Trichotillomania

Why trichotillomania? In their opening chapter, the editors anticipate the reasonable criticism that a textbook on compulsive hair-pulling may interest only a few specialists. They reply, correctly, that in many cases the problem is disabling and that better understanding of this condition will shed light on other so-called obsessive-compulsive disorder (OCD) spectrum disorders. This volume represents the most comprehensive reference available to date on this overlooked problem, and all of the editors and contributors are leaders in the field.

Like most contemporary comprehensive textbooks on anxiety or impulse disorders, after reviewing the scientific knowledge about this condition this volume then describes the first-line treatments for hair pulling: selective serotonin reuptake inhibitors (SSRIs) and roughly 10 sessions of cognitive behavior therapy (alone or in combination). What is unique here is that 1) behavior therapy is described in sufficient detail in two chapters to permit a clinician with some familiarity with behavior therapy to try the treatment; 2) detailed chapters are included on treatment approaches other than these two approaches (they demonstrate that hypnosis is at times effective for trichotillomania, as is psychoanalytic treatment); and 3) numerous assessment and rating scales are provided to help treaters gauge both symptomatic and functional improvement.

Reading this mass of information about this very specific behavior caused me to wonder whether the trend for treaters and researchers to specialize in more and narrower diagnostic categories comes at a cost in understanding. Is there some basic unifying function of the various grooming, self-injurious, and self-manipulative behaviors (the specific term seems to depend largely on the diagnostician’s discipline and the sufferer’s intellectual level) scattered throughout DSM-IV? Is it best to follow the current custom and view these behaviors as part of an OCD spectrum, or might it be more productive to adopt the Darwinian perspective suggested by Nesse and Williams (1) and view these behaviors as varying manifestations of a common ancient defensive function (ridding the skin or hair of dangerous parasites, for example) that also acts to soothe overstimulation? This approach is touched upon in a fascinating veterinary chapter that includes arresting imagery of a dog powerless to stop chewing his leg and a bird plucking all feathers within reach of his beak—both stopping in response to SSRI or opiate antagonist drugs.

Enough splitting of hairs—Trichotillomania will be a valuable reference on any clinician’s shelf. As a bonus, the treatment methods described here apply equally well to a variety of impulsive disorders seen by the clinician, including but not limited to destructive picking of scabs or pimples, nasal passages, or nails.