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DSM-IV

Diagnostic Criteria

A. Recurrent pulling out of one's 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 causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Differential Diagnosis

Other causes of alopecia

Other causes of alopecia should be considered in individuals who deny hair pulling (e.g., alopecia areata, male-pattern baldness, chronic discord lupus erythematosus, lichen planopilaris, folliculitis decalvans, pseudopelade, and alopecia mucinosa).

Other mental disorders

A separate diagnosis of Trichotillomania is not given if the behavior is better accounted for by another mental disorder (e.g., in response to a delusion or a hallucination in Schizophrenia). The repetitive hair pulling in Trichotillomania must be distinguished from a compulsion, as in Obsessive-Compulsive Disorder. In Obsessive-Compulsive Disorder, the repetitive behaviors are performed in response to an obsession, or according to rules that must be applied rigidly. An additional diagnosis of Stereotypic Movement Disorder is not made if the repetitive behavior is limited to hair pulling. The self-induced alopecia in Trichotillomania must be distinguished from Factitious Disorder With Predominantly Physical Signs and Symptoms, in which the motivation for the behavior is assuming the sick role.

Normal hair-pulling

Many individuals twist and play with hair, especially during states of heightened anxiety, but this behavior does not usually qualify for a diagnosis of Trichotillomania. Some individuals may present with features of Trichotillomania, but the resulting hair damage may be so slight as to be virtually undetectable. In such situations, the diagnosis should only be considered if the individual experiences significant distress. In children, self-limited periods of hair pulling are common and may be considered a temporary "habit." Therefore, among children, the diagnosis should be reserved for situations in which the behavior has persisted for several months.

DSM-5

Diagnostic Criteria

A. Recurrent pulling out of one's hair, resulting in hair loss.

B. Repeated attempts to decrease or stop hair pulling.

C. The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition).

E. The hair pulling is not better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder).

Differential Diagnosis

Normative hair removal/manipulation

Trichotillomania should not be diagnosed when hair removal is performed solely for cosmetic reasons (i.e., to improve one's physical appearance). Many individuals twist and play with their hair, but this behavior does not usually qualify for a diagnosis of trichotillomania. Some individuals may bite rather than pull hair; again, this does not qualify for a diagnosis of trichotillomania.

Other obsessive-compulsive and related disorders

Individuals with OCS and symmetry concerns may pull out hairs as part of their symmetry rituals, and individuals with body dysmorphic disorder may remove body hair that they perceive as ugly, asymmetrical, or abnormal; in such cases a diagnosis of trichotillomania is not given. The description of body-focused repetitive behavior disorder in other specified obsessive-compulsive and related disorders excludes individuals who meet diagnostic criteria for trichotillomania.

Neurodevelopmental disorders

In neurodevelopmental disorders, hair pulling may meet the definition of stereotypies (e.g., in stereotypic movement disorder). Tics (in the disorders) rarely lead to hair pulling.

Psychotic disorder

Individuals with a psychotic disorder may remove hair in response to a delusion or hallucination. Trichotillomania is not diagnosed in such cases.

Another medical condition

Trichotillomania is not diagnosed if the hair pulling or hair loss is attributable to another medical condition (e.g., inflammation of the skin or other dermatological conditions). Other causes of scarring alopecia (e.g., alopecia areata, androgenic alopecia, telogen effluvium) or nonscarring alopecia (e.g., chronic discoid lupus erythematosus, lichen planopilaris, central centrifugal cicatricial alopecia, pseudopelade, folliculitis decalvans, dissecting folliculitis, acne keloidalis nuchae) should be considered in individuals with hair loss who deny hair pulling. Skin biopsy or dermoscopy can be used to differentiate individuals with trichotillomanic from those with dermatological disorders.

Substance-related disorders

Hair-pulling symptoms may be exacerbated by certain substance - for example, stimulants - but it is less likely that substances are the primary cause of persistent hair pulling.