2002 Trichotillomania

CONTINUING
MEDICAL EDUCATION
Trichotillomania
Giuseppe Hautmann, MD,a Jana Hercogova, MD,b and Torello Lotti, MDa
Florence, Italy, and Prague, Czech Republic
Trichotillomania is a neglected psychiatric disorder with dermatologic expression that has only recently
received research attention. On the basis of clinical data, trichotillomania appears to be far more common
than previously believed. Like obsessive-compulsive disorder, the hair-pulling behavior is recognized as
senseless and undesirable but is performed in response to several emotions and affects, such as increasing
anxiety, or unconscious conflicts with resultant tension relief. The condition may be episodic but is usually
chronic and difficult to treat. On the basis of possible medical and psychiatric complications, it is important
that the diagnosis is exact and early. We describe the comorbidity and the phenomenology of trichotillomania, paying attention to the possible available treatments. (J Am Acad Dermatol 2002;46:807-21.)
Learning objective: At the conclusion of this learning activity, participants should be familiar with clinical
and histologic aspects of trichotillomania and should be able to cope with the risks of medical and
psychiatric complications in these patients. Finally, participants will be able to easily interact with psychiatrists, when needed, to identify the most successful treatment.
EPIDEMIOLOGY
From the Departments of Dermatology and Venereology, University

of Florence,a and Charles University, Prague.b
Reprint requests: Giuseppe Hautmann, MD, Via J. Nardi, 50, 50132
Florence, Italy. E-mail: ghautmann@hotmail.com.
Copyright 2002 by the American Academy of Dermatology, Inc.
0190-9622/2002/$35.00 0 16/2/122749
doi:10.1067/mjd.2002.122749
Until the 1990s, trichotillomania was thought to

be quite rare. For example, case frequency was
reported as 2 per 1200 patients treated for psychiatric disorders in a university outpatient clinic,2 and 5
per 10,000 children treated for psychiatric disorders.3 The disorder was thought to be more common, though still infrequent, in dermatological practice.4,5 Now that media attention is increasing
awareness of treatments for trichotillomania, affected individuals are increasingly seeking care.
Nevertheless, some researchers have reported an
extremely low incidence,3,6-8 whereas others estimate a high occurrence, approximately 1 in every
200 persons by the age of 18 years.9-12 It is noted
predominantly in girls and women and occurs more
commonly in children than in adults; men may be
able to hide their hair pulling better by masking it as
male pattern baldness and shaving their mustaches
and beards. When it occurs later in life, such as
during adulthood or in older patients, it is associated
with more psychopathology and with a poorer prognosis. Age at onset is frequently between 5 and 12
years or early childhood to adolescence.5,11 Nevertheless, trichotillomania that has its onset in infancy
and early childhood is sometimes considered separately because it may be a different disorder from
that which presents during adolescence and young
adulthood.
n 1889 Hallopeau, a French dermatologist, reported a case of self-inflicted depilation of the

scalp and coined the term trichotillomania
(from the Greek thrix, hair; tillein, pulling out; mania, madness).1 More than 100 years later, the epidemiology, etiology, natural history, and appropriate treatment of trichotillomania are still unclear.
The question is whether trichotillomania is a syndrome by itself, a form of obsessive-compulsive disorder, or a symptom observed in various disorders;
in fact, although hair pulling may be considered to
be a symptom of a broad spectrum of psychopathologies (from a transient mild habit, through impulse
control disorder, obsessive-compulsive disorder
spectrum, personality disorders such as borderline
personality or histrionic personality, body dysmorphic disorder, major mental retardation, to schizophrenia and depression), in this review we refer to
trichotillomania as defined by the diagnostic criteria
of the American Pyschiatric Association (APA),
which were set forth in the fourth edition of the
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). We outline that in dermatological
practice the DSM-IV criteria for trichotillomania fit
only a proportion of hair pullers; thus hair pulling

does not mean tout court trichotillomania.
807
808 Hautmann, Hercogova, and Lotti
J AM ACAD DERMATOL
JUNE 2002
clinical hair pulling, that is, with clinical evidence

of patches of hair loss. Nonclinical hair pullers are
very common in the general population.
Moreover, patients seen by psychiatrists usually
acknowledge their hair-pulling activity (otherwise,
they would not be there), whereas the large proportion of patients seen by dermatologists are not yet at
that point and often present a generic hair loss.
CLINICAL FEATURES
Fig 1. Typical case of adult trichotillomania: tonsural pattern of baldness with hairs of varying length; shortest are
those more recently removed.
The scalp is the most frequent hair-pulling site,

followed by the eyebrows, eyelashes, pubic area,
trunk, and extremities. The prevalence of trichotillomania in the general population has not been
studied. A 1989 questionnaire survey of approximately 2500 college freshmen in the United States at
two state universities and a liberal arts college, with
a 97.9% response rate, indicated a lifetime trichotillomania prevalence of 0.6% in both male and female
students (trichotillomania criteria set forth in the
APAs Diagnostic and Statistical Manual, third edition, revised [DSM-III-R]).13 When the investigators
ignored the diagnostic criteria referring to tension,
pleasure, and gratification, the prevalence increased
to 3.4% of female students and 1.5% of male students. A similar survey of about 700 college freshmen found that 11% pulled their hair on a regular
basis for other than cosmetic reasons and that 1%
met DSM-IV criteria for trichotillomania by selfreport.14
In treated case series, women outnumber men by
a ratio that approximates 3.5:1.15,16 In modern pharmacological trials, the female/male ratio has been
7:1 or higher.17-20 The female preponderance may be
due in part to womens greater willingness to seek
medical care. As already mentioned, men may hide
their hair pulling by masking it as male pattern
baldness and shaving their mustaches and beards; in
addition, beard pulling may represent symptomatic
behavior of an underlying body dysmorphic disorder; thus it is very difficult to evaluate the exact
epidemiologic dimension of trichotillomania. Moreover, it is important to note that the epidemiologic,
clinical, prognostic, and therapeutic data of the recent literature on trichotillomania referenced in this
article refer to the psychiatric patient population and
not to patients who come to the dermatologist for
treatment; moreover, epidemiology considers only
In the majority of cases, trichotillomania results in

patchy or full alopecia of the scalp5,21 (Fig 1). Many
subjects also pull out eyelashes, eyebrows, or facial
hairs, and some extract pubic, axillary, chest, abdominal, or extremity hairs. Hair pulling usually occurs daily, or nearly daily, and can occupy several
hours or more.22 The scalp is involved more frequently than other hair-bearing areas, and the clinical presentation of the lesion is characteristic. Hairs
at the occiput and base of the head are spared,
resulting in the tonsural pattern of baldness typifying
severe trichotillomania. Less severely affected patients may have only small areas of baldness or
imperceptible thinning over the entire head. In a
study on the effects of menstruation on pulling,
slightly more than half of 45 women providing data
reported that in the week before menses, pulling
urges were more frequent and intense, pulling was
more frequent, and the ability to resist was weaker,
with a return to baseline during menses or soon
thereafter.23 With the exception of this gender-specific finding, men and women hair pullers do not
exhibit clinically relevant differences.24
Plucking is accomplished either in a wavelike
fashion across the scalp or centrifugally from a single starting point. This results in linear or circular
patches with irregular borders containing hairs of
varying length, the shortest being those most recently removed, whereas increasing hair length distal to that point signifies the interval between the
time plucking and the time of clinical evaluation.
The process of plucking frequently fractures the hair
shaft above or within the follicle, so that the emerging hair, instead of having the finely tapered silkiness of newly grown anagen hair, has a fractured
end. This gives a stubbly sensation as the hand is
passed lightly over the the involved area. Plucking is
confined to a single patch of varying size. This patch
may be quite large and indeed in rare instances may
involve the entire scalp.25-27 When the process has
extended to a point that is uncomfortable to reach,
then the cycle is repeated, starting once again at the
beginning point.
In many cases, a specific time and location are
reserved for the process of plucking, which then
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takes on a ritualized character. Feelings of shame

and humiliation cause patients to avoid exposing the
damaged areas. However, unlike neurotic excoriations, because of embarrassment or shame, it is
more common for the patient not to acknowledge
his or her hair plucking; typically he or she will claim
to wake to find balls of hair strewn about the bed, or
if he or she does acknowledge it, the plucking may
be rationalized on the basis of some aberrant sensation in the scalp. Parents often will share in this
denial.
Patients commonly attempt to conceal the alopecia with creative hair styling, wigs, hair pieces, and
constant use of hats or bandanas, makeup, or false
eyelashes. Patients often present to a dermatologist
or a psychiatrist for treatment after a long period of
avoiding dating, intimate relationships, sports such
as swimming, and outdoor exposure to windy
places. More frequent hair pulling, greater body dissatisfaction, and greater anxiety and depression are
associated with lower self-esteem.22
The disorder usually has periods of exacerbation
and remission and in most cases is chronic.7 According to some authors, there appears to be both a
remitting and a chronic form, which are related to
age at onset and sex distribution, with older women
being more susceptible to the chronic form.28
Some researchers have emphasized the disturbed
family relations in patients with trichotillomania.5,7,29,30 These authors have reported poor marital
relations; family tension; and faulty mother-child interaction patterns characterized by ambivalence,
hostility, and separation anxiety. It often develops in
the context of family psychosocial stress (eg, child or
mother hospitalizations, the additional stress from
moving to a new house) or with developmental
problems such as sibling rivalry, inability of a
younger child to focus activities or play, or school
problems in a older child.31 In addition, it accompanies poor pair relationships and academic problems.
Just as patients with obsessive-compulsive disorder (OCD) describe an overwhelming anxiety accompanying a compulsive urge that is temporarily
relieved by performing the ritual, patients with
trichotillomania often describe an irresistible impulse and concomitant anxiety that cause them to
pull out a specific hair. Frequently, the chosen hair is
identified as different from the others (eg, too kinky/
straight, brittle/supple), and its removal is necessary
to make the hair feel just right. Despite the patient
having a definite sense of knowing which one hair is
sought, many hairs are pulled to get just the right
one. Tweezers may be used to get the entire hair
out, but the patients rarely report associated pain.
Some patients compulsively pick at the scalp, in
Hautmann, Hercogova, and Lotti 809
addition to pulling the hair, resulting in numerous

