Diagnosis and management of trichotillomania in children and adolescents

Trichotillomania (TTM), a disorder characterized by the repeated non-cosmetic pulling out of hair from any part of the body, was first described in 1889. The disorder can be associated with serious social and psychologic dysfunction, as well as medical problems. A large proportion of the published scientific literature on TTM consists of case reports, and the disorder has only received significant clinical and research attention over the last 20 years. The disorder occurs across age groups and tends to follow a chronic course in the majority of cases. There is evidence for a bimodal onset, with peaks in the pre-school years and in early adolescence. TTM in child and adolescent populations has not been extensively studied, and the etiology, natural course, and best treatment approaches for the disorder are not known. Assessment for TTM in children and adolescents focuses on making the diagnosis and documenting the response to treatment. Despite the lack of validity studies in child and adolescent populations, most assessments for TTM use one or more formal TTM measures. Although classified as an impulse control disorder in the Diagnostic and Statistical Manual of Mental Disorders (4th Edition), there is some controversy about making the diagnosis in child populations because of criteria B (pattern of rising tension prior to pulling) and C (relief after pulling). There is no consensus for the treatment of TTM in children and adolescents. As in adults, a variety of interventions have been reported, including dynamic therapy, behavioral therapy, and psychopharmacology. Use of pharmacologic interventions in the pre-school age group is rare, but becomes more common as the child ages into adolescence. The most frequently used agents include clomipramine, fluoxetine, and paroxetine. The effectiveness of psychopharmacologic interventions for TTM in children and adolescents is, at best, mixed. A multiple modal approach that includes behavioral, pharmacologic, and other therapies may be the best strategy. There have been no controlled treatment trials in child and adolescent populations. Case reports favor a behavioral approach as the first-line single modality of treatment. Controlled studies of single modalities and combined treatment approaches are clearly needed.