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'''For patient information click [[Trichotillomania (patient information)|here]]'''
{{DiseaseDisorder infobox
|  Name        = Trichotillomania
|  ICD10      = F63.3
|  ICD9        = {{ICD9|312.39}}
| DiseasesDB    = 29681
| MedlinePlus    = 001517
|}}
{{SI}}
{{SI}}
{{CMG}}; {{AE}} {{KS}}
{{CMG}}; {{AE}} {{Sharma}}


{{SK}} Hair-pulling; trich; trichologia; trichomania; trichotillosis;TTM
{{SK}} TTM, hair-pulling, trich, trichophagia, trichobezoar


==Overview==
==Overview==
Trichotillomania is an [[Impulse-control disorder not elsewhere classified|impulse control disorder]] characterized by the repeated urge to pull out scalp hair, eyelashes, facial hair, nose hair, pubic hair, eyebrows or other body hair. Trichotillomania is classified in the [[Diagnostic and Statistical Manual of Mental Disorders|DSM-IV]] as an [[impulse control disorder]] that is not elsewhere classified under another axis or disorder. It is classified in this manner to control diagnoses of TTM. It is an [[Diagnostic and Statistical Manual of Mental Disorders#Multi-axial system|Axis I]] disorder. The name derives from Greek ''tricho-'' (hair), + ''mania''.
Trichotillomania (TTM) is a condition characterized by the repeated irresistible desire to pull out [[Scalp|scalp hair]], [[Eyelash|eyelashes]], [[facial hair]], [[pubic hair]], nose hair, [[Eyebrow|eyebrows]], and/or other body hair. The hair pulling relieves the [[anxiety]] preceding the event but leaves behind [[Scar|scars]] and [[Injury|injuries]]. The feeling of losing control and fear of pulling out all of the hair leaves the individual in severe frustration. The person very often pulls out a significant amount of hair amounting to [[hair loss]]. It also results in enormous [[distress]] and functional impairment in several areas of life. Secondary to this behavior, there is a progressive deterioration of [[self-esteem]] and eventually, self-isolation. These individuals unsuccessfully try to stop this [[behavior]] due to physical and mental [[Stress (medicine)|stress]] experienced after the act, or harsh comments from the family and friends. Therefore, trichotillomania is emotionally traumatizing as well as socially stigmatizing.


Trichotillomania is a condition in which individual pulls out hair amounting to [[hair loss]]. It results in significant [[distress]] and functional impairment in several areas of life. Secondary to this behavior, there is progressive deterioration of self esteem and ultimately, ends up in self-isolation. It is emotionally traumatizing as well as socially stigmatizing for the patient.
==Historical Perspective==
*The term "trichotillomania" is Greek in origin.  It is a compilation of three words- trich, tillo, and [[mania]].
*"[[Trich]]" stands for hair, "tillo" means to pull, and "[[mania]]" denotes an unusual fascination towards an object, place, or action. The resulting word "trichotillomania" signifies the irresistible urge to pull hair. <ref name="SalaamCarr20052">{{cite journal|last1=Salaam|first1=Karriem|last2=Carr|first2=Joel|last3=Grewal|first3=Harsh|last4=Sholevar|first4=Ellen|last5=Baron|first5=David|title=Untreated Trichotillomania and Trichophagia: Surgical Emergency in a Teenage Girl|journal=Psychosomatics|volume=46|issue=4|year=2005|pages=362–366|issn=00333182|doi=10.1176/appi.psy.46.4.362}}</ref>
*It was first mentioned in a published scientific report about hair pulling behavior in 1885. <ref name="SalaamCarr2005">{{cite journal|last1=Salaam|first1=Karriem|last2=Carr|first2=Joel|last3=Grewal|first3=Harsh|last4=Sholevar|first4=Ellen|last5=Baron|first5=David|title=Untreated Trichotillomania and Trichophagia: Surgical Emergency in a Teenage Girl|journal=Psychosomatics|volume=46|issue=4|year=2005|pages=362–366|issn=00333182|doi=10.1176/appi.psy.46.4.362}}</ref>
*The term, however, was first used by a French [[dermatologist]], Francois Hallopeau, in 1889.<ref name="Hallipeau">{{cite journal | author=Hallopeau M | title=Alopicie par grattage (trichomanie ou trichotillomanie). | journal=Ann Dermatol Venereol | year=1889 | volume=10 | pages=440-441}}</ref>
*Originally, Francois Hallopeau had used this word for [[alopecia]] due to the self-traction of hair. It has now evolved to include the [[syndrome]] of pathological hair-pulling. <ref name="ChavanRaj2005">{{cite journal|last1=Chavan|first1=BS|last2=Raj|first2=Lok|last3=Kaur|first3=Harprit|title=Management of trichotillomania|journal=Indian Journal of Psychiatry|volume=47|issue=4|year=2005|pages=235|issn=0019-5545|doi=10.4103/0019-5545.43063}}</ref>
*A French physician, Baudamant gave details of [[trichobezoar]] (mass of undigested hair in the [[gastrointestinal tract]]) in a 16 year-old adolescent in the late 18th century.<ref name="GrantOdlaug2008">{{cite journal|last1=Grant|first1=Jon E.|last2=Odlaug|first2=Brian L.|title=Clinical characteristics of trichotillomania with trichophagia|journal=Comprehensive Psychiatry|volume=49|issue=6|year=2008|pages=579–584|issn=0010440X|doi=10.1016/j.comppsych.2008.05.002}}</ref>


==Historical Perspective==
==Classification==


* The term "trichotillomania" is Greek in origin. It is a compilation of three words- trich, tillo and [[mania]].
*Among the classification systems, trichotillomania was first mentioned in [[ICD-9]] in the year 1975 under '[[Impulse control|the other disorders of impulse control]]'.
*In 1987, [[DSM-III-R]] included trichotillomania as an [[Impulse control disorder|'impulse control disorder, not classified elsewhere]]'.  <ref name="GrantStein20142">{{cite journal|last1=Grant|first1=Jon E.|last2=Stein|first2=Dan J.|title=Body-focused repetitive behavior disorders in ICD-11|journal=Revista Brasileira de Psiquiatria|volume=36|issue=suppl 1|year=2014|pages=59–64|issn=1516-4446|doi=10.1590/1516-4446-2013-1228}}</ref>
*Trichotillomania was accepted as an independent disorder in [[ICD-10]] in 1990. It has been included under 'the habit and impulse control' category. <ref name="GrantStein20143">{{cite journal|last1=Grant|first1=Jon E.|last2=Stein|first2=Dan J.|title=Body-focused repetitive behavior disorders in ICD-11|journal=Revista Brasileira de Psiquiatria|volume=36|issue=suppl 1|year=2014|pages=59–64|issn=1516-4446|doi=10.1590/1516-4446-2013-1228}}</ref>
*In [[DSM-IV]], two minimal modifications were made in this disorder's descriptions. Criteria B emphasized more on the stress experienced while resisting to pull the hair. The [[distress]] and [[impairment]] experienced by the individual were also brought into focus in Criteria E. <ref name="GrantStein2014">{{cite journal|last1=Grant|first1=Jon E.|last2=Stein|first2=Dan J.|title=Body-focused repetitive behavior disorders in ICD-11|journal=Revista Brasileira de Psiquiatria|volume=36|issue=suppl 1|year=2014|pages=59–64|issn=1516-4446|doi=10.1590/1516-4446-2013-1228}}</ref><ref name="LochnerStein2011">{{cite journal|last1=Lochner|first1=Christine|last2=Stein|first2=Dan J.|last3=Woods|first3=Douglas|last4=Pauls|first4=David L.|last5=Franklin|first5=Martin E.|last6=Loerke|first6=Elizabeth H.|last7=Keuthen|first7=Nancy J.|title=The validity of DSM-IV-TR criteria B and C of hair-pulling disorder (trichotillomania): Evidence from a clinical study|journal=Psychiatry Research|volume=189|issue=2|year=2011|pages=276–280|issn=01651781|doi=10.1016/j.psychres.2011.07.022}}</ref>
*[[DSM-IV-TR]] also described trichotillomania as 'an [[impulse control disorder]], not classified elsewhere'.<ref name="SteinGrant2010">{{cite journal|last1=Stein|first1=Dan J.|last2=Grant|first2=Jon E.|last3=Franklin|first3=Martin E.|last4=Keuthen|first4=Nancy|last5=Lochner|first5=Christine|last6=Singer|first6=Harvey S.|last7=Woods|first7=Douglas W.|title=Trichotillomania (hair pulling disorder), skin picking disorder, and stereotypic movement disorder: toward DSM-V|journal=Depression and Anxiety|volume=27|issue=6|year=2010|pages=611–626|issn=10914269|doi=10.1002/da.20700}}</ref>
*Therefore, it would be appropriate to point out here that [[Diagnostic and statistical manual of mental disorders|DSM]] had only minor changes until the classification change in [[DSM|DSM-5]].
*DSM-5 moved trichotillomania from '[[Impulse control disorder|Impulse Control Disorder]]' to the category of '[[Obsessive-compulsive disorder|Obsessive-Compulsive]] and Related Disorders' (OCRD).
*Unlike [[DSM-IV]], [[Diagnostic and statistical manual of mental disorders|DSM]]-5 Criteria does not require the hair loss in trichotillomania to be noticeable. The individuals with this condition may pull out the hair from a wider region making it difficult to distinguish.<ref name="GrantStein20144">{{cite journal|last1=Grant|first1=Jon E.|last2=Stein|first2=Dan J.|title=Body-focused repetitive behavior disorders in ICD-11|journal=Revista Brasileira de Psiquiatria|volume=36|issue=suppl 1|year=2014|pages=59–64|issn=1516-4446|doi=10.1590/1516-4446-2013-1228}}</ref>
*DSM-5 has included a criterion that the individual should have made multiple attempts to stop the hair pulling behavior. This has replaced the [[DSM-IV]] criteria of preceding tension and immense gratification following hair pulling, this explains the transition from impulse control disorder to OCRD.<ref name="LochnerGrant2012">{{cite journal|last1=Lochner|first1=Christine|last2=Grant|first2=Jon E.|last3=Odlaug|first3=Brian L.|last4=Woods|first4=Douglas W.|last5=Keuthen|first5=Nancy J.|last6=Stein|first6=Dan J.|title=DSM-5 FIELD SURVEY: HAIR-PULLING DISORDER (TRICHOTILLOMANIA)|journal=Depression and Anxiety|volume=29|issue=12|year=2012|pages=1025–1031|issn=10914269|doi=10.1002/da.22011}}</ref>
*It has been further made clear in [[Diagnostic and statistical manual of mental disorders|DSM]]-5 that the condition should not be secondary to medical (various [[dermatological]] conditions) or [[Psychiatric Disorders|psychiatric]] disorders (such as [[body dysmorphic disorder]], [[psychosis]], and [[obsessive-compulsive disorder|obsessive compulsive disorder]]) .