painful traumatic lesions. After plucking the hair, the
patient with trichotillomania frequently will stroke it
against the cheek and/or lips and might eat the root
or entire hair. Some patients have elaborate rituals
surrounding the hair pulling, whereas others pluck
one after another in rapid succession, with little or
no accompanying cognition. Thus a patient may
spend 2 hours pulling 20 to 25 hairs, or he or she
may pull the same number in a few minutes.26
In contrast to patients with OCD compulsions,
patients with trichotillomania do not pull their hair
in response to an obsessive thought, such as harm
coming to the self or loved ones, but only because of
an irresistible urge and accompanying anxiety. In
addition, patients with OCD have compulsions that
are considered to be ego-dystonic, whereas many
patients with trichotillomania report the hair pulling
as being pleasurable. Nevertheless, although some
patients derive pleasure from the actual pulling, for
most patients with trichotillomania the condition
may be felt globally as ego-dystonic, in that it provokes major emotional distress, in the form of
shame, embarrassment, social restriction, and impaired quality of life.
In addition, unlike patients with OCD, whose
symptoms change over time (eg, counting evolves
into repeating, which is then replaced by washing),
patients with trichotillomania only pull their hair;
they do not substitute other compulsive rituals for
this behavior.
In a study of 60 adult chronic hair pullers, the
mean age at onset was 13 8 years (median, 12
years).21 Most subjects pulled from more than one
site, with an average of 8 years elapsing between the
start of hair pulling and the involvement of the
second site. Some patients used the dominant hand;
others used the nondominant hand or both hands in
pulling. Somewhat fewer than half of the patients
had used tweezers to pull out hair. The median
number of pulling episodes per week was 16 for
those primarily plucking scalp hair and 7 for those
primarily plucking eyelashes. A little more than half
of the patients sought out hairs with special tactile
qualities, whether coarse, thick, curly, or short. Hair
pulling was not motivated by pruritus. Oral behaviors were associated with hair pulling in 48% of
patients: chewing hair or biting off the hair bulbs,
rubbing hair around the mouth, licking the hair, or
ingesting it. No patient had a history of a trichobezoar (gastric or intestinal hairball). The vast majority reported some pulling episodes that began or
continued while the patients were completely aware
of the behavior. High-risk situations for hair pulling
included watching television, reading, talking on the
telephone, lying in bed, driving, and writing. Hair

pulling was worse in the evening for 95% of patients.
As already mentioned, onset of trichotillomania in
early childhood has sometimes been considered
separately because it may be a different disorder; it
has been described as a habit disorder analogous to
nail biting and as a symptom of an impaired motherchild relationship as reported by Mannino and Delgado,8 Lenane, Swedo, and Rapoport,20 and Swedo
and Rapoport.28 It is unclear from published reports
whether hair pulling with onset before 5 years of age
constitutes the same disorder as that which presents
during adolescence and young adulthood; the literature data are contradictory, with little overlap between the two age groups.8 Some differences are
apparent; for example, 62% of preschool-aged children with trichotillomania are boys versus 30% in
male patients of other age groups.5 In addition, the
chronic, debilitating condition that affects adolescents and young adults, early-onset trichotillomania,
is reported to be benign and self-limited. Longitudinal reports are not available, but it appears that
early-onset trichotillomania may be outgrown and
that it does not cotinue into adolescence or adulthood.31 Unlike their adult counterparts, the chldren
have a clinical course that is frequently episodic,
with periods of complete remission occurring 2 to 3
times each year. The periods of relapse are most
frequently seen in October or November and in
February.28,36 This raises the possibility of an environmental event releasing the hair pulling; it has
been speculated that the children might have an
underlying genetic susceptibility that is expressed in
response to an autoimmune reaction, triggered by a
bacterial or viral infection (such as streptococcal or
chickenpox infections).28,31
OTHER MEDICAL BEHAVIORS AND

COMPLICATIONS
Trichotillomania appears to be commonly associated with other problematic behaviors such as nail
biting, skin picking, picking at acne, nose picking,
lip biting, and cheek chewing.21,32 These may be
considered as medical concomitants.
Medical complications of trichotillomania are uncommon but may be serious. Trichobezoar is rare,
but potentially life threatening, and may cause intestinal obstruction, gastric or intestinal bleeding or
perforation, acute pancreatitis, or obstructive jaundice, as well as discomfiting symptoms such as abdominal pain, nausea, vomiting, constipation, diarrhea, flatulence, anorexia, and foul breath.5 Other
unusual medical complications include skin infection at the site of pulling; blepharitis; chronic neck,
shoulder, or back pain from prolonged abnormal
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JUNE 2002
pulling postures; carpal tunnel syndrome; and

avoidance of health care to escape shame (eg,
avoiding treatment for basal cell carcinoma of the
scalp).33
CLINICAL ASSESSMENT
Severity of trichotillomania has been rated with 3
measures, summarized as follows34:
1. The Trichotillomania Symptom Severity Scale
(score range: 0-20), consisting of 5 items evaluating (1) average time spent pulling each day, (2)
average time spent pulling on the previous day,
(3) amount of resistance against the hair-pulling
urge, (4) degree of subjective distress, and (5)
interference with daily activity
2. The Trichotillomania Impairment Scale (score
range: 0-10): assessment of overall impairment
resulting from the trichotillomania, in which 0
represents total lack of symptoms and 10 indicates severe impairment (majority of time each
day spent pulling or resisting the urge to pull out
the hair, and large bald patches or total denudation evident)
3. Physicians Rating of Clinical Progress (score
range: 0-20): assessment of clinical change, in
which 0 represents a total cure, 10 the pretreatment baseline, and 20 the worst possible or total
incapacitation secondary to the trichotillomania.
The relative merits and disadvantages of many
assessment methods and instruments have been reviewed by Winchel, Jones, and Molcho.35 For clinical purposes, one can ask the patient to daily count
the pulled hairs and collect the hairs in envelopes.
However, patients who swallow their plucked hairs
must first stop this behavior. Patients can also be
asked to keep a diary that records each pulling
episode (duration, situation, precipitating factor,
and response), but some find this too time consuming. The National Institute for Mental Healths
(NIMH) Trichotillomania Questionnaire,36 a modified form of the Yale-Brown Obsessive-Compulsive
Scale (Y-BOCS), rates pulling behavior, but not related thoughts. The Psychiatric Institute Trichotillomania Scale allows the clinician to record the sites of
pulling and to rate on a 0-7 scale the quantity of
observable hair loss, time spent pulling and thinking
about pulling, success in resisting the impulse to
pull, distress related to trichotillomania, and the degree to which hair pulling interferes with activities.
The only validated self-rating scale is the Massachusetts General Hospital Hairpulling Scale.37,38 The
patient rates 7 items weekly on a 0-4 scale: the
frequency of urges to pull, their intensity, ability to
control the urges, frequency of hair pulling, attempts
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to resist, control over hair pulling, and associated

distress.
In accordance with Koran,39 we believe that engaging the patient in any assessment method that
increases awareness of pulling behavior and enhances accountability for the amount of hair pulled
may be useful in treatment.
HISTOLOGIC FEATURES AND

TRICHOLOGIC EXAMINATION
Sometimes histology is needed for a correct diagnosis. Microscopic examination of hairs emerging
from the affected area usually reveals that they have
a blunt end. Tapering of the proximal shaft (exclamation point hairs) and loss of pigment are not
observed. It is also not unusual for the patient with
trichotillomania to cut the hair to give the impression
that it is not growing. One should search carefully
for cleanly cut ends because this can only result
from cutting and is physical proof that the individual
is manipulating the hair. Hair plucks from alopecic
areas show few if any telogen bulbs because these
require less force to extract and have already been
removed by the patients pulling.
The most relevant histologic feature of trichotillomania is the presence of normally growing hairs
among empty hair follicles in a noninflammatory
dermis.40 These features are due to the mechanical
traction on the hair. Follicular plugging with keratin
debris can be prominent. Many of the empty hair
follicles show evidence of changing into the catagen
state, with transformation of the lower follicular epithelium into a cord of undifferentiated basaloid
cells4: the follicles may appear gathered in the dermis. There are dystrophic features of the follicular
epithelium with dyskeratotic cells. The hair shaft is
often broken or reduced to little dark bodies.
Strands of basaloid-appearing cells may be
present in the base of plucked follicles, and this is
accompanied by thickening of the hyaline membrane similar to the appearance of the catagen state.
Evidence of traumatic damage is often seen on the
retained portion of partially extracted hairs, such as
clefts separating the cells of the matrix from one
another and there is evidence of trichomalacia,
which is distortion and curling of the bulb; this is
seen deep in the follicle and is almost always a sign
of pulling (Figs 2-5). In the latter condition, the hair
shaft within the lower follicular duct appears small,
wavy, amorphous, and sometimes corkscrew-like.4
If the trauma of extraction is severe, one may observe separation of the follicular epithelium from the
surrounding sheath of connective tissue and areas of
intraepithelial and parafollicular hemorrhage in a
notable absence of inflammatory cells. Finally, the
presence of normal anagen follicles in the affected

