2002 trichotillomania

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CONTINUING MEDICAL EDUCATION

Trichotillomania

Giuseppe Hautmann, MD,a Jana Hercogova, MD,b and Torello Lotti, MDa

Florence, Italy, and Prague, Czech Republic

Trichotillomania is a neglected psychiatric disorder with dermatologic expression that has only recently received research attention. On the basis of clinical data, trichotillomania appears to be far more commonthan previously believed. Like obsessive-compulsive disorder, the hair-pulling behavior is recognized assenseless and undesirable but is performed in response to several emotions and affects, such as increasinganxiety, or unconscious conflicts with resultant tension relief. The condition may be episodic but is usually chronic and difficult to treat. On the basis of possible medical and psychiatric complications, it is importantthat the diagnosis is exact and early. We describe the comorbidity and the phenomenology of trichotillo-mania, paying attention to the possible available treatments. (J Am Acad Dermatol 2002;46:807-21.)

Learning objective: At the conclusion of this learning activity, participants should be familiar with clinical

and histologic aspects of trichotillomania and should be able to cope with the risks of medical andpsychiatric complications in these patients. Finally, participants will be able to easily interact with psychi-atrists, when needed, to identify the most successful treatment.

In 1889 Hallopeau, a French dermatologist, re-ported a case of self-inflicted depilation of thescalp and coined the term trichotillomania

(from the Greek thrix, hair; tillein, pulling out; mania, madness).1 More than 100 years later, the epi-demiology, etiology, natural history, and appropri-

ate treatment of trichotillomania are still unclear.The question is whether trichotillomania is a syn-drome by itself, a form of obsessive-compulsive dis-order, or a symptom observed in various disorders;in fact, although hair pulling may be considered tobe a symptom of a broad spectrum of psychopathol-ogies (from a transient mild habit, through impulsecontrol disorder, obsessive-compulsive disorderspectrum, personality disorders such as borderlinepersonality or histrionic personality, body dysmor-phic disorder, major mental retardation, to schizo-phrenia and depression), in this review we refer to

trichotillomania as defined by the diagnostic criteriaof the American Pyschiatric Association (APA), which were set forth in the fourth edition of theDiagnostic and Statistical Manual of Mental Disor-

ders (DSM-IV ). We outline that in dermatologicalpractice the DSM-IV criteria for trichotillomania fit

only a proportion of hair pullers; thus hair pullingdoes not mean tout court trichotillomania.

EPIDEMIOLOGY Until the 1990s, trichotillomania was thought to

be quite rare. For example, case frequency wasreported as 2 per 1200 patients treated for psychiat-ric disorders in a university outpatient clinic,2 and 5per 10,000 children treated for psychiatric disor-ders.3 The disorder was thought to be more com-mon, though still infrequent, in dermatological prac-tice.4,5 Now that media attention is increasingawareness of treatments for trichotillomania, af-fected individuals are increasingly seeking care.Nevertheless, some researchers have reported anextremely low incidence,3,6-8 whereas others esti-mate a high occurrence, approximately 1 in every 200 persons by the age of 18 years.9-12 It is notedpredominantly in girls and women and occurs more

commonly in children than in adults; men may beable to hide their hair pulling better by masking it asmale pattern baldness and shaving their mustachesand beards. When it occurs later in life, such asduring adulthood or in older patients, it is associated with more psychopathology and with a poorer prog-nosis. Age at onset is frequently between 5 and 12 years or early childhood to adolescence.5,11 Never-theless, trichotillomania that has its onset in infancy and early childhood is sometimes considered sepa-rately because it may be a different disorder fromthat which presents during adolescence and young

adulthood.

Fromthe Departmentsof Dermatologyand Venereology,University

of Florence,a and Charles University, Prague.b

Reprint requests: Giuseppe Hautmann, MD, Via J. Nardi, 50, 50132

Florence, Italy. E-mail: [email protected].

Copyright © 2002 by the American Academy of Dermatology, Inc.

0190-9622/2002/$35.00 0 16/2/122749

doi:10.1067/mjd.2002.122749

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The scalp is the most frequent hair-pulling site,

followed by the eyebrows, eyelashes, pubic area,trunk, and extremities. The prevalence of trichotil-lomania in the general population has not beenstudied. A 1989 questionnaire survey of approxi-mately 2500 college freshmen in the United States attwo state universities and a liberal arts college, witha 97.9% response rate, indicated a lifetime trichotil-lomania prevalence of 0.6% in both male and femalestudents (trichotillomania criteria set forth in the APA’s Diagnostic and Statistical Manual, third edi-tion, revised [DSM-III-R ]).13 When the investigatorsignored the diagnostic criteria referring to tension,

pleasure, and gratification, the prevalence increasedto 3.4% of female students and 1.5% of male stu-dents. A similar survey of about 700 college fresh-men found that 11% pulled their hair on a regularbasis for other than cosmetic reasons and that 1%met DSM-IV criteria for trichotillomania by self-report.14

In treated case series, women outnumber men by a ratio that approximates 3.5:1.15,16 In modern phar-macological trials, the female/male ratio has been7:1 or higher.17-20 The female preponderance may bedue in part to women’s greater willingness to seek

medical care. As already mentioned, men may hidetheir hair pulling by masking it as male patternbaldness and shaving their mustaches and beards; inaddition, beard pulling may represent symptomaticbehavior of an underlying body dysmorphic disor-der; thus it is very dif ficult to evaluate the exactepidemiologic dimension of trichotillomania. More-over, it is important to note that the epidemiologic,clinical, prognostic, and therapeutic data of the re-cent literature on trichotillomania referenced in thisarticle refer to the psychiatric patient population andnot to patients who come to the dermatologist for

treatment; moreover, epidemiology considers only

“clinical” hair pulling, that is, with clinical evidenceof patches of hair loss. “Nonclinical” hair pullers are very common in the general population.

Moreover, patients seen by psychiatrists usually acknowledge their hair-pulling activity (otherwise,they would not be there), whereas the large propor-tion of patients seen by dermatologists are not yet atthat point and often present a “generic hair loss.”

CLINICAL FEATURESIn the majority of cases, trichotillomania results in

patchy or full alopecia of the scalp5,21 (Fig 1). Many subjects also pull out eyelashes, eyebrows, or facialhairs, and some extract pubic, axillary, chest, ab-dominal, or extremity hairs. Hair pulling usually oc-curs daily, or nearly daily, and can occupy severalhours or more.22 The scalp is involved more fre-

quently than other hair-bearing areas, and the clin-ical presentation of the lesion is characteristic. Hairsat the occiput and base of the head are spared,resulting in the tonsural pattern of baldness typifyingsevere trichotillomania. Less severely affected pa-tients may have only small areas of baldness orimperceptible thinning over the entire head. In astudy on the effects of menstruation on pulling,slightly more than half of 45 women providing datareported that in the week before menses, pullingurges were more frequent and intense, pulling wasmore frequent, and the ability to resist was weaker, with a return to baseline during menses or soonthereafter.23 With the exception of this gender-spe-cific finding, men and women hair pullers do notexhibit clinically relevant differences.24

Plucking is accomplished either in a wavelikefashion across the scalp or centrifugally from a sin-gle starting point. This results in linear or circularpatches with irregular borders containing hairs of varying length, the shortest being those most re-cently removed, whereas increasing hair length dis-tal to that point signifies the interval between thetime plucking and the time of clinical evaluation.The process of plucking frequently fractures the hair

shaft above or within the follicle, so that the emerg-ing hair, instead of having the finely tapered silki-ness of newly grown anagen hair, has a fracturedend. This gives a stubbly sensation as the hand ispassed lightly over the the involved area. Plucking isconfined to a single patch of varying size. This patchmay be quite large and indeed in rare instances may involve the entire scalp.25-27 When the process hasextended to a point that is uncomfortable to reach,then the cycle is repeated, starting once again at thebeginning point.

