Volume 6 Issue 8 August, 2016
Consultation Liaison Psychiatry Focus: Dermatology
Trichotillomania is a disorder characterized by inability to control over pulling one’s own hair from various parts of a body resulting in noticeable hair loss. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), places trichotillomania in the category of obsessive-compulsive and related disorders. Though the exact etiology of trichotillomania is not known, the genetic, environmental and temperamental factors are distinguished. Individuals with trichotillomania has higher risk of comorbid mood disorders, especially Depressive disorders and frequency of anxiety symptoms are higher. Common co-occurrence of other body focused impulse control disorders like skin picking and nail biting has been noted.
Hair pulling can occur in any area of the body where hair grows. The scalp is the most common area, followed by the eyelashes and eyebrows. Patients frequently complain of unexplainable alopecia or hair loss, because they typically conduct the pulling or plucking behavior in private and often deny engaging in it especially children. Sometimes patients may report hair loss related directly to hair pulling or plucking. Some individuals tend to avoid social situations so that they can maintain the privacy to engage in hair-pulling behavior. Sometimes patients may present with anxiety associated with their hair-pulling behavior. This common presentation consists of areas of hair loss with broken hairs of varying lengths arranged in a circular pattern, with unaffected hairs surrounding the area of hair loss (Friar Tuck sign). Dermoscopy shows black dots, coiled hair, shafts of varying lengths with fraying or split ends.
A high index of suspicion is essential for the diagnosis. Often it is misdiagnosed as alopecia areata or tinea capitus. The specific DSM-5 criteria for trichotillomania (hair-pulling disorder) are as follows:
- Recurrent pulling out of one’s hair, resulting in hair loss
- Repeated attempts to decrease or stop the hair-pulling behavior
- The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
- The hair pulling or hair loss cannot be attributed to another medical condition (e.g., a dermatologic condition)
- The hair pulling cannot be better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance, such as may be observed in body dysmorphic disorder)
Currently available evidence suggests that the first line of treatment for trichotillomania is behavioral treatment and intervention, with a focus on self-awareness & affective regulation. Habit reversal training is a specific type of behavioral intervention with established efficacy. A psychiatrist should be consulted when a serious psychiatric disorder is suspected. Selective serotonin reuptake inhibitors (SSRIs) have been tried in few cases.
Dr. Shilpa. K, Assistant professor, Department of dermatology, BMCRI, Bangalore Email.shilpakvinod@gmail.com
