Trichotillomania (TTM) aka Hair Pulling in Youth and Adults: Information for Primary Care
Case, Part 1
History of hair pulling
- Some people have a habit of pulling out their hair, especially when stressed or bored.
- How about you?
- Any troubles with low self-esteem?
- Any troubles with your mood?
- Any troubles with focus or concentration?
Functional impairment with work, home and relationships
- Any troubles with your work? Home? Relationships?
Traumatic alopecia secondary to physical or chemical factors such as
- Traction, Chemical, or
- Physical hair relaxers, or
Other itchy conditions of the scalp.
- Alopecia areata, tinea capitis, and secondary syphilis.
- Major depression
- Anxiety disorders
- Substance use disorders
- Although studies have been done on SSRIs, there is no clear evidence of their effectiveness (Grant, 2016).
- Clomipramine may show efficacy (Ninan, 2000; Swedo, 1989)
- NAC is a glutamate modulator.
- One study showed NAC is effective compared to placebo (Grant, 2009)
- Recent systematic review of 4 randomized, double-blind placebo-controlled trials on the use of NAC in the treatment of TTM found inconclusive evidence, but suggested that NAC may still be useful as a treatment for OCD owing to its relatively benign side effects (Grant, 2016)
- Some initial studies and case reports were promising, however a double blind, placebo controlled study did not show any greater reduction on outcomes compared to placebo (Leppink, 2017).
- RCT of olanzapine showed “strong evidence that olanzapine is effective when compared to placebo” (Van Ameringen, 2010)
- Consider if patient has comorbid bipolar disorder
- CNS stimulants
- Opioid antagonists
Psychotherapy and Non-Medication Treatment
Habit reversal therapy (HRT)
- Patients are trained to recognize their impulse to pull, and learn to redirect this impulse
Acceptance and Commitment Therapy (ACT) (Woods, 2006)
- ACT uses both 1) acceptance and mindfulness strategies, along with 2) commitment and behaviour change strategies.
- One theory about TTM is that at least for some patients, hair pulling may be about an attempt at self-regulation such as boredom.
- As a result, finding alternate ways to cope with boredom (i.e. self regulate) may show promise.
Where to Refer
- Private practice psychologist
Case, Part 2
About this Document
Written by members of the eMentalHealth.ca/PrimaryCare team which includes members of the Department of Psychiatry and Family Medicine at the University of Ottawa. Reviewed by members of the Family Medicine Program at the University of Ottawa, including Dr's Farad Motamedi; Mireille St-Jean; Eric Wooltorton.
Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from a health professional. Always contact a qualified health professional for further information in your specific situation or circumstance.
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Date of Last Revision: Oct 11, 2017