What Is Trichotillomania? And How Is It Treated?

Bret S. Stetka, MD; Lindsey M. Muller, MS

Disclosures

April 30, 2015

In This Article

Editor's Note: In her new book Life Is Trichy: Memoir of a Mental Health Therapist With a Mental Health Disorder, behavioral therapist Lindsey M. Muller, MS, writes about her own struggles with trichotillomania, a condition in which patients uncontrollably pull out their hair. The disorder is more common than you might think, and Medscape recently interviewed Ms Muller on what exactly trichotillomania is and how to manage it.

Background

Medscape: What is trichotillomania?

Ms Muller: According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), the symptoms of trichotillomania are:

  • Recurrent pulling out of one's hair, resulting in hair loss;

  • Repeated attempts to decrease or stop hair-pulling;

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

  • The hair-pulling or hair loss is not attributable to another medical condition (eg, a dermatologic condition); and

  • The hair-pulling is not better explained by the symptoms of another mental disorder (eg, attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder).

Medscape: Can you briefly review the history of the condition? When was it first described, and how has understanding of it has evolved over the years?

Ms Muller: The name of the disorder was coined by French dermatologist François Hallopeau in 1889 and comes from the Greek words trich (hair), tillein (to pull), and mania (madness). However, the disorder was not formally introduced as a disorder and added to the DSM-III-R until 1987.

Classification of the disorder has been vague and questioned by many researchers and clinicians; it has been conceptualized as an obsessive-compulsive spectrum disorder, anxiety disorder, and an impulse control disorder, and most recently it appears under "Obsessive-Compulsive and Related Disorders" in DSM-5. The understanding of the disorder as sometimes present without reported feelings of anxiety and with inclusion of a sensory processing component has greatly altered how the disorder is presented in various DSM versions. From the DSM-IV-TR to the DSM-5, the following changes were made:

  • Trichotillomania moved from the impulse control disorder category to the obsessive-compulsive and related disorders category;

  • Criterion B, "an increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior" was removed; and

  • Criterion C, "pleasure, gratification, or relief when pulling out the hair" was also removed.

Medscape: Whom does trichotillomania affect, and how widely?

Ms Muller: The lifetime prevalence of trichotillomania is estimated to be between 1% and 4% of the overall population. It is expected that this percentage is probably higher owing to the shame and stigma associated with the disorder. Even with increased research and media exposure to shed light on this disorder, many people are still unaware that there is a name for the behavior of hair-pulling.

With regard to gender distribution, the female-to-male ratio is 3 to 1. Again, this statistic is questionable, given that men may underreport symptoms because they shave to "manage" the behavior.

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