area is evidence against an underlying disease.
DERMATOLOGIC AND PSYCHIATRIC

DIAGNOSIS
Dermatologic and psychiatric evaluations are
needed. The major diagnostic problem is in distinguishing trichotillomania from alopecia areata. Even
if the patient denies pulling the hair, absence of an
initial area of almost total hair loss favors trichotillomania. Admission of any manipulation of hair also
suggests trichotillomania because most patients with
spontaneous loss are concerned about increasing
the hair loss by handling it. On physical examination
one should look for exclamation point hairs and
loss of large numbers of hairs (particularly with
dystrophic ends) from the periphery of lesions with
gentle pulling, all characteristic of alopecia areata.
Hair loss in other areas of the body should be evaluated, although this may be present in patients with
trichotillomania. The nails should be examined for
pitting and other signs of alopecia areata.
Repeated manipulation of the hair over long periods can result in secondary infection with possible
subsequent irreversible scarring alopecia. Most individuals with this complication have been pulling
their hairs for years.
Fungal infection can be ruled out by Woods light
examination and by microscopic examination of
scrapings, culture, and biopsy material; the inflammatory dermatoses are ruled out by absence of the
characteristic features of inflammation, observed
clinically and microscopically.
Finally, trichotillomania must be distinguished
from other causes of patchy hair loss, including
alopecia, caused by medications or by poisons such
as thallium; alopecia toxica (loss from a febrile illness); alopecia traumatica (loss from excessive use
of hair softeners or hot combs); alopecia syphilitica (seen in secondary syphilis); alopecia secondary to irradiation; myxedematous alopecia; and alopecia mucinosa and other rare dermatologic
conditions. In adults, these diagnoses need be considered only in patients who deny or rationalize the
signs; denial is more common in children and adolescents.11 If necessary, the diagnosis can be established or confirmed by a punch biopsy specimen of
the affected area, which will usually reveal multiple
catagen hairs, melanin casts, and dilated follicular
ostia with keratin plugs.15
Not all chronic hair pulling is trichotillomania,
and the DSM-IV diagnostic criteria probably identify
individuals suffering from differing psychopathologic or pathophysiologic conditions. For example,
Fig 2. Histologic characteristics of trichotillomania. Infundibulum appears hyperkeratotic and dilated, in a relatively
noninflammatory dermis. (Hematoxylin-eosin stain; original magnification l00.)
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JUNE 2002
Fig 4. Histologic characteristics of trichotillomania. Atrophied follicle filled with the products of degeneration of
the hair matrix (hair keratin, pigment casts). Hair appears
dystrophic and separated from the internal epithelial
sheath. (Hematoxylin-eosin stain; original magnification
l00.)
Fig 3. Histologic characteristics of trichotillomania. Fragment of the hair shaft with hyperpigmentation. (Hematoxylin-eosin stain; original magnification 200.)
Christenson and Crow41 have drawn attention to the

distinction between patients who experience
mounting tension and center their attention on pulling and those who pull while distracted by other
activities. These authors suggest a closer relationship
to OCD in the former group. Whether the degree to
which trichotillomanic behavior is associated with
tension, impulsivity, pleasure, and awareness has
important treatment implications and deserves investigation.
Chronic hair pulling has been reported in association with major depression, severe anxiety, psychosis, and dysthymia.42-45 Hair pulling that occurs in
infancy and early childhood appears to be a different syndrome; boys predominate in treated preschool children and the behavior appears to be
more likely to remit spontaneously or with minimal
treatment.46 There has also been a case of hair pulling concomitant with Sydenhams chorea in childhood.47
Fig 5. Histologic characteristics of trichotillomania. Massive fragmentation of the follicle not readily recognized
and substituted by intense fibrosis. (Hematoxylin-eosin
stain; original magnification 100.)
Trichotillomania entered the American Psychiatric Associations diagnostic classification system with
the 1987 publication of DSM-III-R, where it was
grouped with the Impulse-Control Disorders Not
Elsewhere Classified. DSM-IV48 added the criterion
causes clinically significant distress or impairment
to the 4 criteria contained in DSM-III-R (Table I).
Approximately 20% of individuals who chronically
pull out their hair do not meet DSM-IV criteria for
trichotillomania in that they deny the presence of
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Table I. DSM-IV diagnostic criteria for trichotillomania

A. Recurrent pulling out of ones hair resulting in
noticeable hair loss.
B. An increasing sense of tension immediately before
pulling out the hair or when attempting to resist the
behavior.
C. Pleasure, gratification, or relief when pulling out the
hair.
D. The disturbance is not better accounted for by another
mental disorder and is not due to a general medical
condition (e.g., a dermatological condition).
E. The disturbance provokes clinically marked distress
and/or impairment in occupational, social, or other
areas of functioning.
either tension (criterion B) or gratification (criterion

C).21,49 Whether these individuals differ in important
clinical respects from those meeting the full criteria
is unknown.
The International Statistical Classification of Diseases and Health-related Problems, 10th revision
(ICD-10),50 places trichotillomania in the analogous
category, Habit and impulse disorders. This category
is characterized by impulses that cannot be controlled. Because the suggestion that an impulse is
irresistible carries implications of diminished responsibility under the law, DSM-IV avoided ascribing irresistibility to the Impulse-Control Disorders.
Although the ICD-10 description of trichotillomania
is generally consistent with the DSM-IV diagnostic
criteria, ICD-10 does not mention associated distress
or impairment of functioning.
Finally, we personally believe that patients with
hair pulling represent an extremely heterogeneous
group; as stated earlier in this review, though phenomenologically somewhat similar, there are
marked differences, over a broad spectrum of psychopathologies, from a transient mild habit through
impulse control disorder, the OCD spectrum, various personality disorders (eg, borderline personality, histrionic personality), body dysmorphic disorder, mental retardation, to psychosis. In each of
these disorders, in fact, hair pulling may be present
as a symptom.
Therefore it is important to have an accurate psychiatric evaluation to assess the eventually present
psychiatric comorbidities and to classify the symptom of hair pulling in the aforementioned spectrum of mental diseases.
The available data concerning the prevalence of
comorbid conditions are tainted by serious methodological shortcomings, such as ascertainment bias
and limited geographic representation. These problems preclude generalization of the reported figures.
However, the data begin to suggest that the prevalence of comorbid mood and anxiety disorders is
higher in individuals with trichotillomania than in
the general population. In the study by Christenson,
Mackenzie, and Mitchell,21 60 patients aged 18 to 61
years (mean standard deviation, 34 8 years)
were evaluated for hair pulling with a semistructured interview that utilized DSM-III-R criteria. Another set of estimates is provided by a study of 43
older children, adolescents, and adults (mean age,
30 11 years) who responded to advertisements for
drug studies at the NIMH and were evaluated with a
semistructured interview.46 This study utilized modified diagnostic criteria for trichotillomania; neither
gratification nor tension relief was required.
In a methodologically limited study, respondents
to print media materials that sought individuals with
trichotillomania or self-injury were mailed a survey
package.51 Only 16% of 772 individuals surveyed
returned usable questionnaires and recorded their
formally diagnosed disorders on a self-report form.
In addition to trichotillomania, which was reported
by 40% of these 123 respondents, 13% reported a
formal diagnosis of OCD; 14%, depressive disorder;
3%, bipolar disorder; 15%, anxiety disorder; and 7%,
substance abuse.
Case reports and small case series link trichotillomania to a variety of other disorders, but the diagnostic criteria vary widely. Most cases of the literature data reporting behavioral and hypnotic
treatments do not carry additional diagnoses, although patients are usually described as guilty,
ashamed, anxious, depressed, or suffering low selfesteem. Because of ascertainment and reporting
bias, conclusions about comorbid risk cannot be
drawn from these sources.
The prevalence of DSM Axis II personality disorders has been examined in 3 convenience samples,
but again, these figures cannot be generalized. The
limited diagnostic validity of all structured instruments used to evaluate personality disorders52 further complicates the interpretation of these data. In
a study to examine the prevalence of personality
disorders in subjects with trichotillomania and gender-matched patients seeking psychiatric treatment
at the same center, no differences were found between the two groups.49
RELATIONSHIP TO OCD
As anticipated in the abstract, the question is
whether trichotillomania is a syndrome on its own, a
form of OCD, or a symptom observed in various
disorders. It can be present as a major mental retardation symptom,53 in schizophrenia,54 in borderline
personality disorder,11 and in depression.43 Some
researchers have suggested that it may be a form of

