Skip to main content Accessibility help
Hostname: page-component-568f69f84b-jg9p7 Total loading time: 0.207 Render date: 2021-09-18T11:40:35.413Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "metricsAbstractViews": false, "figures": true, "newCiteModal": false, "newCitedByModal": true, "newEcommerce": true, "newUsageEvents": true }

Challenges in the Classification and Treatment of Trichotillomania

Published online by Cambridge University Press:  07 November 2014


The behavioral syndrome of trichotillomania (TTM) is well characterized, but challenges pertaining to TTM remain in several areas, including diagnostic classification, assessment of severity, and determination of relevance of comorbid psychiatric disorders. Acute pharmacological studies have focused on serotonin transport inhibitors, and preliminary evidence suggests that inhibition of both serotonin and norepinephrine transporters (ie, by clomipramine and venlafaxine) provides a clinical improvement. Dopamine antagonists are promising agents in need of systematic evaluation in TTM. Cognitive-behavioral therapy appears to achieve a decrease in acute symptoms in many patients. However, longitudinal maintenance of benefits has not been rigorously tested with either pharmacological or behavioral therapy. Clinical impressions and treatment data indicate that achieving durability of treatment benefits remains a major challenge in many patients with TTM, although there is evidence of improved outcome with comprehensive multimodal treatment.

Feature Article
Copyright © Cambridge University Press 1998

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)


