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Is there an effective treatment for hair pulling (trichotillomania)?

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Treatment for this psychiatric disorder— trichotillomania or pathological hair pulling—is still poorly defined. In the American Psychiatric Association’s diagnostic manual, it is classified as an impulse control disorder, and it’s more common than many believe. Patients with this problem can’t resist pulling out their hair and do so to the point where it becomes noticeable. As in other impulse control disorders, the hair pulling is preceded by increasing tension and followed by a sense of relief or even pleasure. Some people with trichotillomania pull out hair most of the time, but for others the symptoms come and go, often emerging under stress. Hair is pulled mostly from the scalp, but also from the eyebrows, eyelashes, and pubic region. In some cases the disorder is mild, but in others the suffering and incapacitation are severe. Apart from the cosmetic effect of hair loss—some people pull all their hair from the area they target—scalp irritation and repetitive stress syndrome can develop. Some people with trichotillomania eat their hair, which can cause dental problems and gastrointestinal symptoms. If hair accumulates in the stomach, it may form a clump called a trichobezoar that causes pain, nausea, vomiting, and occasionally a dangerous obstruction. Trichotillomania often begins in childhood or adolescence, and it affects up to 3.5% of adults; the exact figure is difficult to determine because of embarrassment that leads to secrecy. The disorder seems to be twice as common in women, but it’s possible that men just don’t acknowledge it or never seek help. Trichotillomania can interfere seriously with work, school, and career advancement. Surveys show that, when compared with the general population, people with this disorder are less satisfied with their lives and have lower selfesteem. Out of shame, some sufferers avoid both intimate relationships and going out in public. Many have anxiety or depression that requires treatment, and some turn to cigarettes, alcohol, or illicit drugs for relief.

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The cause is still unknown, but many researchers suspect a link with obsessive-compulsive disorder (OCD). There is evidence that people with trichotillomania have difficulty inhibiting motor activity and shifting tasks (which is called cognitive flexibility). This may indicate that the problem arises in the connections between the frontal lobes, seat of planning and reasoning, and the striatum, which is involved in regulating action. The cerebellum, another region that regulates movements, may also be involved; one study has shown that it is smaller in people with trichotillomania. So far, though, all these findings are preliminary. Getting back to the question of treatment: We still do not know which ones are most effective. The type of cognitive behavioral therapy called habit reversal training is effective in the short run, but symptoms often recur after the treatment ends. No medication has been proved effective in controlled trials, so most psychiatrists start with the medications used for OCD, such as the selective serotonin reuptake inhibitors fluoxetine (Prozac) and sertraline (Zoloft) and the tricyclic antidepressant clomipramine. If the first medication doesn’t help, they may add another antidepressant, an antianxiety drug, a mood stabilizer, or even a stimulant or antipsychotic drug. It may look as though they are simply pulling whatever they can out of their medicine bags to throw at the problem. But the suffering and incapacitation of people with trichotillomania can be so great that getting creative in this way is sometimes necessary. We can hope that advances in understanding the underlying biology will help refine treatments. Meanwhile, recent studies suggest that a combination of psychotherapy and medication may be the best path to relief.

Michael Craig Miller, M.D. Editor in Chief

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APRIL 2007