History: Bald at age 9
Ms. D, age 41, began compulsively pulling out and eating her hair at age 8. When she didn’t get her way at home or was nervous about school, she would sit for hours, pulling and eating a strand or two at a time, ultimately ingesting a clump of hair.
By age 9, Ms. D was bald. In grade school, she often wore hats and scarves to class to avoid teasing from other children about her baldness. In high school, she kept to herself and frequently wore wigs.
Ms. D stops pulling for brief periods and her hair grows out, but she invariably resumes pulling when psychosocial stressors mount. Many of life’s normal anxieties—job interviews, work-related stress, social rejection—trigger episodes.
When she is bald, Ms. D pulls and eats hair off her wig. Over the years, she has spent thousands of dollars on custom-made wigs that mask her baldness while feeding her habit.
Ms. D’s episodes are increasingly interfering with her life. She has been steadily employed as an office assistant, but does not socialize with coworkers. She has not dated in years, and during an exacerbation leaves home only to go to work. She also pulls her eyelashes and eyebrows and picks her nails and cuticles.
Ms. D first presented in 1994 after seeing a television segment I did on trichotillomania. At intake, she was wearing a wig and exhibited anxious mood. She also has Crohn’s disease; a gastroenterologist monitors her closely.
Ms. D reports compulsive counting and checking but denies other similar behaviors. No immediate family members have exhibited obsessive-compulsive or hair-pulling behaviors. Her father abused alcohol and a sister has a stuttering problem, although Ms. D denies that these have affected her psychologically.
Ms. D’s hair-pulling behavior suggests:
- a pica disorder
- an impulse control disorder
- or an obsessive-compulsive disorder?
DSM-IV-TR diagnostic criteria for trichotillomania
- Recurrent pulling out of one’s own hair, resulting in noticeable hair loss.
- Increasing tension immediately before pulling out the hair or when attempting to resist the behavior.
- Pleasure, gratification, or relief while pulling out the hair.
- The disturbance is not better explained as another mental disorder and is not caused by a dermatological or other general medical condition.
- The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Source: Reprinted with permission from the Diagnostic and statistical manual of mental disorders, 4th ed., text revision. Copyright 2000. American Psychiatric Association.
Dr. Lundt’s observations
Trichotillomania, defined as compulsive pulling of hair, usually begins in childhood or adolescence. Scalp hair is most commonly pulled, but some patients also pull their eyelashes, pubic hair, and other body hair. Some, especially children, have reportedly pulled their pets’ hair.
Mansueto et al estimate that trichotillomania afflicts approximately 1.5% of males and 3.5% of females.1 These estimates, however, do not include persons with the disorder who are too embarrassed to seek treatment.
DSM-IV-TR classifies trichotillomania as an impulse control disorder (Box). Although comorbid anxiety and depressive disorders are common, Ms. D did not meet criteria for any other psychiatric disorder.
Trichotillomania often is episodic. Months or years of abstinence is common after periods of exacerbation, usually caused by stress (Figure).
Many clinicians mistakenly consider trichotillomania a benign disorder with few consequences beyond alopecia.2 Some patients, however, progress into trichophagia—ingestion of pulled hair. Trichophagia is a form of pica disorder, typically defined as persistent eating of non-nutritive substances. Patients often harbor tremendous shame over their hair-eating behavior and resist psychiatric or medical treatment.2
The undigested hair can form sometimes massive clumps called trichobezoars, which are most common among children and the developmentally disabled.4 Persons with trichophagia face a 37.5% risk of forming a trichobezoar.5 The mass can cause abdominal pain, nausea, vomiting, and weight loss; complications include GI obstruction, ulceration, perforation, and peritonitis.6 An untreated trichobezoar can be fatal,7 although such deaths are rare among patients being treated for trichotillomania.
Patients with trichotillomania often respond to medications used to treat obsessive-compulsive disorder, such as clomipramine. Some clinicians believe this agent is more effective than selective serotonin reuptake inhibitors (SSRIs) but more difficult to tolerate. For Ms. D, I started with both.
Treatment: ‘I Don’t need medication’
Initial treatments—including fluoxetine, 20 mg/d for 6 months; hypnotherapy; and clomipramine, 25 mg/d—were unsuccessful. Ms. D was only marginally compliant, believing that she did not need medication.
I referred Ms. D to an out-of-state residential behavioral program specializing in trichotillomania, but she refused to go even as her hair-pulling intensified. Clomipramine was gradually increased to 75 mg nightly, briefly decreasing her pulling, then to 100 mg nightly when symptoms re-emerged. Clomipramine blood levels were monitored with each dosage change to guard against CNS and cardiac toxicity and other side effects (GI complaints, dizziness, cardiac arrhythmias, somnolence).