Trichotillomania

Trichotillomania is usually confined to one or two sites, The classic presentation is the "Friar Tuck" form of crown alopecia (loss of hair at the "crown" of the head, also known as the "vertex"). Children are less likely to pull from areas other than the scalp. Individuals with trichotillomania exhibit hair of differing lengths; some are broken hairs with blunt ends, some new growth with tapered ends, some broken mid-shaft, or some uneven stubble. Scaling on the scalp is not present, overall hair density is normal, and a hair pull test is negative (the hair can not be pulled out easily). Hair is often pulled out, leaving an unusual shape. Individuals with trichotillomania may be secretive of their hair pulling behavior, which is often associated with shame. Some people with trichotillomania wear hats, wigs, false eyelashes, use makeup such as an eyebrow pencil, or style their hair in an effort to avoid such attention. Some individuals with trichotillomania may feel isolated, as if they are the only person with this problem, due to low rates of reporting. For some people, trichotillomania is a mild, if frustrating, problem. But for many, embarrassment about hair pulling causes isolation and results in a great deal of emotional distress, placing them at risk for a co-occurring psychiatric disorder, such as a mood or anxiety disorder. Hair pulling can lead to tension and strained relationships with family members and friends. Family members may need professional help in coping with this problem. Other medical complications include infection, permanent loss of hair, repetitive stress injury, carpal tunnel syndrome, and gastrointestinal obstruction as a result of trichophagia. Environment is a large factor which affects hair pulling. A common example of a sedentary activity promoting hair pulling is lying in a bed while trying to rest or fall asleep. == Causes ==

Anxiety, depression and obsessive–compulsive disorder are more frequently encountered in people with trichotillomania. Trichotillomania has a high overlap with post traumatic stress disorder, and some cases of trichotillomania may be triggered by stress. Another school of thought emphasizes hair pulling as addictive or negatively reinforcing, as it is associated with rising tension beforehand and relief afterward. One study found that individuals with trichotillomania have decreased cerebellar volume on average, which suggests some differences between OCD and trichotillomania. Abnormalities in the caudate nucleus are noted in OCD, but there is no evidence to support that these abnormalities can also be linked to trichotillomania. 5HT2A, SAPAP3, FOXP1, and NF1 genes have been associated with trichotillomania. In addition, HOXB8 knockout mice display pathological grooming behavior similar to trichotillomania, although associations between trichotillomania and the HOXB8 gene have not been demonstrated in humans. ==Diagnosis==

Patients may be ashamed or actively attempt to disguise their symptoms. This can make diagnosis difficult as symptoms are not always immediately obvious, or have been deliberately hidden to avoid disclosure. Diagnostic criteria from the DSM-5 provides the following criteria for trichotillomania: • Criterion A: Recurrent pulling of hair that must result in loss of hair. because many individuals with trichotillomania may not realize they are pulling their hair, and patients presenting for diagnosis may deny the criteria for tension prior to hair pulling or a sense of gratification after hair is pulled. The most common age of onset of trichotillomania is between ages 9 and 13. In this age range, trichotillomania is usually chronic, and continues into adulthood. Trichotillomania that begins in adulthood most commonly arises from underlying psychiatric causes. hence, trichotillomania is subdivided into "automatic" versus "focused" hair pulling. Children are more often in the automatic, or unconscious, subtype and may not consciously remember pulling their hair. Other individuals may have focused, or conscious, rituals associated with hair pulling, including seeking specific types of hairs to pull, pulling until the hair feels "just right", or pulling in response to a specific sensation. Knowledge of the subtype is helpful in determining treatment strategies. ==Treatment==

Treatment is based on a person's age. Most pre-school age children outgrow the condition if it is managed conservatively. In young adults, establishing the diagnosis and raising awareness of the condition is an important reassurance for the family and patient. Non-pharmacological interventions, including behavior modification programs, may be considered; referrals to psychologists or psychiatrists may be considered when other interventions fail. When trichotillomania begins in adulthood, it is often associated with other mental disorders, and referral to a psychologist or psychiatrist for evaluation or treatment is considered best. The hair pulling may resolve when other conditions are treated. With HRT, the individual is trained to learn to recognize their impulse to pull and also teach them to redirect this impulse. In comparisons of behavioral versus pharmacologic treatment, cognitive behavioral therapy (including HRT) have shown significant improvement over medication alone. Acceptance and commitment therapy (ACT) is also demonstrating promise in trichotillomania treatment. A systematic review from 2012 found tentative evidence for "movement decoupling". Medication The United States Food and Drug Administration (FDA) has not approved any medications for trichotillomania treatment. However, some medications have been used to treat trichotillomania, with mixed results. Treatment with clomipramine, a tricyclic antidepressant, was shown in a small double-blind study to improve symptoms, but results of other studies on clomipramine for treating trichotillomania have been inconsistent. Fluoxetine and other selective serotonin reuptake inhibitors (SSRIs) have limited usefulness in treating trichotillomania, and can often have significant side effects. Behavioral therapy has proven more effective when compared to fluoxetine. A study found that memantine, a drug typically used to treat symptoms of Alzheimer's disease, was effective in reducing trichotillomania behaviour. Similar to N-acetylcysteine mentioned above, memantine acts to regulate glutamate levels. Different medications, depending on the individual, may increase hair pulling. There are also wearable devices that track the position of a user's hands. They produce sound or vibrating notifications so that users can track rates of these events over time. == Prognosis ==

When it occurs in early childhood (before five years of age), the condition is typically self-limiting and intervention is not required. In adults, the onset of trichotillomania may be secondary to underlying psychiatric disturbances, and symptoms are generally more long-term. Secondary infections may occur due to picking and scratching, but other complications are rare. Individuals with trichotillomania often find that support groups are helpful in living with and overcoming the disorder. ==Epidemiology==

Although no broad-based population epidemiologic studies had been conducted as of 2009, the lifetime prevalence of trichotillomania is estimated to be between 0.6% and 4.0% of the overall population. Trichotillomania is diagnosed in all age groups; onset is more common during preadolescence and young adulthood, with mean age of onset between 9 and 13 years of age, and a notable peak at 12–13. Among preschool children the genders are equally represented; there appears to be a female predominance among preadolescents to young adults, with between 70% and 93% of patients being female. Among adults, females typically outnumber males by 3 to 1. "Automatic" pulling occurs in approximately three-quarters of adult patients with trichotillomania. == History ==

Hair pulling was first mentioned by Aristotle in the fourth century B.C., was first described in modern literature in 1885, and the term trichotillomania was coined by the French dermatologist François Henri Hallopeau in 1889. == Society and culture ==

Support groups and internet sites can provide recommended educational material and help persons with trichotillomania in maintaining a positive attitude and overcoming the fear of being alone with the disorder. Trichster is a 2016 documentary that follows seven individuals living with trichotillomania, as they navigate the complicated emotions surrounding the disorder, and the effect it has on their daily lives. "Trichotillomania" is a 2017 song by rapper Marcus Orelias from the 2017 studio album 20s A Difficult Age. Fiction The trichotillomania of a prominent character is a key plot element in the 1999 novel Whatever Love Means by David Baddiel. Ashley Barret, a character portrayed by Colby Minifie in the superhero fiction series The Boys, is shown suffering from it. Beth, a character portrayed by Amy Schumer is shown to have it in the comedy-drama series Life & Beth. This is primarily in flashbacks, where she is portrayed by Violet Young. Skye Riley, a character portrayed by Naomi Scott in the supernatural horror film Smile 2, is shown with trichotillomania. == See also ==