OCD,20,34,36,55-58 whereas others have stated that it is
not an OCD variant.21,59,60
The question of whether or not trichotillomania is
part of a spectrum of obsessive-compulsiverelated
disorders was first raised by the patients themselves.
After a 20/20 television segment (ABC News, March
1987) concerning OCD, several women telephoned
to request treatment for their hair pulling compulsion, insisting it was just as disabling and stressful
as the checking, hoarding, and hand washing shown
on the television program. Their comments sparked
several ongoing investigations of the similarities and
differences between trichotillomania and OCD.
Actually, several similarities suggest a relationship
between trichotillomania and OCD. Patients often
describe their pulling as compulsive. Available
data suggest, but do not prove, that the rate of OCD
in probands and in their first-degree relatives19,20 is
increased over the rate in the general population.
Approximately 5% to 8% of the first-degree relatives of probands with trichotillomania have the
condition, but it is still unknown whether this reflects nature or nurture.19,20 In fact, to explore a
possible relationship between trichotillomania and
OCD, 65 of 69 first-degree relatives of 16 female
probands with severe chronic trichotillomania were
compared with two control groups, one with OCD
and one with trichotillomania. Three of 16 trichotillomania probands had at least one first-degree relative with a lifetime history of OCD, and there was an
age-correlated rate of 6.4% of first-degree relatives
with OCD. No relatives in the normal control group
met OCD criteria.20 Thus the authors concluded that
the higher OCD rate in families with trichotillomania
suggests that trichotillomania is an OCD spectrum
disorder along with other pathologic grooming behaviors.
Like OCD, trichotillomania has been thought to
have origins in psychosexual development and traumas.61,62 The case reports in literature seem to suggest that, like OCD, hair pulling is poorly responsive
to psychoanalytic psychotherapy11,61,63-65 and often
responds to serotonin reuptake inhibitors (SRIs). Response to similar treatments, however, is a weak
argument for a relationship between disorders (eg,
many unrelated conditions respond to propranolol).
On the other hand, important differences separate trichotillomania and OCD. OCD compulsions
are ego-dystonic, never pleasurable, are performed
in full awareness, and aim at avoiding increased
anxiety. As already stated, although hair pulling is
ego-dystonic (provoking major emotional distress,
in the form of shame, embarrassment, social restriction, and impaired quality of life) insofar as patients
J AM ACAD DERMATOL
JUNE 2002
feel ashamed and dislike the physical stigmata, they

often report that actual hair pulling itself is pleasurable,59 engaged in with minimal awareness, and
carried out in response to, rather than to avoid,
increased anxiety.
In addition, hair pulling is not elicited by an
obsession and is less strenuously resisted than are
compulsions.59 Hair pulling appears to be much
more common in girls and women than in boys or
men, whereas the female/male ratio for OCD in
epidemiologic studies rarely exceeds 1.5:1.66,67 Finally, hair pulling has been successfully treated (at
least in the short term) with brief courses of hypnosis and many behavioral therapy techniques to
which OCD is resistant.
Neurobiologic studies, reviewed by Christenson
and Crow,41 provide the strongest evidence that the
relationship between trichotillomania and OCD is, at
most, limited. For example, unlike patients with
OCD, those with trichotillomania do not exhibit an
increased number of neurologic soft signs, abnormalities of serotonins cerebral spinal fluid metabolite (5-hydroxyindoleacetic acid), blunted neuroendocrine response to meta-chlorophenylpiperazine,
or elevated resting glucose metabolism in the orbital
frontal, anterior cingulate, and caudate regions.68
Baer 69 stated that there were at least 2 important
differences between OCD and trichotillomania: (1)
patients with OCD provide a logical explanation of
their behavior, whereas patients with trichotillomania rarely justify their hair pulling and (2) response
prevention in patients with OCD leads eventually to
anxiety reduction, whereas in patients with trichotillomania, it leads to an increase in anxiety. Moreover, patients with trichotillomania have fewer associated obsessive-compulsive symptoms, as well as
less depression and anxiety, than patients with
OCD.
Thus, as stated above, it is difficult to reach any
conclusions on the basis of these studies. It appears
that some patients with trichotillomania may indeed
have OCD, whereas others with the same behavior
may not. It seems that classification of trichotillomania as an OCD variant depends on the phenomenology reported by the patient. Patients who experience hair pulling as an irresistible urge with
accompanying anxiety elevation, followed by a reduction in anxiety after pulling, may have an OCD
variant. Probably within this patient subset are those
15% of patients who are aware of their urges and
behaviors, similar to patients with OCD who are
aware of their compulsions. Within this group, the
act is purposeful and reduces anxiety. This patient
population responded to clomipramine in the study
of Swedo, Leonard, and Rapoport.34 Those patients
J AM ACAD DERMATOL
VOLUME 46, NUMBER 6
who are mostly unaware of pulling and experience

it as pleasurable probably have a bad habit that may
respond to habit reversal.70
PROGNOSIS
As already stated and observed by other authors,7,10,13,21,24,41 trichotillomania has periods of exacerbation and remission and in most cases is
chronic. According to some authors, there appears
to be both a remitting and a chronic form, which are
related to age at onset and sex distribution, with
older female patients being more susceptible to the
chronic form.21
TREATMENT
Treatment begins with taking a thorough history
of the disorder and its effects and inquiring after
possible comorbid conditions. The data reviewed
earlier suggest that mood and anxiety disorders will
commonly be found. No treatment approach has
been established as effective in a large controlled
trial. Case reports, small series, and a few uncontrolled and controlled trials present a variety of treatment methods that merit exploration. Patients are
often quite relieved to find that others pull out hair
and should be guided to organizations offering educational material and contact with kindred sufferers. Behavior therapy, hypnosis, insight-oriented
psychotherapy, and pharmacologic therapy have
been considered. Obviously, all these nonmedical
treatments require specialized training.
Behavior therapy
The behavior therapy literature shares the shortcomings of the pharmacotherapy literature: mostly
uncontrolled observations, short follow-up periods,
and a publication bias toward favorable outcomes.
Much of this literature is presented in detail elsewhere.71-74 All reports include at least two treatment
elements and most include at least 4, making it
difficult to identify the essential factors. Placebo effects and the nonspecific elements of supportive
psychotherapy may have contributed to the reported results. The first reported behavioral intervention for trichotillomania consisted of self-monitoring paired with response chain interruption,
whereby patients monitored their hair-pulling attempts and then told their hands to stop.70,75 Other
interventions are counting and recording hair
pulls,70,76 denial of privileges and applying eye
drops to stop pulling,77 aversive self-stimulation
with a rubber band,78-80 and punishment via sit-ups
whenever a pull attempt is made.81 Except for
Sapers study,64 at the end of treatment patients reported hair-pulling rates of zero.
Unfortunately, deriving conclusive evidence from
these reports is difficult because of the small number

of patients who participated in the various treatment
modalities (ie, one or two patients).
To increase the validity of self-report data and the
treatment effects of self-monitoring as described earlier, several investigators added other objective measurements, such as having patients count the number of pulled hairs,82-84 measure their hair length,85
or both.86 Others combined self-monitoring, hair
counting, and measuring hair length with token reinforcement,83 self-denial of privileges,87 and behavioral contracting.82 The addition of these techniques
increased treatment success rate.70
In addition to self-monitoring, other behavior
therapies have been applied. Moderate to positive
improvement has resulted from covert desensitization88; attention reflection and response prevention
by cutting hair close to the scalp89; attention-reflection combined with punishment90; facial screening
(covering the patients face and hair with a soft cloth
when he or she attempted to pull)91; and a multiplecomponent treatment package consisting of self-monitoring, hair collection, goal setting, relaxation, and
stimulus control.92 The last of these researchers introduced a new dependent measure: size of bald spots.70
The most successful self-management treatment
in the remediation of hair pulling is habit reversal.
This treatment includes 13 components:
1. Competing response training
2. Habit awareness training
3. Identifying response precursors (eg, face touching, hair straightening)
4. Identifying situations in which the habit is likely
to occur (eg, being alone, watching television,
studying
5. Relaxation training
6. Response prevention training (eg, practicing the
competing reaction for 3 minutes, such as grasping or clenching fists when a habit response
precursor or a situation that makes the habit
likely to occur exists)
7. Habit interruption (grasping or clenching to interrupt hair pulling)
8. Positive attention/overcorrection (practice positive hair care, such as combing or brushing hair
after pulling)
9. Practicing motor responses that compete with
the habit in front of a mirror
10. Self-monitoring
11. Solicitation of social support (eg, significant others encourage the patient to stop hair pulling)
12. Habit inconvenience review
13. Display of improvement (ie, have the patient
approach situations that were previously avoided)39,70
Habit reversal was first introduced as a general

effective treatment for nervous habits by Azrin and
Nunn93 and was later tested against negative practice
in 34 hair-pulling patients.16 Azrin, Nunn, and
Frantz16 randomly assigned 34 subjects to one
2-hour session of instruction in either habit reversal
or negative practice. The results were remarkable;
14 of 19 habit reversal subjects (74%) reported no
hair pulling at the 4-week follow-up, starting with
the first posttreatment day, compared with only 5 of
15 negative practice subjects (33%). At the 4-month
evaluation, 11 of 18 habit reversal subjects were still
refraining from hair pulling. At 22 months, 9 of 12
habit reversal subjects reached were in remission,
compared with 2 of 8 negative practice subjects.
Other researchers have found similarly encouraging
results with habit reversal in 4 patients with a positive 6-month follow-up.94
In patients with trichotillomania uncomplicated
by serious comorbidity, some researchers39 have
had good results with a modified form of habit
reversal derived from the behavioral literature. The 7
treatment elements utilized are hair collection, identifying preventive strategies for high-risk situations,
motivation enhancement, changing the internal
monologue, awareness training, competing response training, and relaxation training.39
Self-monitoring. Ask the patient to collect all
the hairs pulled each day in an envelope, count
them, write the number and the date on each envelope, and bring the envelopes to the next treatment
session. Explain that this will provide the patient and
the clinician with a daily measure of progress and
will help the patient be accountable to himself or
herself, since he or she will know exactly how much
hair he or she is pulling. This task seems to reduce
hair pulling by increasing the behavioral cost of
pulling and by drawing on patients reluctance to
share this embarrassing information. Azrin, Nunn,
and Frantz16 used a daily diary, and some patients
find this method more practical and acceptable.
Coping strategies. After identifying the situations in which pulling occurs, help the patient develop coping strategies. For example, ask the patient
to commit to keeping both hands on the steering
wheel unless shifting or turning a radio dial, or ask
the patient to commit to keeping both hands on the
book while reading. If pulling occurs during long
stays in the bathroom, ask the patient to set a timer
to 1 to 2 minutes and leave when it goes off. Making
these commitments to the clinician seems to be an
important motivator.39
Motivation enhancement. Give the patient a
list of possible reasons for wanting to stop hair
pulling. Ask him or her to check off all that apply
J AM ACAD DERMATOL
JUNE 2002
and write in any additional reasons he or she wishes.