* "[[Trich]]" stands for hair, "tillo" means to pull and "[[mania]]" denotes an unusual fascination towards an object, place or action. The resulting word "trichotillomania" signifies the irresistible urge to pull hair. <ref name="SalaamCarr20052">{{cite journal|last1=Salaam|first1=Karriem|last2=Carr|first2=Joel|last3=Grewal|first3=Harsh|last4=Sholevar|first4=Ellen|last5=Baron|first5=David|title=Untreated Trichotillomania and Trichophagia: Surgical Emergency in a Teenage Girl|journal=Psychosomatics|volume=46|issue=4|year=2005|pages=362–366|issn=00333182|doi=10.1176/appi.psy.46.4.362}}</ref>
==Pathophysiology==
* It was first mentioned in a published scientific report about hair pulling behavior in 1885. <ref name="SalaamCarr2005">{{cite journal|last1=Salaam|first1=Karriem|last2=Carr|first2=Joel|last3=Grewal|first3=Harsh|last4=Sholevar|first4=Ellen|last5=Baron|first5=David|title=Untreated Trichotillomania and Trichophagia: Surgical Emergency in a Teenage Girl|journal=Psychosomatics|volume=46|issue=4|year=2005|pages=362–366|issn=00333182|doi=10.1176/appi.psy.46.4.362}}</ref>
* The term, however, was first used by a French dermatologist, Francois Hallopeau, in 1889.<ref name="Hallipeau">{{cite journal | author=Hallopeau M | title=Alopicie par grattage (trichomanie ou trichotillomanie). | journal=Ann Dermatol Venereol | year=1889 | volume=10 | pages=440-441}}</ref>
*Originally, Francois Hallopeau had used this term for [[alopecia]] due to self-traction of hair. It has now evolved to include the syndrome of pathological hair-pulling. <ref name="ChavanRaj2005">{{cite journal|last1=Chavan|first1=BS|last2=Raj|first2=Lok|last3=Kaur|first3=Harprit|title=Management of trichotillomania|journal=Indian Journal of Psychiatry|volume=47|issue=4|year=2005|pages=235|issn=0019-5545|doi=10.4103/0019-5545.43063}}</ref>
*


==Classification==
*The [[pathophysiology]] of trichotillomania (TTM) is proposed to be due to the dysregulation of the glutaminergic system.<ref name="ÖzcanSeçkin2016">{{cite journal|last1=Özcan|first1=D.|last2=Seçkin|first2=D.|title=N-Acetylcysteine in the treatment of trichotillomania: remarkable results in two patients|journal=Journal of the European Academy of Dermatology and Venereology|volume=30|issue=9|year=2016|pages=1606–1608|issn=09269959|doi=10.1111/jdv.13690}}</ref>.
*Similar to [[body dysmorphic disorder]], [[impulse control disorder]], [[kleptomania]], and [[tourette's syndrome]], individuals with TTM have a reduced ability to transport [[serotonin]] at the [[Presynaptic|presynaptic level]].<ref name="pmid10708268">{{cite journal |author=Marazziti D, Dell'Osso L, Presta S, ''et al'' |title=Platelet [3H]paroxetine binding in patients with OCD-related disorders |journal=Psychiatry research |volume=89 |issue=3 |pages=223-8 |year=1999 |pmid=10708268}}</ref>
*The imaging studies performed have shown the involvement of various [[brain]] regions.
*The patients with trichotillomania have [[subcortical]] brain abnormalities on [[Magnetic Resonance Imaging]] ([[MRI|MRI Scan]]). Decreased [[putamen]] and [[amygdala]] volumes as well as variation in curvature of [[caudate nuclei|caudate]] and [[nucleus accumbens]] have been noted. These areas are involved in affect modulation and reward processing, the basis of trichotillomania pathophysiology. <ref name="IsobeRedden2018">{{cite journal|last1=Isobe|first1=Masanori|last2=Redden|first2=Sarah A.|last3=Keuthen|first3=Nancy J.|last4=Stein|first4=Dan J.|last5=Lochner|first5=Christine|last6=Grant|first6=Jon E.|last7=Chamberlain|first7=Samuel R.|title=Striatal abnormalities in trichotillomania: A multi-site MRI analysis|journal=NeuroImage: Clinical|volume=17|year=2018|pages=893–898|issn=22131582|doi=10.1016/j.nicl.2017.12.031}}</ref>
*MRI findings suggest a reduced volume of both right and left [[Cerebellar|cerebellar cortices]]. It is further substantiated by the motor involvement in the symptomatology of this disorder. <ref name="KeuthenMakris2007">{{cite journal|last1=Keuthen|first1=Nancy J.|last2=Makris|first2=Nikos|last3=Schlerf|first3=John E.|last4=Martis|first4=Brian|last5=Savage|first5=Cary R.|last6=McMullin|first6=Katherine|last7=Seidman|first7=Larry J.|last8=Schmahmann|first8=Jeremy D.|last9=Kennedy|first9=David N.|last10=Hodge|first10=Steven M.|last11=Rauch|first11=Scott L.|title=Evidence for Reduced Cerebellar Volumes in Trichotillomania|journal=Biological Psychiatry|volume=61|issue=3|year=2007|pages=374–381|issn=00063223|doi=10.1016/j.biopsych.2006.06.013}}</ref>
*An increase in [[Frontal cortex|right frontal cortical thickness]] has been noticed. However, the extent of thickness does not correspond to the symptom severity.<ref name="ChamberlainHarries2017">{{cite journal|last1=Chamberlain|first1=Samuel R.|last2=Harries|first2=Michael|last3=Redden|first3=Sarah A.|last4=Keuthen|first4=Nancy J.|last5=Stein|first5=Dan J.|last6=Lochner|first6=Christine|last7=Grant|first7=Jon E.|title=Cortical thickness abnormalities in trichotillomania: international multi-site analysis|journal=Brain Imaging and Behavior|volume=12|issue=3|year=2017|pages=823–828|issn=1931-7557|doi=10.1007/s11682-017-9746-3}}</ref>
*The [[white matter]] tracts are also affected in this condition. These tracts have a role in habit formation and suppression as well as affect regulation.
*Reduction in [[Anisotropy|fractional anisotropy]] is seen in [[anterior cingulate]], and [[temporal]] cortical region. It does not relate to disease severity. <ref name="ChamberlainHampshire2010">{{cite journal|last1=Chamberlain|first1=Samuel R.|last2=Hampshire|first2=Adam|last3=Menzies|first3=Lara A.|last4=Garyfallidis|first4=Eleftherios|last5=Grant|first5=Jon E.|last6=Odlaug|first6=Brian L.|last7=Craig|first7=Kevin|last8=Fineberg|first8=Naomi|last9=Sahakian|first9=Barbara J.|title=Reduced Brain White Matter Integrity in Trichotillomania|journal=Archives of General Psychiatry|volume=67|issue=9|year=2010|pages=965|issn=0003-990X|doi=10.1001/archgenpsychiatry.2010.109}}</ref>
*Therefore, this disorder has complex [[pathophysiology]] with the involvement of multiple brain areas on [[neuroimaging]].


* Among the classification systems, trichotillomania was first mentioned in [[ICD-9]] in 1975 under '[[Impulse control|the other disorders of impulse control]]'.
==Clinical Features==
*[[DSM-III-R]] first included trichotillomania in 1987 as an [[Impulse control disorder|'impulse control disorder, not classified elsewhere]]'.  <ref name="GrantStein20142">{{cite journal|last1=Grant|first1=Jon E.|last2=Stein|first2=Dan J.|title=Body-focused repetitive behavior disorders in ICD-11|journal=Revista Brasileira de Psiquiatria|volume=36|issue=suppl 1|year=2014|pages=59–64|issn=1516-4446|doi=10.1590/1516-4446-2013-1228}}</ref>
* In 1990, trichotillomania was accepted as an independent disorder in [[ICD-10]]. It has been included under 'the habit and impulse control' category<ref name="GrantStein20143">{{cite journal|last1=Grant|first1=Jon E.|last2=Stein|first2=Dan J.|title=Body-focused repetitive behavior disorders in ICD-11|journal=Revista Brasileira de Psiquiatria|volume=36|issue=suppl 1|year=2014|pages=59–64|issn=1516-4446|doi=10.1590/1516-4446-2013-1228}}</ref>
* In [[DSM-IV]], two minimal modifications were made regarding the details of the disorder's descriptions. Criteria B emphasized more on the stress experienced while resisting to pull the hair. The [[distress]] and [[impairment]] experienced by the individual were also brought into focus as enclosed in Criteria E. <ref name="GrantStein2014">{{cite journal|last1=Grant|first1=Jon E.|last2=Stein|first2=Dan J.|title=Body-focused repetitive behavior disorders in ICD-11|journal=Revista Brasileira de Psiquiatria|volume=36|issue=suppl 1|year=2014|pages=59–64|issn=1516-4446|doi=10.1590/1516-4446-2013-1228}}</ref><ref name="LochnerStein2011">{{cite journal|last1=Lochner|first1=Christine|last2=Stein|first2=Dan J.|last3=Woods|first3=Douglas|last4=Pauls|first4=David L.|last5=Franklin|first5=Martin E.|last6=Loerke|first6=Elizabeth H.|last7=Keuthen|first7=Nancy J.|title=The validity of DSM-IV-TR criteria B and C of hair-pulling disorder (trichotillomania): Evidence from a clinical study|journal=Psychiatry Research|volume=189|issue=2|year=2011|pages=276–280|issn=01651781|doi=10.1016/j.psychres.2011.07.022}}</ref>
* In [[DSM-IV-TR]] also trichotillomania has been described as 'an impulse control disorder, not classified else where'.<ref name="SteinGrant2010">{{cite journal|last1=Stein|first1=Dan J.|last2=Grant|first2=Jon E.|last3=Franklin|first3=Martin E.|last4=Keuthen|first4=Nancy|last5=Lochner|first5=Christine|last6=Singer|first6=Harvey S.|last7=Woods|first7=Douglas W.|title=Trichotillomania (hair pulling disorder), skin picking disorder, and stereotypic movement disorder: toward DSM-V|journal=Depression and Anxiety|volume=27|issue=6|year=2010|pages=611–626|issn=10914269|doi=10.1002/da.20700}}</ref>
* Therefore, it would be appropriate to point here that [[Diagnostic and statistical manual of mental disorders|DSM]] had minor changes in the description of trichotillomania till the classification change in [[DSM|DSM-5]].
* Earlier it was considered an impulse control disorder but DSM-5 included it under the 'Obsessive Compulsive and Related Disorders' (OCRD).
* Unlike [[DSM-IV]], DSM-5 Criteria does not require the loss of hair in trichotillomania to be noticable. The individuals with this condition may pull out the hair from a wider region making it difficult to distinguish.<ref name="GrantStein20144">{{cite journal|last1=Grant|first1=Jon E.|last2=Stein|first2=Dan J.|title=Body-focused repetitive behavior disorders in ICD-11|journal=Revista Brasileira de Psiquiatria|volume=36|issue=suppl 1|year=2014|pages=59–64|issn=1516-4446|doi=10.1590/1516-4446-2013-1228}}</ref>
*DSM-5 has included a criteria that makes it mandatory that the individual should have made repeated attempts to discontinue hair pulling behavior to be diagnosed as trichotillomania. This has replaced the [[DSM-IV]] criteria of preceding tension and immense gratification following hair pulling. <ref name="LochnerGrant2012">{{cite journal|last1=Lochner|first1=Christine|last2=Grant|first2=Jon E.|last3=Odlaug|first3=Brian L.|last4=Woods|first4=Douglas W.|last5=Keuthen|first5=Nancy J.|last6=Stein|first6=Dan J.|title=DSM-5 FIELD SURVEY: HAIR-PULLING DISORDER (TRICHOTILLOMANIA)|journal=Depression and Anxiety|volume=29|issue=12|year=2012|pages=1025–1031|issn=10914269|doi=10.1002/da.22011}}</ref>  This explains the transition from impulse control disorder to OCRD of [[DSM|DSM-5]].
*It has further made it clear that the condition should not be secondary to medical (various [[dermatological]] conditions) or psychiatric (Body dysmorhic disorder, [[psychosis]], [[Obsessive-compulsive disorder|Obsessive Compulsive Disorder]] etc) disorders.


