Trichotillomania: Difference between revisions

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==Pathophysiology==
==Pathophysiology==


*[[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 [[pathophysiology]] of trichotillomania is proposed to be related 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>
*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 on individuals with trichotillomania have shown involvement of various brain regions.
*The imaging studies performed on individuals with trichotillomania have shown the 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>
*These patients have [[subcortical]] brain abnormalities noted on [[Magnetic Resonance Imaging]] ([[MRI|MRI Scan]]). There has been decreased [[putamen]] and [[amygdala]] volumes as well as variation in curvature of [[Caudate nuclei|caudate]] and [[nucleus accumbens]]. It 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>
*MRI findings have also shown that in patients with trichotillomania, there is 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 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>
*An increase in [[Frontal cortex|right frontal cortical thickness]] has been noticed. 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.  
*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]] 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>
*Reduction in [[Anisotropy|fractional anisotropy]] has been seen in [[anterior cingulate]], and temporal cortical region. It has not been found to 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 which is further substantiated by the involvement of numerous brain areas as shown on neuroimaging.  
*Therefore, this disorder has complex pathophysiology which is further substantiated by the involvement of numerous brain areas on neuroimaging.


==Clinical Features==
==Clinical Features==


* Repetitive hair pulling from various sites like [[scalp]], [[Eyelash|eyelashes]], [[Eyebrow|eyebrows]],[[eyelashes]],[[legs]] and arms. Sometimes patients may also pull hair from [[Axillae|axilla]], [[Chest|chest,]] [[Pubic hair|pubic]] 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>
* Repetitive hair pulling from various sites like [[scalp]], [[Eyelash|eyelashes]], [[Eyebrow|eyebrows]], [[eyelashes]], [[legs]], and arms. Sometimes patients may also pull hair from the [[Axillae|axilla]], [[Chest|chest,]] [[Pubic hair|pubic]] 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 variable length of the broken hair left behind 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>
* [[Hair loss]] in trichotillomania is characterized by the variable length of the broken hair left behind 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>
*[[Scalp]] is the most common affected site.<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> However, when stopped from one site the same individual can start pulling hair from other places.
*The [[scalp]] is the most commonly affected site.<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> However, when stopped from one site the same individual can start pulling hair from other places.
*The hair-pulling [[behavior]] is preceded by severe [[anxiety]], which is relieved after performing the act. Most of these individuals live with extreme guilt.
*Hair-pulling [[behavior]] is preceded by severe [[anxiety]], which is relieved after performing the act. Most of these individuals live with extreme guilt later.
*Often the people with this condition pull hair from multiple sites at the same time and are associated with many [[comorbidities]] like 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>
*Often the people with this condition pull hair from multiple sites at the same time and are associated with many [[comorbidities]] like 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]] and it has been observed that the persons with later onset as compared to [[Childhood|childhood onset]] form, have more severe from of this condition and spend plenty 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>
*Trichotillomania can begin at any [[age]] and it has been observed that the persons with later onset as compared to [[Childhood|childhood-onset]] form, have more severe condition and spend plenty 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 individuals perform rituals with hairs after they are pulled out like 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>
* Some people perform rituals with hairs after being plucked like 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>
* When the hair is swallowed ([[trichophagia]]) as a result of this ritualistic behavior, it may lead to formation of a hairball ([[trichobezoar]]) in the [[gastrointestinal tract]] causing [[obstruction]]. If adequate and timely attention is not given to this condition, 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 hair is swallowed ([[trichophagia]]) as a result of this ritualistic behavior, it may lead to the formation of a hairball ([[trichobezoar]]) in the [[gastrointestinal tract]] causing an [[obstruction]]. If adequate and timely attention is not given here, 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]] extend from [[stomach]] to [[intestine]], the condition is called [[Rapunzel syndrome|Rapunzel Syndrome]]. This may lead to [[Gastrointestinal perforation|intestinal perforation]] and is a highly fatal condition.<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>
*When the tail from [[Bezoar|trichobezoar]] extends from [[stomach]] to [[intestine]], the condition is called [[Rapunzel syndrome|Rapunzel Syndrome]]. It may result in [[Gastrointestinal perforation|intestinal perforation]] and is a highly fatal condition.<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>


==Differential Diagnosis==
==Differential Diagnosis==
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==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 cases have increased over the years, likely due to a decreased perceived stigma.  
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 cases has increased over the years, likely due to a decreased perceived stigma.  


