Trichotillomania
What is trichotillomania?
-It is a disorder characterized by a compulsive desire to pull out one’s hair. It does have some overlap with skin picking.
What motivates a patient with trichotillomania to pull their hair?
The reasons vary but usually fall into 2 categories:
-Autonomic, or an almost absent minded habit (seen in those who absentmindedly twirl their hair for instance) vs
-Focused Reasons, which can vary:
-Thinking about the act causes tension build up, which leads to an insatiable need to follow through with the thoughts.
-A subcategory of these patients may fixate on hair that feels different, such as being more coarse or kinked compared to surrounding hair.
-A feeling of pleasure when a hair is plucked out— sometimes this little bit of pain gives the patient pleasure and reinforces the pulling.
-Sometimes there is a motivation to do something with the hair, such as lick it, taste it, or consume/eat it (called dermatophagia).
Is trichotillomania a form of OCD?
No, it is not the same as OCD. While there is a higher rate of OCD in those who have trichotillomania, there are many with trichotillomania who do not have OCD.
What kind of therapy treats trichotillomania?
Habit reversal training, which also helps with skin picking and nail biting. This type of therapy tends to be offered at anxiety treatment centers that also treat OCD (OCD is treated via a different type of therapy called exposure and response prevention).
What medications can help with trichotillomania?
There are only a few medications with legitimate evidence behind them:
*N-acetylcysteine (NAC) has demonstrated benefit in double-blind placebo-controlled studies. Click here to learn more about NAC.
*Olanzapine (brand name Zyprexa) is an atypical antipsychotic that has shown to be effective in lowering the incidence of trichotillomania in a double blinded study. The average dose in the study is 10mg and doses range from 2.5mg to 15mg per day. It has high side effect potential including significant weight gain.
*Dronabinol, a cannabinoid agonist, showed reduction in trichotillomania symptoms in an open label trial at a mean dose of 11.6 mg/day. Doses range from 2.2mg to 15mg per day divided into two daily doses. The research supporting dronabinol is not as powerful as placebo controlled studies for NAC & Olanzapine but it is still promising.
*Naltrexone does have some evidence in lowering symptoms of trichotillomania in those patients who get a burst of pleasure when they pluck the hair but in larger studies it hasn’t done as well, even at doses of 150mg.
Do SSRIs, which treat OCD very well, help in trichotillomania?
No, there is not much evidence to support their use. However, if there is an uptick in OCD or generalized anxiety that has led to worsening symptoms of trichotillomania, it may be worth trying SSRIs.
There is a smaller study that supports the use of clomipramine, but that is an older antidepressant that has other side effects to watch out for.