Explain that the motives driving the pulling behavior
have overwhelmed the motives to stop. Ask the
patient to strengthen the motives to stop by posting
this list where he or she will review it at least once a
day, for example, on the refrigerator door or bathroom mirror. It is useful to keep a copy for review
during therapy.39
Changing the internal monologue. Ask the
patient to become aware of the internal monologue
that gives him or her permission to pull (eg, Ill only
pull a few, or Ive already done so much damage,
it doesnt matter, or It feels good.) Ask him or her
to change his or her self-talk and to substitute a
more functional message for these rationalizations
each time they occur. Offer a positive and a negative
statement because patients vary in the approach
preferred: I deserve to take better care of myself
than to pull out my hair or Hair pulling is damaging, disfiguring and self-destructive, and I dont want
to do that to myself.39
Awareness training. Ask the patient to slowly
bring his or her hand(s) to the pulling area and,
while doing so, to become exquisitely aware of the
sensations in every part of the arm, from the shoulder to the fingertips. Ask him or her to also pay
attention to the hand as it enters the peripheral and
central visual fields. Azrin, Nunn, and Frantz16 utilized practice in front of a mirror. Explain that you
do not want him or her to be able to pull without
being fully aware of it, and ask him or her to practice
this awareness training 12 minutes twice a day.39
Competing response. Ask the patient to lightly
clench her thumbs inside her fists for 3 minutes
whenever he or she has the urge to pull or to
perform some other socially inconspicuous, incompatible response. Explain that this precludes pulling
and that the urge will usually pass within this time.
Some patients prefer to substitute a form of tactile
stimulation, and holding a soft eraser, stroking a soft
makeup brush, squeezing a rubber isometric hand
exerciser, or fingering a string of beads can be suggested.39
Relaxation training. Explain that tension and
anxiety promote pulling. Ask the patient to choose a
form of relaxation exercise (visualization of a pleasant scene, progressive muscle relaxation, or diaphragmatic breathing) and to practice it for a few
minutes one to several times a day to lower your
general level of tension.
Not every element needs to be utilized with each
patient. After the treatment package is in place, one
can review at each session whether or not the patient has followed through with his or her commitments. When the patient fails to carry out a treatment
J AM ACAD DERMATOL
VOLUME 46, NUMBER 6
task, it may be useful to adopt a problem-solving

approach (eg, What prevented you from doing
this?) and explore both motivational factors, such as
ambivalence about stopping, and situational factors,
including continued environmental stressors. This
noncritical stance helps to maintain the therapeutic
alliance, contradicts the expectations of reprimand,
and counterbalances the internalized criticism that
patients usually bring from parental responses to
their hair pulling.39
Once hair pulling has ceased, sustained improvement seems to require teaching the patient relapse
prevention strategies and arranging 3- to 6-month
follow-up visits. Patients should be asked to continue to rehearse the changed internal monologue,
to review the motivations for stopping, and to utilize
the competing response as needed. In addition, it is
helpful to encourage patients to view lapses as signals to return to active treatment, rather than as
occasions for self-denigration or signs of an inescapable, prolonged relapse.39
Hypnotic treatments
A variety of hypnotic techniques have been applied in case reports or small series of patients,
usually as adjuncts to other behavioral or psychotherapeutic treatment elements. These elements included awareness training,61,65 relaxation training,2,61,65,92 counseling,2,65 competing response
training,95 and changing self-statements about hair
pulling.96 Treatment outcome seems unrelated to the
number of hypnotic sessions, but a correlation has
been noted97 between outcome and patients ability
to be hypnotized, as reflected in their abilities to
engage in age regression and to learn autohypnosis.
Hypnotic suggestions have included pain on touching the scalp or pulling hair (in cases where pulling
was pleasurable),61,96 increased awareness of hair
pulling behavior through associated hand warming,92 and rituals other than hair pulling to decrease
anxiety.2 Several researchers have outlined the relevance of shaping posthypnotic suggestions to enhance the patients sense of self-control.2,61,65,97
In view of the heterogeneity of techniques used
and the absence of controlled studies, no conclusions can be drawn about the utility of hypnosis in
treating trichotillomania.39
Psychotherapy
In the past decade great strides have been made
in the pharmacology of impulsive and compulsive
disorders (beta-blocking agents, mood stabilizers,
serotoninergic antidepressants); despite these welcome advances, there is still a role for psychotherapy in many of these conditions. The domain of
psychotherapy itself has been expanded and modi-
fied, the better to provide treatment for patients with

this important group of disorders. Now it has become clear that compulsive rituals, whether of
cleaning or of checking, although some underlying
psychodynamic can eventually be discerned, can
seldom be treated successfully merely by the discovery and interpretation of the relevant dynamic. In
general, it seem that patients with disorders characterized by compulsivity are more apt to derive benefit from verbal psychotherapy than those with disorders characterized by impulsivity. There are two
interrelated reasons as to why this is so; first, persons
who are predominantly impulsive usually have an
external locus of control and utilize mostly alloplastic coping mechanism, whereas compulsive persons
as a rule have an internal locus of control and rely on
autoplastic defenses. Second, those who try to
change the environment (ie, mostly utilize alloplastic coping mechanisms) rather than themselves, and
who are controlled more by shame (via external
sources) than by guilt, tend to externalize the origins
of their difficulties in living (eg, blaming the other
guy), remaining themselves faultless (in their own
view) and thus without much motivation for change.
In contrast, compulsive persons are more likely to
accept responsibility for their problems, perhaps
even to an exaggerated and unwarranted degree,
and tend as a consequence to accept patienthood
more readily, at least submitting to the need for
treatment with less complaint, if such need is suggested by a spouse, relative, or friend.
Trichotillomania, which is included in the impulse control disorders in the DSM-IV, has much
more in common with a compulsive than with an
impulsive disorder because the activity tends to be
repetitive and frequent, as with other behavioral
manifestations of OCD. One might view trichotillomania as a subtype of compulsive disorders, along
with cleaning and checking. Moreover, the other 4
DSM-IV impulse control disorders (pyromania, intermittent explosive disorder, kleptomania, pathological gambling) are often found in conjunction with
antisocial personality disorder (either with antisocial
personality traits or with the full-fledged disorder),
in which case the amenability to psychotherapy may
be seriously reduced or nullified. In fact, there
seems to be tacit agreement about the reduced amenability to psychotherapy in persons with both impulse-control disorders and antisocial personality
even in the earlier psychoanalytic literature.
Symbolically, hair represents beauty, attraction,
and virility. Hair pulling has been viewed as a fetish,
determined by a variety of unconscious conflicts.98
Buxbaum98 cited the expression to tear ones hair
as a sign of despair and mourning. She felt that hair
pulling might not only reflect aggression against self

secondary to ambivalence toward the parents but
might also resemble a form of autoeroticism to
which the child resorts in periods of anxiety and
loneliness. Buxbaum related hair pulling to separation anxiety, whereas Greenberg and Sarner11
viewed this symptom as a result of multiple fixation
points at all levels of psychosexual development;
they also reported hair pulling after actual or threatened object loss.
Pharmacotherapy
Many drugs appear promising, but actually the
only one found effective in controlled trials appears
to be clomipramine. Instead of and in addition to
drug effects, the improvements reported by the literature data of uncontrolled trials may reflect nonspecific therapeutic factors, such as the placebo effect, self-monitoring, or the benefits of supportive
psychotherapy. Frequently, the duration of improvement is unspecified or the follow-up period is limited to a few weeks or months, which we believe to
be too brief to evaluate outcomes of this chronic
condition. In many cases, improvement was transitory. Nevertheless, these uncontrolled observations
present hypotheses to be weighed critically and
tested, both in the clinical situation and in carefully
designed, controlled trials.39 There are case reports
of response to imipramine,42 isocarboxazid,43,99 trazodone,45 and sertraline100,101; these need a distinction: in fact, in these cases, trichotillomania improved concomitantly with other comorbid
psychiatric disorders such as major depression or
dysthymia, which suggests that treatment of comorbid mood disorders may ameliorate trichotillomania.
There have been isolated cases that responded to
amitriptyline102 and the progestin levonorgestrel103
in the absence of mood disorders and to buspirone
in the presence of generalized anxiety disorder.39,104
Uncontrolled observations have also suggested
efficacy for the combination of serotoninergic reuptake inhibitors (SRIs) and neuroleptics. In a chart
review study, two patients who had a moderate
response to adequate trials of clomipramine had
marked improvement, sustained for 6 months, after
the addition of 1 to 2 mg/d of pimozide, and 2 of 4
patients with unsatisfactory or unsustained response
during a fluoxetine trial had a moderate to marked
sustained response during a subsequent trial of clomipramine (50-200 mg/d) combined with pimozide
(2-3 mg/d).105 In this case series an important side
effect was represented by the weight gain.
In a second chart review study, 3 of 4 patients
showed significant improvement for some months
after risperidone, 1 mg/d, was added to clomipra-
J AM ACAD DERMATOL
JUNE 2002
mine; a fifth patient, receiving citalopram, did not

