Trichotillomania

Disease Description (Causes and Symptoms)

• Definition summary: Trichotillomania is an impulse control disorder in which a person cannot suppress the urge to repeatedly pull out their own hair. Tension tends to increase before pulling, followed by a sense of relief and satisfaction after pulling.
• Causes and pathophysiology: Psychological and environmental factors (stress, family relationship problems, loss of an attachment figure, depression, anxiety, etc.) and biological factors (such as abnormalities in the serotonin system) act in combination. Although it has some similarities to obsessive-compulsive disorder, it is typically characterized by behavior following anxiety provocation (behavior-centered).
• Main symptoms: Localized hair loss on the scalp, eyebrows, eyelashes, beard, etc.; repeated hair-pulling behavior; pain is often not reported; tension before pulling and a sense of relief afterward. There may be a tendency to hide the behavior, along with psychological and social functional impairment.
• Prevalence and course: The lifetime prevalence is reported to be around 1%, but the actual prevalence may be higher. It usually begins in childhood or adolescence. Childhood-onset cases tend to improve spontaneously, whereas adult-onset cases are more likely to become chronic. It is more common in females.

Treatment Methods

• First-line treatment (non-pharmacological treatment, recommended as the priority)
  • Behavioral therapy: Habit Reversal Training (HRT) has the strongest evidence. It includes self-monitoring and stimulus control.
  • Cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) may also be helpful.
  • In children and adolescents, family therapy and education are recommended in combination.
• Adjunctive and pharmacological treatment
  • Selective serotonin reuptake inhibitors (SSRIs) and clomipramine may help improve symptoms in some patients (with considerable individual variation in effectiveness).
  • N-acetylcysteine (NAC) may be considered because some efficacy has been reported in studies of adults.
  • Although some case reports and small studies have reported that antipsychotics such as aripiprazole may be helpful, they are not standard first-line treatments.
  • When skin complications (infection or inflammation) are present, dermatological treatment (topical antibiotics, disinfection if necessary, etc.) should be provided concurrently. Topical steroids may be used to relieve inflammation in some cases, but they are not a fundamental treatment for reducing the hair-pulling behavior itself (limited evidence).
• Other
  • Biofeedback, relaxation therapy, and stress management (psychotherapy and lifestyle improvement) are recommended.
  • A multidisciplinary approach (Department of Psychiatry + Department of Dermatology) is recommended.
• Precautions during treatment and risk of complications
  • Behavioral punishment (scolding or corporal punishment) should be avoided because it may worsen symptoms.
  • Comorbid mental disorders such as depression, anxiety, and obsessive-compulsive disorder should be assessed and treated concurrently.
  • Repeated hair pulling may cause skin damage, infection, scarring, and permanent hair loss.

Checklist Before an Outpatient Visit (Including Example Questions)

• Items and records to prepare
  • List of medications currently being taken (including prescription medications, OTC medications, and supplements)
  • Past medical history (including psychiatric care and dermatological treatment) and family history
  • Symptom records: age when hair pulling began, frequency (per day/week), duration, triggering situations (stress, boredom, etc.), feelings before and after pulling (tension and sense of relief), treatments tried and their effects
  • Photos: photos of the areas of hair loss before and after (useful for diagnosis and follow-up)
  • Results of previous tests (skin examinations, blood tests, etc.)
  • Lifestyle changes (sleep, caffeine, smoking, medication use, etc.)
• Assessments available during an outpatient visit
  • Physical and skin examination (pattern of hair loss, skin damage and presence of infection)
  • Standardized assessment scales may be used (e.g., MGH-HPS)
  • Screening assessment for comorbid mental disorders (depression, anxiety, OCD)
• Warning signs to check before an outpatient visit (report immediately)
  • Presence of self-harm intent or suicidal thoughts
  • Suspected skin infection (redness, abscess, or warmth)

Examples of General Questions to Ask the Doctor

• "What is the most recommended (priority) treatment for my condition?"
• "What are the expected effects and side effects of this medication?"
• "How many sessions of behavioral therapy will I need, and over what period of time?"
• "I also have another psychiatric disorder (depression or anxiety). Will the order or method of treatment be different?"
• "After starting treatment, when does the effect usually appear, and how long must it last for the treatment to be considered successful?"

Examples of Condition-Specific Questions

• "I would like to start Habit Reversal Training. Specifically, what training (such as replacement behaviors and self-monitoring) should I perform, when should I start, and how should I do it?"
• "If medications such as N-acetylcysteine (NAC) or clomipramine are considered, how would the choice and management of side effects be tailored to my situation (age, comorbidities, and current medications)?"