Trichotillomania in the broadest sense is self induced loss of hair. It is classified in DSM-IV as an nerve impulse control disorder with pyromania pathological gambling and kleptomania and includes the criterion of an increasing sense of tension before pulling the hair and gratification or relief when pulling the hair. However some people with trichotillomania do not endorse the increase of rising tension and subsequent pleasure gratification or relief as part of the criteria because many individuals with trichotillomania may not realize they are pulling their hair patients presenting for diagnosis may deny the criteria for tension prior to hair pulling or a sense of gratification after hair is pulled.
Trichotillomania has been hypothesized to position on the obsessive compulsive spectrum(OCD) which is proposed to encompass obsessive compulsive disorder nail biting and skin picking tic disorders and eating disorders. These conditions may share clinical features genetic contributions and possibly treatment reception however differences between trichotillomania and OCD are present in symptoms neural function and cognitive profile. In the sense that it is associated with irresistible urges to execute unwanted repetitive behavior trichotillomania is akin to some of these conditions and rates of trichotillomania among relatives of OCD patients is higher than expected by chance. how differences between the disorder and OCD have been noted including differing peak ages at onset rates of comorbidity gender differences and neural dysfunction and cognitive profile. When it occurs in early childhood it can be regarded as a clear cut clinical entity.
Trichotillomania is often not a focused act but quite hair pulling occurs in a trance like state hence trichotillomania is subdivided into automatic versus focused hair pulling. Children are more often in the automatic or unconscious subtype and may not consciously remember pulling their hair. Other individuals may have focused or conscious rituals associated with hair clouting including seeking specific types of hairs to clout clouting until the hair feels just right or clouting in response to a specific sensation. Knowledge of the subtype is helpful in determining handling strategies.
Individuals with trichotillomania exhibit hair of differing lengths; some are broken hairs with blunt ends some raw growth with tapered ends some broken mid shaft or some uneven stubble. Scaling on the scalp is not present overall hair density is normal and a hair device test is negative (the hair does not device out easily). Hair is often pulled out leaving an unusual shape, individuals with trichotillomania may be secretive or shameful of the hair pull behavior.
An additional psychological effect can be low self esteem frequently associated with being shunned by peers and the fear of socializing due to appearance and negative attention they may receive. location seems to be a strong stress-related component. In low stress environments some exhibit no symptoms whatsoever. This pulling much resumes upon leaving this environment. Some individuals with TTM may feel they are the only person with this problem due to unrefined rates of reporting.
Other medical complications include infection permanent loss of hair repetitive stress injury carpal tunnel syndrome and gastrointestinal obstruction as a result of trichophagia. In trichophagia family with trichotillomania also ingest the hair that they pull in extreme and rare cases this can lead to a hair ball (trichobezoar). Rapunzel syndrome an extreme form of trichobezoar in which the tail of the hair globe extends into the intestines can be fatal if misdiagnosed.
Environment is a big factor which affects hair pulling. Sedentary activities such as being in a relaxed environment are contributing to hair pulling. A common example of a sedentary activity promoting body covering pulling is lying in a bed while trying to rest or fall asleep. An extreme example of automatic TTM is found when some patients have been ascertained to pull their hair out while asleep. This is named sleep isolated trichotillomania.