In many cases, a specific time and location are

reserved for the process of plucking, which then

Fig 1. Typical case of adult trichotillomania: tonsural pat-tern of baldness with hairs of varying length; shortest arethose more recently removed.

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takes on a ritualized character. Feelings of shameand humiliation cause patients to avoid exposing thedamaged areas. However, unlike neurotic excoria-tions, because of embarrassment or shame, it ismore common for the patient not to acknowledgehis or her hair plucking; typically he or she will claimto wake to find balls of hair strewn about the bed, orif he or she does acknowledge it, the plucking may be rationalized on the basis of some aberrant sensa-tion in the scalp. Parents often will share in thisdenial.

Patients commonly attempt to conceal the alope-cia with creative hair styling, wigs, hair pieces, andconstant use of hats or bandanas, makeup, or falseeyelashes. Patients often present to a dermatologistor a psychiatrist for treatment after a long period of avoiding dating, intimate relationships, sports suchas swimming, and outdoor exposure to windy places. More frequent hair pulling, greater body dis-satisfaction, and greater anxiety and depression areassociated with lower self-esteem.22

The disorder usually has periods of exacerbationand remission and in most cases is chronic.7 Accord-ing to some authors, there appears to be both aremitting and a chronic form, which are related toage at onset and sex distribution, with older womenbeing more susceptible to the chronic form.28

Some researchers have emphasized the disturbedfamily relations in patients with trichotilloma-nia.5,7,29,30 These authors have reported poor marital

relations; family tension; and faulty mother-child in-teraction patterns characterized by ambivalence,hostility, and separation anxiety. It often develops inthe context of family psychosocial stress (eg, child ormother hospitalizations, the additional stress frommoving to a new house) or with developmentalproblems such as sibling rivalry, inability of a younger child to focus activities or play, or schoolproblems in a older child.31 In addition, it accompa-nies poor pair relationships and academic problems.

Just as patients with obsessive-compulsive disor-der (OCD) describe an overwhelming anxiety ac-

companying a compulsive urge that is temporarily relieved by performing the ritual, patients withtrichotillomania often describe an irresistible im-pulse and concomitant anxiety that cause them topull out a specific hair. Frequently, the chosen hair isidentified as different from the others (eg, too kinky/straight, brittle/supple), and its removal is necessary to make the hair feel “just right.” Despite the patienthaving a definite sense of knowing which one hair issought, many hairs are pulled to get just the rightone. Tweezers may be used to get the entire hairout, but the patients rarely report associated pain.

Some patients compulsively pick at the scalp, in

addition to pulling the hair, resulting in numerouspainful traumatic lesions. After plucking the hair, thepatient with trichotillomania frequently will stroke itagainst the cheek and/or lips and might eat the rootor entire hair. Some patients have elaborate ritualssurrounding the hair pulling, whereas others pluckone after another in rapid succession, with little orno accompanying cognition. Thus a patient may spend 2 hours pulling 20 to 25 hairs, or he or shemay pull the same number in a few minutes.26

In contrast to patients with OCD compulsions,patients with trichotillomania do not pull their hairin response to an obsessive thought, such as harmcoming to the self or loved ones, but only because of an irresistible urge and accompanying anxiety. Inaddition, patients with OCD have compulsions thatare considered to be ego-dystonic, whereas many patients with trichotillomania report the hair pullingas being pleasurable. Nevertheless, although somepatients derive pleasure from the actual pulling, formost patients with trichotillomania the conditionmay be felt globally as ego-dystonic, in that it provokes major emotional distress, in the form of shame, embarrassment, social restriction, and im-paired quality of life.

In addition, unlike patients with OCD, whosesymptoms change over time (eg, counting evolvesinto repeating, which is then replaced by washing),patients with trichotillomania only pull their hair;they do not substitute other compulsive rituals for

this behavior.In a study of 60 adult chronic hair pullers, the

mean age at onset was 13 8 years (median, 12 years).21 Most subjects pulled from more than onesite, with an average of 8 years elapsing between thestart of hair pulling and the involvement of thesecond site. Some patients used the dominant hand;others used the nondominant hand or both hands inpulling. Somewhat fewer than half of the patientshad used tweezers to pull out hair. The mediannumber of pulling episodes per week was 16 forthose primarily plucking scalp hair and 7 for those

primarily plucking eyelashes. A little more than half of the patients sought out hairs with special tactilequalities, whether coarse, thick, curly, or short. Hairpulling was not motivated by pruritus. Oral behav-iors were associated with hair pulling in 48% of patients: chewing hair or biting off the hair bulbs,rubbing hair around the mouth, licking the hair, oringesting it. No patient had a history of a tricho-bezoar (gastric or intestinal hairball). The vast ma-jority reported some pulling episodes that began orcontinued while the patients were completely awareof the behavior. High-risk situations for hair pulling

included watching television, reading, talking on the

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telephone, lying in bed, driving, and writing. Hairpulling was worse in the evening for 95% of patients.

As already mentioned, onset of trichotillomania inearly childhood has sometimes been consideredseparately because it may be a different disorder; ithas been described as a habit disorder analogous tonail biting and as a symptom of an impaired mother-child relationship as reported by Mannino and Del-gado,8 Lenane, Swedo, and Rapoport,20 and Swedoand Rapoport.28 It is unclear from published reports whether hair pulling with onset before 5 years of ageconstitutes the same disorder as that which presentsduring adolescence and young adulthood; the liter-ature data are contradictory, with little overlap be-tween the two age groups.8 Some differences areapparent; for example, 62% of preschool-aged chil-dren with trichotillomania are boys versus 30% inmale patients of other age groups.5 In addition, the

chronic, debilitating condition that affects adoles-cents and young adults, early-onset trichotillomania,is reported to be benign and self-limited. Longitudi-nal reports are not available, but it appears thatearly-onset trichotillomania may be “outgrown” andthat it does not cotinue into adolescence or adult-hood.31 Unlike their adult counterparts, the chldrenhave a clinical course that is frequently episodic, with periods of complete remission occurring 2 to 3times each year. The periods of relapse are mostfrequently seen in October or November and inFebruary.28,36 This raises the possibility of an envi-

ronmental event releasing the hair pulling; it hasbeen speculated that the children might have anunderlying genetic susceptibility that is expressed inresponse to an autoimmune reaction, triggered by abacterial or viral infection (such as streptococcal orchickenpox infections).28,31

OTHER MEDICAL BEHAVIORS ANDCOMPLICATIONS

Trichotillomania appears to be commonly associ-ated with other problematic behaviors such as nailbiting, skin picking, picking at acne, nose picking,

lip biting, and cheek chewing.21,32 These may beconsidered as medical concomitants.

Medical complications of trichotillomania are un-common but may be serious. Trichobezoar is rare,but potentially life threatening, and may cause in-testinal obstruction, gastric or intestinal bleeding orperforation, acute pancreatitis, or obstructive jaun-dice, as well as discomfiting symptoms such as ab-dominal pain, nausea, vomiting, constipation, diar-rhea, flatulence, anorexia, and foul breath.5 Otherunusual medical complications include skin infec-tion at the site of pulling; blepharitis; chronic neck,

shoulder, or back pain from prolonged abnormal

pulling postures; carpal tunnel syndrome; andavoidance of health care to escape shame (eg,avoiding treatment for basal cell carcinoma of thescalp).33

CLINICAL ASSESSMENTSeverity of trichotillomania has been rated with 3

measures, summarized as follows34:1. The Trichotillomania Symptom Severity Scale

(score range: 0-20), consisting of 5 items evalu-ating (1) average time spent pulling each day, (2)average time spent pulling on the previous day,(3) amount of resistance against the hair-pullingurge, (4) degree of subjective distress, and (5)interference with daily activity

2. The Trichotillomania Impairment Scale (scorerange: 0-10): assessment of overall impairment

resulting from the trichotillomania, in which 0represents total lack of symptoms and 10 indi-cates severe impairment (majority of time eachday spent pulling or resisting the urge to pull outthe hair, and large bald patches or total denuda-tion evident)

3. Physician’s Rating of Clinical Progress (scorerange: 0-20): assessment of clinical change, in which 0 represents a total “cure,” 10 the pretreat-ment baseline, and 20 the worst possible or totalincapacitation secondary to the trichotillomania.

