Behavioral Addictions _ _______________________________________________________________________
ious, bored, tense, angry), or cognitive (e.g., thoughts about hair and appearance, rigid thinking, cognitive errors). Many patients report not being fully aware of their pulling behaviors at least some of the time—a phenomenon termed “automatic” pulling. “Focused” pulling, in contrast, generally occurs when the patient sees or feels a hair that is “not right” or if the hair feels coarse, irregular, or “out of place” [312; 314]. The inability to stop hair pulling and the resultant alopecia can lead to low self-esteem, psychosocial dysfunction, and social anxiety. Individuals commonly report failing to pursue job advancements or avoiding job interviews because of the pulling and/or their appearance. A low or very low quality of life is reported by close to 33% of adults with trichotillomania [315]. In patients with trichotillomania, greater functional impairment is associated with later symptom onset, lower quality of life, and worse disease severity [316]. Unwanted medical consequences from trichotillomania include skin damage or infection that results from using sharp instruments (e.g., tweezers, needles) to pull hair. More than 20% of patients eat hair after pulling it out (trichophagia); gastrointestinal obstruction and formation of intestinal hair- balls (trichobezoars) can ensue, requiring surgical intervention in extreme cases [317]. COMORBIDITY Patients with trichotillomania have high rates of comorbidity, including major depressive disorder (39% to 65%), anxiety disorders (27% to 32%), and substance use disorders (15% to 19%). Trichotillomania is often misdiagnosed as OCD. Rates of comorbid OCD are significantly higher in clinical (13% to 27%) than community (1% to 3%) populations [312; 318]. The age of trichotillomania onset is generally earlier than its common comorbidities. In a large trichotillomania survey, patients sought to alleviate negative feelings associated with hair pulling through use of tobacco products (17.7%), alcohol (14.1%), or illicit drugs (6.0%). Also, 83% reported anxiety and 70% reported depression due to pulling, indicating that clinicians should screen for trichotillomania and the second- ary manifestations of the behavior to better ensure successful treatment outcomes [318; 319]. PATHOPHYSIOLOGY The similarity between repetitive motor symptoms of hair pull- ing and repetitive compulsive rituals in OCD led to proposals that both disorders shared common neurobiologic pathways. However, evidence indicates that trichotillomania and OCD are distinct. In contrast to OCD, patients with trichotilloma- nia are more commonly female, and body-focused repetitive behavior disorders (e.g., skin picking, compulsive nail biting) more frequently occur in these patients and their first-degree relatives. In OCD, compulsions are often driven by intrusive and obsessional thoughts, which are seldom found in patients with trichotillomania and are not listed in diagnostic criteria. The typical age of onset is early adolescence for trichotilloma-
nia and late adolescence for OCD. Treatment response also differs, with SSRIs effective in OCD but not trichotillomania [320; 321]. Hair pulling is considered a means of escaping or avoiding aversive experiences, and the temporary relief from nega- tive emotions can maintain the behavior through a cycle of negative reinforcement. Patients with trichotillomania have demonstrated greater difficulty regulating negative affective states than controls. In some individuals, boredom may trig- ger hair pulling. Some have hypothesized that in a subgroup of patients, hair pulling alleviates negative emotions resulting from perfectionism and an inability to relax, with pulling serving the function of releasing tension [322]. In the few trichotillomania neuroimaging studies conducted, patients with trichotillomania showed volume deficits and disorganization in neurocircuits that mediate affective regula- tion, motor habit generation, and suppression (compared with healthy controls) [323]. An analysis of MRI scans of 23 girls/women with trichotillomania (compared with 16 healthy controls) implicated somatosensory, sensorimotor, and frontal- striatal circuitry, and partially overlapped with structural con- nectivity findings in OCD [324]. One study sought to deter- mine whether recently identified subtypes of trichotillomania mapped to any unique neurobiological underpinnings [325]. In this study, 193 adults with trichotillomania and 58 healthy controls were recruited for a between-group comparison using structural neuroimaging. Differences in whole brain structure were compared across the subtypes, while controlling for age, sex, scanning site, and intracranial volume. Patients with trichotillomania with low awareness demonstrated increased cortical volume in the lateral occipital lobes compared to controls. Additionally, impulsive/perfectionist patients showed relative decreased volume near the lingual gyrus of the interior occipital-parietal lobe compared with controls [325]. Another study of subjects with trichotillomania failed to identify abnor- malities in implicit learning or striatal/hippocampal activation, characteristics of OCD [326]. DIAGNOSIS Trichotillomania was not officially endorsed as a mental health disorder by the APA until 1987, when it was included in the DSM-III-R as an impulse control disorder not elsewhere clas- sified [300]. Trichotillomania was moved to the chapter on Obsessive-Compulsive and Related Disorders in the DSM-5, alongside OCD, excoriation disorder, body dysmorphic dis- order, and hoarding disorder [11]. As discussed, this designa- tion of trichotillomania as an OCD-related disorder can be misleading. One trichotillomania criterion in the DSM-IV was “an increas- ing sense of tension prior to hair pulling or when resisting the urge; pleasure, gratification, or relief when pulling out hair” [256]. The DSM-5 omitted this criterion because not all trichotillomania sufferers had this experience [308]. The DSM-5-TR criteria are [11]:
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