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A dermatologist refers a 13-year-old girl for a psychiatric evaluation due to concerns she is pulling out her hair, even though she states she is not doing this and her parents have not witnessed it. Which of the following findings would be consistent with a primary psychiatric rather than dermatologic disorder?

A Decreased hair density, short vellus hair, and broken shafts of different lengths
B Microscopic exam demonstrating a beaded appearance of the hair shafts
C Observation of the child biting her own hairs during the visit
D Scaly patches with alopecia and black dots at follicular orifices representing broken hairs
E Smooth, circular, discrete areas of complete hair loss developing over a few weeks

Trichotillomania, or hair-pulling disorder, was placed under the new category of obsessive-compulsive and related disorders in the DSM-5 after previously having resided within the category of impulse control disorders not elsewhere classified in the DSM-IV-TR. Trichotillomania is characterized by recurrent pulling out of one’s hair, resultant hair loss, repeated attempts to decrease or stop hair pulling, and clinically significant distress or functional impairment. The scalp, eyebrows, and eyelids are the most common sites of hair-pulling, but it can occur from anywhere. The hair loss required for a diagnosis may not be easily visible due to individuals pulling single hairs from all over a site, or they may try to conceal or camouflage hair loss. Most patients will report their hair-pulling, but skin biopsy and trichoscopy can confirm the diagnosis if needed. Decreased hair densityshort vellus hair, and broken shafts of different lengths are consistent with a diagnosis of trichotillomania. Onset most frequently occurs around the time of puberty, the female to male ratio is approximately 10:1, and the course is chronic if untreated. Medical complications can include digit purpura, carpal tunnel syndrome, blepharitis, and trichobezoars, with the latter potentially progressing to bowel obstruction and perforation. Habit reversal therapy is the mainstay of treatment. Selective serotonin reuptake inhibitors have not demonstrated efficacy.

Microscopic exam demonstrating a beaded appearance of the hair shafts (B) is consistent with a diagnosis of monilethrix, which is an autosomal dominant disorder characterized by hair shaft abnormalities and hair fragility. Observation of the child biting her own hairs during the visit (C) is not a symptom of trichotillomania, nor is twisting and playing with one’s hair. Scaly patches with alopecia and black dots at follicular orifices representing broken hairs (D) are characteristic of tinea capitis, which can be confirmed by potassium hydroxide examination and fungal culture. Smoothcirculardiscrete areas of complete hair loss developing over a few weeks (E) is a manifestation of alopecia areata, a chronic and relapsing disorder characterized by nonscarring hair loss.


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Trichotillomania, hair-pulling disorder

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Q: What are some other body-focused repetitive behaviors in addition to trichotillomania and excoriation disorder?


A: Nail-biting and lip-chewing.

Trichotillomania (Hair-Pulling Disorder)

  • Subclassified under obsessive compulsive and related disorders (DSM-5)
  • Onset often in childhood or adolescence and associated with a stressful event (25% of cases)
  • Recurrent, repetitive, intentional pulling out of one's hair causing visible hair loss
  • Often involves the scalp but can also include eyebrows, eyelashes, facial and pubic hair
  • Tension experienced immediately before the pulling behavior—pleasure or relief occurs afterwards
  • Cognitive behavioral therapy first line
  • Pharmacologic: SSRIs, TCAs, antipsychotics, and lithium

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Thank you for preparing me for my certification exam. What kind of sorcery are you doing? I got the exact score you predicted I would get. Creepy but good!


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