The relative merits and disadvantages of many

assessment methods and instruments have been reviewed by Winchel, Jones, and Molcho.35 For clini-cal purposes, one can ask the patient to daily countthe pulled hairs and collect the hairs in envelopes.However, patients who swallow their plucked hairsmust first stop this behavior. Patients can also beasked to keep a diary that records each pullingepisode (duration, situation, precipitating factor,and response), but some find this too time consum-ing. The National Institute for Mental Health’s(NIMH) Trichotillomania Questionnaire,36 a modi-fied form of the Yale-Brown Obsessive-Compulsive

Scale (Y-BOCS), rates pulling behavior, but not re-lated thoughts. The Psychiatric Institute Trichotillo-mania Scale allows the clinician to record the sites of pulling and to rate on a 0-7 scale the quantity of observable hair loss, time spent pulling and thinkingabout pulling, success in resisting the impulse topull, distress related to trichotillomania, and the de-gree to which hair pulling interferes with activities.

The only validated self-rating scale is the Massa-chusetts General Hospital Hairpulling Scale.37,38 Thepatient rates 7 items weekly on a 0-4 scale: thefrequency of urges to pull, their intensity, ability to

control the urges, frequency of hair pulling, attempts



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Christenson and Crow 41 have drawn attention to thedistinction between patients who experiencemounting tension and center their attention on pull-ing and those who pull while distracted by otheractivities. These authors suggest a closer relationshipto OCD in the former group. Whether the degree to which trichotillomanic behavior is associated with

tension, impulsivity, pleasure, and awareness hasimportant treatment implications and deserves in- vestigation.

Chronic hair pulling has been reported in associ-ation with major depression, severe anxiety, psycho-sis, and dysthymia.42-45 Hair pulling that occurs ininfancy and early childhood appears to be a differ-ent syndrome; boys predominate in treated pre-school children and the behavior appears to bemore likely to remit spontaneously or with minimaltreatment.46 There has also been a case of hair pull-ing concomitant with Sydenham’s chorea in child-

hood.47

Trichotillomania entered the American Psychiat-ric Association’s diagnostic classification system withthe 1987 publication of DSM-III-R , where it wasgrouped with the Impulse-Control Disorders NotElsewhere Classified. DSM-IV 48 added the criterion“causes clinically significant distress or impairment”to the 4 criteria contained in DSM-III-R (Table I). Approximately 20% of individuals who chronically pull out their hair do not meet DSM-IV criteria for

trichotillomania in that they deny the presence of

Fig 2. Histologic characteristics of trichotillomania. Infun-dibulum appears hyperkeratotic and dilated, in a relatively noninflammatory dermis. (Hematoxylin-eosin stain; origi-nal magnification l00.)

Fig 3. Histologic characteristics of trichotillomania. Frag-ment of the hair shaft with hyperpigmentation. (Hematox-

ylin-eosin stain; original magnification 200.)

Fig 4. Histologic characteristics of trichotillomania. Atro-phied follicle filled with the products of degeneration of the hair matrix (hair keratin, pigment casts). Hair appearsdystrophic and separated from the internal epithelialsheath. (Hematoxylin-eosin stain; original magnificationl00.)

Fig 5. Histologic characteristics of trichotillomania. Mas-sive fragmentation of the follicle not readily recognizedand substituted by intense fibrosis. (Hematoxylin-eosin

stain; original magnification 100.)



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either tension (criterion B) or gratification (criterion

C).21,49

Whether these individuals differ in importantclinical respects from those meeting the full criteriais unknown.

The International Statistical Classification of Dis- eases and Health-related Problems, 10th revision(ICD-10 ),50 places trichotillomania in the analogouscategory, Habit and impulse disorders. This category is characterized by impulses “that cannot be con-trolled.” Because the suggestion that an impulse isirresistible carries implications of diminished re-sponsibility under the law, DSM-IV avoided ascrib-ing irresistibility to the Impulse-Control Disorders. Although the ICD-10 description of trichotillomaniais generally consistent with the DSM-IV diagnosticcriteria, ICD-10 does not mention associated distressor impairment of functioning.

Finally, we personally believe that patients withhair pulling represent an extremely heterogeneousgroup; as stated earlier in this review, though phe-nomenologically somewhat similar, there aremarked differences, over a broad spectrum of psy-chopathologies, from a transient mild habit throughimpulse control disorder, the OCD spectrum, vari-ous personality disorders (eg, borderline personal-ity, histrionic personality), body dysmorphic disor-

der, mental retardation, to psychosis. In each of these disorders, in fact, hair pulling may be presentas a symptom.

Therefore it is important to have an accurate psy-chiatric evaluation to assess the eventually presentpsychiatric comorbidities and to classify the symp-tom of “hair pulling” in the aforementioned spec-trum of mental diseases.

The available data concerning the prevalence of comorbid conditions are tainted by serious method-ological shortcomings, such as ascertainment biasand limited geographic representation. These prob-

lems preclude generalization of the reported figures.

However, the data begin to suggest that the preva-lence of comorbid mood and anxiety disorders ishigher in individuals with trichotillomania than inthe general population. In the study by Christenson,Mackenzie, and Mitchell,21 60 patients aged 18 to 61 years (mean standard deviation, 34 8 years) were evaluated for hair pulling with a semistruc-tured interview that utilized DSM-III-R criteria. An-other set of estimates is provided by a study of 43older children, adolescents, and adults (mean age,30 11 years) who responded to advertisements fordrug studies at the NIMH and were evaluated with asemistructured interview.46 This study utilized mod-ified diagnostic criteria for trichotillomania; neithergratification nor tension relief was required.

In a methodologically limited study, respondentsto print media materials that sought individuals withtrichotillomania or self-injury were mailed a survey

package.51 Only 16% of 772 individuals surveyedreturned usable questionnaires and recorded their“formally diagnosed” disorders on a self-report form.In addition to trichotillomania, which was reportedby 40% of these 123 respondents, 13% reported aformal diagnosis of OCD; 14%, depressive disorder;3%, bipolar disorder; 15%, anxiety disorder; and 7%,substance abuse.

Case reports and small case series link trichotil-lomania to a variety of other disorders, but the di-agnostic criteria vary widely. Most cases of the liter-ature data reporting behavioral and hypnotic

treatments do not carry additional diagnoses, al-though patients are usually described as guilty,ashamed, anxious, depressed, or suffering low self-esteem. Because of ascertainment and reportingbias, conclusions about comorbid risk cannot bedrawn from these sources.

The prevalence of DSM Axis II personality disor-ders has been examined in 3 convenience samples,but again, these figures cannot be generalized. Thelimited diagnostic validity of all structured instru-ments used to evaluate personality disorders52 fur-ther complicates the interpretation of these data. In

a study to examine the prevalence of personality disorders in subjects with trichotillomania and gen-der-matched patients seeking psychiatric treatmentat the same center, no differences were found be-tween the two groups.49

RELATIONSHIP TO OCD As anticipated in the abstract, the question is

whether trichotillomania is a syndrome on its own, aform of OCD, or a symptom observed in variousdisorders. It can be present as a major mental retar-dation symptom,53 in schizophrenia,54 in borderline

personality disorder,11 and in depression.43 Some

Table I. DSM-IV diagnostic criteria for trichotillomania

A. Recurrent pulling out of one’s hair resulting in

noticeable hair loss.B. An increasing sense of tension immediately before

pulling out the hair or when attempting to resist the

behavior.C. Pleasure, gratification, or relief when pulling out the

hair.D. The disturbance is not better accounted for by another

mental disorder and is not due to a general medical

condition (e.g., a dermatological condition).E. The disturbance provokes clinically marked distress

and/or impairment in occupational, social, or other

areas of functioning.



