Trichotillomania

Definition & Epidemiology - Hair Havoc

• Definition: Recurrent pulling out of one's own hair, leading to hair loss.
• Accompanied by repeated attempts to ↓ or stop hair pulling.
• Causes clinically significant distress or impairment.
• Not attributable to another medical condition (e.g., dermatological).
• Not better explained by another mental disorder (e.g., body dysmorphic disorder).

• Prevalence: 12-month prevalence in adults & adolescents is 1-2%.
• Age of Onset: Commonly coincides with or follows puberty.
• Gender: Females are more frequently affected than males (approx. 10:1 ratio).

⭐ Exam Favourite: Trichotillomania is classified under Obsessive-Compulsive and Related Disorders in DSM-5, not as an impulse control disorder as in ICD-10 (F63.3).

Clinical Features - Telltale Tufts

• Hair Loss Pattern:
  • Irregular, patchy alopecia; hairs of varying lengths (key diagnostic feature).
  • Broken hairs (blunt/tapered ends); "telltale tufts" of short, stubbly hair.
  • 📌 "Friar Tuck" sign: characteristic peripheral scalp sparing.
• Common Sites: Scalp (vertex/crown), eyebrows, eyelashes. Less frequent: axillary, pubic, beard.
• Associated Behaviors:
  • Rituals: inspecting root, twirling, mouthing; trichophagia (~20%), risk of trichobezoar.
  • Pulling: focused (tension relief) or automatic (unaware, e.g., reading).
• Skin Findings: Typically non-scarring. Erythema, excoriations, black dots (broken hairs).

⭐ Hairs of varying lengths in alopecia patches distinguish TTM from alopecia areata (smooth patches, exclamation mark hairs).

Diagnosis & DDx - Spotting Signs

DSM-5 Based Diagnosis (📌 H.A.I.R.S.):

• Hair pulling: Recurrent, resulting in hair loss.
• Attempts: Repeated efforts to decrease/stop pulling.
• Impairment: Clinically significant distress or functional impairment.
• Ruled out: Not due to other medical conditions (e.g., dermatological).
• Separate: Not better explained by another mental disorder (e.g., BDD, OCD).

Key Differentiators (DDx):

• Alopecia Areata: Autoimmune; smooth patches; "!" hairs.
• Tinea Capitis: Fungal; scaling, black dots, broken hairs; +KOH.
• OCD: Pulling ritualistic, secondary to unrelated obsession/symmetry; not for tension relief.
• BDD: Hair removal to "fix" perceived appearance defect.

⭐ Trichobezoars (hairballs) from ingesting pulled hair can cause serious GI complications like obstruction.

Treatment Approaches - Taming Urges

• Primary Goal: Reduce hair pulling, manage urges, improve psychosocial functioning.
• First-line Therapy: Behavioral Interventions
  • Habit Reversal Training (HRT): Core component; involves awareness training & competing response.
  • Cognitive Behavioral Therapy (CBT): Addresses dysfunctional thoughts & beliefs.
  • Acceptance and Commitment Therapy (ACT).
• Pharmacotherapy: Adjunctive or for severe/refractory cases.
  • SSRIs (e.g., Fluoxetine, Sertraline): Often initial choice, variable efficacy.
  • Clomipramine (TCA): Strongest evidence; dose 25-250 mg/day. Monitor side effects.
  • N-acetylcysteine (NAC): Glutamate modulator; dose 1200-2400 mg/day.
  • Atypical Antipsychotics (e.g., Olanzapine, Risperidone): Low dose for refractory cases.

⭐ Clomipramine has demonstrated the most robust efficacy among pharmacological agents for trichotillomania in clinical trials, though often reserved due to its side effect profile compared to SSRIs or NAC.

Comorbidities & Complications - Tangled Troubles

• Psychiatric:
  • MDD (Major Depressive Disorder)
  • Anxiety disorders (esp. GAD, Social Anxiety)
  • OCD
  • Excoriation (skin-picking) disorder
  • Substance use disorders
• Physical:
  • Trichobezoars (hairballs) → GI obstruction, malnutrition
  • Skin irritation, infection
  • Dental damage (from biting hair)
  • Carpal tunnel syndrome (repetitive motion)

⭐ Trichobezoars are a serious, potentially life-threatening complication requiring surgical intervention in some cases of trichotillomania with trichophagia (hair eating).

High‑Yield Points - ⚡ Biggest Takeaways

• Recurrent hair pulling causes significant hair loss, despite repeated unsuccessful attempts to stop.
• Preceded by increasing tension, followed by relief, pleasure, or gratification.
• Common sites: scalp, eyebrows, eyelashes; rarely involves trichophagia (hair eating).
• High comorbidity with anxiety disorders, MDD, and excoriation (skin-picking) disorder.
• Treatment options include SSRIs (fluoxetine, clomipramine) and N-acetylcysteine.
• Cognitive Behavioral Therapy (CBT), especially Habit Reversal Training (HRT), is the mainstay.
• Typical onset is childhood or early adolescence; can be chronic if untreated.