Trichotillomania

Basics

  • Trichotillomania (TTM) is a hair-pulling disorder characterized by self-induced, repeated, and often noticeable hair loss. It can become severe and difficult to control.
  • TTM is currently conceptualized as a compulsive behavior related to obsessive-compulsive disorder (OCD). Tension or boredom typically plays a significant role, and the individual may be conscious or unconscious that they are pulling hair.

Description

  • TTM causes uncontrollable hair pulling from anywhere on the body, although the scalp is the most common area followed by the eyelashes, eyebrows, pubic/perirectal area, axilla, and face. It usually results in variable degrees of alopecia.
  • TTM usually presents in childhood or early adolescence.
  • Denial and hiding of hair pulling is common.
  • Recurrence or worsened hair pulling is associated with increased stress/anxiety, but TTM can also occur at times of relaxation and distraction, such as when reading.
  • The three subtypes of TTM: early onset, automatic, and focused
  • When TTM is associated with trichophagia, it may also result in GI complaints secondary to bezoars.
  • TTM has frequent comorbidity with other psychiatric diagnoses.

Epidemiology

  • It is difficult to assess the exact number of individuals affected by TTM because of the social stigma associated with it. Small studies have estimated a range of 1–3.5% for late adolescents and young adults.
  • It is possible that up to 1 of 50 individuals are affected by TTM at least once in their lifetime.
  • The mean age of onset is 8 years in boys and 12 years in girls.
  • During childhood, males and females are equally affected by TTM. During adulthood, females are far more affected than males.

Etiology and Pathophysiology

  • Serotonin deficiency
  • Tension relief
  • Habitual behavior
  • There is currently a significant flux in the conceptualizations of the mechanisms and causes of impulse control, behavior, anxiety, and OCDs. Brain imaging and biochemical and neuropsychological studies should help to resolve this issue. It can be expected that there will be increased differentiation as well as redefinitions of disorders that are based on neurophysiology and brain circuitry.
  • Adults with TTM display sensory over responsivity and maladaptive emotional regulation, a pattern also seen in OCD (1)[C].

Genetics
Genetics appears to contribute to the development of TTM as demonstrated by a higher rate of concordance in monozygotic twins (38.1%) versus dizygotic twins (0%). Genetic involvement is multifaceted and not clearly understood at this time.

Risk Factors

  • Positive family history
  • Other psychiatric disorders: depression, OCD, anxiety, posttraumatic stress disorder (PTSD), eating disorders, nail biting, skin picking

Commonly Associated Conditions

  • Depression
  • Anxiety
  • OCD
  • Eating disorders

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