Trichotillomania
Synonyms and keywords: TTM, hair-pulling, trich, trichophagia, trichobezoar

# Overview
Trichotillomania (TTM) is a condition characterized by the repeated irresistible desire to pull out scalp hair, eyelashes, facial hair, pubic hair, nose hair, eyebrows, and/or other body hair. The hair pulling relieves the anxiety preceding the event but leaves behind scars and injuries. The feeling of losing control and fear of pulling out all of the hair leaves the individual in severe frustration. The person very often pulls out a significant amount of hair amounting to hair loss. It also results in enormous distress and functional impairment in several areas of life. Secondary to this behavior, there is a progressive deterioration of self-esteem and eventually, self-isolation. These individuals unsuccessfully try to stop this behavior due to physical and mental stress experienced after the act, or harsh comments from the family and friends. Therefore, trichotillomania is emotionally traumatizing as well as socially stigmatizing.

# 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. 
- It was first mentioned in a published scientific report about hair pulling behavior in 1885. 
- The term, however, was first used by a French dermatologist, Francois Hallopeau, in 1889.
- Originally, Francois Hallopeau had used this word for alopecia due to the self-traction of hair. It has now evolved to include the syndrome of pathological hair-pulling. 
- A French physician, Baudamant gave details of trichobezoar (mass of undigested hair in the gastrointestinal tract) in a 16 year-old adolescent in the late 18th century.

# Classification
- Among the classification systems, trichotillomania was first mentioned in ICD-9 in the year 1975 under 'the other disorders of impulse control'.
- In 1987, DSM-III-R included trichotillomania as an 'impulse control disorder, not classified elsewhere'.  
- Trichotillomania was accepted as an independent disorder in ICD-10 in 1990. It has been included under 'the habit and impulse control' category. 
- In DSM-IV, two minimal modifications were made in this 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 in Criteria E. 
- DSM-IV-TR also described trichotillomania as 'an impulse control disorder, not classified elsewhere'.
- Therefore, it would be appropriate to point out here that DSM had only minor changes until the classification change in DSM-5.
- DSM-5 moved trichotillomania from 'Impulse Control Disorder' to the category of 'Obsessive-Compulsive and Related Disorders' (OCRD).
- Unlike DSM-IV, DSM-5 Criteria does not require the hair loss in trichotillomania to be noticeable. The individuals with this condition may pull out the hair from a wider region making it difficult to distinguish.
- DSM-5 has included a criterion that the individual should have made multiple attempts to stop the hair pulling behavior. This has replaced the DSM-IV criteria of preceding tension and immense gratification following hair pulling, this explains the transition from impulse control disorder to OCRD.
- It has been further made clear in DSM-5 that the condition should not be secondary to medical (various dermatological conditions) or psychiatric disorders (such as body dysmorphic disorder, psychosis, and obsessive compulsive disorder) .

# Pathophysiology
- The pathophysiology of trichotillomania (TTM) is proposed to be due to the dysregulation of the glutaminergic system..
- 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.
- The imaging studies performed have shown the involvement of various brain regions.
- The patients with trichotillomania have subcortical brain abnormalities on Magnetic Resonance Imaging (MRI Scan). Decreased putamen and amygdala volumes as well as variation in curvature of caudate and nucleus accumbens have been noted. These areas are involved in affect modulation and reward processing, the basis of trichotillomania pathophysiology. 
- MRI findings suggest a reduced volume of both right and left cerebellar cortices. It is further substantiated by the motor involvement in the symptomatology of this disorder. 
- An increase in right frontal cortical thickness has been noticed. However, the extent of thickness does not correspond to the symptom severity.
- The white matter tracts are also affected in this condition. These tracts have a role in habit formation and suppression as well as affect regulation.
- Reduction in fractional anisotropy is seen in anterior cingulate, and temporal cortical region. It does not relate to disease severity. 
- Therefore, this disorder has complex pathophysiology with the involvement of multiple brain areas on neuroimaging.

