Trichotillomania

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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: 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].
  • 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 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. [15]
  • 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. [16]
  • 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.[17]
  • 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. [18]
  • 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

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 have 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 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 of studies support the female predominance but there are some studies showing both genders being equally affected by this condition. [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 birth of the child. [39]

Race

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

Risk Factors

The risk factors associated with trichotillomania are-[43]

Natural History, Complications and Prognosis

  • Individuals with TTM can spend normal lives but they may 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]
  • Many clinicians classify TTM as a habit behavior, belonging to the same family as nail biting (onychophagia) or compulsive skin picking (dermatillomania).
  • Anxiety, depression, as well as frank OCD is more frequently encountered in people with TTM.[47]
  • Due to under-reporting, many individuals with TTM feel they are the only persons with this condition and face immense stress.[35]
  • Trichophagia presents with multiple complications like trichobezoars, intestinal obstruction, intestinal perforation, malnutrition, acute pancreatitis, obstructive jaundice and bleeding ulcerations. [48]
  • Poor long-term prognosis is seen in children with trichotillomania who have increased focused pulling and older age at diagnosis. Children with TTM eventually develop depression and anxiety with age.[49]

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

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.[51] 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.[52] 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.[53]

  • 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.[54]

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; 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.
  42. ↑ 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.
  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. ↑ 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.
  52. ↑ 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.
  53. ↑ Penzel (2003) The Hair-Pulling Problem: A Complete Guide to Trichotillomania; Oxford University Press, p. 3. ISBN 0-19-514942-4
  54. ↑ 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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