Trichotillomania

“Ms. G” is a 22-year-old single woman who pulls hair from the crown of her head on a daily basis. She began pulling at her eyebrows at age 14, but the pulling shifted to her head and became a daily routine during the past 3 years. Ms. G tends to pull her hair during times of stress, but only on approximately 50% of occasions is she aware that she is doing it. The rest of the time, she reports, she pulls “automatically” and then notices a pile of hair on the floor or on her desk after she has “snapped out of it.” Ms. G often pulls her hair for 1–2 hours each day. The urge to pull immediately precedes or is simultaneous with touching the hair, and she reports that she is generally unable to resist this urge. The pulling episode usually ends when she feels the “right” tugging sensation and then sees a “good” root. She then plays with the hair, caressing her lips with the hair shaft and the root and then ingesting the hair. The feeling of accomplishment from the pulling quickly turns into shame and embarrassment. Because of the alopecia from pulling, Ms. G does not date, and she limits her social activities to only a few friends. She had never sought help for her pulling before finding information about it on a web site.On examination, Ms. G has a 3-inch-diameter area of alopecia on the crown of her head. Although she sometimes swallows hairs, there is no evidence of gastrointestinal problems. Ms. G meets the diagnostic criteria for trichotillomania, and over the course of the next several weeks, she undergoes 12 sessions of habit reversal therapy as well as treatment with N-acetylcysteine. Ms. G is able to reduce her pulling to only 5−10 minutes every several days, which she has generally maintained for over a year.