==Pathophysiology==
*Repetitive hair pulling occurs from various sites such as the [[scalp]], [[Eyelash|eyelashes]], [[Eyebrow|eyebrows]], [[eyelashes]], [[legs]], and arms. Sometimes patients may also pull hair from the [[Axillae|axilla]], [[Chest|chest,]] or other regions.<ref name="MinichielloO'Sullivan1994">{{cite journal|last1=Minichiello|first1=William E.|last2=O'Sullivan|first2=Richard L.|last3=Osgood-Hynes|first3=Deborah|last4=Baer|first4=Lee|title=Trichotillomania: Clinical Aspects and Treatment Strategies|journal=Harvard Review of Psychiatry|volume=1|issue=6|year=1994|pages=336–344|issn=1067-3229|doi=10.3109/10673229409017100}}</ref>
*[[Hair loss]] in trichotillomania is characterized by the variable length of the broken hair left after plucking.<ref name="MehtaMalakar2017">{{cite journal|last1=Mehta|first1=PurvaRanjit|last2=Malakar|first2=Subrata|title=“i hair”: A prognostic marker in alopecia areata & trichotillomania|journal=Indian Journal of Dermatology|volume=62|issue=6|year=2017|pages=550|issn=0019-5154|doi=10.4103/ijd.IJD_337_17}}</ref>
*The [[scalp]] is the most commonly affected site. However, when stopped from one site the individual can start pulling hair from other places.<ref name="SahKoo2008">{{cite journal|last1=Sah|first1=Deborah E|last2=Koo|first2=John|last3=Price|first3=Vera H|title=Trichotillomania|journal=Dermatologic Therapy|volume=21|issue=1|year=2008|pages=13–21|issn=1396-0296|doi=10.1111/j.1529-8019.2008.00165.x}}</ref><ref name="TayLevy2004">{{cite journal|last1=Tay|first1=Y.-K.|last2=Levy|first2=M. L.|last3=Metry|first3=D. W.|title=Trichotillomania in Childhood: Case Series and Review|journal=PEDIATRICS|volume=113|issue=5|year=2004|pages=e494–e498|issn=0031-4005|doi=10.1542/peds.113.5.e494}}</ref>
*Hair-pulling [[behavior]] is preceded by severe [[anxiety]], which is relieved after performing the act. Most patients live with extreme guilt later.
*Often the people with this condition pull hair from multiple sites at the same time and have [[comorbidities]] such as [[depression]] and [[anxiety disorders]].<ref>{{cite journal|title=Characteristics of 60 adult chronic hair pullers|journal=American Journal of Psychiatry|volume=148|issue=3|year=1991|pages=365–370|issn=0002-953X|doi=10.1176/ajp.148.3.365}}</ref>
*Trichotillomania can begin at any [[age]]. As compared to [[Childhood|childhood-onset]], the persons with later-onset form have a more severe condition and spend a considerable amount of time pulling hair each day. <ref name="OdlaugChamberlain2012">{{cite journal|last1=Odlaug|first1=Brian L.|last2=Chamberlain|first2=Samuel R.|last3=Harvanko|first3=Arit M.|last4=Grant|first4=Jon E.|title=Age at Onset in Trichotillomania|journal=The Primary Care Companion For CNS Disorders|year=2012|issn=2155-7780|doi=10.4088/PCC.12m01343}}</ref>
*Some people perform rituals with hair such as biting, [[Mastication|chewing]], or playing with them.<ref name="GrantOdlaug20082">{{cite journal|last1=Grant|first1=Jon E.|last2=Odlaug|first2=Brian L.|title=Clinical characteristics of trichotillomania with trichophagia|journal=Comprehensive Psychiatry|volume=49|issue=6|year=2008|pages=579–584|issn=0010440X|doi=10.1016/j.comppsych.2008.05.002}}</ref>
*As a result of this ritualistic behavior, the swallowed hair ([[trichophagia]]) may form a [[hairball]] ([[trichobezoar]]) in the [[gastrointestinal tract]] and cause an [[obstruction]]. In absence of adequate and prompt attention, it may cause a life-threatening [[emergency]] requiring immediate [[Surgery operation|surgery]]. <ref name="GrantOdlaug20083">{{cite journal|last1=Grant|first1=Jon E.|last2=Odlaug|first2=Brian L.|title=Clinical characteristics of trichotillomania with trichophagia|journal=Comprehensive Psychiatry|volume=49|issue=6|year=2008|pages=579–584|issn=0010440X|doi=10.1016/j.comppsych.2008.05.002}}</ref>
*When the tail from [[Bezoar|trichobezoar]] extends from [[stomach]] to [[intestine]], the condition is called [[Rapunzel syndrome|Rapunzel Syndrome]]. It may cause a highly fatal [[Gastrointestinal perforation|intestinal perforation]].<ref name="VenturaMardiros Herbella2005">{{cite journal|last1=Ventura|first1=Denise Estefan|last2=Mardiros Herbella|first2=Fernando A.|last3=Schettini|first3=Sergio T.|last4=Delmonte|first4=Carlos|title=Rapunzel syndrome with a fatal outcome in a neglected child|journal=Journal of Pediatric Surgery|volume=40|issue=10|year=2005|pages=1665–1667|issn=00223468|doi=10.1016/j.jpedsurg.2005.06.038}}</ref>


*[[Pathophysiology]] of trichotillomania is proposed to be related to the dysregulation of glutaminergic system.<ref name="ÖzcanSeçkin2016">{{cite journal|last1=Özcan|first1=D.|last2=Seçkin|first2=D.|title=N-Acetylcysteine in the treatment of trichotillomania: remarkable results in two patients|journal=Journal of the European Academy of Dermatology and Venereology|volume=30|issue=9|year=2016|pages=1606–1608|issn=09269959|doi=10.1111/jdv.13690}}</ref>.
*The imaging studies performed on individuals with trichotillomania have shown involvement of various brain regions.
*In patients with trichotillomania, there are [[subcortical]] brain abnormalities noted on [[Magnetic Resonance Imaging]] ([[MRI|MRI Scan]]). The decreased [[putamen]] and [[amygdala]] volumes as well as variation in curvature of [[Caudate nuclei|caudate]] and [[nucleus accumbens]] points towards their involvement in affect modulation and reward processing, which forms the basis of trichotillomania pathophysiology. <ref name="IsobeRedden2018">{{cite journal|last1=Isobe|first1=Masanori|last2=Redden|first2=Sarah A.|last3=Keuthen|first3=Nancy J.|last4=Stein|first4=Dan J.|last5=Lochner|first5=Christine|last6=Grant|first6=Jon E.|last7=Chamberlain|first7=Samuel R.|title=Striatal abnormalities in trichotillomania: A multi-site MRI analysis|journal=NeuroImage: Clinical|volume=17|year=2018|pages=893–898|issn=22131582|doi=10.1016/j.nicl.2017.12.031}}</ref>
*MRI findings have also shown that in patients with trichotillomania, there is reduced volume of both right and left [[Cerebellar|cerebellar cortices]]. It is further substantiated by the motor involvement in symptomatology of this disorder. <ref name="KeuthenMakris2007">{{cite journal|last1=Keuthen|first1=Nancy J.|last2=Makris|first2=Nikos|last3=Schlerf|first3=John E.|last4=Martis|first4=Brian|last5=Savage|first5=Cary R.|last6=McMullin|first6=Katherine|last7=Seidman|first7=Larry J.|last8=Schmahmann|first8=Jeremy D.|last9=Kennedy|first9=David N.|last10=Hodge|first10=Steven M.|last11=Rauch|first11=Scott L.|title=Evidence for Reduced Cerebellar Volumes in Trichotillomania|journal=Biological Psychiatry|volume=61|issue=3|year=2007|pages=374–381|issn=00063223|doi=10.1016/j.biopsych.2006.06.013}}</ref>
*An increase in [[Frontal cortex|right frontal cortical thickness]] has been observed in these individuals. However, the extent of thickness does not correspond to the severity of symptoms.<ref name="ChamberlainHarries2017">{{cite journal|last1=Chamberlain|first1=Samuel R.|last2=Harries|first2=Michael|last3=Redden|first3=Sarah A.|last4=Keuthen|first4=Nancy J.|last5=Stein|first5=Dan J.|last6=Lochner|first6=Christine|last7=Grant|first7=Jon E.|title=Cortical thickness abnormalities in trichotillomania: international multi-site analysis|journal=Brain Imaging and Behavior|volume=12|issue=3|year=2017|pages=823–828|issn=1931-7557|doi=10.1007/s11682-017-9746-3}}</ref>
*The white matter tracts are also affected in trichotillomania. They have a role in habit formation and suppression as well as affect regulation.
*Reduction in [[Anisotropy|fractional anisotropy]] has been noticed in [[anterior cingulate]], and temporal cortical region. It has not been found to relate with disease severity. <ref name="ChamberlainHampshire2010">{{cite journal|last1=Chamberlain|first1=Samuel R.|last2=Hampshire|first2=Adam|last3=Menzies|first3=Lara A.|last4=Garyfallidis|first4=Eleftherios|last5=Grant|first5=Jon E.|last6=Odlaug|first6=Brian L.|last7=Craig|first7=Kevin|last8=Fineberg|first8=Naomi|last9=Sahakian|first9=Barbara J.|title=Reduced Brain White Matter Integrity in Trichotillomania|journal=Archives of General Psychiatry|volume=67|issue=9|year=2010|pages=965|issn=0003-990X|doi=10.1001/archgenpsychiatry.2010.109}}</ref>
*Therefore, this disorder has complex pathophysiology which is further substantiated by the involvement of numerous brain areas as shown on neuroimaging. <br />
==Differential Diagnosis==
==Differential Diagnosis==
Trichotillomania should be differentiated from other medical and [[psychiatric]] conditions like-<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref><ref name="SahKoo20083">{{cite journal|last1=Sah|first1=Deborah E|last2=Koo|first2=John|last3=Price|first3=Vera H|title=Trichotillomania|journal=Dermatologic Therapy|volume=21|issue=1|year=2008|pages=13–21|issn=1396-0296|doi=10.1111/j.1529-8019.2008.00165.x}}</ref>


*Another medical condition
*Other medical conditions-
:*[[Acne keloidalis nuchae]]
:*[[Acne keloidalis nuchae]]
:*[[Alopecia areata]]
:*[[Alopecia areata]]
:*[[Androgenic alopecia]]
:*[[Androgenic alopecia]]
:*[[Central centrifugal cicatricial alopecia]]  
:*[[Chronic discoid lupus erythematosus]]
:*[[Chronic discoid lupus erythematosus]]
:*[[Tinea capitis]]
:*[[Dissecting folliculitis]]
:*[[Dissecting folliculitis]]
:*[[Lichen planopilaris]]  
:*[[Lichen planopilaris]]
:*[[Pseudopelade folliculitis decalvans]]
:*[[Pseudopelade folliculitis decalvans]]
:*[[Telogen effluvium]]
:*[[Telogen effluvium]]
*Neuro-developmental disorders
:*[[Central centrifugal cicatricial alopecia]]
 
*Neuro-developmental disorder
:*[[Stereotypic movement disorder]]
:*[[Stereotypic movement disorder]]
*Normative hair removal/manipulation
 
*Other [[obsessive-compulsive]] and related disorders
*Other [[obsessive-compulsive]] and related disorders
:*[[Body dysmorphic disorder]]
:*[[Body dysmorphic disorder]]
*[[Psychotic disorder]]
*[[Psychotic disorder]]
*Substance-related disorders<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
*[[Substance-related disorder|Substance-related disorders]]
*Normal [[hair]] manipulation


==Epidemiology and Demographics==
==Epidemiology and Demographics==
===Prevalence===
===Prevalence===
The prevalence of trichotillomania is 1,000-2,000 per 100,000 (1%-2%) of the overall population.<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref> The number of reported trichotillomania cases has increased throughout the years, possibly due to a reduced stigma around the condition.  
*The [[prevalence]] of trichotillomania is 1,000-2,000 per 100,000 (1%-2%) of the overall [[population]]. The number of reported cases has increased over the years, likely due to a decreased perceived stigma.<ref name="DSMV" />
 
