Continuing Education Activity

Trichotillomania (TTM) also known as hair-pulling disorder, was first described in ancient Greece, but its current name was coined in the later part of the 18th century. In these cases the hair is pulled from anywhere on the body repeatedly, appearing as hair loss but is caused by the action of the patient. As this condition can greatly affect the appearance of the patient, it is associated with societal stigma. This activity describes the etiology, presentation, and management of trichotillomania and highlights the role of the interprofessional team in the care of patients with this condition.

Objectives:

• Describe the etiology of trichotillomania.
• Review the presentation of a patient with trichotillomania.
• Summarize the treatment options for trichotillomania.
• Explain the importance of improving care coordination among interprofessional team members to improve outcomes for patients affected by trichotillomania.

Introduction

Obsessive-compulsive disorders encompass a large portion of diverse disorders and presentations that revolve around the central theme of repeated thoughts and repeated activities. In its most general description, obsessive-compulsive disorder (OCD) is just as the name states, an obsession known as repeated thoughts, or compulsions known as repeated activities. Under this particular spectrum of disorders, there is trichotillomania (TTM) also known as hair-pulling disorder. It was first described in ancient Greece, but its current name was coined in the later part of the 18th century.[1] In these cases the hair is pulled from anywhere on the body repeatedly, appearing as hair loss but is caused by the action of the patient. As this condition can greatly affect the appearance of the patient, it is associated with societal stigma. This stigma creates an environment of underreporting, attempts to conceal the disorder, and often a patient will seek treatment with a dermatologist before or completely in place of a psychiatrist.

Etiology

Trichotillomania is part of OCD and is thought to be largely related to anxiety disorders. There have been twin studies that have demonstrated genetic anomalies associated with trichotillomania and other OCD-related disorders.[2] Some imaging studies have shown thickening of the right inferior frontal gyrus, and others have shown reduced cerebellar volumes.[3][4] The structural abnormalities had been observed in prior research, but most had low participant numbers, and generally, there has been little robust research in this regard.

The more recent focus has been on the grey and white matter tracts. One study found the reduced integrity of the white matter within the anterior cingulate, pre-supplementary motor area, and the right and left temporal cortex in people with a diagnosis of TTM.[5] Studies have shown a significantly increased diffusivity in the tracts of the frontostriatal-thalamic pathway with more severe and longer cases of TTM.[6] Studies like these demonstrate that structural abnormalities may be present in those with TTM. Positron emission tomography (PET), and single-photon emission computed tomography (SPECT) studies have shown higher cerebral glucose metabolic rates in the cerebellum and right parietal cortex.[3] SPECT studies have shown decreased perfusion of the temporal lobes.[3]

Studies focusing on neurochemistry have shown a relationship with the serotonin 2A receptor.[7] Most studies that focus on neurotransmitters or neurochemistry are based on the patient's response to therapy that modulates these neurotransmitters. For example, multiple randomized controlled studies look at treatment with selective serotonin reuptake inhibitors (SSRIs). Some have yielded positive results, and some have been equivocal.[7][8][9][10] One meta-analysis that looked at SSRIs showed moderate effects on patient symptoms, compared to more sizeable effects of behavior therapy.[11] Other studies suggest that the dopamine system is also involved. There have been double-blind, placebo-controlled trials that have shown positive effects with olanzapine, and the reversal of TTM has been shown with aripiprazole treatment.[12][13][14] There have been studies that have shown clomipramine also can be effective.[15] Generally, these studies suggest the involvement of the monoamine system with serotonin, norepinephrine, and dopamine receptors. Data in these studies are often not robust and need to be replicated.

Other factors in the etiology are neuropsychology and the cognitive components. Many patients with trichotillomania report that there was a stressful situation that occurred before the hair-pulling behavior. Others describe boredom before hair-pulling.[16] These feelings of boredom or stress are negative effects, or internal feelings or emotions, which have been shown in research to correlate to the increased behavior of pulling hair. If we examine the action in behavioral terms, there is a sense of tension that precedes hair-pulling behavior.[16][17] This tension is then relieved by the hair pulling itself. This creates a cycle of learned and reinforced behavioral activity. The negative effect, or emotion, is paired with the behavior which relieves the negative effect and thus is reinforced and repeated.[7][8][18] For example, the patient feels stressed, pulls hair, stress goes away, and thus the alleviation of the stress reinforces the behavior of hair-pulling. Some patients report an association of depressive symptoms likely resulting in some response of TTM to SSRI treatment. Since the psychiatric and psychological symptomatology is diverse, no single predictor can be named at this time. Currently, it is accepted that behavioral therapy is the mainstay of treatment and that the neuropsychology of TTM is the greater of the etiological components.