# Clinical Features
- Repetitive hair pulling occurs from various sites such as the scalp, eyelashes, eyebrows, eyelashes, legs, and arms. Sometimes patients may also pull hair from the axilla, chest, or other regions.
- Hair loss in trichotillomania is characterized by the variable length of the broken hair left after plucking.
- The scalp is the most commonly affected site. However, when stopped from one site the individual can start pulling hair from other places.
- Hair-pulling behavior is preceded by severe anxiety, which is relieved after performing the act. Most patients live with extreme guilt later.
- Often the people with this condition pull hair from multiple sites at the same time and have comorbidities such as depression and anxiety disorders.
- Trichotillomania can begin at any age. As compared to childhood-onset, the persons with later-onset form have a more severe condition and spend a considerable amount of time pulling hair each day. 
- Some people perform rituals with hair such as biting, chewing, or playing with them.
- As a result of this ritualistic behavior, the swallowed hair (trichophagia) may form a hairball (trichobezoar) in the gastrointestinal tract and cause an obstruction. In absence of adequate and prompt attention, it may cause a life-threatening emergency requiring immediate surgery. 
- When the tail from trichobezoar extends from stomach to intestine, the condition is called Rapunzel Syndrome. It may cause a highly fatal intestinal perforation.

# Differential Diagnosis
Trichotillomania should be differentiated from other medical and psychiatric conditions like-
- Other medical conditions-
- Acne keloidalis nuchae
- Alopecia areata
- Androgenic alopecia
- Chronic discoid lupus erythematosus
- Tinea capitis
- Dissecting folliculitis
- Lichen planopilaris
- Pseudopelade folliculitis decalvans
- Telogen effluvium
- Central centrifugal cicatricial alopecia
- Neuro-developmental disorder
- Stereotypic movement disorder
- Other obsessive-compulsive and related disorders
- Body dysmorphic disorder
- Psychotic disorder
- Substance-related disorders
- Normal hair manipulation

# Epidemiology and Demographics

## Prevalence
- The prevalence of trichotillomania is 1,000-2,000 per 100,000 (1%-2%) of the overall population. The number of reported cases has 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.
- Contrary to the popular belief, childhood-onset trichotillomania is common but differs in neurobiology from the adult-onset type. 
- From childhood to adolescence, focused hair pulling increases whereas the automatic hair pulling remains the same.
- As the children grow older, more frequent urges and decreased ability to resist have been noticed. 
- The post-pubertal onset is associated with greater severity of symptoms. 

## Gender
- Most studies support the female predominance but there are some studies show mixed results. 
- With the male and female subjects having the same severity of symptoms, the females experience more distress and functional impairment due to hair pulling. 
- It has been observed that men have a later age of onset of trichotillomania and are significantly affected by the coexisting anxiety.
- In females with trichotillomania, the symptoms exacerbate during menstruation. The condition may start during pregnancy or soon after the child birth. 

## Race
- African American females mostly pull their hair from the scalp region.
- Before hair pulling, anxiety has been the predominant feature observed in African American adults. 
- Caucasians report pulling hair predominantly 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 as compared to their minority counterparts.

# Risk Factors
The risk factors associated with trichotillomania are
- Genetic predisposition
- First-degree relatives with trichotillomania
- Obsessive-compulsive disorder
- Emotional temperament
- Harm avoidance trait
- Novelty seeking trait
- An under-stimulated environment like boredom
- Stress
- Trauma

# Natural History, Complications and Prognosis
- Individuals with trichotillomania can spend normal lives but most have bald spots on the head, among the eyelashes, pubic hair, or eyebrows.
- It is associated with significant psychological effects such as low self-esteem, and feeling of outcast by the peers.
- They develop the fear of interacting with others due to their appearance and dread social rejection.
- 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.
- Many clinicians classify it as a habit behavior, belonging to the same family as nail biting (onychophagia) and compulsive skin picking (dermatillomania).
- Anxiety, depression, and OCD are frequent comorbidities.
- Due to under-reporting, many individuals with trichotillomania feel they are the only persons with this condition and face distress.
- Trichophagia presents with multiple complications like trichobezoars, intestinal obstruction, intestinal perforation, malnutrition, acute pancreatitis, obstructive jaundice, and bleeding ulcerations. 
- Long-term prognosis is poor in children with trichotillomania. They mostly have focused hair pulling and are diagnosed at a later age. 
- Most of these children develop severe depression and anxiety with age.

