Trichotillomania (Hair-Pulling Disorder)

*(TTM, classified under Obsessive-Compulsive and Related Disorders in DSM-5)*

A body-focused repetitive behavior (BFRB) characterized by recurrent pulling out of one’s hair, leading to hair loss and significant distress.

DSM-5 Diagnostic Criteria

  1. Recurrent hair pulling resulting in noticeable hair loss.
  2. Repeated attempts to decrease or stop the behavior.
  3. Clinically significant distress or impairment (social, occupational).
  4. Not attributable to another medical condition (e.g., dermatologic) or mental disorder (e.g., psychosis).

Clinical Features

Common Pulling Sites:

✔ Scalp (most common)
✔ Eyebrows, eyelashes
✔ Beard, pubic hair, limbs

Behavioral Patterns:

  • Focused pulling: Intentional, tension-relieving (often with rituals like examining/chewing hair).
  • Automatic pulling: Unconscious (e.g., while reading, watching TV).

Associated Behaviors:

  • Trichophagy (eating pulled hair; may lead to trichobezoars [hairballs] in severe cases).
  • Camouflage efforts (wigs, makeup, hats).

Psychological Impact:

  • Shame/embarrassment → social withdrawal.
  • High comorbidity with anxiety (60%), depression (40%), and OCD (15%).

Etiology & Risk Factors

Biological:

  • Genetic predisposition (familial link with OCRDs).
  • Dysregulation in frontostriatal circuits (similar to OCD).
  • Low serotonin/dopamine activity.

Psychological:

  • Stress, boredom, perfectionism.
  • Sensory triggers (e.g., coarse or “wrong-feeling” hairs).

Environmental:

  • Childhood trauma (link with BFRBs).
  • Learned behavior (e.g., mimicking family members).

Assessment Tools

  1. Massachusetts General Hospital Hairpulling Scale (MGH-HPS) – Severity measure.
  2. National Institute of Mental Health Trichotillomania Scale (NIMH-TSS) – Clinician-administered.
  3. Dermatologic exam – Rule out alopecia areata, infections.

Treatment Approaches

1. Psychotherapy (First-Line)

  • Habit Reversal Training (HRT):
    • Awareness training (identify triggers).
    • Competing response (e.g., fist-clenching, using fidget toys).
  • Cognitive Behavioral Therapy (CBT):
    • Address perfectionism, shame.
    • Stress-management techniques.
  • Acceptance and Commitment Therapy (ACT):
    • Mindfulness of urges without acting.

2. Pharmacotherapy

  • SSRIs (Fluoxetine, Sertraline): Limited efficacy (better for comorbid anxiety/depression).
  • N-Acetylcysteine (NAC): Glutamate modulator (1200–2400 mg/day; some evidence for reducing urges).
  • Olanzapine/Aripiprazole: For refractory cases (low-dose antipsychotics).

3. Adjunctive Strategies

  • Barrier methods: Gloves, bandanas, fake nails.
  • Sensory substitutes: Stress balls, textured jewelry.
  • Support groups: TLC Foundation for BFRBs.

Differential Diagnosis

ConditionKey Distinction
Alopecia AreataAutoimmune hair loss (no pulling urges).
OCDHair pulling is ritualistic (e.g., to fix asymmetry).
Factitious DisorderIntentional hair removal for secondary gain.

Prognosis

  • Chronic but manageable with treatment.
  • 50–60% improve with CBT/HRT.
  • Poorer outcomes with:
    • Early onset (childhood).
    • Comorbid depression/OCD.

Patient Self-Help Strategies

✔ Track triggers (journaling apps like “SkinPick”).
✔ Create barriers (wear a hat at night).
✔ Healthy substitutes (chewy jewelry for oral urges).

Resource: TrichStop – Online support programs.