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Letter to the Editor   |    
New Behavioral Approach to Trichotillomania
SAMIR A. SALAMA, M.D.; A. AZIZ A. SALAMA, M.D.
Am J Psychiatry 1999;156:1469-1470.

To the Editor: According to DSM-IV, the essential feature of trichotillomania is the recurrent pulling of one’s hair, which results in noticeable hair loss and great tension before pulling out hair or when attempting to resist the behavior, followed by relief when pulling out hair.

Trichotillomania shares features in common with obsessive-compulsive disorder, especially with drug response (1). Unfortunately, patients do not seek treatment for years because of embarrassment. Patients with trichotillomania respond best to a combination of psychopharmacology, psychotherapy, and behavior-modification therapy rather than to psychopharmacology alone (2). We present the cases of three young women who responded well to a combination of medication and habit substitution (3).

Ms. A was a 17-year-old adolescent with a history of low self-esteem, depression, anxiety, and hair pulling. She was described as a perfectionist and a loner. She reported hair pulling because of nervousness but was concerned about the way it affected her looks. She was treated with paroxetine, 30 mg/day, and clomipramine, 100 mg at bedtime. Her depression improved, but her hair pulling continued. One day, her mother asked her to pull the weeds in their flower beds. She noticed being fascinated by pulling each weed and looking at its roots. When she pulled her hair, she noted that her hair also had roots. She reported feeling relief by pulling weeds. In a few weeks, she stopped pulling her hair, which started growing back, and realized that her nervousness was calmed by pulling weeds instead of her hair.

Anna was a 9-year-old child who was admitted to an inpatient hospitalization program. Her main complaint was, "I am pulling my hair out." Her head was bald, and she was isolated from other children. A mental status examination showed depressed mood and hostile behavior. She was treated with fluoxetine, 20 mg/day. Encouraged by Ms. A, she was advised to practice weed pulling at home. After 3 months of outpatient visits, her condition showed improvement, and her hair started growing. Anna reported that feeling the roots of the weeds made her less tense and reduced the urge to pull her hair.

Ms. C was a 23-year-old woman treated on an outpatient basis for trichotillomania. She presented with severe depression related to the divorce of her parents and reported pulling her hair out and creating balding areas on a regular basis since the age of 12. She was placed on a regimen of clomipramine, 50 mg/day. Encouraged by Ms. A and Anna, Ms. C was advised to practice weed pulling. Also, as with these two patients, Ms. C began to show significant improvement after the initiation of medication and habit substitution.

As in the cases mentioned, patients with trichotillomania report an overwhelming urge to pull their hair. After this hair pulling, their inner tension is relieved until the return of the compulsive urge and its accompanying anxiety. These symptoms are similar to those of patients with obsessive-compulsive disorder, who have a similar response to treatment. It is, however, noteworthy that all three patients may have responded either partially or fully to psychopharmacology alone, because not all studies have found drug therapy beneficial for trichotillomania.

Swedo SE, Leonard HL, Lenana MD, Rettew DC: Trichotillomania, a profile of the disorder from infancy through adulthood. Int Pediatrics  1992; 7:144–150
 
Swedo SE, Leonard HL, Rapoport JL, Lenane MC, Goldberger EL, Cheslow DL: A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania. N Engl J Med  1989; 321:497–501
[PubMed]
[CrossRef]
 
Azrin NH, Nunn RG: Habit reversal: a method of eliminating nervous habits and tics. Behav Res Ther  1973; 11:619–628
[PubMed]
[CrossRef]
 
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References

Swedo SE, Leonard HL, Lenana MD, Rettew DC: Trichotillomania, a profile of the disorder from infancy through adulthood. Int Pediatrics  1992; 7:144–150
 
Swedo SE, Leonard HL, Rapoport JL, Lenane MC, Goldberger EL, Cheslow DL: A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania. N Engl J Med  1989; 321:497–501
[PubMed]
[CrossRef]
 
Azrin NH, Nunn RG: Habit reversal: a method of eliminating nervous habits and tics. Behav Res Ther  1973; 11:619–628
[PubMed]
[CrossRef]
 
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