Trichotillomania

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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 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 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 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 it 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 repeated attempts to stop the hair pulling behavior. 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 disorders (such as Body dysmorphic disorder, psychosis, and Obsessive Compulsive Disorder) .

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 most of them have bald spots on the head, among the 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 secondary to another medical condition
    • Other Specified Obsessive-Compulsive and Related Disorder
    • Unspecified Obsessive-Compulsive and Related Disorder


According to DSM-5, to diagnose trichotillomania all of 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. The 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. Behavioral therapy has shown better results than pharmacotherapy in the majority of studies.[51] [52]Contrary to this, some studies suggest the combination of two produces 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 psychotherapy options like Cognitive Behavioral Therapy (CBT) have also been tried but after successful treatment, higher chances of relapse with CBT have been noticed. [56]
  • Group supportive therapy has also been associated with minimal improvement in the condition. In fact, behavior therapy when employed in groups also reveal 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. ↑ 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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