Case, Part 1
J. is a 24-yo female who works in an office. You are seeing her for complaints of allergies, when you notice that she has bare patches of hair in her scalp. She tells you that she has a history of pulling hair from her scalp and eyebrows which started in high school. She is embarrassed about it, to the point it often stops her from going out in public.
What are you going to do about it?
Introduction
The word trichotillomania is derived from the Greek tricho (hair), tillein (to pull) and mania (madness).
Individuals have irresistible urges to pull their hair, and as they pull their hair, it can cause significant impairment.
Worse, patients are often reluctant to seek help due to feeling embarrassed and ashamed.
The behaviour is often when the person is in relaxed situations, e.g. on the telephone, watching television, reading or writing.
History
-
History of hair pulling

- Some people have a habit of pulling out their hair, especially when stressed or bored.
- How about you?
-
Self-esteem
- 
Any troubles with low self-esteem?
-
Mood issues
- Any troubles with your mood?
-
ADHD
- Any troubles with focus or concentration?
-
Functional impairment with work, home and relationships
- Any troubles with your work? Home? Relationships?
DSM-5 Diagnosis
Under the DSM-IV, trichotillomania was previously considered an impulse control disorder
Under DSM-5, trichotillomania is considered to be an obsessive–compulsive and related disorder (OCRD).
DDx
-
Traumatic alopecia secondary to physical or chemical factors such as 

- Traction, Chemical, or 

- Physical hair relaxers, or 

-
Other itchy conditions of the scalp. 

- Alopecia areata, tinea capitis, and secondary syphilis.

Comorbidity
- Major depression 

- Anxiety disorders

- Substance use disorders 

Medical Hx
Some patients swallow hair after their hair pulling, aka trichophagia. As a result, there have been case reports of individuals with hairballs (aka trichobezoars).
This may lead to anemia, intestinal obstruction, intussusception, ulceration, and perforation.
Consider this possibility if patients present with unexplained abdominal pain.
Physical Exam
Head and Neck: May show loss of hair over affected areas such as scalp, eyebrows.
Investigations
There are no diagnostic investigations for trichotillomania.
Medication Treatment
There are no medications for TTM approved by the US Food and Drug Administration (FDA) (Grant, 2016).
Medications studied have included:
-
SSRIs 

- Although studies have been done on SSRIs, there is no clear evidence of their effectiveness (Grant, 2016). 

-
TCA

- Clomipramine may show efficacy (Ninan, 2000; Swedo, 1989)

-
N-acetylcysteine (NAC)

- NAC is a glutamate modulator.
- One study showed NAC is effective compared to placebo (Grant, 2009)

- Recent systematic review of 4 randomized, double-blind placebo-controlled trials on the use of NAC in the treatment of TTM found inconclusive evidence, but suggested that NAC may still be useful as a treatment for OCD owing to its relatively benign side effects (Grant, 2016)

-
Inositol

- Some initial studies and case reports were promising, however a double blind, placebo controlled study did not show any greater reduction on outcomes compared to placebo (Leppink, 2017). 

- Neuroleptics

-
Olanzapine

- RCT of olanzapine showed “strong evidence that olanzapine is effective when compared to placebo” (Van Ameringen, 2010)

-
Mood stabilizations

- Consider if patient has comorbid bipolar disorder

- Anticonvulsants

- CNS stimulants

- Opioid antagonists 

Psychotherapy and Non-Medication Treatment
The best evidence is for behavioural therapy, specifically:
-
Habit reversal therapy (HRT)

- Patients are trained to recognize their impulse to pull, and learn to redirect this impulse 

Promising interventions include:
-
Acceptance and Commitment Therapy (ACT) (Woods, 2006)

- ACT uses both 1) acceptance and mindfulness strategies, along with 2) commitment and behaviour change strategies. 

-
Self-regulation strategies

- One theory about TTM is that at least for some patients, hair pulling may be about an attempt at self-regulation such as boredom. 

- As a result, finding alternate ways to cope with boredom (i.e. self regulate) may show promise.

Prognosis
Child have generally better outcomes than adults.
Positive prognostic factors are short period of hair pulling; the shorter the period of hair pulling, the better the outcome.
Where to Refer
Consider referring to mental health professionals such as
- Private practice psychologist

- Psychiatrist 

Case, Part 2
You tell her that she is not alone, that there are other people that pull their hair, and that it has a name “trichotillomania”.
It turns out that she has an employee assistance program (EAP) through her work, and as a result, she starts seeing a psychologist for a few sessions to help her. The psychologists helps her with lifestyle changes to reduce her overall stress, along with lifestyle modifications such as getting enough sleep, exercise and proper nutrition. She learns some ‘habit reversal’ strategies as well. You are pleased to see that at a future visit, her hair in her scalp and eyebrows has grown back.
References
Sharma V: Psychopharmatherapy of trichotillomania, J. Psychiatry Neurosc 2017; 42(3): 216.
Toledo EL, De Togni Muniz E, Brito A, et al. Group treatment for trichotillomania: cognitive-behavioral therapy versus supportive therapy. J Clin Psychiatry 2015;76:447-55.
Grant JE, Chamberlain S. Trichotillomania. Am J Psychiatry 2016;173:868-74.
Leppink EW, Redden SA, Grant, JE. A double-blind, placebo-controlled study of inositol in trichotillomania. Int Clin Psychopharm: 2017 ; 32(2): 107–114.
Ninan PT, Rothbaum BO, Marsteller FA, Knight BT, Eccard MA. A placebo-controlled trial of cognitive-behavioral therapy and clomipramine in trichotillomania. Journal of Clinical Psychiatry 2000;61(1):47-50.
Swedo SE, Leonard HL, Rapoport JL, Lenane MC, Goldberger EL, Cheslow DL. A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling). New England Journal of Medicine 1989;321(8):497-501.
Van Ameringen M, Mancini C, Patterson B, Bennett M, Oakman J. A randomized, double-blind, placebo-controlled trial of olanzapine in the treatment of trichotillomania. Journal of Clinical Psychiatry 2010;71(10):1336-43.
Woods, D. W., Wetterneck, C. T., & Flessner, C. A. (2006). A controlled evaluation of Acceptance and Commitment Therapy plus habit reversal for trichotillomania. Behaviour Research and Therapy, 44(5), 639-656.
About this Document
Written by members of the eMentalHealth.ca/PrimaryCare team which includes members of the Department of Psychiatry and Family Medicine at the University of Ottawa. Reviewed by members of the Family Medicine Program at the University of Ottawa, including Dr's Farad Motamedi; Mireille St-Jean; Eric Wooltorton.
Disclaimer
Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from a health professional. Always contact a qualified health professional for further information in your specific situation or circumstance.
Creative Commons License
You are free to copy and distribute this material in its entirety as long as 1) this material is not used in any way that suggests we endorse you or your use of the material, 2) this material is not used for commercial purposes (non-commercial), 3) this material is not altered in any way (no derivative works). View full license at http://creativecommons.org/licenses/by-nc-nd/2.5/ca/
Vous imprimez pour quelqu’un?
PDF