# Diagnosis

## DSM-5 Diagnostic Criteria
- Obsessive-compulsive and related disorders consist of:
Obsessive-compulsive disorder
Body dysmorphic disorder
Hoarding disorder
Trichotillomania
Excoriation disorder
Substance/Medication-induced obsessive-compulsive and related Disorder
Obsessive-compulsive and related disorder secondary to another medical condition
Other specified obsessive-compulsive and related disorder
Unspecified obsessive-compulsive and related disorder
- Obsessive-compulsive disorder
- Body dysmorphic disorder
- Hoarding disorder
- Trichotillomania
- Excoriation disorder
- Substance/Medication-induced obsessive-compulsive and related Disorder
- Obsessive-compulsive and related disorder secondary to another medical condition
- Other specified obsessive-compulsive and related disorder
- Unspecified obsessive-compulsive and related disorder
According to DSM-5, to diagnose trichotillomania all the following criteria (A to E) should be fulfilled-

## Physical Examination
- Trichotillomania. Adapted from Dermatology Atlas.
- Trichotillomania. Adapted from Dermatology Atlas.
- Trichotillomania. Adapted from Dermatology Atlas.
- Trichotillomania. Adapted from Dermatology Atlas.
- Trichotillomania. Adapted from Dermatology Atlas.
- Trichotillomania. Adapted from Dermatology Atlas.

# Treatment
- Trichotillomania is a chronic condition where hair pulling is self-directed and irresistible.  It is often difficult to treat but can be controlled with repeated attempts.
- Psychotherapy and to some extent pharmacotherapy are useful. Behavioral therapy has shown better results than pharmacotherapy in most studies. 
- Contrary to this, some studies suggest a combination of the two.

## Psychotherapy
- Habit reversal training (HRT) has been considered a useful adjunct to pharmacotherapy for managing trichotillomania.
- HRT focuses on increasing awareness about the behavior. The emphasis is on gaining information about the pattern of the behavior and finding a way to control it ahead of time. They are also trained to decrease the tension before hair-pulling.
- Some studies have considered HRT superior to pharmacotherapy.
- Other psychotherapy options like cognitive behavioral therapy (CBT) have also been tried but have higher chances of relapse after successful treatment. 
- Group supportive therapy has also been associated with minimal improvement in the condition. In fact, behavior therapy when employed in groups show less favorable outcomes than individual therapy. 

## Pharmacotherapy
- Many medications have been tried for trichotillomania but none are superior to the other. 
- Selective serotonin reuptake inhibitors (SSRI) and Tricyclic antidepressants (TCA) are commonly used for this purpose.
- SSRIs commonly used are Fluoxetine, Sertraline, Fluvoxamine, and Paroxetine.
- Clomipramine and desipramine are the TCAs used. Clomipramine has shown superior results than desipramine in the short-term management of the symptoms.
- Evidence also suggests that Clomipramine is superior to SSRIs for this condition.
- Atypical antipsychotics are used for Tic disorder and Tourette Syndrome. Based on the resemblance of trichotillomania with these conditions, Olanzapine has been tried and resulted in improvement without major side effects. Further studies are needed to elaborate on the effects of this medication in trichotillomania.  
- Lithium reduces impulsivity and provides mood-stability in these patients. However, it has shown inconsistent results and higher relapse rates. 
- Due to the involvement of the glutaminergic system, N-acetylcysteine (NAC) has been proposed to treat trichotillomania. 
- NAC is a glutamate modulator. It has the ability to restore glutamate extracellularly and decrease the oxidative stress in nucleus accumbens, resulting in improvement.