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who are mostly unaware of pulling and experienceit as pleasurable probably have a bad habit that may respond to habit reversal.70

PROGNOSIS As already stated and observed by other au-

thors,7,10,13,21,24,41 trichotillomania has periods of ex-acerbation and remission and in most cases ischronic. According to some authors, there appearsto be both a remitting and a chronic form, which arerelated to age at onset and sex distribution, witholder female patients being more susceptible to thechronic form.21

TREATMENTTreatment begins with taking a thorough history

of the disorder and its effects and inquiring afterpossible comorbid conditions. The data reviewed

earlier suggest that mood and anxiety disorders willcommonly be found. No treatment approach hasbeen established as effective in a large controlledtrial. Case reports, small series, and a few uncon-trolled and controlled trials present a variety of treat-ment methods that merit exploration. Patients areoften quite relieved to find that others pull out hairand should be guided to organizations offering ed-ucational material and contact with kindred suffer-ers. Behavior therapy, hypnosis, insight-orientedpsychotherapy, and pharmacologic therapy havebeen considered. Obviously, all these nonmedical

treatments require specialized training.

Behavior therapy The behavior therapy literature shares the short-

comings of the pharmacotherapy literature: mostly uncontrolled observations, short follow-up periods,and a publication bias toward favorable outcomes.Much of this literature is presented in detail else- where.71-74 All reports include at least two treatmentelements and most include at least 4, making itdif ficult to identify the essential factors. Placebo ef-fects and the nonspecific elements of supportivepsychotherapy may have contributed to the re-

ported results. The first reported behavioral intervention for trichotillomania consisted of self-moni-toring paired with response chain interruption, whereby patients monitored their hair-pulling at-tempts and then told their hands to stop.70,75 Otherinterventions are counting and recording hairpulls,70,76 denial of privileges and applying eyedrops to stop pulling,77 aversive self-stimulation with a rubber band,78-80 and punishment via sit-ups whenever a pull attempt is made.81 Except forSaper’s study,64 at the end of treatment patients re-ported hair-pulling rates of zero.

Unfortunately, deriving conclusive evidence from

these reports is dif ficult because of the small numberof patients who participated in the various treatmentmodalities (ie, one or two patients).

To increase the validity of self-report data and thetreatment effects of self-monitoring as described ear-lier, several investigators added other objective mea-surements, such as having patients count the num-ber of pulled hairs,82-84 measure their hair length,85

or both.86 Others combined self-monitoring, haircounting, and measuring hair length with token re-inforcement,83 self-denial of privileges,87 and behav-ioral contracting.82 The addition of these techniquesincreased treatment success rate.70

In addition to self-monitoring, other behaviortherapies have been applied. Moderate to positiveimprovement has resulted from covert desensitiza-tion88; attention reflection and response preventionby cutting hair close to the scalp89; attention-reflec-tion combined with punishment90; facial screening(covering the patient’s face and hair with a soft cloth when he or she attempted to pull)91; and a multiple-component treatment package consisting of self-mon-itoring, hair collection, goal setting, relaxation, andstimulus control.92 The last of these researchers intro-duced a new dependent measure: size of bald spots.70

The most successful self-management treatmentin the remediation of hair pulling is habit reversal.This treatment includes 13 components:

1. Competing response training2. Habit awareness training

3. Identifying response precursors (eg, face touch-ing, hair straightening)

4. Identifying situations in which the habit is likely to occur (eg, being alone, watching television,studying

5. Relaxation training6. Response prevention training (eg, practicing the

competing reaction for 3 minutes, such as grasp-ing or clenching fists when a habit responseprecursor or a situation that makes the habitlikely to occur exists)

7. Habit interruption (grasping or clenching to in-

terrupt hair pulling)8. Positive attention/overcorrection (practice posi-

tive hair care, such as combing or brushing hairafter pulling)

9. Practicing motor responses that compete withthe habit in front of a mirror

10. Self-monitoring11. Solicitation of social support (eg, significant oth-

ers encourage the patient to stop hair pulling)12. Habit inconvenience review 13. Display of improvement (ie, have the patient

approach situations that were previously avoid-

ed)39,70



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Habit reversal was first introduced as a generaleffective treatment for nervous habits by Azrin andNunn93 and was later tested against negative practicein 34 hair-pulling patients.16 Azrin, Nunn, andFrantz16 randomly assigned 34 subjects to one2-hour session of instruction in either habit reversalor negative practice. The results were remarkable;14 of 19 habit reversal subjects (74%) reported nohair pulling at the 4-week follow-up, starting withthe first posttreatment day, compared with only 5 of 15 negative practice subjects (33%). At the 4-monthevaluation, 11 of 18 habit reversal subjects were stillrefraining from hair pulling. At 22 months, 9 of 12habit reversal subjects reached were in remission,compared with 2 of 8 negative practice subjects.Other researchers have found similarly encouragingresults with habit reversal in 4 patients with a posi-tive 6-month follow-up.94

In patients with trichotillomania uncomplicatedby serious comorbidity, some researchers39 havehad good results with a modified form of habitreversal derived from the behavioral literature. The 7treatment elements utilized are hair collection, iden-tifying preventive strategies for high-risk situations,motivation enhancement, changing the internalmonologue, awareness training, competing re-sponse training, and relaxation training.39

Self-monitoring. Ask the patient to collect allthe hairs pulled each day in an envelope, countthem, write the number and the date on each enve-

lope, and bring the envelopes to the next treatmentsession. Explain that this will provide the patient andthe clinician with a daily measure of progress and will help the patient be accountable to himself orherself, since he or she will know exactly how muchhair he or she is pulling. This task seems to reducehair pulling by increasing the behavioral cost of pulling and by drawing on patients’ reluctance toshare this embarrassing information. Azrin, Nunn,and Frantz16 used a daily diary, and some patientsfind this method more practical and acceptable.

Coping strategies. After identifying the situa-

tions in which pulling occurs, help the patient de- velop coping strategies. For example, ask the patientto commit to keeping both hands on the steering wheel unless shifting or turning a radio dial, or askthe patient to commit to keeping both hands on thebook while reading. If pulling occurs during longstays in the bathroom, ask the patient to set a timerto 1 to 2 minutes and leave when it goes off. Makingthese commitments to the clinician seems to be animportant motivator.39

Motivation enhancement. Give the patient alist of possible reasons for wanting to stop hair

pulling. Ask him or her to check off all that apply

and write in any additional reasons he or she wishes.Explain that the motives driving the pulling behaviorhave overwhelmed the motives to stop. Ask thepatient to strengthen the motives to stop by postingthis list where he or she will review it at least once aday, for example, on the refrigerator door or bath-room mirror. It is useful to keep a copy for review during therapy.39

Changing the internal monologue. Ask thepatient to become aware of the internal monologuethat gives him or her permission to pull (eg, “I’ll only pull a few,” or “I’ ve already done so much damage,it doesn’t matter,” or “It feels good.”) Ask him or herto change his or her “self-talk” and to substitute amore functional message for these rationalizationseach time they occur. Offer a positive and a negativestatement because patients vary in the approachpreferred: “I deserve to take better care of myself than to pull out my hair” or “Hair pulling is damag-ing, disfiguring and self-destructive, and I don’t wantto do that to myself.”39

Awareness training. Ask the patient to slowly bring his or her hand(s) to the pulling area and, while doing so, to become exquisitely aware of thesensations in every part of the arm, from the shoul-der to the fingertips. Ask him or her to also pay attention to the hand as it enters the peripheral andcentral visual fields. Azrin, Nunn, and Frantz16 uti-lized practice in front of a mirror. Explain that youdo not want him or her to be able to pull without

being fully aware of it, and ask him or her to practicethis awareness training 12 minutes twice a day.39

Competing response. Ask the patient to lightly clench her thumbs inside her fists for 3 minutes whenever he or she has the urge to pull or toperform some other socially inconspicuous, incom-patible response. Explain that this precludes pullingand that the urge will usually pass within this time.Some patients prefer to substitute a form of tactilestimulation, and holding a soft eraser, stroking a softmakeup brush, squeezing a rubber isometric handexerciser, or fingering a string of beads can be sug-

gested.39Relaxation training. Explain that tension and

anxiety promote pulling. Ask the patient to choose aform of relaxation exercise (visualization of a pleas-ant scene, progressive muscle relaxation, or dia-phragmatic breathing) and to practice it for a few minutes one to several times a day “to lower yourgeneral level of tension.”

