Trichotillomania: A challenge to research and practice

doi:10.1016/S0272-7358(98)00083-X

Clinical Psychology Review

Volume 20, Issue 3, April 2000, Pages 289-309

https://doi.org/10.1016/S0272-7358(98)00083-X Get rights and content

Abstract

This review explores several aspects of trichotillomania relevant to clinical theory and practice. It is concluded that research outlining the phenomenology and patterns of comorbidity of trichotillomania have been advanced significantly in recent years. However, no current diagnostic category appropriately classifies trichotillomania. Research with nonclinical populations suggests that trichotillomania is more common than previously believed and that additional epidemiological research is warranted. Continued elaboration of existing etiological models incorporating varying theoretical perspectives is also encouraged. Assessment of trichotillomania could also be improved by the continued development of reliable and valid standardized measures. This article reviews both pharmacological and psychological treatments for trichotillomania, with an emphasis on habit-reversal training. Though some interventions appear effective in the short-term, reported relapse rates are high and future research on treatment for trichotillomania should focus on improving long-term outcomes. It is clear that despite a recent flux of research centering on trichotillomania, significant challenges for understanding and treating this psychological disorder still exist for researchers and clinicians. Based on this review of the literature, and on our clinical experience with trichotillomania, we propose directions for future research with this underserved psychiatric group.

Section snippets

What is trichotillomania?: diagnostic classification and criteria

Trichotillomania is presently categorized as an impulse control disorder (American Psychiatric Association, 1994). A diagnosis of trichotillomania requires (a) recurrent episodes of hair pulling resulting in noticeable hair loss; (b) increasing tension experienced prior to pulling or while trying to resist pulling; (c) pleasure, gratification, or decreasing tension associated with pulling; (d) significant distress or impairment in social, occupational, or other important areas of functioning

Phenomenology

The phenomenology of trichotillomania is variable across patients, but some common elements have been documented. Pulling can occur at any site on the body, and frequently at multiple sites (Christenson, Mackenzie, & Mitchell, 1991). The most common site of pulling is the scalp, followed by lashes, brows, and pubic hair Christenson, Mackenzie, & Mitchell 1991, Schlosser et al. 1994. Negative affective states and sedentary or contemplative activities are cues that often prompt or exacerbate hair

Epidemiology

To date, no epidemiological research has been conducted on trichotillomania in the general population. Early estimates based on extrapolation from clinic referrals suggested pathological hair pulling was a rare condition (Mannino & Delgado, 1969), while more recent estimated prevalence rates are as high as 4% (Azrin & Nunn, 1978). In the first study on the prevalence of trichotillomania in a nonclinical group, Christenson, Pyle et al. (1991) surveyed 2579 college students about hair pulling

Comorbidity

Clinical lore suggests patients diagnosed with trichotillomania do not have significant secondary psychopathology (Winchel, 1992). However, researchers have found that other psychiatric disorders are more prevalent in groups diagnosed with trichotillomania than would be expected in the general population Christenson, Mackenzie, & Mitchell 1991, Schlosser et al. 1994. Rates as high as 82% lifetime prevalence of Axis I disorders have been found (Christenson, Mackenzie, & Mitchell, 1991). While no

What causes trichotillomania? etiological models

Some authors describe trichotillomania as “a disorder of unknown etiology” (Peterson, Campise, & Azrin, 1994, p. 434). While there is no consensus on the cause of trichotillomania, several etiological models have been proposed from differing theoretical perspectives; primarily psychoanalytic, biological, and behavioral.

Assessment

Assessment of trichotillomania is closely related to the therapeutic process (Rothbaum & Ninan, 1994). Clinical assessment can be used to establish a diagnosis, develop a functional analysis of hair pulling, and provide a baseline in order to evaluate treatment progress. It is also important to rule out organic etiology for hair loss and assess for secondary psychopathology. Currently, there is no widely accepted assessment package for trichotillomania. However, several different methods for

Treatment

A review of the treatment outcome literature on trichotillomania indicates a large number of case reports, with progressively more systematic and controlled investigations in recent years. Primarily three treatment approaches have been discussed in the literature: psychoanalytic, pharmacological, and behavioral; mirroring the three etiological theories reviewed earlier. Treatment of trichotillomania using psychoanalytic techniques has only been reported in uncontrolled case studies, and

Conclusion and directions for future research

The existing literature on trichotillomania is relatively limited, but growing, thanks to the efforts of a small but active group of clinician-researchers. Increased research attention has been provided to trichotillomania in recent years, in part because of greater awareness that symptomatic hair pulling is more common than once believed. Though prevalence rates in the general population remain speculative, best estimates suggest that trichotillomania is roughly as common as schizophrenia