===Age===
*Patients of all age groups may develop trichotillomania.
*Based on the age at onset, it is divided predominantly into three types- children of pre-school age, pre-adolescents and [[Adolescence|adolescent]]<nowiki/>s, and [[Adult|adults]].<ref name="SahKoo20082">{{cite journal|last1=Sah|first1=Deborah E|last2=Koo|first2=John|last3=Price|first3=Vera H|title=Trichotillomania|journal=Dermatologic Therapy|volume=21|issue=1|year=2008|pages=13–21|issn=1396-0296|doi=10.1111/j.1529-8019.2008.00165.x}}</ref>
*Contrary to the popular belief, childhood-onset trichotillomania is common but differs in [[neurobiology]] from the adult-onset type. <ref name="OdlaugChamberlain20122">{{cite journal|last1=Odlaug|first1=Brian L.|last2=Chamberlain|first2=Samuel R.|last3=Harvanko|first3=Arit M.|last4=Grant|first4=Jon E.|title=Age at Onset in Trichotillomania|journal=The Primary Care Companion For CNS Disorders|year=2012|issn=2155-7780|doi=10.4088/PCC.12m01343}}</ref>
*From [[Child development|childhood]] to [[adolescence]], focused hair pulling increases whereas the automatic hair pulling remains the same.<ref name="PanzaPittenger20132">{{cite journal|last1=Panza|first1=Kaitlyn E.|last2=Pittenger|first2=Christopher|last3=Bloch|first3=Michael H.|title=Age and Gender Correlates of Pulling in Pediatric Trichotillomania|journal=Journal of the American Academy of Child & Adolescent Psychiatry|volume=52|issue=3|year=2013|pages=241–249|issn=08908567|doi=10.1016/j.jaac.2012.12.019}}</ref>
*As the children grow older, more frequent urges and decreased ability to resist have been noticed. <ref name="PanzaPittenger20133">{{cite journal|last1=Panza|first1=Kaitlyn E.|last2=Pittenger|first2=Christopher|last3=Bloch|first3=Michael H.|title=Age and Gender Correlates of Pulling in Pediatric Trichotillomania|journal=Journal of the American Academy of Child & Adolescent Psychiatry|volume=52|issue=3|year=2013|pages=241–249|issn=08908567|doi=10.1016/j.jaac.2012.12.019}}</ref>
*The post-[[Puberty|pubertal]] onset is associated with greater severity of [[Symptom|symptoms]]. <ref name="OdlaugChamberlain20123">{{cite journal|last1=Odlaug|first1=Brian L.|last2=Chamberlain|first2=Samuel R.|last3=Harvanko|first3=Arit M.|last4=Grant|first4=Jon E.|title=Age at Onset in Trichotillomania|journal=The Primary Care Companion For CNS Disorders|year=2012|issn=2155-7780|doi=10.4088/PCC.12m01343}}</ref>


===Gender===
===Gender===
Sixty-five percent of those afflicted are female.<ref name="Christenson94">{{cite journal |author=Christenson GA, MacKenzie TB, Mitchell JE |title=Adult men and women with trichotillomania. A comparison of male and female characteristics |journal=Psychosomatics |volume=35 |issue=2 |pages=142–9 |year=1994 |pmid=8171173}}</ref>
*Most studies support the female predominance but there are some studies show mixed results. <ref name="Christenson94">{{cite journal |author=Christenson GA, MacKenzie TB, Mitchell JE |title=Adult men and women with trichotillomania. A comparison of male and female characteristics |journal=Psychosomatics |volume=35 |issue=2 |pages=142–9 |year=1994 |pmid=8171173}}</ref><ref name="GrantDougherty2020">{{cite journal|last1=Grant|first1=Jon E.|last2=Dougherty|first2=Darin D.|last3=Chamberlain|first3=Samuel R.|title=Prevalence, gender correlates, and co-morbidity of trichotillomania|journal=Psychiatry Research|volume=288|year=2020|pages=112948|issn=01651781|doi=10.1016/j.psychres.2020.112948}}</ref>
*With the male and female subjects having the same severity of [[Symptom|symptoms]], the females experience more [[distress]] and functional impairment due to hair pulling. <ref name="PanzaPittenger2013">{{cite journal|last1=Panza|first1=Kaitlyn E.|last2=Pittenger|first2=Christopher|last3=Bloch|first3=Michael H.|title=Age and Gender Correlates of Pulling in Pediatric Trichotillomania|journal=Journal of the American Academy of Child & Adolescent Psychiatry|volume=52|issue=3|year=2013|pages=241–249|issn=08908567|doi=10.1016/j.jaac.2012.12.019}}</ref>
*It has been observed that men have a later age of onset of trichotillomania and are significantly affected by the coexisting [[anxiety]].<ref name="GrantChristenson2007">{{cite journal|last1=Grant|first1=Jon E.|last2=Christenson|first2=Gary A.|title=Examination of Gender in Pathologic Grooming Behaviors|journal=Psychiatric Quarterly|volume=78|issue=4|year=2007|pages=259–267|issn=0033-2720|doi=10.1007/s11126-007-9045-z}}</ref>
*In females with trichotillomania, the symptoms exacerbate during [[Menses|menstruation]]. The condition may start during pregnancy or soon after [[Birth|the child birth]]. <ref name="LochnerStein2001">{{cite journal|last1=Lochner|first1=C.|last2=Stein|first2=D. J.|title=Gender in obsessive-compulsive disorder and obsessive-compulsive spectrum disorders|journal=Archives of Women's Mental Health|volume=4|issue=1|year=2001|pages=19–26|issn=1434-1816|doi=10.1007/s007370170004}}</ref>
 
===Race===
 
*African American females mostly pull their hair from the [[scalp]] region.<ref name="Neal-BarnettStatom2011">{{cite journal|last1=Neal-Barnett|first1=Angela|last2=Statom|first2=Deborah|last3=Stadulis|first3=Robert|title=Trichotillomania Symptoms in African American Women: Are they Related to Anxiety and Culture?|journal=CNS Neuroscience & Therapeutics|volume=17|issue=4|year=2011|pages=207–213|issn=17555930|doi=10.1111/j.1755-5949.2010.00138.x}}</ref>
*Before hair pulling, [[anxiety]] has been the predominant feature observed in African American adults. <ref name="Neal-BarnettStatom20112">{{cite journal|last1=Neal-Barnett|first1=Angela|last2=Statom|first2=Deborah|last3=Stadulis|first3=Robert|title=Trichotillomania Symptoms in African American Women: Are they Related to Anxiety and Culture?|journal=CNS Neuroscience & Therapeutics|volume=17|issue=4|year=2011|pages=207–213|issn=17555930|doi=10.1111/j.1755-5949.2010.00138.x}}</ref>
*Caucasians report pulling hair predominantly from [[Eyebrow|eyebrows]] and [[Eyelash|eyelashes]], more tension before hair pulling, higher interruption in their academic life, and greater [[Stress (medicine)|stress]] experienced on a day-to-day basis as compared to their minority counterparts.<ref name="Neal-BarnettFlessner2010">{{cite journal|last1=Neal-Barnett|first1=Angela|last2=Flessner|first2=Christopher|last3=Franklin|first3=Martin E.|last4=Woods|first4=Douglas W.|last5=Keuthen|first5=Nancy J.|last6=Stein|first6=Dan J.|title=Ethnic differences in trichotillomania: Phenomenology, interference, impairment, and treatment efficacy|journal=Journal of Anxiety Disorders|volume=24|issue=6|year=2010|pages=553–558|issn=08876185|doi=10.1016/j.janxdis.2010.03.014}}</ref><br />


==Risk Factors==
==Risk Factors==
*Genetic predispositon<ref name="EntrezGene">{{cite web  | last = EntrezGene  | title = Gene  | publisher = [[National Center for Biotechnology Information]]  | date= 12-Aug-2006  | url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=gene&cmd=Retrieve&dopt=Graphics&list_uids=3218  | format = UTF-8}} </ref><ref name="BBC">{{cite web | url= http://news.bbc.co.uk/1/hi/health/5381232.stm | title= Hair pulling disorder gene found | accessdate=2007-05-01}}</ref>
The [[Risk factor|risk factors]] associated with trichotillomania are<ref name="SnorrasonBelleau2012">{{cite journal|last1=Snorrason|first1=Ivar|last2=Belleau|first2=Emily L.|last3=Woods|first3=Douglas W.|title=How related are hair pulling disorder (trichotillomania) and skin picking disorder? A review of evidence for comorbidity, similarities and shared etiology|journal=Clinical Psychology Review|volume=32|issue=7|year=2012|pages=618–629|issn=02727358|doi=10.1016/j.cpr.2012.05.008}}</ref>
*[[Genetic|Genetic predisposition]]<ref name="EntrezGene">{{cite web  | last = EntrezGene  | title = Gene  | publisher = [[National Center for Biotechnology Information]]  | date= 12-Aug-2006  | url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=gene&cmd=Retrieve&dopt=Graphics&list_uids=3218  | format = UTF-8}} </ref><ref name="BBC">{{cite web | url= http://news.bbc.co.uk/1/hi/health/5381232.stm | title= Hair pulling disorder gene found | accessdate=2007-05-01}}</ref>
*First-degree relatives with trichotillomania
*[[Obsessive-compulsive disorder]]<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
*[[Obsessive-compulsive disorder]]<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
*Emotional temperament
*Harm avoidance trait
*Novelty seeking trait
*An under-stimulated environment like [[boredom]]
*[[Stress (medicine)|Stress]]
*Trauma


==Natural History, Complications and Prognosis==
==Natural History, Complications and Prognosis==
Individuals with trichotillomania can live relatively normal lives; however, they may have bald spots on their head, among their eyelashes, pubic hair, or brows. An additional psychological effect can be low self-esteem, often associated with being shunned by peers and the fear of socializing due to appearance and negative attention they may receive. Some people with TTM wear hats, wigs or style their hair in an effort to avoid such attention.
*Individuals with trichotillomania can spend normal lives but most have bald spots on the head, among the [[Eyelash|eyelashes]], pubic hair, or [[Eyebrow|eyebrows]].
For many there seems to be a strong stress-related component. In low-stress environments, some exhibit no symptoms (known as 'pulling') whatsoever. This 'pulling' often resumes upon leaving this environment.<ref name="Christenson91">{{cite journal |author=Christenson GA, Mackenzie TB, Mitchell JE |title=Characteristics of 60 adult chronic hair pullers |journal=The American journal of psychiatry |volume=148 |issue=3 |pages=365-70 |year=1991 |pmid=1992841}}</ref>
*It is associated with significant psychological effects such as low [[self-esteem]], and feeling of outcast by the peers.
 
