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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?
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 density, short 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. Smooth, circular, discrete 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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