The essential feature of Trichotillomania is the recurrent pulling out of
one's own hair that results in noticeable hair loss (Criterion A). Sites
of hair pulling may include any region of the body in which hair may grow
(including axillary, pubic, and perirectal regions), with the most common
sites being the scalp, eyebrows, and eyelashes. Hair pulling may occur in
brief episodes scattered throughout the day or in less frequent but more
sustained periods that can continue for hours. Stressful circumstances
frequently increase hair-pulling behavior, but increased hair pulling also
occurs in states of relaxation and distraction (e.g., when reading a book
or watching television). An increased sense of tension is present
immediately before pulling out the hair (Criterion B). For some, tension
does not necessarily precede the act but is associated with attempts to
resist the urge. There is gratification, pleasure, or a sense of relief
when pulling out the hair (Criterion C). Some individuals experience an
"itchlike" sensation in the scalp that is eased by the act of
pulling hair. The diagnosis is not given if the hair pulling is better
accounted for by another mental disorder (e.g., in response to a delusion
or a hallucination) or is due to a general medial condition (e.g.,
inflammation of the skin or other dermatological conditions) (Criterion D).
The disturbance must cause significant distress or impairment in social,
occupational, or other important areas of functioning (Criterion E).
Associated Features and Disorders
Associated discriptive features and mental disorders.
hair root, twirling it off, pulling the strand between the teeth, or
trichophagia (eating hairs) may occur with Trichotillomania. Hair pulling
does not usually occur in the presence of other people (except immediate
family members), and social situations may be avoided. Individuals
commonly deny their hair-pulling behavior and conceal or camouflage the
resulgint alopecia. Some individuals have urges to pull hairs from other
people and may sometimes try to find opportunities to do so surreptitiously.
They may pull hairs from pets, dolls, and other fibrous materials (e.g.,
sweaters or carpets). Nail biting, scratching, gnawing, and excoriation
may be associated with Trichotillomania. Individuals with Trichotillomania
may also have Mood Disorders, Anxiety Disorders, or Mental Retardation.
Associated laboratory findings. Certain histological findings are
considered characteristic and may aid diagnosis when Trichotillomania is
suspected and the affected individual denies symptoms. Biopsy samples from
involved areas may reveal short and broken hairs. Histological examination
will reveal normal and damaged follicles in the same area, as well as an
increased number of catagen hairs. Some hair follicles may show signs of
trauma (wrinkling of the outer root sheath). Involved follicles may be
empty or may contain a deeply pigmented keratinous material. The absence
of inflammation distinguishes Trichotillomania-induced alopecia from
Associated physical examination findings and general medical
condiitons. Pain is not routinely reported to accompany the hair
pulling; pruritus and tingling in the involved areas may be present. The
patterns of hair loss are highly variable. Areas of complete alopecia are
common, as well as areas of noticeably thinned hair density. When the
scalp is involved, there may be a predilection for the crown or parietal
regions. The surface of the scalp usually shows no evidence of
excoriation. There may be a pattern of nearly complete baldness except for
a narrow perimeter around the outer margins of the scalp, particularly at
the nape of the neck ("tonsure trichotillomania"). Eyebrows and
eyelashes may be completely absent. Thinning of pubic hairs may be
apparent on inspection. There may be areas of absent hair on the limbs or
torso. Trichophagia may result in bezoars (hair balls) that may lead to
anemia, abdominal pain, hematemesis, nausea and vomiting, and bowel
obstruction and even perforation.
Specific Culture, Age, and Gender Features
Among children with Trichotillomania, males and females are equally
represented. Among adults, Trichotillomania appears to be much more common
among females than among males. This may reflect the true gender ratio of
the condition or it may reflect differential treatment seeking based on
cultural or gender-based attitudes regarding appearance (e.g., acceptance
of normative hair loss among males).
No systematic data are available on the prevalence of Trichotillomania.
Although Trichotillomania was previously thought to be an uncommon
condition, it is now believed to occur more frequently. Recent surveys of
college samples suggest that 1%-2% of students have a past or current
history of Trichotillomania.
Transient periods of hair pulling in early childhood may be considered a
benign "habit" with a self-limiting course. However, many
individuals who present with chronic Trhichtillomania in adulthood report
onset in early childhood. The age at onset is usually before young
adulthood, with peaks at around ages 5-8 years and age 13 years. Some
individuals have continuous symptoms for decades. For others, the disorder
may come and go for weeks, months, or years at a time. Sites of hair
pulling may vary over time.
Other causes of alopecia
should be considered in individuals who
deny hair pulling (e.g., alopecia areata, male-pattern baldness, chronic
discoid lupus erythematosus, lichen planopilaris, folliculitis, decalvans,
pseudopelade, and alopecia mucinosa). A separate diagnosis of
Trichotillomania is not given if the behavior is better accounted for by
another mental disorder
(e.g., in response to a delusion or a
hallucination in Schizophrenia). The repetitive hair pulling in
Trichotillomania must be distinguished from a compulsion, as in
. In Obsessive-Compulsive Disorder,
the repetitive behaviors are performed in response to an obsession, or
according to rules that must be applied rigidly. An additional diagnosis
of Stereotypic Movement Disorder
is not made if the repetitive
behavior is limited to hair pulling. The self-induced alopecia in
Trichotillomania must be distinguished from Factitious Disorder With
Predominantly Physical Signs and Symptoms
, in which the motivation for
the behavior is assuming the sick role.
Many individuals twist and play with hair, especially during states of
heightened anxiety, but this behavior does not usually qualify for a
diagnosis of Trichotillomania. Some individuals may present with features
of Trichotillomania, but the resulting hair damage may be so slight as to
be virtually undetectable. In such situations, the diagnosis should only
be considered if the individual experiences significant distress. In
children, self-limiting periods of hair pulling are common and may be
considered a temporary "habit." Therefore, among children, the
diagnosis should be reserved for situations in which the behavior has
persisted for several months.
Diagnostic criteria for Trichotillomania
- A. Recurrent pulling out of one's hair resulting in noticeable hair
- B. An increasing sense of tension immediately before pulling out the
hair or when attempting to resist the behavior.
- C. Pleasure, gratification, or relief when pulling out the hair.
- D. The disturbance is not better accounted for by another mental
disorder and is not due to a general medical condition (e.g., a
- E. The disturbance causes clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
Taken from Diagnostic and Statistical Manual of Mental Disorders,
, American Psychiatric Association, 1994.