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


* Repetitive hair pulling
* 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>
* [[Hair loss]] is characterized by variable lengths of hair.
* [[Hair loss]] in trichotillomania is characterized by variable length of the hair left behind after plucking.
* Some individuals perform rituals with hairs after they are pulled out like biting, 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>
*[[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>
* When the hair is swallowed 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>
*Often the individuals with this condition pull hair from multiple sites and are associated with many [[comorbidities]].<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>
*<br />
* 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>
* 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 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>


==Differential Diagnosis==
==Differential Diagnosis==

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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: Kiran Singh, M.D. [2]

Synonyms and keywords: Hair-pulling; trich; trichologia; trichomania; trichotillosis;TTM

Overview

Trichotillomania is an 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 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 Axis I disorder. The name derives from Greek tricho- (hair), + mania.

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. [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 term for alopecia due to 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 gastrointestinal tract) in a 16 year-old adolescent in the late 18th centuary.[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 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. [8][9]
  • In DSM-IV-TR also trichotillomania has been described as 'an impulse control disorder, not classified else where'.[10]
  • Therefore, it would be appropriate to point here that DSM had minor changes in the description of trichotillomania till 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 noticable. 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 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. [12] This explains the transition from impulse control disorder to OCRD of 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 etc) disorders.

Pathophysiology

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

Clinical Features

Differential Diagnosis

  • Another medical condition
  • Neuro-developmental disorders

Epidemiology and Demographics

Prevalence

The prevalence of trichotillomania is 1,000-2,000 per 100,000 (1%-2%) of the overall population.[25] The number of reported trichotillomania cases has increased throughout the years, possibly due to a reduced stigma around the condition.

Gender

Sixty-five percent of those afflicted are female.[26]

Risk Factors

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. 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.[29]

Many clinicians 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.[30] People with TTM are no more likely to have significant personality disorders than anyone else.[citation needed] One study showed that individuals with TTM have decreased cerebellar volume.[31] 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.[32] Anxiety, depression, as well as frank OCDs are more frequently encountered in people with TTM.[33] 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.[34][35][36] Some individuals with TTM may feel they are the only person with this problem due to low rates of reportage.[26]

Diagnosis

DSM-V Diagnostic Criteria for Trichotillomania[25]

“
  • A. Recurrent pulling out of one’s hair, resulting in hair loss.

AND

  • B. Repeated attempts to decrease or stop hair pulling.

AND

  • C. The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

AND

  • D. The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition).

AND

  • 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).
 ”

Physical Examination

Skin

Scalp

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

Habit Reversal Training or HRT, has been shown to be a successful adjunct to pharmacotherapy as a way to treat TTM.[38] 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.[citation needed] 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.

Medical Therapy

Selective serotonin reuptake inhibitors 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.[39] Clinical trials for other drugs such as fluoxetine, and 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.[citation needed] According to F. Penzel, antidepressants can even increase the severity of the TTM.[30]

  • 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.[40]

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. ↑ 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.
  15. ↑ 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.
  16. ↑ 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.
  17. ↑ 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.
  18. ↑ 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.
  19. ↑ 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.
  20. ↑ "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.
  21. ↑ 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.
  22. ↑ 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.
  23. ↑ 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.
  24. ↑ 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.
  25. ↑ 25.0 25.1 25.2 25.3 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
  26. ↑ 26.0 26.1 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.
  27. ↑ EntrezGene (12-Aug-2006). "Gene" (UTF-8). National Center for Biotechnology Information. Check date values in: |date= (help)
  28. ↑ "Hair pulling disorder gene found". Retrieved 2007-05-01.
  29. ↑ 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.
  30. ↑ 30.0 30.1 Penzel (2003) The Hair-Pulling Problem: A Complete Guide to Trichotillomania; Oxford University Press, p. 3. ISBN 0-19-514942-4
  31. ↑ Keuthen NJ, Makris N, Schlerf JE; et al. (2007). "Evidence for reduced cerebellar volumes in trichotillomania". Biol. Psychiatry. 61 (3): 374–81. doi:10.1016/j.biopsych.2006.06.013. PMID 16945351.
  32. ↑ 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.
  33. ↑ 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)
  34. ↑ Ventura DE, Herbella FA, Schettini ST, Delmonte C (2005). "Rapunzel syndrome with a fatal outcome in a neglected child". J. Pediatr. Surg. 40 (10): 1665–7. doi:10.1016/j.jpedsurg.2005.06.038. PMID 16227005.
  35. ↑ Pul N, Pul M (1996). "The Rapunzel syndrome (trichobezoar) causing gastric perforation in a child: a case report". Eur. J. Pediatr. 155 (1): 18–9. PMID 8750804.
  36. ↑ "Hairball kills teenager". hairgrowthnews.com. Retrieved 2007-08-11.
  37. ↑ 37.0 37.1 37.2 37.3 37.4 37.5 "Dermatology Atlas".
  38. ↑ 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.
  39. ↑ 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.
  40. ↑ 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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