*They develop the fear of interacting with others due to their appearance and dread social rejection.
Many [[psychiatrist|clinician]]s classify TTM as a habit behavior, in the same family as [[nail biting]] (onychophagia) or [[compulsive skin picking]] (dermatillomania).  These disorders are a cross between mental disorders, such as OCD  [[obsessive compulsive disorder ]] because the sight or feel of a body part causes the individual anxiety, and physical disorders such as [[Stereotypic Movement Disorder]] because the person performs repetitive movements without being bothered by or completely aware of them. The current classification of trich as an impulse disorder with [[pyromania]], [[pathological gambling]] and [[kleptomania]], has been called into question as inadequate and in need of revision.<ref name="Penzel">Penzel (2003) ''The Hair-Pulling Problem: A Complete Guide to Trichotillomania''; Oxford University Press, p. 3. ISBN 0-19-514942-4
*These people wear hats, wigs, or style their hair in an attempt to avoid attention.
</ref> People with TTM are no more likely to have significant [[personality disorder]]s than anyone else.{{Fact|date=February 2007}} One study showed that individuals with TTM have decreased cerebellar volume.<ref name="pmid16945351">{{cite journal
*It is a stress-related condition. In low-stress environments, some individuals exhibit no symptoms whereas the 'hair-pulling' resumes upon leaving this environment.<ref name="Christenson91">{{cite journal |author=Christenson GA, Mackenzie TB, Mitchell JE |title=Characteristics of 60 adult chronic hair pullers |journal=The American journal of psychiatry |volume=148 |issue=3 |pages=365-70 |year=1991 |pmid=1992841}}</ref>
|author=Keuthen NJ, Makris N, Schlerf JE, ''et al'' |title=Evidence for reduced cerebellar volumes in trichotillomania |journal=Biol. Psychiatry |volume=61 |issue=3 |pages=374–81 |year=2007 |pmid=16945351 |doi=10.1016/j.biopsych.2006.06.013}}</ref> Like people with other OCD-related disorders (for example, body dysmorphic disorder, impulse control disorder, kleptomania, Tourette's syndrome), people with TTM have a reduced ability to transport serotonin at the presynaptic level.<ref name="pmid10708268">{{cite journal |author=Marazziti D, Dell'Osso L, Presta S, ''et al'' |title=Platelet [3H]paroxetine binding in patients with OCD-related disorders |journal=Psychiatry research |volume=89 |issue=3 |pages=223-8 |year=1999 |pmid=10708268}}</ref> Anxiety, depression, as well as frank OCDs are more frequently encountered in people with TTM.<ref name="pmid8698680">{{cite journal |author=Christenson GA, Crow SJ |title=The characterization and treatment of trichotillomania |journal=The Journal of clinical psychiatry |volume=57 Suppl 8 |issue= |pages=42-7; discussion 48-9 |year=1996 |pmid=8698680 |doi= |issn= |accessdate=2007-07-24}}</ref> People with TTM may also eat/chew the roots of the hair that they pull, referred to as [[trichophagia]]. In extreme cases this can lead to [[Rapunzel syndrome]], and even death.<ref>{{cite journal |author=Ventura DE, Herbella FA, Schettini ST, Delmonte C |title=Rapunzel syndrome with a fatal outcome in a neglected child |journal=J. Pediatr. Surg. |volume=40 |issue=10 |pages=1665-7 |year=2005 |pmid=16227005 |doi=10.1016/j.jpedsurg.2005.06.038}}</ref><ref>{{cite journal |author=Pul N, Pul M |title=The Rapunzel syndrome (trichobezoar) causing gastric perforation in a child: a case report |journal=Eur. J. Pediatr. |volume=155 |issue=1 |pages=18–9 |year=1996 |pmid=8750804}}</ref><ref>{{cite web | url=http://www.keratin.com/ar/ar012.shtml  | title=Hairball kills teenager |publisher=hairgrowthnews.com | accessdate=2007-08-11}}</ref>  Some individuals with TTM may feel they are the only person with this problem due to low rates of reportage.<ref name="Christenson94" />
*Many [[psychiatrist|clinician]]s classify it as a habit behavior, belonging to the same family as [[nail biting]] ([[onychophagia]]) and [[compulsive skin picking]] ([[dermatillomania]]).
*Anxiety, depression, and OCD are frequent comorbidities.<ref name="pmid8698680">{{cite journal |author=Christenson GA, Crow SJ |title=The characterization and treatment of trichotillomania |journal=The Journal of clinical psychiatry |volume=57 Suppl 8 |issue= |pages=42-7; discussion 48-9 |year=1996 |pmid=8698680 |doi= |issn= |accessdate=2007-07-24}}</ref>
*Due to under-reporting, many individuals with trichotillomania feel they are the only persons with this condition and face distress.<ref name="Christenson94" />
*[[Trichophagia]] presents with multiple complications like [[Bezoar|trichobezoars]], [[Bowel obstruction|intestinal obstruction]], [[Gastrointestinal perforation|intestinal perforation]], malnutrition, [[acute pancreatitis]], [[Jaundice|obstructive jaundice]], and [[Ulcerations|bleeding ulcerations]]. <ref name="WadlingtonRose1992">{{cite journal|last1=Wadlington|first1=William B.|last2=Rose|first2=Michael|last3=Holcomb|first3=George W.|title=Complications of Trichobezoars: A 30-Year Experience|journal=Southern Medical Journal|volume=85|issue=10|year=1992|pages=1020–1022|issn=0038-4348|doi=10.1097/00007611-199210000-00024}}</ref>
*Long-term [[prognosis]] is poor in [[Child|children]] with trichotillomania. They mostly have focused hair pulling and are diagnosed at a later age. <ref name="SchumerPanza2015" />
*Most of these children develop severe [[depression]] and [[anxiety]] with age.<ref name="SchumerPanza2015">{{cite journal|last1=Schumer|first1=Maya C.|last2=Panza|first2=Kaitlyn E.|last3=Mulqueen|first3=Jilian M.|last4=Jakubovski|first4=Ewgeni|last5=Bloch|first5=Michael H.|title=LONG-TERM OUTCOME IN PEDIATRIC TRICHOTILLOMANIA|journal=Depression and Anxiety|volume=32|issue=10|year=2015|pages=737–743|issn=10914269|doi=10.1002/da.22390}}</ref>


==Diagnosis==
==Diagnosis==


===DSM-V Diagnostic Criteria for Trichotillomania<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>===
===DSM-5 Diagnostic Criteria===
{{cquote|
*[[Obsessive-compulsive disorder|Obsessive-compulsive]] and related disorders consist of:<ref name="DSMV" />
 
**[[Obsessive-compulsive disorder]]
*A. Recurrent pulling out of one’s hair, resulting in hair loss.
**[[Body dysmorphic disorder]]
 
**[[Hoarding disorder]]
'''''AND'''''
**Trichotillomania
*B. Repeated attempts to decrease or stop hair pulling.
**[[Excoriation disorder]]
 
**Substance/Medication-induced [[Obsessive-compulsive disorder|obsessive-compulsive]] and related Disorder
'''''AND'''''
**[[Obsessive-compulsive disorder|Obsessive-compulsive]] and related disorder secondary to another medical condition
*C. The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
**Other specified [[Obsessive-compulsive disorder|obsessive-compulsive]] and related disorder
**Unspecified [[Obsessive-compulsive disorder|obsessive-compulsive]] and related disorder


'''''AND'''''


*D. The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition).
According to [[DSM]]-5, to diagnose trichotillomania all the following criteria (A to E) should be fulfilled-
 
{| class="wikitable"
'''''AND'''''
|+
 
!'''''<big>DSM-5 Diagnostic Criteria for Trichotillomania (Hair-Pulling Disorder)</big>'''''
*E. The hair pulling is not better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder).
|-
}}
|A. Recurrent pulling out of one's own hair leading to hair loss
|-
|B. Repeated attempts to reduce or stop pulling hair
|-
|C. Clinically significant distress or impairment in social and occupational functioning
|-
|D. The hair pulling is not secondary to another medical condition
|-
|E. The hair pulling is not better explained by another [[psychiatric]] condition
|}
<br />


===Physical Examination===
===Physical Examination===
====Skin====
=====Trichotillomania of the scalp=====
=====Scalp=====
<gallery>
<gallery>
 
File:Trichotillomania01.jpg|Trichotillomania. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/ Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
 
File:Trichotillomania02.jpg|Trichotillomania. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/ Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
Image:Trichotillomania01.jpg|Trichotillomania. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/ Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
File:Trichotillomania03.jpg|Trichotillomania. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/ Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
 
File:Trichotillomania04.jpg|Trichotillomania. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/ Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
 
File:Trichotillomania05.jpg|Trichotillomania. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/ Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
 
File:Trichotillomania06.jpg|Trichotillomania. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/ Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
 
Image:Trichotillomania02.jpg|Trichotillomania. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/ Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
 
 
 
 
Image:Trichotillomania03.jpg|Trichotillomania. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/ Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
 
Image:Trichotillomania04.jpg|Trichotillomania. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/ Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
 
Image:Trichotillomania05.jpg|Trichotillomania. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/ Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
 
 
 
 
 
 
 
Image:Trichotillomania06.jpg|Trichotillomania. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/ Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
 
 
 
 
 
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==Treatment==
==Treatment==
Trichotillomania is a chronic problem, meaning that although one can recover from it, there is currently no cure.  It can be stubborn, but with proper treatment and persistence, picking and/or pulling hairs can be greatly reduced and even brought under control (often called "hibernation").  Clinicians who are specialized in treating this problem are not always easy to find, but do have the techniques and training to bring about substantial improvement.


===Behavioral Therapy===
*Trichotillomania is a [[Chronic (medical)|chronic]] condition where hair pulling is self-directed and irresistible.  It is often difficult to treat but can be controlled with repeated attempts.
[[Habit Reversal Training]] or HRT, has been shown to be a successful adjunct to [[pharmacotherapy]] as a way to treat TTM.<ref>{{cite journal |author=Woods DW, Wetterneck CT, Flessner CA |title=A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania |journal=Behaviour research and therapy |volume=44 |issue=5 |pages=639-56 |year=2006 |pmid=16039603 |doi=10.1016/j.brat.2005.05.006}}</ref> HRT was developed by Dr. Prasandy Azrin and colleagues and first published in 1973 in an article titled ''Habit Reversal: A Method of Eliminating Nervous Habits and Tics.''  The treatment focused on getting patients to increase their awareness of their behavior by recording and learning as much as possible about when, where, and how it occurred, and how to know ahead of time when it would occur.  They were next trained to focus on, and reduce the tension that preceded the pulling.  Finally, they were taught to perform a muscular movement that was inconspicuous, that was the opposite of and incompatible with the behavior they wished to eliminate. Many patients who pull their hair don’t realize that they are doing this; it is a [[conditioned response]].{{Fact|date=February 2007}} With Habit Reversal Training, doctors train the individual to learn to recognize their impulse to pull and also teach them to redirect this impulse. As a part of the behavioral record-keeping component of HRT, patients are often instructed to keep a journal of their hair-pulling episodes. They may be asked to record the date, time, location, and number of hairs pulled, as well what they are thinking or feeling at the time. This can help the patient learn to identify situations where they commonly pull out their hair and develop strategies for avoiding episodes.
*[[Psychotherapy]] and to some extent [[pharmacotherapy]] are useful. [[Behaviour therapy|Behavioral therapy]] has shown better results than pharmacotherapy in most studies.<ref name="van MinnenHoogduin2003">{{cite journal|last1=van Minnen|first1=Agnes|last2=Hoogduin|first2=Kees A. L.|last3=Keijsers|first3=Ger P. J.|last4=Hellenbrand|first4=Inge|last5=Hendriks|first5=Gert-Jan|title=Treatment of Trichotillomania With Behavioral Therapy or Fluoxetine|journal=Archives of General Psychiatry|volume=60|issue=5|year=2003|pages=517|issn=0003-990X|doi=10.1001/archpsyc.60.5.517}}</ref> <ref name="Keijsersvan Minnen2006">{{cite journal|last1=Keijsers|first1=Ger P.J.|last2=van Minnen|first2=Agnes|last3=Hoogduin|first3=Cees A.L.|last4=Klaassen|first4=Bram N.W.|last5=Hendriks|first5=Mathieu J.|last6=Tanis-Jacobs|first6=Jorg|title=Behavioural treatment of trichotillomania: Two-year follow-up results|journal=Behaviour Research and Therapy|volume=44|issue=3|year=2006|pages=359–370|issn=00057967|doi=10.1016/j.brat.2005.03.004}}</ref>
*Contrary to this, some studies suggest a combination of the two.<ref name="DoughertyLoh2006">{{cite journal|last1=Dougherty|first1=Darin D.|last2=Loh|first2=Rebecca|last3=Jenike|first3=Michael A.|last4=Keuthen|first4=Nancy J.|title=Single Modality Versus Dual Modality Treatment for Trichotillomania|journal=The Journal of Clinical Psychiatry|volume=67|issue=07|year=2006|pages=1086–1092|issn=0160-6689|doi=10.4088/JCP.v67n0711}}</ref>


===Medical Therapy===
===Psychotherapy===
[[Selective serotonin reuptake inhibitor]]s are effective in the treatment of [[obsessive-compulsive disorder]] and are commonly used in the treatment of trichotillomania.  [[Clomipramine]] treatment was shown to significantly improve symptoms when tested in a doubled-blind study.<ref name="pmid2761586">{{cite journal |author=Swedo SE, Leonard HL, Rapoport JL, Lenane MC, Goldberger EL, Cheslow DL |title=A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling) |journal=N. Engl. J. Med. |volume=321 |issue=8 |pages=497-501 |year=1989 |pmid=2761586 |doi=}}</ref>  Clinical trials for other drugs such as [[fluoxetine]], and [[Lithium pharmacology|lithium]] have not shown to be effective.