Not every element needs to be utilized with eachpatient. After the treatment package is in place, onecan review at each session whether or not the pa-tient has followed through with his or her commit-

ments. When the patient fails to carry out a treatment



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task, it may be useful to adopt a problem-solvingapproach (eg, “ What prevented you from doingthis?”) and explore both motivational factors, such asambivalence about stopping, and situational factors,including continued environmental stressors. Thisnoncritical stance helps to maintain the therapeuticalliance, contradicts the expectations of reprimand,and counterbalances the internalized criticism thatpatients usually bring from parental responses totheir hair pulling.39

Once hair pulling has ceased, sustained improve-ment seems to require teaching the patient relapseprevention strategies and arranging 3- to 6-monthfollow-up visits. Patients should be asked to con-tinue to rehearse the changed internal monologue,to review the motivations for stopping, and to utilizethe competing response as needed. In addition, it ishelpful to encourage patients to view lapses as sig-

nals to return to active treatment, rather than asoccasions for self-denigration or signs of an inescap-able, prolonged relapse.39

Hypnotic treatments A variety of hypnotic techniques have been ap-

plied in case reports or small series of patients,usually as adjuncts to other behavioral or psycho-therapeutic treatment elements. These elements in-cluded awareness training,61,65 relaxation train-ing,2,61,65,92 counseling,2,65 competing responsetraining,95 and changing self-statements about hair

pulling.96

Treatment outcome seems unrelated to thenumber of hypnotic sessions, but a correlation hasbeen noted97 between outcome and patients’ ability to be hypnotized, as reflected in their abilities toengage in age regression and to learn autohypnosis.Hypnotic suggestions have included pain on touch-ing the scalp or pulling hair (in cases where pulling was pleasurable),61,96 increased awareness of hairpulling behavior through associated hand warm-ing,92 and rituals other than hair pulling to decreaseanxiety.2 Several researchers have outlined the relevance of shaping posthypnotic suggestions to en-hance the patient’s sense of self-control.2,61,65,97

In view of the heterogeneity of techniques usedand the absence of controlled studies, no conclu-sions can be drawn about the utility of hypnosis intreating trichotillomania.39

Psychotherapy In the past decade great strides have been made

in the pharmacology of impulsive and compulsivedisorders (beta-blocking agents, mood stabilizers,serotoninergic antidepressants); despite these wel-come advances, there is still a role for psychother-apy in many of these conditions. The domain of

psychotherapy itself has been expanded and modi-

fied, the better to provide treatment for patients withthis important group of disorders. Now it has be-come clear that compulsive rituals, whether of cleaning or of checking, although some underlyingpsychodynamic can eventually be discerned, canseldom be treated successfully merely by the discov-ery and interpretation of the relevant dynamic. Ingeneral, it seem that patients with disorders charac-terized by compulsivity are more apt to derive ben-efit from verbal psychotherapy than those with dis-orders characterized by impulsivity. There are twointerrelated reasons as to why this is so; first, persons who are predominantly impulsive usually have anexternal locus of control and utilize mostly alloplas-tic coping mechanism, whereas compulsive personsas a rule have an internal locus of control and rely onautoplastic defenses. Second, those who try tochange the environment (ie, mostly utilize alloplas-tic coping mechanisms) rather than themselves, and who are controlled more by shame (via externalsources) than by guilt, tend to externalize the originsof their dif ficulties in living (eg, blaming the “otherguy ”), remaining themselves “faultless” (in their own view) and thus without much motivation for change.In contrast, compulsive persons are more likely toaccept responsibility for their problems, perhapseven to an exaggerated and unwarranted degree,and tend as a consequence to accept “patienthood”more readily, at least submitting to the need fortreatment with less complaint, if such need is sug-

gested by a spouse, relative, or friend.Trichotillomania, which is included in the im-

pulse control disorders in the DSM-IV , has muchmore in common with a compulsive than with animpulsive disorder because the activity tends to berepetitive and frequent, as with other behavioralmanifestations of OCD. One might view trichotillo-mania as a subtype of compulsive disorders, along with cleaning and checking. Moreover, the other 4DSM-IV impulse control disorders (pyromania, inter-mittent explosive disorder, kleptomania, pathologi-cal gambling) are often found in conjunction with

antisocial personality disorder (either with antisocialpersonality traits or with the full-fledged disorder),in which case the amenability to psychotherapy may be seriously reduced or nullified. In fact, thereseems to be tacit agreement about the reduced ame-nability to psychotherapy in persons with both im-pulse-control disorders and antisocial personality even in the earlier psychoanalytic literature.

Symbolically, hair represents beauty, attraction,and virility. Hair pulling has been viewed as a fetish,determined by a variety of unconscious conflicts.98

Buxbaum98 cited the expression “to tear one’s hair”

as a sign of despair and mourning. She felt that hair



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pulling might not only reflect aggression against self secondary to ambivalence toward the parents butmight also resemble a form of autoeroticism to which the child resorts in periods of anxiety andloneliness. Buxbaum related hair pulling to separa-tion anxiety, whereas Greenberg and Sarner11

viewed this symptom as a result of multiple fixationpoints at all levels of psychosexual development;they also reported hair pulling after actual or threat-ened object loss.

Pharmacotherapy Many drugs appear promising, but actually the

only one found effective in controlled trials appearsto be clomipramine. Instead of and in addition todrug effects, the improvements reported by the lit-erature data of uncontrolled trials may reflect non-specific therapeutic factors, such as the placebo ef-fect, self-monitoring, or the benefits of supportivepsychotherapy. Frequently, the duration of improve-ment is unspecified or the follow-up period is lim-ited to a few weeks or months, which we believe tobe too brief to evaluate outcomes of this chroniccondition. In many cases, improvement was transi-tory. Nevertheless, these uncontrolled observationspresent hypotheses to be weighed critically andtested, both in the clinical situation and in carefully designed, controlled trials.39 There are case reportsof response to imipramine,42 isocarboxazid,43,99 tra-zodone,45 and sertraline100,101; these need a distinc-

tion: in fact, in these cases, trichotillomania im-proved concomitantly with other comorbidpsychiatric disorders such as major depression ordysthymia, which suggests that treatment of comor-bid mood disorders may ameliorate trichotillomania.There have been isolated cases that responded toamitriptyline102 and the progestin levonorgestrel103

in the absence of mood disorders and to buspironein the presence of generalized anxiety disorder.39,104

Uncontrolled observations have also suggestedef ficacy for the combination of serotoninergic re-uptake inhibitors (SRIs) and neuroleptics. In a chart

review study, two patients who had a moderateresponse to adequate trials of clomipramine hadmarked improvement, sustained for 6 months, afterthe addition of 1 to 2 mg/d of pimozide, and 2 of 4patients with unsatisfactory or unsustained responseduring a fluoxetine trial had a moderate to markedsustained response during a subsequent trial of clo-mipramine (50-200 mg/d) combined with pimozide(2-3 mg/d).105 In this case series an important sideeffect was represented by the weight gain.