Epidemiology

Beginning in adolescence, the lifetime prevalence of TTM is reported as high as 3.5%.[19] The adolescent patients do not all meet the criteria for trichotillomania as described by the DSM-V criteria but they do experience some form of the symptoms. The disorder is reported more commonly in females, with the ratio shown to be about 9:1 toward females.[7][20][21] It is thought that the stigma of the disorder creates underreporting in general.

Pathophysiology

The disease is a clinical diagnosis but can be confirmed by punch biopsy of the scalp.[8] Typically the hands are used to pull the hair, but tweezers or other devices can be used. The hair from the head is the most common to be pulled but can be from anywhere. Some individuals exhibit the Friar Tuck sign with hair loss in a distinct area at the crown and maintenance of hair in temporal and occipital regions.[8] There can be a ritualistic manner of choosing the hair and the act of pulling, for example searching for the coarse hair at the beginning of the hairline after combing hands through the hair. After the hair is pulled, some individuals will inspect it and eat all or portions of the hair. If eating the hair is involved, then the patient is at risk for a trichobezoar. If the patient suffers pain, nausea, vomiting, or constipation, trichobezoar should be sought because it can potentially get large enough to cause bowel obstruction or perforation.[22] Important to note is that the hair-pulling may be considered automatic, done when the patient is not aware or focused, or completed when the patient is solely focused on the pulling behavior.[16]

Histopathology

Punch biopsy will show evidence of traumatic removal of the hair; this step can help with diagnosis but is not required. The slide will show a non-inflammatory non-scarring alopecia where there is follicular damage secondary to external insult. The anatomy of the hair follicle gets distorted. There can be loss of hair shafts and noticeable trichomalacia of the hair.[23] The number of hair follicles is normal.[23] Important to note is that with chronic traumatic insult, this non-scarring condition eventually results in scarring leading to permanent hair loss.

History and Physical

Generally, as with any patient seeking psychiatric care, start with a semistructured diagnostic interview. There is, unfortunately, no structured interview technique that has been validated for DSM-V. There are some that have been validated for TTM based on DSM-IV-TR criteria. These older structured interviews incorporate the National Institute of Mental Health Trichotillomania Severity Scale and the National Institute of Mental Health Trichotillomania Impairment Scale. Some more recent studies have attempted to use adapted scales that have shown positive interrater reliability in assessing for TTM.[7] When gathering a history, the patient must meet the criteria as stated in the Diagnostic and Statistical Manual-V. 

The current DSM-V manual lists 5 criteria necessary for a diagnosis of TTM. The criteria are as follows:

• Criteria A: The patient must be removing hair from a body region. The hairs can be from a concentrated region or a diffuse area. There may be associated bald spots or thinning of the hair.
• Criteria B: The patient must have tried to stop or decrease hair removal.
• Criteria C: The removal must cause significant distress or impairment in at least one area of functioning.
• Criteria D: The hair pulling or loss cannot be caused by another medical condition (e.g., alopecia areata, tinea capitis).
• Criteria E: The hair pulling is not better explained by some other mental disorder and its symptoms.

Other symptoms that are also screened for in a structured interview would include those in other psychiatric disorders.

When patients visit a practitioner that is not a psychiatrist, as usual, a history and physical exam should be completed. There should be a high level of suspicion when discussing hair loss. Patients may deny that they are pulling the hair out. They may complain of other psychiatric disorders and their associated symptoms. They may have somatic gastrointestinal complaints, possibly due to trichobezoar. The patient’s history of hair loss can be varied, and there may be vague answers if they are trying to minimize this stigmatizing behavior.

The physical exam should assess the skin specifically looking at the areas of hair loss which can be obvious in some cases and barely visible in others. The hair can be missing from any area of the body that hair grows. The areas of hair loss will be noted to have hair of differing lengths and various stages of regrowth. There is often an identifiable geometric area of hair loss. Rash or other skin changes should be noted to the site as these can be associated with another diagnosis in the differential. To determine the potential for regrowth, clinicians will need to check for scarring of the skin at the follicles. If no scarring is present, then regrowth can occur.[8] There should also be a thorough abdominal examination for masses, pain, or fecal impaction because all are indicative of possible trichobezoar.