[[Fluoxetine]] and other similar drugs, which some professionals prescribe on a one-size-fits-all basis, tend to have limited usefulness in treating TTM, and can often have significant side effects.{{fact|date=August 2007}} According to F. Penzel, antidepressants can even increase the severity of the TTM.<ref name="Penzel" />
*[[Habit reversal training]] (HRT) has been considered a useful adjunct to [[pharmacotherapy]] for managing trichotillomania.<ref>{{cite journal |author=Woods DW, Wetterneck CT, Flessner CA |title=A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania |journal=Behaviour research and therapy |volume=44 |issue=5 |pages=639-56 |year=2006 |pmid=16039603 |doi=10.1016/j.brat.2005.05.006}}</ref>
*HRT focuses on increasing awareness about the [[behavior]]. The emphasis is on gaining information about the pattern of the [[behavior]] and finding a way to control it ahead of time. They are also trained to decrease the [[tension]] before hair-pulling.
*Some studies have considered HRT superior to [[pharmacotherapy]].<ref name="BlochLanderos-Weisenberger2007">{{cite journal|last1=Bloch|first1=Michael H.|last2=Landeros-Weisenberger|first2=Angeli|last3=Dombrowski|first3=Philip|last4=Kelmendi|first4=Ben|last5=Wegner|first5=Ryan|last6=Nudel|first6=Jake|last7=Pittenger|first7=Christopher|last8=Leckman|first8=James F.|last9=Coric|first9=Vladimir|title=Systematic Review: Pharmacological and Behavioral Treatment for Trichotillomania|journal=Biological Psychiatry|volume=62|issue=8|year=2007|pages=839–846|issn=00063223|doi=10.1016/j.biopsych.2007.05.019}}</ref>
*Other [[psychotherapy]] options like [[cognitive behavioral therapy]] ([[Cognitive-behavioral therapy|CBT]]) have also been tried but have higher chances of [[relapse]] after successful [[treatment]]. <ref name="LernerFranklin1998">{{cite journal|last1=Lerner|first1=Julie|last2=Franklin|first2=Martin E.|last3=Meadows|first3=Elizabeth A.|last4=Hembree|first4=Elizabeth|last5=Foa|first5=Edna B.|title=Effectiveness of a cognitive behavioral treatment program for trichotillomania: An uncontrolled evaluation|journal=Behavior Therapy|volume=29|issue=1|year=1998|pages=157–171|issn=00057894|doi=10.1016/S0005-7894(98)80036-1}}</ref>
*[[Group therapy|Group supportive therapy]] has also been associated with minimal improvement in the condition. In fact, [[Behaviour therapy|behavior therapy]] when employed in groups show less favorable outcomes than individual therapy. <ref name="DiefenbachTolin2006">{{cite journal|last1=Diefenbach|first1=Gretchen J.|last2=Tolin|first2=David F.|last3=Hannan|first3=Scott|last4=Maltby|first4=Nicholas|last5=Crocetto|first5=Johanna|title=Group Treatment for Trichotillomania: Behavior Therapy Versus Supportive Therapy|journal=Behavior Therapy|volume=37|issue=4|year=2006|pages=353–363|issn=00057894|doi=10.1016/j.beth.2006.01.006}}</ref>


* Due to involvement of glutaminergic system, N-acetylcysteine (NAC) has been proposed to treat this disorder. NAC is a glutamate modulator. It has the ability to restore glutamate extracellulary and decrease the oxidative stress in nucleus accumbens, resulting in improvement in symptoms.<ref name="GrantOdlaug2009">{{cite journal|last1=Grant|first1=Jon E.|last2=Odlaug|first2=Brian L.|last3=Won Kim|first3=Suck|title=N-Acetylcysteine, a Glutamate Modulator, in the Treatment of Trichotillomania|journal=Archives of General Psychiatry|volume=66|issue=7|year=2009|pages=756|issn=0003-990X|doi=10.1001/archgenpsychiatry.2009.60}}</ref>
===Pharmacotherapy===
 
*Many [[Medication|medications]] have been tried for trichotillomania but none are superior to the other. <ref name="SahKoo20085">{{cite journal|last1=Sah|first1=Deborah E|last2=Koo|first2=John|last3=Price|first3=Vera H|title=Trichotillomania|journal=Dermatologic Therapy|volume=21|issue=1|year=2008|pages=13–21|issn=1396-0296|doi=10.1111/j.1529-8019.2008.00165.x}}</ref>
*[[Selective serotonin reuptake inhibitor]]s ([[Selective serotonin reuptake inhibitor|SSRI]]) and [[Tricyclic antidepressant]]<nowiki/>s<nowiki/> (TCA) are commonly used for this purpose.
*[[Selective serotonin reuptake inhibitor|SSRIs]] commonly used are [[Fluoxetine Hcl|Fluoxetine]], [[Sertraline Hydrochloride|Sertraline]], [[Fluvoxamine]], and [[Paroxetine detailed information|Paroxetine]].<ref name="van MinnenHoogduin20033">{{cite journal|last1=van Minnen|first1=Agnes|last2=Hoogduin|first2=Kees A. L.|last3=Keijsers|first3=Ger P. J.|last4=Hellenbrand|first4=Inge|last5=Hendriks|first5=Gert-Jan|title=Treatment of Trichotillomania With Behavioral Therapy or Fluoxetine|journal=Archives of General Psychiatry|volume=60|issue=5|year=2003|pages=517|issn=0003-990X|doi=10.1001/archpsyc.60.5.517}}</ref><ref name="pmid86986802">{{cite journal| author=Christenson GA, Crow SJ| title=The characterization and treatment of trichotillomania. | journal=J Clin Psychiatry | year= 1996 | volume= 57 Suppl 8 | issue=  | pages= 42-7; discussion 48-9 | pmid=8698680 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8698680  }}</ref>
*[[Clomipramine]] and [[desipramine]] are the TCAs used. [[Clomipramine]] has shown superior results than [[desipramine]] in the short-term management of the symptoms.<ref name="pmid2761586">{{cite journal |author=Swedo SE, Leonard HL, Rapoport JL, Lenane MC, Goldberger EL, Cheslow DL |title=A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling) |journal=N. Engl. J. Med. |volume=321 |issue=8 |pages=497-501 |year=1989 |pmid=2761586 |doi=}}</ref>
*Evidence also suggests that [[Clomipramine]] is superior to [[SSRI|SSRIs]] for this condition.<ref name="BlochLanderos-Weisenberger20072">{{cite journal|last1=Bloch|first1=Michael H.|last2=Landeros-Weisenberger|first2=Angeli|last3=Dombrowski|first3=Philip|last4=Kelmendi|first4=Ben|last5=Wegner|first5=Ryan|last6=Nudel|first6=Jake|last7=Pittenger|first7=Christopher|last8=Leckman|first8=James F.|last9=Coric|first9=Vladimir|title=Systematic Review: Pharmacological and Behavioral Treatment for Trichotillomania|journal=Biological Psychiatry|volume=62|issue=8|year=2007|pages=839–846|issn=00063223|doi=10.1016/j.biopsych.2007.05.019}}</ref>
*[[Atypical antipsychotics]] are used for [[Tic disorder]] and [[Tourette Syndrome]]. Based on the resemblance of trichotillomania with these conditions, [[Olanzapine]] has been tried and resulted in improvement without major [[Adverse effect (medicine)|side effects]]. Further studies are needed to elaborate on the effects of this medication in trichotillomania.  <ref name="Van AmeringenMancini2010">{{cite journal|last1=Van Ameringen|first1=Michael|last2=Mancini|first2=Catherine|last3=Patterson|first3=Beth|last4=Bennett|first4=Mark|last5=Oakman|first5=Jonathan|title=A Randomized, Double-Blind, Placebo-Controlled Trial of Olanzapine in the Treatment of Trichotillomania|journal=The Journal of Clinical Psychiatry|volume=71|issue=10|year=2010|pages=1336–1343|issn=0160-6689|doi=10.4088/JCP.09m05114gre}}</ref>
*[[Lithium]] reduces [[impulsivity]] and provides mood-stability in these patients. However, it has shown inconsistent results and higher [[relapse]] rates. <ref name="SahKoo20084">{{cite journal|last1=Sah|first1=Deborah E|last2=Koo|first2=John|last3=Price|first3=Vera H|title=Trichotillomania|journal=Dermatologic Therapy|volume=21|issue=1|year=2008|pages=13–21|issn=1396-0296|doi=10.1111/j.1529-8019.2008.00165.x}}</ref>
*Due to the involvement of the glutaminergic system, [[Acetylcysteine|N-acetylcysteine]] ([[NAC]]) has been proposed to treat trichotillomania. <ref name="Rodrigues-BarataRodríguez-Pichardo2012">{{cite journal|last1=Rodrigues-Barata|first1=AnaRita|last2=Rodríguez-Pichardo|first2=Antonio|last3=Tosti|first3=Antonella|last4=Camacho-Martínez|first4=Francisco|title=N-acetylcysteine in the treatment of trichotillomania|journal=International Journal of Trichology|volume=4|issue=3|year=2012|pages=176|issn=0974-7753|doi=10.4103/0974-7753.100090}}</ref>
*NAC is a [[glutamate]] modulator. It has the ability to restore glutamate [[Extracellular|extracellularly]] and decrease the [[oxidative stress]] in [[nucleus accumbens]], resulting in improvement.<ref name="GrantOdlaug2009">{{cite journal|last1=Grant|first1=Jon E.|last2=Odlaug|first2=Brian L.|last3=Won Kim|first3=Suck|title=N-Acetylcysteine, a Glutamate Modulator, in the Treatment of Trichotillomania|journal=Archives of General Psychiatry|volume=66|issue=7|year=2009|pages=756|issn=0003-990X|doi=10.1001/archgenpsychiatry.2009.60}}</ref>


==References==
==References==
{{reflist|2}}
{{reflist|2}}
{{Mental and behavioural disorders}}
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List of terms related to Trichotillomania

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vatsala Sharma; M.B.B.S[2]

Synonyms and keywords: TTM, hair-pulling, trich, trichophagia, trichobezoar

Overview

Trichotillomania (TTM) is a condition characterized by the repeated irresistible desire to pull out scalp hair, eyelashes, facial hair, pubic hair, nose hair, eyebrows, and/or other body hair. The hair pulling relieves the anxiety preceding the event but leaves behind scars and injuries. The feeling of losing control and fear of pulling out all of the hair leaves the individual in severe frustration. The person very often pulls out a significant amount of hair amounting to hair loss. It also results in enormous distress and functional impairment in several areas of life. Secondary to this behavior, there is a progressive deterioration of self-esteem and eventually, self-isolation. These individuals unsuccessfully try to stop this behavior due to physical and mental stress experienced after the act, or harsh comments from the family and friends. Therefore, trichotillomania is emotionally traumatizing as well as socially stigmatizing.

Historical Perspective

  • The term "trichotillomania" is Greek in origin. It is a compilation of three words- trich, tillo, and mania.
  • "Trich" stands for hair, "tillo" means to pull, and "mania" denotes an unusual fascination towards an object, place, or action. The resulting word "trichotillomania" signifies the irresistible urge to pull hair. [1]
  • It was first mentioned in a published scientific report about hair pulling behavior in 1885. [2]
  • The term, however, was first used by a French dermatologist, Francois Hallopeau, in 1889.[3]
  • Originally, Francois Hallopeau had used this word for alopecia due to the self-traction of hair. It has now evolved to include the syndrome of pathological hair-pulling. [4]
  • A French physician, Baudamant gave details of trichobezoar (mass of undigested hair in the gastrointestinal tract) in a 16 year-old adolescent in the late 18th century.[5]

Classification

  • Among the classification systems, trichotillomania was first mentioned in ICD-9 in the year 1975 under 'the other disorders of impulse control'.
  • In 1987, DSM-III-R included trichotillomania as an 'impulse control disorder, not classified elsewhere'. [6]
  • Trichotillomania was accepted as an independent disorder in ICD-10 in 1990. It has been included under 'the habit and impulse control' category. [7]
  • In DSM-IV, two minimal modifications were made in this disorder's descriptions. Criteria B emphasized more on the stress experienced while resisting to pull the hair. The distress and impairment experienced by the individual were also brought into focus in Criteria E. [8][9]
  • DSM-IV-TR also described trichotillomania as 'an impulse control disorder, not classified elsewhere'.[10]
  • Therefore, it would be appropriate to point out here that DSM had only minor changes until the classification change in DSM-5.
  • DSM-5 moved trichotillomania from 'Impulse Control Disorder' to the category of 'Obsessive-Compulsive and Related Disorders' (OCRD).
  • Unlike DSM-IV, DSM-5 Criteria does not require the hair loss in trichotillomania to be noticeable. The individuals with this condition may pull out the hair from a wider region making it difficult to distinguish.[11]
  • DSM-5 has included a criterion that the individual should have made multiple attempts to stop the hair pulling behavior. This has replaced the DSM-IV criteria of preceding tension and immense gratification following hair pulling, this explains the transition from impulse control disorder to OCRD.[12]
  • It has been further made clear in DSM-5 that the condition should not be secondary to medical (various dermatological conditions) or psychiatric disorders (such as body dysmorphic disorder, psychosis, and obsessive compulsive disorder) .