In a second chart review study, 3 of 4 patientsshowed significant improvement for “some months”

after risperidone, 1 mg/d, was added to clomipra-

mine; a fifth patient, receiving citalopram, did notrespond to added risperidone.106 One patient dis-continued risperidone because of worsening de-pression.

Controlled drug trials have been less encourag-ing. Two placebo-controlled, double-blind cross-over trials have failed to corroborate the effective-ness of fluoxetine.10,18 In a case report, a therapeuticresponse to fluoxetine stopped when isotretinoin was started for cystic acne and resumed when thismedication was discontinued.107

In contrast, a 10-week, double-blind, crossovertrial comparing clomipramine (100-250 mg) to des-ipramine (100-200 mg) in 13 patients reported thatclomipramine decreased hair pulling by 50% ormore in 9 subjects and induced complete remissionin 3.34 Only one patient responded more favorably to desipramine than to clomipramine. A follow-upevaluation indicated that benefit was maintained for6 months; after about 4 years, however, fewer thanhalf the patients continued to be at least moderately improved, despite intervening treatments.108

Stein, Bouwer, and Maud109 have used citalopram(a highly selective SRI [SSRI]) on an open-label nat-uralistic basis in 14 patients who presented withchronic hair pulling and met DSM-IV criteria fortrichotillomania. Ratings were completed every 2 weeks for 12 weeks during which time dosage wasincreased to a maximum of 60 mg daily. One patientdropped out, whereas in those who completed the

study, ratings on each of the scales employed weresignificantly improved after treatment; of com-pleters, 30.5% were responders at week 12.109

Other SSRIs have been used in the treatment of trichotillomania; paroxetine and fluvoxamine may prove to be effective therapies.110,111 According toseveral authors,34,36,46,108 trichotillomania may havean intermediate response, with good initial responseto SSRIs, but an unclear long-term outcome.105 Phar-macological factors in treatment resistance includeinsuf ficent dosage, slow onset of response (12 weeks are often needed), inadequate duration of

treatment (at least 12 months are often necessary forinitial treatment length), and symptom relapse afterdiscontinuation. Treatment resistance may also re-sult from inadequate treatment of comorbid Axis IIconditions, such as cluster A (odd) or cluster B(impulsive) personality disorders, social phobia, ortics or other neurological illness.

Because clomipramine appears to be the only medication whose effectiveness has been demon-strated in a double-blind trial, it deserves primary consideration; nevertheless, clomipramine’s adverseeffects (especially sedation, weight gain, and anti-

cholinergic side effects) are often problematic, and



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relapse has been reported in several cases despitecontinued treatment. Thus the first-line strategy shouldbe a trial of clomipramine or an SSRI (fluvoxamine,fluoxetine, paroxetine, sertraline, or citalopram).

Venlafaxine and mirtazapine, which, like clo-mipramine, strongly enhance both serotonergic andnoradrenergic functioning, may ultimately prove tobe alternative therapies, but their use in trichotillo-mania has not been investigated. The addition of alow dose of pimozide, risperidone, or haloperidolcan be considered in patients with a partial or un-sustained response to clomipramine. The small riskof tardive dyskinesia must be weighed and dis-closed.39

In the absence of better guides to treatment, thepatient’s subjective experience may be helpful andprovide clues. If pruritus motivates pulling, a shorttrial of adding topical steroid to a partially effectiveregimen may be indicated.

The observation of long-term benefit from lith-ium, albeit uncontrolled, suggests that lithium andother drugs that diminish neuronal excitability, such

as valproate or gabapentin, are worth investigatingin patients who complain of overwhelming impulsesto pull. Patients whose pulling is strongly motivatedby pleasurable sensation may deserve a trial of theopiate antagonist naltrexone.39

Obviously, comorbid conditions will influencedrug choice. From among all the drugs known to beeffective for the comorbid condition, the clinicianshould choose one that, on the basis of availabledata, is also beneficial in trichotillomania.112-114

An approach to planning integrated treatment forthe patient with trichotillomania that has reached the

point of acknowledging his or her participation, as

proposed by Koran,39 is displayed in Table II; obvi-ously, these guidelines are somewhat idealistic. Wefirst want to emphasize the relevance of a goodphysician-patient relationship and a successful refer-ral to a psychiatrist.

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Table II. Guidelines for the treatment of trichotillomania*

•Adequate physician-patient relationship to improve insight, acknowledgment of disease, and compliance with treatment• Evaluate all sites of pulling and measure baseline rates•Assess motivation for treatment• Inquire about trichophagia• Successful referral to the psychiatrist• Evaluate and treat comorbid conditions (eg, skin picking, mood disorders, anxiety disorders)•Guide patient toward educational and support groups• Institute modified habit reversal• Evaluate pharmacotherapy:

Clomipramine (evaluating the adverse effects of clomipramine) or SSRIsAdd low doses of neuroleptics (haloperidol, pimozide, or risperidone) in cases of partial or unsustained response to

antidepressants (clomipramine or SSRIs)Lithium carbonateNaltrexone

• Consider introducing posthypnotic suggestions• Institute relapse prevention strategies

*Modified from Koran LM. Trichotillomania. In: Obsessive-compulsive and related disorders in adults. A comprehensive clinical guide. Cam-

bridge (UK): University Press; 1999. p. 185-201.



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ing trichotillomania. Behav Ther 1981;12:473-81.

95. Hall JR, McGill JC. Hypnobehavioral treatment of self destruc-

tivebehavior:trichotillomaniaand bulimiain the samepatient.

Am J Clin Hypn 1986;29:39-46.

96. Rowen R. Hypnotic age regression in the treatment of a self-

destructive habit: trichotillomania. Am J Clin Hypn

1981;23:195-7.

97. Hynes JV. Hypnotic treatment of five adult cases of trichotillo-

mania. Aust J Clin Exp Hypn 1982;10:109-16.

98. Buxbaum E. Hair pullingand fetishism.Psychoanal Study Child

1960;15:243-60.

99. Parsons B, Quitkin FM, McGrath PJ. Phenelzine, imipramine,

and placebo in borderline patients meetingcriteriafor atypicaldepression. Psychopharmacol Bull 1989;25:524-34.

100. Rahman MA, Gregory R. Trichotillomania associated with HIV

infection and response to sertraline. Psychosomatics 1995;36:

417-8.

101. Bradford JMW, Gratzer TG.A treatment forimpulse control dis-

orders and paraphilia: a case report. Can J Psychiatry 1995;40:

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102. Snyder S. Trichotillomania treated with amitriptyline. J Nerv

Ment Dis 1980;168:505-7.

103. Perciaccante M, Perciaccante RG. Progestin treatment for ob-

sessive-compulsive disorder. Psychosomatics 1993;34:284-5.

104. Reid TL. Treatment of generalized anxietydisorder andtricho-

tillomania with buspirone [letter]. Am J Psychiatry 1992;149:

573-4.

105. SteinDJ, HollanderE. Lowdose pimozide augmentation of se-rotonin reuptake blockers in the treatment of trichotillomania.


106. SteinDJ, BouwerC, Hawkridge S. Risperidoneaugmentation of

serotonin reuptake inhibitors in obsessive-compulsive and re-

lated disorders. J Clin Psychiatry 1997;58:119-22.

107. Mahr G. Isotretinoin and trichotillomania [letter]. Psychoso-

matics 1990;31:235.

108. Swedo SE, Lenane MC, Leonard HL. Long-term treatment of

trichotillomania (hairpulling) [letter]. N Engl J Med 1993;329:

141-2.