===Age===
===Age===
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* 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>
* 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 the [[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>
* Contrary to the popular belief, childhood-onset trichotillomania is common but differs in the [[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]], hair pulling increases in focused manner 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>
* From [[Child development|childhood]] to [[adolescence]], hair pulling increases in a focused manner 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, reaching the [[Adolescence|adolescent]] group more frequent urges have been noticed and there has also been decreased ability to resist. <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>
* As the children grow older, reaching the [[Adolescence|adolescent]] group more frequent urges have been noticed and there has also been decreased ability to resist. <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>
* It has been observed that post-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>
* It has been observed that post-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>
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* Sixty-five percent of those affected are [[Female|females]].<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>
* Sixty-five percent of those affected are [[Female|females]].<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 of studies support the female predominance but there are some studies showing both genders being equally affected by this condition. <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>
* Most studies support the female predominance but there are some studies showing both genders being equally affected. <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 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>
* With the male and female subjects having the same severity of 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 later age of onset of trichotillomania and were found to be 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>
*It has been observed that men have later age of onset of trichotillomania and were found to be 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 who have trichotillomania, the symptoms exacerbate during [[Menses|menstruation]]. The condition may start during pregnancy or soon after [[Birth|birth of the child]]. <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>
*In females who have trichotillomania, the symptoms exacerbate during [[Menses|menstruation]]. The condition may start during pregnancy or soon after [[Birth|the birth of the child]]. <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>
*  
*  


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* African American females mostly pull their hair from the [[scalp]] region like their white counterparts.<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>
* African American females mostly pull their hair from the [[scalp]] region like their white counterparts.<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>
* Caucasians reported more pulling hair 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 when 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>
*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>
* 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><br />
* Caucasians report more pulling hair 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 when 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==
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*Emotional temperament
*Emotional temperament
*Harm avoidance trait
*Harm avoidance trait
*Novelty Seeking trait
*Novelty seeking trait
*Under-stimulated Environment like [[boredom]]
*Under-stimulated Environment like [[boredom]]
*[[Stress (medicine)|Stress]]
*[[Stress (medicine)|Stress]]
Line 136: Line 136:
==Natural History, Complications and Prognosis==
==Natural History, Complications and Prognosis==


* Individuals with trichotillomania can spend normal lives but they may have bald spots on their head, among their [[Eyelash|eyelashes]], pubic hair, or [[Eyebrow|eyebrows]].
* Individuals with trichotillomania can spend normal lives but mostly have bald spots on their head, among their [[Eyelash|eyelashes]], pubic hair, or [[Eyebrow|eyebrows]].
* It is associated with a significant psychological effect characterized by low [[self-esteem]], often associated with the feeling of outcast by the peers.
* It is associated with a significant psychological effect characterized by low [[self-esteem]], often associated with the feeling of outcast by the peers.
* They develop the fear of interacting with others due to their appearance and dread the social rejection they might encounter.  
* They develop the fear of interacting with others due to their appearance and dread the social rejection they might encounter.  

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [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 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 the hair leaves these individuals with extreme 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, ends up in self-isolation. These individuals unsuccessfully try to stop this behavior due to physical and mental stress experienced later as well as the harsh comments from the family and friends. Therefore, trichotillomania is emotionally traumatizing as well as socially stigmatizing for the sufferers.

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 16 year-old adolescent in the late 18th century.[5]

Classification

  • Among the classification systems, trichotillomania was first mentioned in ICD-9 in 1975 under 'the other disorders of impulse control'.
  • DSM-III-R first included trichotillomania in 1987 as an 'impulse control disorder, not classified elsewhere'. [6]
  • In 1990, trichotillomania was accepted as an independent disorder in ICD-10. It has been included under 'the habit and impulse control' category[7]
  • In DSM-IV, two minimal modifications were made regarding 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 as enclosed in Criteria E. [8][9]
  • In DSM-IV-TR also trichotillomania has been described as 'an impulse control disorder, not classified elsewhere'.[10]
  • Therefore, it would be appropriate to point here that DSM had only minor changes in the description of trichotillomania until the classification change in 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 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 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. [12] This explains the transition from impulse control disorder to OCRD of DSM-5.
  • It has been further made clear in DSM-5 that the condition should not be secondary to medical (various dermatological conditions) or psychiatric (Body dysmorphic disorder, psychosis, Obsessive Compulsive Disorder, etc) disorders.

Pathophysiology

  • The pathophysiology of trichotillomania is proposed to be related to the dysregulation of the glutaminergic system.[13].
  • 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 level.[14]
  • The imaging studies performed on individuals with trichotillomania have shown the involvement of various brain regions.
  • These patients have subcortical brain abnormalities noted on Magnetic Resonance Imaging (MRI Scan). There has been decreased putamen and amygdala volumes as well as variation in curvature of caudate and nucleus accumbens. It points towards their involvement in affect modulation and reward processing, which forms the basis of trichotillomania pathophysiology. [15]
  • MRI findings have also shown that in patients with trichotillomania, there is a reduced volume of both right and left cerebellar cortices. It is further substantiated by the motor involvement in the symptomatology of this disorder. [16]
  • An increase in right frontal cortical thickness has been noticed. However, the extent of thickness does not correspond to the severity of symptoms.[17]
  • 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 fractional anisotropy has been seen in anterior cingulate, and temporal cortical region. It has not been found to relate to disease severity. [18]
  • Therefore, this disorder has complex pathophysiology which is further substantiated by the involvement of numerous brain areas on neuroimaging.

