Mayo Foundation for Medical Education and Research. (2023, November 22). Trichotillomania (hair-pulling disorder). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/trichotillomania/diagnosis-treatment/drc-20355193 

Reference for Treatment for Trichotillomania

A study decided to test how a stepped-care model would fare when treating trichotillomania. The first step of the program involved 10 weeks of web-based self-help. The second step was voluntary enrollment in an 8-week in-person habit reversal training. It was found that having multiple steps did not decrease motivation to complete the program. About 76% of those who completed the first step chose to engage in the second stage of the program. Those who finished all the steps of the program showed significant improvement in their condition. So, this shows that habit reversal training is an effective intervention for trichotillomania and also that a stepped-care model program is an acceptable approach.

Stepped Care and Habit Reversal Training for Trichotillomania

Reference for Stepped Care and Habit Reversal Training for Trichotillomania

• Habit Reversal Therapy/Training: Recognize situations where you may have the urge to pull out your hair and replace this behavior with a healthier behavior

•Acceptance and Commitment Therapy: Learn to accept hair-pulling tendencies without acting on them

•Cognitive Therapy

• Medications to control mental health conditions that often occur with this disorder such as anxiety or depression

Boston College

Trichotillomania is an obsessive-compulsive disorder, in which an individual will repeatedly pull out their own hair. 

Trichotillomania (Hair-Pulling Disorder)

1. Recurrent pulling out of one’s hair, resulting in hair loss.
2. Repeated attempts to decrease or stop hair pulling.
3. The hair pulling causes clinically significant stress or impairment in social, occupational, or other important areas of functioning.
4. The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition).
5. The hair pulling is not better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder). 

[DSM-5-TR] Diagnostic Criteria of Trichotillomania (Hair-Pulling Disorder)

Associated features of trichotillomania may include:
- Hair pulling may be preceded or accompanied by various emotional states; it may be triggered by feelings of anxiety or boredom
- Hair pulling behavior may involve varying degrees of conscious awareness, with some individuals displaying more focused attention on the hair pulling, and other individuals displaying more automatic behavior
- Areas of complete alopecia (i.e., baldness), as well as areas of thinned hair density are common in individuals with trichotillomania
- Patterns of complete baldness except for a narrow perimeter around the outer margins of the scalp, particularly in the nape of the neck (“tonsure trichotillomania”) can occur
- Hair pulling does not usually occur in the presence of other individuals, except immediate family members
- Majority of individuals with trichotillomania also have done one or more other body-focused repetitive behaviors, including skin picking, nail biting, and lip chewing 

Associated Features of Trichotillomania (Hair-Pulling Disorder)

In the general population, data from nonrepresentative U.S. samples have suggested that the 12-month prevalence estimate for trichotillomania in adults and adolescents may be in the range of 1% to 2%. Women are also more frequently affected than men, at a ration estimated at 10:1 or greater. 

Prevalence of Trichotillomania (Hair-Pulling Disorder)

Hair pulling may be seen in infants, and this behavior typically resolves during early development. Onset of hair pulling in trichotillomania most commonly coincides with, or follows the onset of, puberty. The usual course of trichotillomania is chronic, with some waxing and waning if the disorder is untreated. For some individuals, the disorder may come and go for weeks, months, or years at a time. 

Development and Course of Trichotillomania (Hair-Pulling Disorder)

Risk and prognostic factors that affect the diagnosis of trichotillomania (hair-pulling) include:
- Genetic and Physiological

Risk and Prognostic Factors of Trichotillomania (Hair-Pulling Disorder)

For Trichotillomania (Hair-Pulling), there are certain contextual diagnostic issues that should be taken into consideration when making a diagnosis. These diagnostic issues are related to:
- Culture-Related

Related Diagnostic Issues with Trichotillomania (Hair-Pulling)

Most individuals with trichotillomania admit to hair pulling; thus, dermatopathological diagnosis is rarely required. Skin biopsy and dermoscopy (or trichoscopy) of trichotillomania are able to differentiate the disorder from other causes of alopecia. In trichotillomania, dermoscopy shows a range of characteristic features, including decreased hair density, short vellus hair, and broken hairs with different shaft lengths. 

Diagnostic Markers of Trichotillomania (Hair-Pulling Disorder)

Functional consequences of trichotillomania may include:
- Distress and social and occupational impairment
- Irreversible damage to hair growth and hair quality
- Infrequent medical consequences of trichotillomania including digit purpura (i.e., redness of fingers caused by twining the hair around fingers before pulling hair), musculoskeletal injury (e.g., carpal tunnel syndrome; back, shoulder, and neck pain), blepharitis (i.e., inflammation of eyelids), and dental damage (e.g., worn or broken teeth resulting from hair biting)
- Swallowing of hair (trichophagia) may lead to trichobezoars (i.e., hairball), with subsequent anemia, abdominal pain, nausea and vomiting, bowel obstruction, and even bowel perforation

Functional Consequences of Trichotillomania (Hair-Pulling Disorder)

Differential diagnoses to Trichotillomania (Hair-Pulling Disorder) include:
- Normative Hair Removal/Manipulation
- Other Obsessive-Compulsive and Related Disorders
- Stereotypic Movement Disorder
- Psychotic Disorders
- Another Medical Condition
- Substance-Related Disorders 

Differential Diagnoses of Trichotillomania (Hair-Pulling Disorder)

Trichotillomania is often accompanied by other mental disorders, most commonly major depressive disorder and excoriation (skin-picking) disorder. Repetitive body-focused symptoms other than hair pulling or skin picking (e.g., nail biting) occur in the majority of individuals with trichotillomania and may deserve an additional diagnosis of other specified obsessive-compulsive and related disorder (i.e., other body-focused repetitive behavior disorder).

Comorbidity in Trichotillomania (Hair-Pulling Disorder)

This includes the intersection of connections and/or research related to Trichotillomania (Hair-Pulling Disorder) in other fields of study and research. Such fields include:
- TBD

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