Pathophysiology

Clinical Features

Differential Diagnosis

Trichotillomania should be differentiated from other medical and psychiatric conditions like-[28][29]

  • Other medical conditions-
  • Neuro-developmental disorder

Epidemiology and Demographics

Prevalence

  • The prevalence of trichotillomania is 1,000-2,000 per 100,000 (1%-2%) of the overall population. The number of reported cases has increased over the years, likely due to a decreased perceived stigma.[28]

Age

  • Patients of all age groups may develop trichotillomania.
  • Based on the age at onset, it is divided predominantly into three types- children of pre-school age, pre-adolescents and adolescents, and adults.[30]
  • Contrary to the popular belief, childhood-onset trichotillomania is common but differs in neurobiology from the adult-onset type. [31]
  • From childhood to adolescence, focused hair pulling increases whereas the automatic hair pulling remains the same.[32]
  • As the children grow older, more frequent urges and decreased ability to resist have been noticed. [33]
  • The post-pubertal onset is associated with greater severity of symptoms. [34]

Gender

  • Most studies support the female predominance but there are some studies show mixed results. [35][36]
  • With the male and female subjects having the same severity of symptoms, the females experience more distress and functional impairment due to hair pulling. [37]
  • It has been observed that men have a later age of onset of trichotillomania and are significantly affected by the coexisting anxiety.[38]
  • In females with trichotillomania, the symptoms exacerbate during menstruation. The condition may start during pregnancy or soon after the child birth. [39]

Race

  • African American females mostly pull their hair from the scalp region.[40]
  • Before hair pulling, anxiety has been the predominant feature observed in African American adults. [41]
  • Caucasians report pulling hair predominantly from eyebrows and eyelashes, more tension before hair pulling, higher interruption in their academic life, and greater stress experienced on a day-to-day basis as compared to their minority counterparts.[42]

Risk Factors

The risk factors associated with trichotillomania are[43]

Natural History, Complications and Prognosis

Diagnosis

DSM-5 Diagnostic Criteria


According to DSM-5, to diagnose trichotillomania all the following criteria (A to E) should be fulfilled-

DSM-5 Diagnostic Criteria for Trichotillomania (Hair-Pulling Disorder)
A. Recurrent pulling out of one's own hair leading to hair loss
B. Repeated attempts to reduce or stop pulling hair
C. Clinically significant distress or impairment in social and occupational functioning
D. The hair pulling is not secondary to another medical condition
E. The hair pulling is not better explained by another psychiatric condition


Physical Examination

Trichotillomania of the scalp

Treatment

  • Trichotillomania is a chronic condition where hair pulling is self-directed and irresistible. It is often difficult to treat but can be controlled with repeated attempts.
  • Psychotherapy and to some extent pharmacotherapy are useful. Behavioral therapy has shown better results than pharmacotherapy in most studies.[51] [52]
  • Contrary to this, some studies suggest a combination of the two.[53]