respond to added risperidone.106 One patient discontinued risperidone because of worsening depression.
Controlled drug trials have been less encouraging. Two placebo-controlled, double-blind crossover trials have failed to corroborate the effectiveness of fluoxetine.10,18 In a case report, a therapeutic
response to fluoxetine stopped when isotretinoin
was started for cystic acne and resumed when this
medication was discontinued.107
In contrast, a 10-week, double-blind, crossover
trial comparing clomipramine (100-250 mg) to desipramine (100-200 mg) in 13 patients reported that
clomipramine decreased hair pulling by 50% or
more in 9 subjects and induced complete remission
in 3.34 Only one patient responded more favorably
to desipramine than to clomipramine. A follow-up
evaluation indicated that benefit was maintained for
6 months; after about 4 years, however, fewer than
half the patients continued to be at least moderately
improved, despite intervening treatments.108
Stein, Bouwer, and Maud109 have used citalopram
(a highly selective SRI [SSRI]) on an open-label naturalistic basis in 14 patients who presented with
chronic hair pulling and met DSM-IV criteria for
trichotillomania. Ratings were completed every 2
weeks for 12 weeks during which time dosage was
increased to a maximum of 60 mg daily. One patient
dropped out, whereas in those who completed the
study, ratings on each of the scales employed were
significantly improved after treatment; of completers, 30.5% were responders at week 12.109
Other SSRIs have been used in the treatment of
trichotillomania; paroxetine and fluvoxamine may
prove to be effective therapies.110,111 According to
several authors,34,36,46,108 trichotillomania may have
an intermediate response, with good initial response
to SSRIs, but an unclear long-term outcome.105 Pharmacological factors in treatment resistance include
insufficent dosage, slow onset of response (12
weeks are often needed), inadequate duration of
treatment (at least 12 months are often necessary for
initial treatment length), and symptom relapse after
discontinuation. Treatment resistance may also result from inadequate treatment of comorbid Axis II
conditions, such as cluster A (odd) or cluster B
(impulsive) personality disorders, social phobia, or
tics or other neurological illness.
Because clomipramine appears to be the only
medication whose effectiveness has been demonstrated in a double-blind trial, it deserves primary
consideration; nevertheless, clomipramines adverse
effects (especially sedation, weight gain, and anticholinergic side effects) are often problematic, and
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VOLUME 46, NUMBER 6
Table II. Guidelines for the treatment of trichotillomania*

Adequate physician-patient relationship to improve insight, acknowledgment of disease, and compliance with treatment
Evaluate all sites of pulling and measure baseline rates
Assess motivation for treatment
Inquire about trichophagia
Successful referral to the psychiatrist
Evaluate and treat comorbid conditions (eg, skin picking, mood disorders, anxiety disorders)
Guide patient toward educational and support groups
Institute modified habit reversal
Evaluate pharmacotherapy:
Clomipramine (evaluating the adverse effects of clomipramine) or SSRIs
Add low doses of neuroleptics (haloperidol, pimozide, or risperidone) in cases of partial or unsustained response to
antidepressants (clomipramine or SSRIs)
Lithium carbonate
Naltrexone
Consider introducing posthypnotic suggestions
Institute relapse prevention strategies
*Modified from Koran LM. Trichotillomania. In: Obsessive-compulsive and related disorders in adults. A comprehensive clinical guide. Cambridge (UK): University Press; 1999. p. 185-201.
relapse has been reported in several cases despite

continued treatment. Thus the first-line strategy should
be a trial of clomipramine or an SSRI (fluvoxamine,
fluoxetine, paroxetine, sertraline, or citalopram).
Venlafaxine and mirtazapine, which, like clomipramine, strongly enhance both serotonergic and
noradrenergic functioning, may ultimately prove to
be alternative therapies, but their use in trichotillomania has not been investigated. The addition of a
low dose of pimozide, risperidone, or haloperidol
can be considered in patients with a partial or unsustained response to clomipramine. The small risk
of tardive dyskinesia must be weighed and disclosed.39
In the absence of better guides to treatment, the
patients subjective experience may be helpful and
provide clues. If pruritus motivates pulling, a short
trial of adding topical steroid to a partially effective
regimen may be indicated.
The observation of long-term benefit from lithium, albeit uncontrolled, suggests that lithium and
other drugs that diminish neuronal excitability, such
as valproate or gabapentin, are worth investigating
in patients who complain of overwhelming impulses
to pull. Patients whose pulling is strongly motivated
by pleasurable sensation may deserve a trial of the
opiate antagonist naltrexone.39
Obviously, comorbid conditions will influence
drug choice. From among all the drugs known to be
effective for the comorbid condition, the clinician
should choose one that, on the basis of available
data, is also beneficial in trichotillomania.112-114
An approach to planning integrated treatment for
the patient with trichotillomania that has reached the
point of acknowledging his or her participation, as
proposed by Koran,39 is displayed in Table II; obviously, these guidelines are somewhat idealistic. We
first want to emphasize the relevance of a good
physician-patient relationship and a successful referral to a psychiatrist.
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68. Swedo SE, Rapoport JL, Leonard HL. Regional cerebral glucose
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74. Panconesi E, Hautmann G. Psychotherapeutic approach in
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78. Mathew A, Kumaraiah V. Behavioral intervention in the treatment of trichotillomania. Indian J Pediatr 1988;55:451-3.
79. Stevens MJ. Behavioral treatment of trichotillomania. Psychol
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80. Mastellone M. Aversion therapy: a new use for the old rubber
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81. MacNeil J, Thomas MR. Treatment of obsessive compulsive
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82. Stabler B, Warren AA. Behavioral contracting in treating trichotillomania: case note. Exp Psychiatry 1974;7:391-2.
83. Wolfsohn D, Barling J. From external to self-control: behavioral
treatment of trichotillomania in an eleven-year-old girl. Psychol Rep 1978;42:1171-4.
84. Bayer CA. Self-monitoring and mild aversion treatment of
trichotillomania. J Behav Ther Exp Psychiatry 1972;3:139-41.
85. Anthony WZ. Brief intervention in a case of childhood trichotillomania by self-monitoring. J Behav Ther Exp Psychiatry 1978;
9:173-5.
86. McLaughlin JG, Nay WR. Treatment of trichotillomania using
positive covariance and response cost: a case report. Behav
Ther 1975;6:87-91.
87. Cordle CJ, Long CC. The use of operant self-control procedures
in the treatment of compulsive hair-pulling. J Behav Ther Exp
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88. Levine BA. Treatment of trichotillomania by covert sensitization. Behav Ther Exp Psychiatry 1976;7:75-6.
89. Massong SR, Edwards RP, Range-Sitton L. A case of trichotillomania in a three-year-old boy treated by response prevention.
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90. Altman K, Grahs S, Friman P. Treatment of unobserved trichotillomania by attention reflection and punishment of an apparent covariant. J Behav Ther Exp Psychiatry 1982;13:337-40.
91. Barmann BC, Vitali DI. Facial screening to eliminate trichotillomania in developmentally disabled persons. Behav Ther 1982;
13:735-42.
92. Bornstein PH, Rychtarik RG. Multi-component behavioral treatment of trichotillomania: a case study. Behav Res Ther 1978;16:
217-20.
93. Azrin NH, Nunn RG. Habit reversal: a new method of eliminating nervous habits and tics. Behav Res Ther 1973;11:619-28.
94. Rosenbaum MS, Allyon T. The habit reversal technique in treating trichotillomania. Behav Ther 1981;12:473-81.
95. Hall JR, McGill JC. Hypnobehavioral treatment of self destructive behavior: trichotillomania and bulimia in the same patient.
Am J Clin Hypn 1986;29:39-46.
96. Rowen R. Hypnotic age regression in the treatment of a selfdestructive habit: trichotillomania. Am J Clin Hypn
1981;23:195-7.
97. Hynes JV. Hypnotic treatment of five adult cases of trichotillomania. Aust J Clin Exp Hypn 1982;10:109-16.
98. Buxbaum E. Hair pulling and fetishism. Psychoanal Study Child
1960;15:243-60.
99. Parsons B, Quitkin FM, McGrath PJ. Phenelzine, imipramine,
and placebo in borderline patients meeting criteria for atypical
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100. Rahman MA, Gregory R. Trichotillomania associated with HIV
infection and response to sertraline. Psychosomatics 1995;36:
417-8.
101. Bradford JMW, Gratzer TG. A treatment for impulse control disorders and paraphilia: a case report. Can J Psychiatry 1995;40:
4-5.
102. Snyder S. Trichotillomania treated with amitriptyline. J Nerv
Ment Dis 1980;168:505-7.
103. Perciaccante M, Perciaccante RG. Progestin treatment for obsessive-compulsive disorder. Psychosomatics 1993;34:284-5.
104. Reid TL. Treatment of generalized anxiety disorder and trichotillomania with buspirone [letter]. Am J Psychiatry 1992;149:
573-4.
105. Stein DJ, Hollander E. Low dose pimozide augmentation of serotonin reuptake blockers in the treatment of trichotillomania.
106. Stein DJ, Bouwer C, Hawkridge S. Risperidone augmentation of
serotonin reuptake inhibitors in obsessive-compulsive and related disorders. J Clin Psychiatry 1997;58:119-22.
107. Mahr G. Isotretinoin and trichotillomania [letter]. Psychosomatics 1990;31:235.
108. Swedo SE, Lenane MC, Leonard HL. Long-term treatment of
trichotillomania (hairpulling) [letter]. N Engl J Med 1993;329:
141-2.
109. Stein DJ, Bouwer C, Maud CM. Use of the selective serotonin
reuptake inhibitor citalopram in treatment of trichotillomania.
Eur Arch Psychiatry Clin Neurosci 1997;247:234-6.
110. Ravindran AV, Lapierre YD, Anisman H. Obsessive-compulsive
spectrum disorders: effective treatment with paroxetine. Can
J Psychiatry 1999;44:805-7.
111. Figgitt DP, McClellan KJ. Fluvoxamine. An updated review of its
use in the management of adults with anxiety disorders. Drugs
2000;60:925-54.
112. Lotti T, Hautmann G, Panconesi E. Neuropeptides and skin.
J Am Acad Dermatol 1995;33:482-96.
113. Hautmann G, Panconesi E. Terapia psicofarmacologica in dermatologia. In: Finzi AF, Marinovich M, editors. Trattato di
farmacologia e terapia. Dermofarmacologia. Torino: Utet;
1998. p. 240-5.
114. Hautmann G, Panconesi E: Psychoactive agents in dermatology. In: Katsambas AD, Lotti T, editors. European handbook of
dermatological treatments. Berlin: Springer; 1999. p. 803-11.
Answer sheets are bound into the Journal for US, Canadian, and life members. Request additional
answer sheets from American Academy of Dermatology, Member Services Department, PO Box 4014,
Schaumburg, IL 60168-4014. Phone: 847-330-0230; E-mail: tsmith@aad.org
CME examination
Identification No. 802-106
Instructions for Category I CME credit appear in the front advertising section. See last page of Contents for page number.
Questions 1-30, Hautmann G, Hercogova J, Lotti T. J Am Acad Dermatol 2002;46:807-21.
Directions for questions 1-30: Give single best

