu MS,McGuire JF,Storch EA,, The Psychiatric clinics of North America, 2014 Sep     [PubMed]
Trichotillomania: a good response to treatment with N-acetylcysteine., Barroso LAL,Sternberg F,Souza MNIFE,Nunes GJB,, Anais brasileiros de dermatologia, 2017 Jul-Aug     [PubMed]
Carr JM,Mortimer H,Martin K,Kaur M,Goulding JMR, A retrospective review of 12 patients with trichotillomania treated in a psychodermatology service. Clinical and experimental dermatology. 2019 Jan 28;     [PubMed]


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