109. Stein DJ, Bouwer C, Maud CM. Use of the selective serotonin

reuptake inhibitor citalopram in treatment of trichotillomania.

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110. Ravindran AV, Lapierre YD, Anisman H. Obsessive-compulsive

spectrum disorders: effective treatment with paroxetine. CanJ Psychiatry 1999;44:805-7.

111. FiggittDP, McClellanKJ. Fluvoxamine.An updated reviewof its

usein themanagement ofadultswithanxiety disorders. Drugs

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112. Lotti T, Hautmann G, Panconesi E. Neuropeptides and skin.

J Am Acad Dermatol 1995;33:482-96.

113. Hautmann G, Panconesi E. Terapia psicofarmacologica in der-

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dermatological treatments. Berlin: Springer; 1999. p. 803-11.



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Answer sheets are bound into the Journal for US, Canadian, and life members. Request additionalanswer sheets from American Academy of Dermatology, Member Services Department, PO Box 4014,Schaumburg, IL 60168-4014. Phone: 847-330-0230; E-mail: [email protected]

CME examination

Identification No. 802-106

Instructions for Category I CME credit appear in the front advertising section. See last page of Contents for page number.

Questions 1-30, Hautmann G, Hercogova J, Lotti T. J Am Acad Dermatol 2002;46:807-21.

Directions for questions 1-30: Give single best

response.

1. The term trichotillomania means

a. the fear of becoming bald

b. the prodromal symptoms of baldness

c. a self-inflicted depilation of the scalpd. frequent depilation

e. none of the above

2. Trichotillomania

a. presents a high occurrence, approximately 1 in

100 persons

b. presents a high occurrence, approximately 1 in

200 persons

c. presents a low occurrence, approximately 1 in

1000 persons

d. presents a high occurrence, approximately 1 in

200 persons, appearing by the age of 18 years

e. is more frequent in adults than in children3. In trichotillomania,

a. eyebrows are second in frequency as a hair-pull-

ing site

b. extremities are never involved

c. the pubic region is a very frequent hair-pulling area

d. an itching sensation occurs when the eyelashes

are involved

e. approximately 12% of first-degree relatives of pa-

tients have also had it

4. Plucking is

a. diffuse to the scalp

b. confined to a single patch of varying sizec. confined to a single, scaly patch of varying size

d. confined to 2 or 3 patches that are 5 to 7 cm in

diameter

e. diffuse to the scalp that appears erythematous and

scaling

5. Patients with trichotillomania

a. usually present to psychiatrists early

b. always refuse to present to physicians

c. often present to a dermatologist after avoiding

dating for a long period

d. prefer to present to a psychiatrist rather than to a

dermatologist

e. acknowledge their condition

6. Trichotillomania

a. is an acute disease

b. is sometimes an autoresolving and time-limited

disease

c. always presents remission periods

d. is classified into remitting and chronic forms

e. is usually chronic with exacerbation and remis-

sion periods

7. Development of the chronic form of trichotillomania

a. appears to occur more frequently in childhood

and adolescence

b. is typical of younger male patients

c. is only related to age at onset

d. appears to occur more frequently in older female

patients

e. appears more frequently in association with mood

disorders

8. Patients with trichotillomania

a. generally report an irresistible impulse without

concomitant anxiety that causes them to pull out

any hair

b. generally report an irresistible impulse with con-

comitant anxiety that causes them to pull out a

specific hair

c. generally report an irresistible impulse with con-

comitant anxiety that causes them to pull out any

haird. refer to pain in the scalp

e. refer to a stinging sensation

9. Trichotillomania is

a. commonly associated with skin picking and nail

biting

b. commonly associated with skin picking, ereuto-

phobia, and nail biting

c. commonly associated with skin picking, nail bit-

ing, acne, and/or rosacea

d. a symptom of obsessive-compulsive disorder

(OCD)

e. usually associated with other symptoms of OCD16/2/124271

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10. The possible medical complications of trichotilloma-

nia are

a. cicatricial alopecia, intestinal obstruction, follicu-

litis, and lombalgia

b. skin cancer, intestinal obstruction, folliculitis, and

chalazion

c. skin cancer, back pain, intestinal obstruction, andperifolliculitis

d. gastric perforation, acute pancreatitis, carpal tun-

nel syndrome, folliculitis, and epidermal cell car-

cinoma

e. gastric perforation, acute pancreatitis, carpal tun-

nel syndrome, constipation, and blepharitis

11. The Trichotillomania Symptom Severity Scale

a. is a modified form of the Yale-Brown Obsessive-

Compulsive Scale

b. has a score range of 0 to 10

c. consists of 5 (evaluative) items

d. does not evaluate the interference of trichotillo-mania with daily activity

e. is a self-rating scale

12. The histologic findings of trichotillomania

a. are pathognomonic, showing normally growing

hairs among empty hair follicles

b. show normally growing hairs among empty hair

follicles in a noninflammatory dermis

c. show normally growing hairs among empty hair

follicles in an inflammatory dermis

d. usually present typical and characteristic evidence

of traumatic damage

e. show that the hair is in a dystrophic anagen state

13. The hair pulling

a. is usually an ego-dystonic behavior

b. is usually an ego-syntonic behavior

c. is often an impulsive behavior

d. has its origins in an aberrant psychosexual devel-

opment

e. is an ego-dystonic, unpleasant behavior

14. Hair pulling is

a. elicited by an obsession

b. a compulsive, pleasurable behavior

c. engaged in with maximal awareness

d. carried out to avoid increased anxiety

e. more strenuously resisted than are compulsions

15. Subjects with trichotillomania

a. exhibit abnormalities of serotonin’s cerebral spi-

nal fluid metabolite

b. like subjects with OCD, present a blunted re-

sponse to metachlorophenylpiperazine

c. present a decreased resting glucose metabolism in

the orbital frontal, anterior cingulate, and caudate

regions

d. present a decreased resting glucose metabolism in

the orbital frontal region, but an increased resting

glucose metabolism in the anterior cingulate and

caudate regions

e. unlike subjects with OCD, do not present abnor-malities of serotonin’s cerebral spinal fluid metab-olite

16. The most successful self-management treatment inthe remediation of hair pullinga. is habit reversalb. consists of self-monitoringc. includes hair collectiond. is stimulus control

17. In the treatment of trichotillomania, the only drugfound to be effective appears to bea. imipramineb. fluoxetinec. clomipramined. clomipramine intravenously administerede. imipramine associated with desipramine

18. In the treatment of trichotillomania, according to achart review study, patients with a moderate responsetoa. clomipramine had marked improvement after the

addition of 8 mg/d of pimozideb. imipramine had marked improvement after the

addition of 2 mg/d of pimozidec. clomipramine had marked improvement after the

addition of 2 mg/d of pimozided. desipramine had marked improvement after the

addition of 2 mg/d of pimozide

19. In the treatment of trichotillomania, according to achart review study, patients with a moderate responseto

a. clomipramine had marked improvement after theaddition of 8 mg/d of risperidone

b. fluoxetine had marked improvement after the ad-dition of 1 mg/d of risperidone

c. fluoxetine had marked improvement after the ad-dition of 2 mg/d of risperidone

d. fluoxetine had marked improvement after the ad-dition of 1 mg/kg per day of isotretinoin

e. clomipramine had marked improvement after theaddition of 1 mg/kg per day of isotretinoin