Clinical Features

  • Repetitive hair pulling from various sites like scalp, eyelashes, eyebrows, eyelashes, legs, and arms. Sometimes patients may also pull hair from the axilla, chest, pubic or other regions.[19]
  • Hair loss in trichotillomania is characterized by the variable length of the broken hair left behind after plucking.[20]
  • The scalp is the most commonly affected site.[21][22] However, when stopped from one site the same individual can start pulling hair from other places.
  • Hair-pulling behavior is preceded by severe anxiety, which is relieved after performing the act. Most of these individuals live with extreme guilt later.
  • Often the people with this condition pull hair from multiple sites at the same time and are associated with many comorbidities like depression and anxiety disorders.[23]
  • Trichotillomania can begin at any age and it has been observed that the persons with later onset as compared to childhood-onset form, have more severe condition and spend plenty of time pulling hair each day. [24]
  • Some people perform rituals with hairs after being plucked like biting, chewing, or playing with them.[25]
  • When the hair is swallowed (trichophagia) as a result of this ritualistic behavior, it may lead to the formation of a hairball (trichobezoar) in the gastrointestinal tract causing an obstruction. If adequate and timely attention is not given here, it may cause a life-threatening emergency requiring immediate surgery. [26]
  • When the tail from trichobezoar extends from stomach to intestine, the condition is called Rapunzel Syndrome. It may result in intestinal perforation and is a highly fatal condition.[27]

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.[28] The number of reported cases has increased over the years, likely due to a decreased perceived stigma.

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 the neurobiology from the adult-onset type. [31]
  • From childhood to adolescence, hair pulling increases in a focused manner whereas the automatic hair pulling remains the same.[32]
  • As the children grow older, reaching the adolescent group more frequent urges have been noticed and there has also been decreased ability to resist. [33]
  • It has been observed that post-pubertal onset is associated with greater severity of symptoms. [34]

Gender

  • Sixty-five percent of those affected are females.[35]
  • Most studies support the female predominance but there are some studies showing both genders being equally affected. [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 later age of onset of trichotillomania and were found to be significantly affected by the coexisting anxiety.[38]
  • In females who have trichotillomania, the symptoms exacerbate during menstruation. The condition may start during pregnancy or soon after the birth of the child. [39]

Race

  • African American females mostly pull their hair from the scalp region like their white counterparts.[40]
  • Before hair pulling, anxiety has been the predominant feature observed in African American adults. [41]
  • Caucasians report more pulling hair 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 when compared to their minority counterparts.[42]

Risk Factors

The risk factors associated with trichotillomania are-[43]

Natural History, Complications and Prognosis

  • Individuals with trichotillomania can spend normal lives but mostly have bald spots on their head, among their eyelashes, pubic hair, or eyebrows.
  • It is associated with a significant psychological effect characterized by low self-esteem, often associated with the feeling of outcast by the peers.
  • They develop the fear of interacting with others due to their appearance and dread the social rejection they might encounter.
  • These people wear hats, wigs or style their hair in an attempt to avoid attention.
  • It is a stress related condition. In low-stress environments, some individuals exhibit no symptoms whereas the 'hair pulling' resumes upon leaving this environment.[46]

Diagnosis

DSM-5 Diagnostic Criteria

  • Obsessive Compulsive and Related Disorders consist of:[28]
    • Obsessive-Compulsive Disorder
    • Body Dysmorphic Disorder
    • Hoarding Disorder
    • Trichotillomania
    • Excoriation Disorder
    • Substance/Medication-Induced Obsessive-Compulsive and Related Disorder
    • Obsessive -Compulsive and Related Disorder Due to Another Medical Condition
    • Other Specified Obsessive-Compulsive and Related Disorder
    • Unspecified Obsessive-Compulsive and Related Disorder
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. Occurrence of 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 for the patient. It is often difficult to treat but with persistent attempts, it can be controlled. Predominantly psychotherapy and to some extent pharmacotherapy, can be employed to treat trichotillomania. Behavioral therapy has shown better results than pharmacotherapy in majority of studies.[51] [52]Contrary to this, some studies suggest the combination of two present with promising results.[53]

Psychotherapy

  • Habit Reversal Training (HRT) has been considered a productive adjunct to pharmacotherapy for managing trichotillomania.[54]
  • HRT focuses on increasing awareness of the patients about the behavior that is desired to be controlled. The emphasis is on gaining information about the pattern of the behavior and finding out a way to control it ahead of time. They are also trained to decrease the tension before the hair pulling.
  • Some studies have considered HRT superior to pharmacotherapy in controlling trichotillomania.[55]
  • Other therapy options like Cognitive Behavioral Therapy (CBT) have also been tried but after successful treatment, it has been observed that there are higher chances of relapse with CBT. [56]
  • Group supportive therapy has also been associated with minimal improvement in the condition. Infact, behavior therapy when employed in groups also revealed lesser favorable outcomes than individual therapy. [57]

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. ↑ 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. ↑ 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.
  66. ↑ 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.


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