Trichotillomania in Children

Trichotillomania is an anxiety disorder characterized by excessive pulling out of one's own hair, to the point of noticeable hair loss. People with trichotillomania pull hair from throughout their body, though the most common areas are from the scalp, eyebrows and eyelashes.

The disorder was first identified in the 1880s by French dermatologist Francois Hallopeau, who had a patient who pulled out all of his body hair. The name is derived from the Greek terms for hair (trich), pulling (tillo), and morbid impulse (mania).

Thrichotillomania often begins in childhood or early adolescence. Korean dermatologist Chull-Wan Ihm, MD, writes that the illness occurs seven times more often in children than in adults, with the peak age of onset between ages 4 and 17.

• Hair-pulling in trichotillomania is far more severe than that implied in this photo.

Clinical Criteria for Trichotillomania

• The DSM-IV-TR, the diagnostic manual for psychiatrists, outlines the following criteria for trichotillomania, which is classified as an impulse-control disorder:

  (1) recurrent pulling out of one's hair, resulting in noticeable hair loss
  (2) an increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior
  (3) pleasure, gratification, or relief when pulling out the hair
  (4) the disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (e.g., a dermatologic condition)
  and
  (5) the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  Some researchers believe that these criteria are too narrow, and that not all people who compulsively pull their hair report the tension and relief captured in these criteria. A 1991 study (by Christensen and colleagues) found that only .6 percent of the college student sample (2,579 students) met full criteria for trichotillomania, but 2.5 percent met criteria when the requirements were broadened to include those who did report prepulling tension or postpulling relief.

  This distinction is especially important in children and adolescents, who might not have the self-awareness to report these psychological symptoms.

  Kathleen Trainor, Psy.D., a pediatric psychologist at Massachusetts General Hospital in Boston, writes in the American Journal of Psychiatry from her experience working with young patients with trichotillomania: "Certainly, individuals with trichotillomania may pull their hair when they are anxious, but they usually pull more often when they are in a state of relaxation. Hair pulling for them is a self-soothing behavior, not unlike thumb sucking, which becomes habitual."

Diagnosis in children

• Trichotillomania in children is sometimes classified as a short-term habit of hair-pulling. Longer-term, careful observation is important to determining if the behavior is more serious. If the hair-pulling lasts several months, it may meet criteria for trichotillomania.

  Adolescent-onset trichotillomania is often a sign that the individual also suffers from more severe psychopathology, such as other impulse-control disorders or obsessive compulsive disorder.

  It is important to conduct a comprehensive exam when evaluating children or teens, to rule out any co-occurring conditions--such as an anxiety or mood disorder--that may contribute to the behavior, and thus warrant different treatment.

Significance of trichotillomania in children

• Trichotillomania can cause real distress in children and adolescents and can impede the child's participation in typical social or academic tasks.

  This distress comes partially because the child looks noticeably different, with missing patches of hair, and also because the habit seems odd and off-putting to peers. According to a guide for clinicians produced by the Scientific Advisory Board of the Trichotillomania Learning Center, the young person is often embarrassed by the habit and the peer taunting that accompanies it, and also loses time to hair-pulling that could be spent socializing or studying.

  Family distress may also arise, since parents do not know how to help their children stop the hair-pulling. Parents may feel that the behavior is under their children's conscious control, and can become frustrated when the children deny the behavior entirely or make little or no progress in reducing the behavior.

Treatment for trichotillomania in young people

• Trainor, the psychologist from Massachusetts General Hospital, reports that cognitive-behavioral therapy (CBT) has proven effective in treatment trichotillomania in young patients. She adds that medication, usually a selective serotonin reuptake inhibitor (SSRI), can be a helpful addition if the patient's hair-pulling is caused by an underlying mood or anxiety disorder. But as mentioned above, she reports that many of her patients engage in compulsive hair-pulling in the absence of a mood or anxiety disorder. For these patients, Trainor writes, medication often shows no effect.

  The course of CBT trains the children or teens to reverse their hair-pulling habit, and requires parental involvement. The treatment is "very hard work for the patient," Trainor writes, because the hair-pulling is an ingrained habit and one that often helps the patient feel good.

Role of the family in treatment

• Family involvement is usually integral to successful treatment for children and adolescents with trichotillomania. With younger children, parents may need to directly oversee behavioral treatment and changes.

  Family discord--whether or not it is overtly related to the hair-pulling--can contribute to or exacerbate the stress and severity of trichotillomania. Thus families may also want to engage in family therapy to address any of these issues, easing the way for the young person's recovery.

  (http://www.trich.org/dnld/Child_Clinicians_Guide_v08.pdf)