Trichotillomania (Hair-Pulling Disorder) (F63.3)

DSM-IV-TR criteria

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.

Associated Features

Individuals with Trichotillomania are often seen by the public as having a habit of playing with their hair. The individual will examine the hair root, twirl it off, pull the strand of hair between their teeth, or may eat their hair. They usually do not pull their hair out in the presence of anyone except family members. The individual suffering from this disorder will deny that they pull out their hair, and will attempt to hide the resulting baldness. If the case is extreme, the individual may have urges to pull others hair, but often can refrain. Dolls, pets, carpet, and sweaters are often pulled on like hair, and nail biting, scratching, gnawing, and excoriation are often associated with this disorder.

Child vs. Adult presentation

The mean age of onset is 9 to 14 years old. It is more common during the first 20 years of someone’s life. There is not a difference in presentation between child and adults, however.

Gender and cultural differences in presentation

When presented in children, the rates between genders tend to be relatively equal. However, when Trichotillomania is present in an adult, it is more common in females. It has been found that 70-90% of pre-adolescents and adults that have this are female. This finding of an off-balance male-to-female ratio may be a result of the true gender ratio of the condition, or it could be due to treatment seeking curve formed due to cultural or gender based attitudes regarding acceptance of the associated features of this disease.

Epidemiology

Trichotillomania is now believed to be more common than it once was. Studies show that today the lifetime prevalence rate of this disorder is 0.6%.

Etiology

• There is evidence of a genetic predisposition, in which mutations found in a gene known as SLITRK1 have been linked to trichotillomania as well as to Tourette syndrome, a neurological disorder that causes a person to make unusual movements and sounds
• Neurochemical problems can also play a role in Trichotillomania. Some studies suggest that abnormalities in the natural brain chemicals serotonin and dopamine may play a role in trichotillomania.

Empirically supported treatments

Proposed Dsm5 Changes (Dsm5.org)

The work group is recommending that this disorder be reclassified from Impulse Control Disorders Not Elsewhere Classified to Anxiety and Obsessive-Compulsive Spectrum Disorders
A. Recurrent pulling out of one’s hair resulting in hair loss.
B. The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C . The hair pulling is not due to a general medical condition (e.g., a dermatological condition).
D. The hair pulling is not restricted to the symptoms of another mental disorder (e.g., hair pulling due to preoccupation with appearance in Body Dysmorphic Disorder).

The work group is considering an additional criterion that addresses urges to pull one’s hair or attempts to resist hair pulling.

Rationale for Change

Name: The term “mania” seems inappropriate for trichotillomania. However, changing too rapidly to a more descriptive term (eg hair-pulling disorder) may be confusing for clinicians, hence we propose to retain trichotillomania in parentheses

A: Hair loss may not always be noticeable in those suffering from this disorder.

B and C: Patients with chronic hair-pulling may or may not meet criteria B or C. Those who do and do not meet these criteria do not appear distinguishable on a range of clinical validators.

D: The exclusion criterion may be more clinically useful if it lists disorders that may be misdiagnosed as trichotillomania. For purposes of clarity and consistency, we have used the phrase “not restricted to” in the hierarchy criterion of other disorders in our section.

Severity

Massachusetts General Hospital Hairpulling Scale (MGH-HPS) (Keuthen et al., 1995)