response.
1. The term trichotillomania means
a. the fear of becoming bald
b. the prodromal symptoms of baldness
c. a self-inflicted depilation of the scalp
d. frequent depilation
e. none of the above
2. Trichotillomania
a. presents a high occurrence, approximately 1
100 persons
b. presents a high occurrence, approximately 1
200 persons
c. presents a low occurrence, approximately 1
1000 persons
d. presents a high occurrence, approximately 1
200 persons, appearing by the age of 18 years
e. is more frequent in adults than in children
in
in
in
in
3. In trichotillomania,
a. eyebrows are second in frequency as a hair-pulling site
b. extremities are never involved
c. the pubic region is a very frequent hair-pulling area
d. an itching sensation occurs when the eyelashes
are involved
e. approximately 12% of first-degree relatives of patients have also had it
4. Plucking is
a. diffuse to the scalp
b. confined to a single patch of varying size
c. confined to a single, scaly patch of varying size
d. confined to 2 or 3 patches that are 5 to 7 cm in
diameter
e. diffuse to the scalp that appears erythematous and
scaling
5. Patients with trichotillomania
a. usually present to psychiatrists early
b. always refuse to present to physicians
c. often present to a dermatologist after avoiding
dating for a long period
16/2/124271
822
d. prefer to present to a psychiatrist rather than to a

dermatologist
e. acknowledge their condition
6. Trichotillomania
a. is an acute disease
b. is sometimes an autoresolving and time-limited
disease
c. always presents remission periods
d. is classified into remitting and chronic forms
e. is usually chronic with exacerbation and remission periods
7. Development of the chronic form of trichotillomania
a. appears to occur more frequently in childhood
and adolescence
b. is typical of younger male patients
c. is only related to age at onset
d. appears to occur more frequently in older female
patients
e. appears more frequently in association with mood
disorders
8. Patients with trichotillomania
a. generally report an irresistible impulse without
concomitant anxiety that causes them to pull out
any hair
b. generally report an irresistible impulse with concomitant anxiety that causes them to pull out a
specific hair
c. generally report an irresistible impulse with concomitant anxiety that causes them to pull out any
hair
d. refer to pain in the scalp
e. refer to a stinging sensation
9. Trichotillomania is
a. commonly associated with skin picking and nail
biting
b. commonly associated with skin picking, ereutophobia, and nail biting
c. commonly associated with skin picking, nail biting, acne, and/or rosacea
d. a symptom of obsessive-compulsive disorder
(OCD)
e. usually associated with other symptoms of OCD
J AM ACAD DERMATOL
VOLUME 46, NUMBER 6
10. The possible medical complications of trichotillomania are

a. cicatricial alopecia, intestinal obstruction, folliculitis, and lombalgia
b. skin cancer, intestinal obstruction, folliculitis, and
chalazion
c. skin cancer, back pain, intestinal obstruction, and
perifolliculitis
d. gastric perforation, acute pancreatitis, carpal tunnel syndrome, folliculitis, and epidermal cell carcinoma
e. gastric perforation, acute pancreatitis, carpal tunnel syndrome, constipation, and blepharitis
11. The Trichotillomania Symptom Severity Scale
a. is a modified form of the Yale-Brown ObsessiveCompulsive Scale
b. has a score range of 0 to 10
c. consists of 5 (evaluative) items
d. does not evaluate the interference of trichotillomania with daily activity
e. is a self-rating scale
12. The histologic findings of trichotillomania
a. are pathognomonic, showing normally growing
hairs among empty hair follicles
b. show normally growing hairs among empty hair
follicles in a noninflammatory dermis
c. show normally growing hairs among empty hair
follicles in an inflammatory dermis
d. usually present typical and characteristic evidence
of traumatic damage
e. show that the hair is in a dystrophic anagen state
13. The hair pulling
a. is usually an ego-dystonic behavior
b. is usually an ego-syntonic behavior
c. is often an impulsive behavior
d. has its origins in an aberrant psychosexual development
e. is an ego-dystonic, unpleasant behavior
14. Hair pulling is
a. elicited by an obsession
b. a compulsive, pleasurable behavior
c. engaged in with maximal awareness
d. carried out to avoid increased anxiety
e. more strenuously resisted than are compulsions
15. Subjects with trichotillomania
a. exhibit abnormalities of serotonins cerebral spinal fluid metabolite
b. like subjects with OCD, present a blunted response to metachlorophenylpiperazine
c. present a decreased resting glucose metabolism in
the orbital frontal, anterior cingulate, and caudate
regions
d. present a decreased resting glucose metabolism in
the orbital frontal region, but an increased resting
glucose metabolism in the anterior cingulate and
caudate regions
CME examination 823
e. unlike subjects with OCD, do not present abnormalities of serotonins cerebral spinal fluid metabolite
16. The most successful self-management treatment in
the remediation of hair pulling
a. is habit reversal
b. consists of self-monitoring
c. includes hair collection
d. is stimulus control
17. In the treatment of trichotillomania, the only drug
found to be effective appears to be
a. imipramine
b. fluoxetine
c. clomipramine
d. clomipramine intravenously administered
e. imipramine associated with desipramine
18. In the treatment of trichotillomania, according to a
chart review study, patients with a moderate response
to
a. clomipramine had marked improvement after the
addition of 8 mg/d of pimozide
b. imipramine had marked improvement after the
c. clomipramine had marked improvement after the
d. desipramine had marked improvement after the
19. In the treatment of trichotillomania, according to a
chart review study, patients with a moderate response
to
a. clomipramine had marked improvement after the
addition of 8 mg/d of risperidone
b. fluoxetine had marked improvement after the addition of 1 mg/d of risperidone
c. fluoxetine had marked improvement after the addition of 2 mg/d of risperidone
d. fluoxetine had marked improvement after the addition of 1 mg/kg per day of isotretinoin
e. clomipramine had marked improvement after the
addition of 1 mg/kg per day of isotretinoin
20. Which of the following are the diagnostic criteria of
DSM-IV for trichotillomania?
a. Acute pulling out of ones hair resulting in noticeable hair loss; an increasing sense of tension immediately before pulling out the hair or when
attempting to resist the behavior; pleasure, gratification, or relief when pulling out the hair; the
disturbance is not better accounted for by another
mental disorder and is not due to a general medical condition (eg, a dermatologic condition); the
disturbance causes clinically significant distress or
impairment in social, occupational, or other areas
of functioning
b. Recurrent pulling out of ones hair; an increasing
sense of tension immediately before pulling out
the hair or when attempting to resist the behavior;
pleasure, gratification, or relief when pulling out
824 CME examination
the hair; the disturbance is not better accounted