20. Which of the following are the diagnostic criteria of DSM-IV for trichotillomania?a. Acute pulling out of one’s hair resulting in notice-

able hair loss; an increasing sense of tension im-mediately before pulling out the hair or whenattempting to resist the behavior; pleasure, grati-fication, or relief when pulling out the hair; thedisturbance is not better accounted for by anothermental disorder and is not due to a general med-ical condition (eg, a dermatologic condition); thedisturbance causes clinically significant distress orimpairment in social, occupational, or other areasof functioning

b. Recurrent pulling out of one’s hair; an increasingsense of tension immediately before pulling outthe hair or when attempting to resist the behavior;

pleasure, gratification, or relief when pulling out

CME examination 823J A M A CAD DERMATOL V OLUME 46, NUMBER 6


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the hair; the disturbance is not better accountedfor by another mental disorder but may be due to

a general medical condition (eg, a dermatologiccondition); the disturbance may cause clinically

significant distress or impairment in social, occu-

pational, or other areas of functioning

c. Recurrent pulling out of one’s hair resulting innoticeable hair loss; anxiety or depression imme-diately before pulling out the hair or when at-

tempting to resist the behavior; pleasure, gratifi-cation, or relief when pulling out the hair; the

disturbance is not better accounted for by anothermental disorder and is not due to a general med-

ical condition (eg, a dermatologic condition); thedisturbance does not cause clinically significant

distress or impairment in social, occupational, orother areas of functioning

d. Recurrent pulling out of one’s hair resulting innoticeable hair loss; an increasing sense of tension

immediately before pulling out the hair or whenattempting to resist the behavior; pleasure, grati-

fication, or relief when pulling out the hair; thedisturbance is not better accounted for by another

mental disorder and is not due to a general med-ical condition (eg, a dermatologic condition); the

disturbance causes clinically significant distress orimpairment in social, occupational, or other areas

of functioninge. Recurrent pulling out of one’s hair resulting in

noticeable hair loss; an increasing sense of tensionimmediately before pulling out the hair or when

attempting to resist the behavior; the disturbance

is not better accounted for by another mentaldisorder and is not due to a general medical con-dition (eg, a dermatologic condition); the distur-

bance causes clinically significant distress or im-

pairment in social, occupational, or other areas of functioning

21. The severity of trichotillomania is usually rated by a. The Trichotillomania Symptom Severity Scale, The

Trichotillomania Impairment Scale, Physician’sRating of Clinical Progress

b. The Trichotillomania Symptom Severity Scale, The Yale-Brown Obsessive-Compulsive Scale, Physi-

cian’s Rating of Clinical Progressc. Psychiatric Institute Trichotillomania Scale, The

Trichotillomania Impairment Scale, The Maudsley Obsessive Compulsive Inventory

d. The Yale-Brown Obsessive-Compulsive Scale,Psychiatric Institute Trichotillomania Scale, The

Trichotillomania Symptom Severity Scale

22. The only validated self-rating scale is

a. The Trichotillomania Symptom Severity Scaleb. The Massachusetts General Hospital Hairpulling

Scalec. The Yale-Brown Obsessive-Compulsive Scale

d. The Trichotillomania Impairment Scale

e. Psychiatric Institute Trichotillomania Scale

23. Histologic findings of trichotillomania show thata. follicular plugging with keratin debris is always

present

b. when follicular plugging with keratin debris ispresent, it is pathognomonic

c. follicular plugging with keratin debris is not

presentd. perifollicular plugging with keratin debris is an

expression of dermal infiltration. follicular plug-ging with keratin debris can be prominent

24. Which of the following histologic features is charac-teristic of trichotillomania?

a. Many of the empty hair follicles show evidence of changing into a dystrophic anagen state, with

transformation of the lower follicular epitheliuminto a cord of undifferentiated basaloid cells.

b. Many of the empty hair follicles show evidence of changing into the catagen state, with transforma-

tion of the lower follicular epithelium into a cordof undifferentiated basaloid cells.

c. Many of the empty hair follicles show evidence of

changing into the catagen state, with transforma-tion of the upper follicular epithelium into a cord

of undifferentiated basaloid cells.d. Many of the empty hair follicles show evidence of

changing into the catagen state, with transforma-tion of the lower epithelium into a cord of epithe-lioid cells.

e. Many of the empty hair follicles show evidence of changing into the telogen state, with transforma-

tion of the lower epithelium into a cord of epithe-lioid cells.

25. Chronic hair pulling has been reported in association with

a. social phobia, recurrent depression, psychosisb. anxiety disorders, schizophrenia, mental retarda-

tion

c. major depression, severe anxiety, psychosis, anddysthymia

d. OCD, severe anxiety, psychosis, and dysthymia

26. Hair pulling in infancy and early childhood is

a. predominant in females and has a negative prog-nosis

b. predominant in males and has a negative progno-sis

c. a praecox sign of Sydenham’s choread. predominant in males and has a favorable prog-

nosis

e. predominant in females and has a favorable prog-nosis

27. Individuals who chronically pull out their haira. suffer from trichotillomania

b. have tension and gratificationc. do not meet DSM-IV criteria for trichotillomania in

20% of casesd. do not meet DSM-IV criteria for trichotillomania in

35% of cases

824 CME examination J A M A CAD DERMATOLJUNE 2002


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e. do not meet DSM-IV criteria for trichotillomania in10% of cases

28. In patients with trichotillomania uncomplicated by serious comorbidity, good results have been reached

with a modified form of habit reversal. Which of thefollowing treatment elements are utilized?a. Hair collection; identifying preventive strategies

for high-risk situations; motivation enhancement;changing the internal monologue; awarenesstraining; competing response training; relaxationtraining

b. Hair collection; identifying preventive strategiesfor high-risk situations; motivation enhancement;awareness training; competing response training;relaxation training

c. Hair collection; identifying preventive strategiesfor high-risk situations; motivation enhancement;identifying situations in which the habit is likely tooccur; changing the internal monologue; aware-

ness training; competing response training; relax-ation training

d. Hair collection; identifying preventive strategiesfor high-risk situations; motivation enhancement;changing the internal monologue; competing re-sponse training; relaxation training

29. The first-line strategy in treatment of trichotillomania

should be a trial of

a. risperidone and one of these selective serotonin

reuptake inhibitors (SSRIs): fluvoxamine, fluox-

etine, paroxetine, sertraline, citalopram

b. clomipramine or one of these SSRIs: fluvoxamine,

fluoxetine, venlafaxine, sertraline, citalopramc. trimipramine or one of these SSRIs: fluvoxamine,

fluoxetine, paroxetine, sertraline, citalopram

d. clomipramine or one of these SSRIs: fluvoxamine,

fluoxetine, venlafaxine, mirtrazapine, citalopram

e. clomipramine and/or one of these SSRIs: fluvox-

amine, fluoxetine, paroxetine, sertraline, citalopram

30. Pharmacologic factors in treatment resistance include

a. slow onset of response (6 weeks are often

needed)

b. inadequate treatment of comorbid Axis II condi-

tions

c. inadequate treatment of comorbid Axis I condi-tions

d. inadequate treatment of comorbid Axis I condi-

tions; insuf ficient drug dosage; slow onset of re-

sponse; inadequate duration of treatment and

symptom relapse after discontinuation

CME examination 825J A M A CAD DERMATOL V OLUME 46, NUMBER 6


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Answers to CME examination

Identification No. 802-106

June 2002 issue of the Journal of the American Academy of Dermatology

Questions 1-30, Hautmann G, Hercogova J, Lotti T. J Am Acad Dermatol 2002;46:807-21.

1. c

2. d

3. a

4. b

5. c

6. e

7. d

8. b

9. a10. e

11. c

12. b

13. a

14. b

15. e

16. a

17. c

18. d

19. b

20. d

21. a

22. b

23. e

24. b25. c

26. d

27. c

28. a

29. e

30. d

AMERICAN BOARD OF DERMATOLOGY EXAMINATION DATES

In 2002, the Certifying Examination of the American Board of Dermatopathology (ABD) will be held

at the Holiday Inn O’Hare International in Rosemont, Illinois on Oct 13 and 14, 2002.

The next examination for subspecialty certification in Dermatopathology will be held in Tampa,

2002 trichotillomania

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