Trichotillomania



Trichotillomania


Leslie G. Millard


Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports


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The term trichotillomania was first used by Hallopeau in 1889 and is derived from the Greek thrix (hair), tillein (to pull out) and mania (madness). Psychiatric classification (ICD 10: F63.3 F68.1; DSM-IV-TR 312.30) lists trichotillomania under impulse-control disorders. Now the definition must encompass a broader spectrum of additional psychopathologies, such as obsessive–compulsive disorder, and mood disorders. The revised diagnostic criteria for trichotillomania include the following:




Management strategy


The management must recognize the contribution of these psychopathologies and therefore centers on three issues. First, the diagnosis of the hair defect; second, the diagnostic grouping and the presence of other psychiatric comorbidities such as depression; and third, the presence of complications such as trichobezoar, the formation of gastric and intestinal hair balls.


Trichotillomania is seen in both children and adults. The latter may also have additional classifiable psychiatric illnesses, which distorts any attempt to make this a homogeneous entity. There appear to be two distinct populations: firstly, those who present in childhood, mainly between the ages of 5 and 12 years, and secondly chronic cases presenting as adults who have continued hair-pulling activity from adolescence or who developed the disorder in early adult life. The early onset group show benign, self-limiting behavior and most are probably suffering from a habit disorder, perhaps as an extension of distracted tension relieving hair-twirling activity. Children may also display other habits such as nail biting, thumb sucking, skin picking, nose picking, lip biting, and cheek chewing. In children, there is an association with anxiety and dysthymia, learning disability, and iron deficiency.


The adolescent group is more likely to be female (ratios of up to 3.5 : 1). The psychopathology may be related to difficult parent relationships, schooling stress, especially bullying, and distress related to the onset of pubertal body image changes. Hidden physical and sexual abuse within the family contributes increasingly to the psychopathology. The adult age groups are associated with this greater psychopathology and show a distinct female preponderance (up to 15 : 1). This also remains true for different racial groups. There is a significant association of trichotillomania with obsessive–compulsive disorder and depressive illness.


In children the persistence of hair plucking and twisting after some months indicates more than a temporary disturbance. It occurs as a conscious though distracted act or occasionally as part of a hypnagogic (dreamlike) state. Most adult patients describe a deliberate act following an increased sense of tension before hair pulling and a sense of relief immediately afterwards. Hair pulling and plucking is commonest from the scalp, but not as a response to scalp symptoms. Most pull hair from the vertex, but temporal, occipital, and frontal hair loss in children may be more obvious on the side of manual dominance. Loss from eyebrows and lashes indicate a more prolonged course of disease. The hair loss may be minimal, commonly a solitary patch, but visible hair thinning may progress to extensive depilation in adult women. With chronicity there are three visible morphologies. Firstly there is normal long hair. Abruptly nearby are recent short, irregular broken hairs progressing to baldness. Lastly are areas of irregular attempted regrowth. In alopecia areata the hair is much smoother. The clinical differentiation is made easier using a dermatoscope which will readily identify the fractured hair shaft from exclamation mark hairs. This will also identify the characteristic cropped hair ends in compulsive hair shavers and cutters and in trichotemnomania, a form of hair cutting artefact.


The pattern of plucking starts from a single point but then progresses to linear, wave-like activity. Children will pluck the eyebrows and eyelashes, but adults will pluck hair on the torso and pubic areas. Children pluck hair as a distracted activity often in public, whereas in adults the activity is more conscious and secretive. This may behave more like a compulsion, with elaboration of the rituals using instruments such as tweezers. Patients disguise the defects using wigs, false eyelashes, and the semi-permanent wearing of hats and scarves even indoors and during inappropriate weather. Secretive plucking often presents as chronic folliculitis of the chin, chest, pubic areas, or thighs.


The hair root alone may be eaten (trichorhizophagia) as a secretive activity, and in a few patients the whole hair is eaten (trichophagia). Occasionally hair may be seen stuck between the teeth. Patients who eat more hair tend to swallow the longer strands, and a small percentage will develop gastrointestinal hair balls (trichobezoars). These are seen almost exclusively in girls and young women; they have a high morbidity, and complications which can be fatal. Children with trichotillomania who present with episodes of obscure abdominal pain, weight loss, nausea, vomiting, anorexia, and foul breath should be investigated. Gastric trichobezoars may cause intestinal bleeding, pancreatitis, or obstructive symptoms.


The disability of hair loss shows as a retreat from socialization with group peers and significant social isolation. Children with trichotillomania can be managed with supportive psychotherapy, and eventual spontaneous resolution can be expected. Habit retraining may be beneficial in adults. Combining SSRI antidepressants and clomipramine with psychological modalities may benefit older patients. Combining modern atypical neuroleptics such as olanzapine and risperidone with SSRIs has been beneficial.

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Aug 7, 2016 | Posted by in Dermatology | Comments Off on Trichotillomania

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