Psychotherapy

Pharmacotherapy

References

  1. ↑ Salaam, Karriem; Carr, Joel; Grewal, Harsh; Sholevar, Ellen; Baron, David (2005). "Untreated Trichotillomania and Trichophagia: Surgical Emergency in a Teenage Girl". Psychosomatics. 46 (4): 362–366. doi:10.1176/appi.psy.46.4.362. ISSN 0033-3182.
  2. ↑ Salaam, Karriem; Carr, Joel; Grewal, Harsh; Sholevar, Ellen; Baron, David (2005). "Untreated Trichotillomania and Trichophagia: Surgical Emergency in a Teenage Girl". Psychosomatics. 46 (4): 362–366. doi:10.1176/appi.psy.46.4.362. ISSN 0033-3182.
  3. ↑ Hallopeau M (1889). "Alopicie par grattage (trichomanie ou trichotillomanie)". Ann Dermatol Venereol. 10: 440–441.
  4. ↑ Chavan, BS; Raj, Lok; Kaur, Harprit (2005). "Management of trichotillomania". Indian Journal of Psychiatry. 47 (4): 235. doi:10.4103/0019-5545.43063. ISSN 0019-5545.
  5. ↑ Grant, Jon E.; Odlaug, Brian L. (2008). "Clinical characteristics of trichotillomania with trichophagia". Comprehensive Psychiatry. 49 (6): 579–584. doi:10.1016/j.comppsych.2008.05.002. ISSN 0010-440X.
  6. ↑ Grant, Jon E.; Stein, Dan J. (2014). "Body-focused repetitive behavior disorders in ICD-11". Revista Brasileira de Psiquiatria. 36 (suppl 1): 59–64. doi:10.1590/1516-4446-2013-1228. ISSN 1516-4446.
  7. ↑ Grant, Jon E.; Stein, Dan J. (2014). "Body-focused repetitive behavior disorders in ICD-11". Revista Brasileira de Psiquiatria. 36 (suppl 1): 59–64. doi:10.1590/1516-4446-2013-1228. ISSN 1516-4446.
  8. ↑ Grant, Jon E.; Stein, Dan J. (2014). "Body-focused repetitive behavior disorders in ICD-11". Revista Brasileira de Psiquiatria. 36 (suppl 1): 59–64. doi:10.1590/1516-4446-2013-1228. ISSN 1516-4446.
  9. ↑ Lochner, Christine; Stein, Dan J.; Woods, Douglas; Pauls, David L.; Franklin, Martin E.; Loerke, Elizabeth H.; Keuthen, Nancy J. (2011). "The validity of DSM-IV-TR criteria B and C of hair-pulling disorder (trichotillomania): Evidence from a clinical study". Psychiatry Research. 189 (2): 276–280. doi:10.1016/j.psychres.2011.07.022. ISSN 0165-1781.
  10. ↑ Stein, Dan J.; Grant, Jon E.; Franklin, Martin E.; Keuthen, Nancy; Lochner, Christine; Singer, Harvey S.; Woods, Douglas W. (2010). "Trichotillomania (hair pulling disorder), skin picking disorder, and stereotypic movement disorder: toward DSM-V". Depression and Anxiety. 27 (6): 611–626. doi:10.1002/da.20700. ISSN 1091-4269.
  11. ↑ Grant, Jon E.; Stein, Dan J. (2014). "Body-focused repetitive behavior disorders in ICD-11". Revista Brasileira de Psiquiatria. 36 (suppl 1): 59–64. doi:10.1590/1516-4446-2013-1228. ISSN 1516-4446.
  12. ↑ Lochner, Christine; Grant, Jon E.; Odlaug, Brian L.; Woods, Douglas W.; Keuthen, Nancy J.; Stein, Dan J. (2012). "DSM-5 FIELD SURVEY: HAIR-PULLING DISORDER (TRICHOTILLOMANIA)". Depression and Anxiety. 29 (12): 1025–1031. doi:10.1002/da.22011. ISSN 1091-4269.
  13. ↑ Özcan, D.; Seçkin, D. (2016). "N-Acetylcysteine in the treatment of trichotillomania: remarkable results in two patients". Journal of the European Academy of Dermatology and Venereology. 30 (9): 1606–1608. doi:10.1111/jdv.13690. ISSN 0926-9959.
  14. ↑ Marazziti D, Dell'Osso L, Presta S; et al. (1999). "Platelet [3H]paroxetine binding in patients with OCD-related disorders". Psychiatry research. 89 (3): 223–8. PMID 10708268.
  15. ↑ Isobe, Masanori; Redden, Sarah A.; Keuthen, Nancy J.; Stein, Dan J.; Lochner, Christine; Grant, Jon E.; Chamberlain, Samuel R. (2018). "Striatal abnormalities in trichotillomania: A multi-site MRI analysis". NeuroImage: Clinical. 17: 893–898. doi:10.1016/j.nicl.2017.12.031. ISSN 2213-1582.
  16. ↑ Keuthen, Nancy J.; Makris, Nikos; Schlerf, John E.; Martis, Brian; Savage, Cary R.; McMullin, Katherine; Seidman, Larry J.; Schmahmann, Jeremy D.; Kennedy, David N.; Hodge, Steven M.; Rauch, Scott L. (2007). "Evidence for Reduced Cerebellar Volumes in Trichotillomania". Biological Psychiatry. 61 (3): 374–381. doi:10.1016/j.biopsych.2006.06.013. ISSN 0006-3223.
  17. ↑ Chamberlain, Samuel R.; Harries, Michael; Redden, Sarah A.; Keuthen, Nancy J.; Stein, Dan J.; Lochner, Christine; Grant, Jon E. (2017). "Cortical thickness abnormalities in trichotillomania: international multi-site analysis". Brain Imaging and Behavior. 12 (3): 823–828. doi:10.1007/s11682-017-9746-3. ISSN 1931-7557.
  18. ↑ Chamberlain, Samuel R.; Hampshire, Adam; Menzies, Lara A.; Garyfallidis, Eleftherios; Grant, Jon E.; Odlaug, Brian L.; Craig, Kevin; Fineberg, Naomi; Sahakian, Barbara J. (2010). "Reduced Brain White Matter Integrity in Trichotillomania". Archives of General Psychiatry. 67 (9): 965. doi:10.1001/archgenpsychiatry.2010.109. ISSN 0003-990X.
  19. ↑ Minichiello, William E.; O'Sullivan, Richard L.; Osgood-Hynes, Deborah; Baer, Lee (1994). "Trichotillomania: Clinical Aspects and Treatment Strategies". Harvard Review of Psychiatry. 1 (6): 336–344. doi:10.3109/10673229409017100. ISSN 1067-3229.
  20. ↑ Mehta, PurvaRanjit; Malakar, Subrata (2017). ""i hair": A prognostic marker in alopecia areata & trichotillomania". Indian Journal of Dermatology. 62 (6): 550. doi:10.4103/ijd.IJD_337_17. ISSN 0019-5154.
  21. ↑ Sah, Deborah E; Koo, John; Price, Vera H (2008). "Trichotillomania". Dermatologic Therapy. 21 (1): 13–21. doi:10.1111/j.1529-8019.2008.00165.x. ISSN 1396-0296.
  22. ↑ Tay, Y.-K.; Levy, M. L.; Metry, D. W. (2004). "Trichotillomania in Childhood: Case Series and Review". PEDIATRICS. 113 (5): e494–e498. doi:10.1542/peds.113.5.e494. ISSN 0031-4005.
  23. ↑ "Characteristics of 60 adult chronic hair pullers". American Journal of Psychiatry. 148 (3): 365–370. 1991. doi:10.1176/ajp.148.3.365. ISSN 0002-953X.
  24. ↑ Odlaug, Brian L.; Chamberlain, Samuel R.; Harvanko, Arit M.; Grant, Jon E. (2012). "Age at Onset in Trichotillomania". The Primary Care Companion For CNS Disorders. doi:10.4088/PCC.12m01343. ISSN 2155-7780.
  25. ↑ Grant, Jon E.; Odlaug, Brian L. (2008). "Clinical characteristics of trichotillomania with trichophagia". Comprehensive Psychiatry. 49 (6): 579–584. doi:10.1016/j.comppsych.2008.05.002. ISSN 0010-440X.
  26. ↑ Grant, Jon E.; Odlaug, Brian L. (2008). "Clinical characteristics of trichotillomania with trichophagia". Comprehensive Psychiatry. 49 (6): 579–584. doi:10.1016/j.comppsych.2008.05.002. ISSN 0010-440X.
  27. ↑ Ventura, Denise Estefan; Mardiros Herbella, Fernando A.; Schettini, Sergio T.; Delmonte, Carlos (2005). "Rapunzel syndrome with a fatal outcome in a neglected child". Journal of Pediatric Surgery. 40 (10): 1665–1667. doi:10.1016/j.jpedsurg.2005.06.038. ISSN 0022-3468.
  28. ↑ 28.0 28.1 28.2 28.3 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
  29. ↑ Sah, Deborah E; Koo, John; Price, Vera H (2008). "Trichotillomania". Dermatologic Therapy. 21 (1): 13–21. doi:10.1111/j.1529-8019.2008.00165.x. ISSN 1396-0296.
  30. ↑ Sah, Deborah E; Koo, John; Price, Vera H (2008). "Trichotillomania". Dermatologic Therapy. 21 (1): 13–21. doi:10.1111/j.1529-8019.2008.00165.x. ISSN 1396-0296.
  31. ↑ Odlaug, Brian L.; Chamberlain, Samuel R.; Harvanko, Arit M.; Grant, Jon E. (2012). "Age at Onset in Trichotillomania". The Primary Care Companion For CNS Disorders. doi:10.4088/PCC.12m01343. ISSN 2155-7780.
  32. ↑ Panza, Kaitlyn E.; Pittenger, Christopher; Bloch, Michael H. (2013). "Age and Gender Correlates of Pulling in Pediatric Trichotillomania". Journal of the American Academy of Child & Adolescent Psychiatry. 52 (3): 241–249. doi:10.1016/j.jaac.2012.12.019. ISSN 0890-8567.
  33. ↑ Panza, Kaitlyn E.; Pittenger, Christopher; Bloch, Michael H. (2013). "Age and Gender Correlates of Pulling in Pediatric Trichotillomania". Journal of the American Academy of Child & Adolescent Psychiatry. 52 (3): 241–249. doi:10.1016/j.jaac.2012.12.019. ISSN 0890-8567.
  34. ↑ Odlaug, Brian L.; Chamberlain, Samuel R.; Harvanko, Arit M.; Grant, Jon E. (2012). "Age at Onset in Trichotillomania". The Primary Care Companion For CNS Disorders. doi:10.4088/PCC.12m01343. ISSN 2155-7780.
  35. ↑ 35.0 35.1 Christenson GA, MacKenzie TB, Mitchell JE (1994). "Adult men and women with trichotillomania. A comparison of male and female characteristics". Psychosomatics. 35 (2): 142–9. PMID 8171173.
  36. ↑ Grant, Jon E.; Dougherty, Darin D.; Chamberlain, Samuel R. (2020). "Prevalence, gender correlates, and co-morbidity of trichotillomania". Psychiatry Research. 288: 112948. doi:10.1016/j.psychres.2020.112948. ISSN 0165-1781.
  37. ↑ Panza, Kaitlyn E.; Pittenger, Christopher; Bloch, Michael H. (2013). "Age and Gender Correlates of Pulling in Pediatric Trichotillomania". Journal of the American Academy of Child & Adolescent Psychiatry. 52 (3): 241–249. doi:10.1016/j.jaac.2012.12.019. ISSN 0890-8567.
  38. ↑ Grant, Jon E.; Christenson, Gary A. (2007). "Examination of Gender in Pathologic Grooming Behaviors". Psychiatric Quarterly. 78 (4): 259–267. doi:10.1007/s11126-007-9045-z. ISSN 0033-2720.
  39. ↑ Lochner, C.; Stein, D. J. (2001). "Gender in obsessive-compulsive disorder and obsessive-compulsive spectrum disorders". Archives of Women's Mental Health. 4 (1): 19–26. doi:10.1007/s007370170004. ISSN 1434-1816.
  40. ↑ Neal-Barnett, Angela; Statom, Deborah; Stadulis, Robert (2011). "Trichotillomania Symptoms in African American Women: Are they Related to Anxiety and Culture?". CNS Neuroscience & Therapeutics. 17 (4): 207–213. doi:10.1111/j.1755-5949.2010.00138.x. ISSN 1755-5930.
  41. ↑ Neal-Barnett, Angela; Statom, Deborah; Stadulis, Robert (2011). "Trichotillomania Symptoms in African American Women: Are they Related to Anxiety and Culture?". CNS Neuroscience & Therapeutics. 17 (4): 207–213. doi:10.1111/j.1755-5949.2010.00138.x. ISSN 1755-5930.
  42. ↑ Neal-Barnett, Angela; Flessner, Christopher; Franklin, Martin E.; Woods, Douglas W.; Keuthen, Nancy J.; Stein, Dan J. (2010). "Ethnic differences in trichotillomania: Phenomenology, interference, impairment, and treatment efficacy". Journal of Anxiety Disorders. 24 (6): 553–558. doi:10.1016/j.janxdis.2010.03.014. ISSN 0887-6185.
  43. ↑ Snorrason, Ivar; Belleau, Emily L.; Woods, Douglas W. (2012). "How related are hair pulling disorder (trichotillomania) and skin picking disorder? A review of evidence for comorbidity, similarities and shared etiology". Clinical Psychology Review. 32 (7): 618–629. doi:10.1016/j.cpr.2012.05.008. ISSN 0272-7358.
  44. ↑ EntrezGene (12-Aug-2006). "Gene" (UTF-8). National Center for Biotechnology Information. Check date values in: |date= (help)
  45. ↑ "Hair pulling disorder gene found". Retrieved 2007-05-01.
  46. ↑ Christenson GA, Mackenzie TB, Mitchell JE (1991). "Characteristics of 60 adult chronic hair pullers". The American journal of psychiatry. 148 (3): 365–70. PMID 1992841.
  47. ↑ Christenson GA, Crow SJ (1996). "The characterization and treatment of trichotillomania". The Journal of clinical psychiatry. 57 Suppl 8: 42–7, discussion 48-9. PMID 8698680. |access-date= requires |url= (help)
  48. ↑ Wadlington, William B.; Rose, Michael; Holcomb, George W. (1992). "Complications of Trichobezoars: A 30-Year Experience". Southern Medical Journal. 85 (10): 1020–1022. doi:10.1097/00007611-199210000-00024. ISSN 0038-4348.
  49. ↑ 49.0 49.1 Schumer, Maya C.; Panza, Kaitlyn E.; Mulqueen, Jilian M.; Jakubovski, Ewgeni; Bloch, Michael H. (2015). "LONG-TERM OUTCOME IN PEDIATRIC TRICHOTILLOMANIA". Depression and Anxiety. 32 (10): 737–743. doi:10.1002/da.22390. ISSN 1091-4269.
  50. ↑ 50.0 50.1 50.2 50.3 50.4 50.5 "Dermatology Atlas".
  51. ↑ van Minnen, Agnes; Hoogduin, Kees A. L.; Keijsers, Ger P. J.; Hellenbrand, Inge; Hendriks, Gert-Jan (2003). "Treatment of Trichotillomania With Behavioral Therapy or Fluoxetine". Archives of General Psychiatry. 60 (5): 517. doi:10.1001/archpsyc.60.5.517. ISSN 0003-990X.
  52. ↑ Keijsers, Ger P.J.; van Minnen, Agnes; Hoogduin, Cees A.L.; Klaassen, Bram N.W.; Hendriks, Mathieu J.; Tanis-Jacobs, Jorg (2006). "Behavioural treatment of trichotillomania: Two-year follow-up results". Behaviour Research and Therapy. 44 (3): 359–370. doi:10.1016/j.brat.2005.03.004. ISSN 0005-7967.
  53. ↑ Dougherty, Darin D.; Loh, Rebecca; Jenike, Michael A.; Keuthen, Nancy J. (2006). "Single Modality Versus Dual Modality Treatment for Trichotillomania". The Journal of Clinical Psychiatry. 67 (07): 1086–1092. doi:10.4088/JCP.v67n0711. ISSN 0160-6689.
  54. ↑ Woods DW, Wetterneck CT, Flessner CA (2006). "A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania". Behaviour research and therapy. 44 (5): 639–56. doi:10.1016/j.brat.2005.05.006. PMID 16039603.
  55. ↑ Bloch, Michael H.; Landeros-Weisenberger, Angeli; Dombrowski, Philip; Kelmendi, Ben; Wegner, Ryan; Nudel, Jake; Pittenger, Christopher; Leckman, James F.; Coric, Vladimir (2007). "Systematic Review: Pharmacological and Behavioral Treatment for Trichotillomania". Biological Psychiatry. 62 (8): 839–846. doi:10.1016/j.biopsych.2007.05.019. ISSN 0006-3223.
  56. ↑ Lerner, Julie; Franklin, Martin E.; Meadows, Elizabeth A.; Hembree, Elizabeth; Foa, Edna B. (1998). "Effectiveness of a cognitive behavioral treatment program for trichotillomania: An uncontrolled evaluation". Behavior Therapy. 29 (1): 157–171. doi:10.1016/S0005-7894(98)80036-1. ISSN 0005-7894.
  57. ↑ Diefenbach, Gretchen J.; Tolin, David F.; Hannan, Scott; Maltby, Nicholas; Crocetto, Johanna (2006). "Group Treatment for Trichotillomania: Behavior Therapy Versus Supportive Therapy". Behavior Therapy. 37 (4): 353–363. doi:10.1016/j.beth.2006.01.006. ISSN 0005-7894.
  58. ↑ Sah, Deborah E; Koo, John; Price, Vera H (2008). "Trichotillomania". Dermatologic Therapy. 21 (1): 13–21. doi:10.1111/j.1529-8019.2008.00165.x. ISSN 1396-0296.
  59. ↑ van Minnen, Agnes; Hoogduin, Kees A. L.; Keijsers, Ger P. J.; Hellenbrand, Inge; Hendriks, Gert-Jan (2003). "Treatment of Trichotillomania With Behavioral Therapy or Fluoxetine". Archives of General Psychiatry. 60 (5): 517. doi:10.1001/archpsyc.60.5.517. ISSN 0003-990X.
  60. ↑ Christenson GA, Crow SJ (1996). "The characterization and treatment of trichotillomania". J Clin Psychiatry. 57 Suppl 8: 42–7, discussion 48-9. PMID 8698680.
  61. ↑ Swedo SE, Leonard HL, Rapoport JL, Lenane MC, Goldberger EL, Cheslow DL (1989). "A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling)". N. Engl. J. Med. 321 (8): 497–501. PMID 2761586.
  62. ↑ Bloch, Michael H.; Landeros-Weisenberger, Angeli; Dombrowski, Philip; Kelmendi, Ben; Wegner, Ryan; Nudel, Jake; Pittenger, Christopher; Leckman, James F.; Coric, Vladimir (2007). "Systematic Review: Pharmacological and Behavioral Treatment for Trichotillomania". Biological Psychiatry. 62 (8): 839–846. doi:10.1016/j.biopsych.2007.05.019. ISSN 0006-3223.
  63. ↑ Van Ameringen, Michael; Mancini, Catherine; Patterson, Beth; Bennett, Mark; Oakman, Jonathan (2010). "A Randomized, Double-Blind, Placebo-Controlled Trial of Olanzapine in the Treatment of Trichotillomania". The Journal of Clinical Psychiatry. 71 (10): 1336–1343. doi:10.4088/JCP.09m05114gre. ISSN 0160-6689.
  64. ↑ Sah, Deborah E; Koo, John; Price, Vera H (2008). "Trichotillomania". Dermatologic Therapy. 21 (1): 13–21. doi:10.1111/j.1529-8019.2008.00165.x. ISSN 1396-0296.
  65. ↑ Rodrigues-Barata, AnaRita; Rodríguez-Pichardo, Antonio; Tosti, Antonella; Camacho-Martínez, Francisco (2012). "N-acetylcysteine in the treatment of trichotillomania". International Journal of Trichology. 4 (3): 176. doi:10.4103/0974-7753.100090. ISSN 0974-7753.
  66. ↑ Grant, Jon E.; Odlaug, Brian L.; Won Kim, Suck (2009). "N-Acetylcysteine, a Glutamate Modulator, in the Treatment of Trichotillomania". Archives of General Psychiatry. 66 (7): 756. doi:10.1001/archgenpsychiatry.2009.60. ISSN 0003-990X.
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