Evaluation

The history and physical are enough for a diagnosis of TTM. A punch biopsy of the scalp can help diagnose but is not necessary. The hairs themselves can be visualized microscopically and will show signs of regrowth. The extent of balding measures the severity of the disorder. Taking pictures to document changes may be useful in evaluating the effectiveness of treatment.[8] The behavioral components of hair-pulling should be evaluated as well. This would include a thorough evaluation of the triggers or antecedents in behavioral terminology and consequences. Antecedents can be cues from the environment like particular situations and also cues from internal factors like emotions.[16][17][18][24] Consequences can be feelings of guilt, poor self-image, or pleasure from the action or the alleviation of negative emotion. Again this is not required for diagnosis but can assist in guiding treatment. Clinician and patient rating scales can be used but are not mandatory for diagnosis.[7] These include:

• NIMH Trichotillomania Scale
• Yale-Brown Obsessive-Compulsive Scale-Trichotillomania
• The Psychiatric Institute Trichotillomania Scale
• Massachusetts General Hospital Hairpulling Scale
• Trichotillomania Scale for Children
• The Milwaukee Inventory for Styles of Trichotillomania- Adult and Child Versions

Treatment / Management

Trichotillomania is a multifaceted disorder that often involves various specialties and cross-specialties as well as multiple treatment modalities. The patient may be seen by a primary care clinician, a dermatologist, a psychiatrist, and a licensed clinical psychologist. The treatment will likely include therapy techniques, and there may be the use of medications. The currently studied therapy techniques for the treatment of trichotillomania include cognitive behavioral therapy (CBT) and habit reversal training.

Habit reversal training is grounded in CBT techniques and it aims to identify cognitive distortions and thought-action pairings and change them. For example, a patient notes that they have stressful group activities at work and after this, they notice that pulling hair out alleviates this stress. The cognitive distortion/thought of all social interaction creating stress is paired with the hair-pulling as a way to alleviate the stress, and so this behavior is negatively reinforced by the alleviation of the stress, and the connection is strengthened. Habit reversal therapy is a low-risk treatment for TTM that has been shown to be effective.[18][24]

Habit reversal therapy has three components: awareness, competing for the response, and social support.[7] The patient is trained to be aware of hair-pulling and of the situations or emotions that cause the hair pulling. They are trained to notice when they are in the act and when they are about to perform the behavior. They are praised for correct awareness and reminded if incorrect. Once this is solidified, then they are taught a competing response which is some action that takes place instead of hair removal. They are to complete this task when they are pulling the hair or if they have the urge to pull. The social support from those around the individual that praise the appropriate use of habit reversal training or remind the patient to use the training when they are not doing so is core to habit reversal training.[7]

Current research suggests modest positive effects with selective serotonin reuptake inhibitors. The effects are more robust in combination with therapy. There have been meta-analysis reviews of more recent research that have shown a moderate positive effect of SSRI medications, but a more pronounced effect was seen with therapy.[11] There are more recent preliminary data that have shown some positive effects with olanzapine, aripiprazole, and quetiapine.[12][13][14][25] The studies with antipsychotics are few and require future studies to replicate results. Past studies using clomipramine and others in the tricyclic antidepressant medication class have been studied to treat TTM and efficacy has been found with more research supporting clomipramine.[15] Other novel treatment case studies using N-acetylcysteine have shown positive results, but there have been no robust studies.[26]

Differential Diagnosis

Other forms of hair loss must be placed on the differential diagnosis. Examples include traction alopecia, male pattern baldness, pressure alopecia, alopecia areata, tinea capitis, short-term habit, obsessive-compulsive disorder, and systemic diseases like cancer, lupus, hypothyroidism, and factitious disorder.[7][8]

Prognosis

The prognosis is better when the disorder is diagnosed early, and treatment begins early. It is also associated with a better prognosis the younger the age of occurrence.

Complications

Long-term complications of the disease include permanent hair loss, and this is seen primarily in people who have been pulling the hair out into adulthood.[8] Individuals that eat all or portions of the hair are at risk for a trichobezoar.

Consultations

Psychiatry may be consulted. A dermatology consult may also be sought. Consultation with a licensed therapist is also part of treatment.

Deterrence and Patient Education

Patients should be encouraged to avoid stressful situations and triggers for their hair-pulling behavior. Certain activities are more likely to be associated with hair-pulling in TTM and include driving, reading or doing paperwork, watching television, and talking on the phone. Patients should be advised to limit these activities when possible and to increase their amount of physical activity.

Pearls and Other Issues

There is a significant stigma surrounding self-inflicted pathological hair loss thus patients may be hesitant to discuss it. Remember to keep a high degree of suspicion.

Often, an interprofessional approach to treatment and management will include, dermatology, psychiatry, and psychology.

Enhancing Healthcare Team Outcomes

Trichotillomania often presents to the primary care provider or mental health nurse. However, this is not a trivial disorder and should be managed by an interprofessional team that includes a psychiatrist, behavior therapist, psychologist, and a dermatologist. The treatment includes therapy techniques combined with anxiety-relieving medications. The currently studied therapy techniques for the treatment of trichotillomania include cognitive behavioral therapy and habit reversal training.

Unfortunately, the disorder has no cure and all treatments have limitations. The disorder has relapses and remissions. In the long run, the patient has permanent loss of hair, scarring, and poor cosmesis. [Level 5][27]