for by another mental disorder but may be due to
a general medical condition (eg, a dermatologic
condition); the disturbance may cause clinically
significant distress or impairment in social, occupational, or other areas of functioning
c. Recurrent pulling out of ones hair resulting in
noticeable hair loss; anxiety or depression immediately before pulling out the hair or when attempting to resist the behavior; pleasure, gratification, or relief when pulling out the hair; the
disturbance does not cause clinically significant
distress or impairment in social, occupational, or
other areas of functioning
d. Recurrent pulling out of ones hair resulting in
noticeable hair loss; an increasing sense of tension
immediately before pulling out the hair or when
attempting to resist the behavior; pleasure, gratification, or relief when pulling out the hair; the
disturbance causes clinically significant distress or
impairment in social, occupational, or other areas
of functioning
e. Recurrent pulling out of ones hair resulting in
noticeable hair loss; an increasing sense of tension
immediately before pulling out the hair or when
attempting to resist the behavior; the disturbance
is not better accounted for by another mental
disorder and is not due to a general medical condition (eg, a dermatologic condition); the disturbance causes clinically significant distress or impairment in social, occupational, or other areas of
functioning
21. The severity of trichotillomania is usually rated by
a. The Trichotillomania Symptom Severity Scale, The
Trichotillomania Impairment Scale, Physicians
Rating of Clinical Progress
b. The Trichotillomania Symptom Severity Scale, The
Yale-Brown Obsessive-Compulsive Scale, Physicians Rating of Clinical Progress
c. Psychiatric Institute Trichotillomania Scale, The
Trichotillomania Impairment Scale, The Maudsley
Obsessive Compulsive Inventory
d. The Yale-Brown Obsessive-Compulsive Scale,
Psychiatric Institute Trichotillomania Scale, The
Trichotillomania Symptom Severity Scale
22. The only validated self-rating scale is
a. The Trichotillomania Symptom Severity Scale
b. The Massachusetts General Hospital Hairpulling
Scale
c. The Yale-Brown Obsessive-Compulsive Scale
d. The Trichotillomania Impairment Scale
e. Psychiatric Institute Trichotillomania Scale
J AM ACAD DERMATOL
JUNE 2002
23. Histologic findings of trichotillomania show that

a. follicular plugging with keratin debris is always
present
b. when follicular plugging with keratin debris is
present, it is pathognomonic
c. follicular plugging with keratin debris is not
present
d. perifollicular plugging with keratin debris is an
expression of dermal infiltration. follicular plugging with keratin debris can be prominent
24. Which of the following histologic features is characteristic of trichotillomania?
a. Many of the empty hair follicles show evidence of
changing into a dystrophic anagen state, with
transformation of the lower follicular epithelium
into a cord of undifferentiated basaloid cells.
b. Many of the empty hair follicles show evidence of
changing into the catagen state, with transformation of the lower follicular epithelium into a cord
of undifferentiated basaloid cells.
c. Many of the empty hair follicles show evidence of
changing into the catagen state, with transformation of the upper follicular epithelium into a cord
of undifferentiated basaloid cells.
d. Many of the empty hair follicles show evidence of
changing into the catagen state, with transformation of the lower epithelium into a cord of epithelioid cells.
e. Many of the empty hair follicles show evidence of
changing into the telogen state, with transformation of the lower epithelium into a cord of epithelioid cells.
25. Chronic hair pulling has been reported in association
with
a. social phobia, recurrent depression, psychosis
b. anxiety disorders, schizophrenia, mental retardation
c. major depression, severe anxiety, psychosis, and
dysthymia
d. OCD, severe anxiety, psychosis, and dysthymia
26. Hair pulling in infancy and early childhood is
a. predominant in females and has a negative prognosis
b. predominant in males and has a negative prognosis
c. a praecox sign of Sydenhams chorea
d. predominant in males and has a favorable prognosis
e. predominant in females and has a favorable prognosis
27. Individuals who chronically pull out their hair
a. suffer from trichotillomania
b. have tension and gratification
c. do not meet DSM-IV criteria for trichotillomania in
20% of cases
d. do not meet DSM-IV criteria for trichotillomania in
35% of cases
J AM ACAD DERMATOL
VOLUME 46, NUMBER 6
e. do not meet DSM-IV criteria for trichotillomania in

10% of cases
28. In patients with trichotillomania uncomplicated by
serious comorbidity, good results have been reached
with a modified form of habit reversal. Which of the
following treatment elements are utilized?
a. Hair collection; identifying preventive strategies
for high-risk situations; motivation enhancement;
changing the internal monologue; awareness
training; competing response training; relaxation
training
b. Hair collection; identifying preventive strategies
awareness training; competing response training;
relaxation training
c. Hair collection; identifying preventive strategies
identifying situations in which the habit is likely to
occur; changing the internal monologue; awareness training; competing response training; relaxation training
d. Hair collection; identifying preventive strategies
changing the internal monologue; competing response training; relaxation training
CME examination 825
29. The first-line strategy in treatment of trichotillomania

should be a trial of
a. risperidone and one of these selective serotonin
reuptake inhibitors (SSRIs): fluvoxamine, fluoxetine, paroxetine, sertraline, citalopram
b. clomipramine or one of these SSRIs: fluvoxamine,
fluoxetine, venlafaxine, sertraline, citalopram
c. trimipramine or one of these SSRIs: fluvoxamine,
fluoxetine, paroxetine, sertraline, citalopram
d. clomipramine or one of these SSRIs: fluvoxamine,
fluoxetine, venlafaxine, mirtrazapine, citalopram
e. clomipramine and/or one of these SSRIs: fluvoxamine, fluoxetine, paroxetine, sertraline, citalopram
30. Pharmacologic factors in treatment resistance include
a. slow onset of response (6 weeks are often
needed)
b. inadequate treatment of comorbid Axis II conditions
c. inadequate treatment of comorbid Axis I conditions
d. inadequate treatment of comorbid Axis I conditions; insufficient drug dosage; slow onset of response; inadequate duration of treatment and
symptom relapse after discontinuation
Answers to CME examination

Identification No. 802-106
June 2002 issue of the Journal of the American Academy of Dermatology
Questions 1-30, Hautmann G, Hercogova J, Lotti T. J Am Acad Dermatol 2002;46:807-21.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
c
d
a
b
c
e
d
b
a
e
c
b
a
b
e
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
a
c
d
b
d
a
b
e
b
c
d
c
a
e
d
AMERICAN BOARD OF DERMATOLOGY EXAMINATION DATES

In 2002, the Certifying Examination of the American Board of Dermatopathology (ABD) will be held
at the Holiday Inn OHare International in Rosemont, Illinois on Oct 13 and 14, 2002.
The next examination for subspecialty certification in Dermatopathology will be held in Tampa,
Florida on Friday, Nov 8, 2002. The deadline for receipt of applications is July 1, 2002.
The next Recertification Examination of the ABD will be administered in 2003. The deadline for
receipt of applications is March 1, 2003.
A certification process is being developed for the subspecialty of Pediatric Dermatology. The first
examination will be administered in 2004. Further details about the examination will be available from
the Board office early in 2003.
For further information about these examinations, please contact:
Antoinette F. Hood, MD
Executive Director, American Board of Dermatology
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2002 Trichotillomania

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2002 Trichotillomania

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CONTINUING

From the Departments of Dermatology and Venereology, University

Until the 1990s, trichotillomania was thought to

n 1889 Hallopeau, a French dermatologist, reported a case of self-inflicted depilation of the

only a proportion of hair pullers; thus hair pulling

808 Hautmann, Hercogova, and Lotti

clinical hair pulling, that is, with clinical evidence

The scalp is the most frequent hair-pulling site,

In the majority of cases, trichotillomania results in

takes on a ritualized character. Feelings of shame

Hautmann, Hercogova, and Lotti 809

addition to pulling the hair, resulting in numerous

810 Hautmann, Hercogova, and Lotti

telephone, lying in bed, driving, and writing. Hair

OTHER MEDICAL BEHAVIORS AND

pulling postures; carpal tunnel syndrome; and

to resist, control over hair pulling, and associated

HISTOLOGIC FEATURES AND

Hautmann, Hercogova, and Lotti 811

presence of normal anagen follicles in the affected

DERMATOLOGIC AND PSYCHIATRIC

812 Hautmann, Hercogova, and Lotti

Christenson and Crow41 have drawn attention to the

Table I. DSM-IV diagnostic criteria for trichotillomania

either tension (criterion B) or gratification (criterion

Hautmann, Hercogova, and Lotti 813

814 Hautmann, Hercogova, and Lotti

researchers have suggested that it may be a form of

feel ashamed and dislike the physical stigmata, they

who are mostly unaware of pulling and experience

Hautmann, Hercogova, and Lotti 815

these reports is difficult because of the small number

816 Hautmann, Hercogova, and Lotti

Habit reversal was first introduced as a general

and write in any additional reasons he or she wishes.

task, it may be useful to adopt a problem-solving

Hautmann, Hercogova, and Lotti 817

fied, the better to provide treatment for patients with

818 Hautmann, Hercogova, and Lotti

pulling might not only reflect aggression against self

mine; a fifth patient, receiving citalopram, did not

Hautmann, Hercogova, and Lotti 819

Table II. Guidelines for the treatment of trichotillomania*

relapse has been reported in several cases despite

820 Hautmann, Hercogova, and Lotti

16. Azrin NH, Nunn RG, Frantz SE. Treatment of hairpulling

40. Muller SA, Winkelmann RK. Trichotillomania. Arch Dermatol

Hautmann, Hercogova, and Lotti 821

Questions 1-30, Hautmann G, Hercogova J, Lotti T. J Am Acad Dermatol 2002;46:807-21.

Directions for questions 1-30: Give single best

d. prefer to present to a psychiatrist rather than to a

10. The possible medical complications of trichotillomania are

CME examination 823

824 CME examination

the hair; the disturbance is not better accounted

23. Histologic findings of trichotillomania show that

e. do not meet DSM-IV criteria for trichotillomania in

CME examination 825

29. The first-line strategy in treatment of trichotillomania

Answers to CME examination

Questions 1-30, Hautmann G, Hercogova J, Lotti T. J Am Acad Dermatol 2002;46:807-21.

AMERICAN BOARD OF DERMATOLOGY EXAMINATION DATES

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