1.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association Press; 1994.Google Scholar
2.Soriano, JL, O'Sullivan, RL, Baer, L, Phillips, KA, McNally, RJ, Jenike, MA. TTM and self-esteem: a survey of 62 female hair pullers. J Clin Psychiatry. 1996;57:7782.Google Scholar
3.Stemberger, RMT, Thomas, AM, Mansueto, CS, Carter, JG. Personal toll of TTM: behavioral and interpersonal sequelae. J Affect Disord. In press.Google Scholar
4.McElroy, SL, Hudson, JI, Pope, HG, Keck, PE, Aizley, HG. The DSM III-R impulse control disorders not elsewhere classified: clinical characteristics and relationship to other psychiatric disorders. Am J Psychiatry. 1992;149:318332.Google Scholar
5.Hollander, E, Kwon, JH, Stein, DJ, Broatch, J, Rowland, CT, Himelein, CA. Obsessive-compulsive and spectrum disorders: overview and quality of life issues. J Clin Psychiatry. 1996;57(suppl 8):36.Google ScholarPubMed
6.Leonard, HL, Lenane, MC, Swedo, SE, Rett, DC, Rapoport, JL. A double-blind comparison of clomipramine and desipramine treatment of severe onychophagia (nail biting). Arch Gen Psychiatry. 1991;48:821827.CrossRefGoogle Scholar
7.Miguel, EC, Coffay, BJ, Baer, L, et al.Phenomenology of intentional repetitive behaviors in obsessive compulsive disorder and Tourette's syndrome. J Clin Psychiatry. 1995;56:246–25.Google Scholar
8.Mansueto, CS, Stemberger, RMT, Thomas, AM, Golomb, RG. TTM: a comprehensive behavioral model. Clin Psychol Rev. 1997;17:567577.CrossRefGoogle Scholar
9.O'Sullivan, RL, Rauch, SL, Breiter, HC, et al.Reduced basal ganglia volumes in TTM measured via morphometric MRI. Biol Psychiatry. In press.Google Scholar
10.Stein, DJ, Coetzer, R, Lee, M, Davids, B, Bouwer, C. Magnetic resonance brain imaging in women with obsessive compulsive disorder and TTM. Psychiatry Res. 1997;74:177182.CrossRefGoogle Scholar
11.O'Sullivan, RL, Christenson, GA, Stein, D. Pharmacotherapy of TTM: a review. In: Trichotillomania: New Developments. Washington, DC: American Psychiatric Association Press. In press.CrossRefGoogle Scholar
12.Christenson, GA, Mackenzie, TB, Mitchell, JE. Characteristics of 60 adult chronic hair pullers. Am J Psychiatry. 1991;148:365370.Google ScholarPubMed
13.Rothbaum, BO, Ninan, PT. The assessment of TTM. Behav Res Ther. 1994;32:651662.CrossRefGoogle Scholar
14.Ninan, PT, Rothbaum, BO, Stipetic, M, Lewine, RJ, Risch, SC. CSF 5HIAA as a predictor of treatment response in TTM. Psychopharmacol Bull. 1992;28:451455.Google Scholar
15.Swedo, SE, Rapoport, JL, Leonard, HL, et al.Regional cerebral glucose metabolism of women with TTM. Arch Gen Psychiatry. 1991;48:828833.CrossRefGoogle Scholar
16.O'Sullivan, RL, Keuthen, NJ, Christenson, GA, Mansueto, CS, Stein, DJ, Swedo, SE. TTM: behavioral symptom or clinical syndrome. Am J Psychiatry. 1997;154:14421449.Google ScholarPubMed
17.Christenson, GA, Mansueto, CS. Descriptive characteristics and phenomenology of TTM. In: Stein, DJ, Christenson, GA, Hollander, E, eds. TTM: Current Concepts. Washington, DC: American Psychiatric Press. 1998.Google Scholar
18.Jenike, MA. Obsessive compulsive and related disorders: a hidden epidemic. N Engl J Med. 1989;321:539541.CrossRefGoogle ScholarPubMed
19.Swedo, SE, Leonard, HL, Rapoport, JL, Lenane, MC, Goldberger, BA, Cheslow, BA. A double-blind comparison of clomipramine and desipramine in the treatment of TTM (hair pulling). N Engl J Med. 1989;321:497501.CrossRefGoogle Scholar
20.Christenson, GA, Mackenzie, TB, Mitchell, JE, et al.A placebo-controlled double-blind crossover study of fluoxetine in TTM. Am J Psychiatry. 1991;148:15661571.Google Scholar
21.Streichenwein, SM, Thornby, JI. A long-term, double-blind, placebo-controlled crossover trial of the efficacy of fluoxetine for TTM. Am J Psychiatry. 1995;152:11921196.Google Scholar
22.Stanley, MA, Breckenridge, JK, Swann, AC, Freeman, EB, Reich, L. Fluvoxamine treatment of TTM. J Clin Psychopharmacol. 1997;17:278283.CrossRefGoogle Scholar
23.Ninan, PT, Knight, B, Kirk, L, Rothbaum, BO, Kelsey, J, Nemeroff, CB. A controlled trial of venlafaxine in TTM: interim phase 1 results. Psychopharmacol Bull. 1998;34:221224.Google Scholar
24.Christenson, GA, Crow, SJ, Mackenzie, TB, et al. A placebo controlled double-blind study of naltrexone for TTM. New Research Abstracts of the Annual Meeting of the American Psychiatric Association; 1994. Abstract NR 597:212.Google Scholar
25.Christenson, GA, Popkin, MK, Mackenzie, TB, et al.Lithium treatment of chronic hair pulling. J Clin Psychiatry. 1991;52:116120.Google ScholarPubMed
26.Stein, DJ, Hollander, E. Low dose pimozide augmentation of serotonin reuptake blockers in the treatment of TTM. J Clin Psychiatry. 1992;53:123126.Google Scholar
27.Van Amerigen, M, Mancini, C. Treatment of TTM with haloperidol. Presented at Anxiety Disorders Association of America Annual Meeting; 1996.Google Scholar
28.Pollard, CA, Ibe, IO, Krojanker, DN, et al.Clomipramine treatment for TTM: a follow-up report on four cases. J Clin Psychiatry. 1991;52:128130.Google Scholar
29.Swedo, SE, Lenane, MC, Leonard, HL. Long-term treatment of TTM (hair pulling) (letter). N Engl J Med. 1993;329:141142.CrossRefGoogle Scholar
30.Iancu, I, Weizman, A, Kindler, S, Sasson, Y, Zohar, J. Serotonergic drugs in TTM: treatment results in 12 patients. J Nerv Ment Dis. 1996;184:641644.CrossRefGoogle Scholar
31.Rothbaum, BO. The behavioral treatment of TTM. Behav Psychother. 1992;20:8590.CrossRefGoogle Scholar
32.Azrin, NH, Nunn, RG, Frantz, SE. Treatment of hair pulling (TTM): a comparative study of habit reversal and negative practice training. Behav Ther and Exp Psychiatry. 1980;11:1320.CrossRefGoogle Scholar
33.Keuthen, NJ, O'Sullivan, RL, Goodchild, P, Rodriguez, D, Jenike, MA, Baer, L. Retrospective review of treatment outcome for 63 patients with TTM. Am J Psychiatry. 1998;155:560561.CrossRefGoogle Scholar
34.Lerner, J, Franklin, ME, Meadows, EA, Hembree, E, Foa, EB. Effectiveness of a cognitive behavioral treatment program for TTM: an uncontrolled evaluation. Behav Ther. 1998;29:157171.CrossRefGoogle Scholar
35.Mansueto, CS, Golomb, RG, Thomas, AM, Stemberger, RMT. A comprehensive model for behavioral treatment of TTM. Cog Behav Pract. In press.Google Scholar
Cited by

Send article to Kindle

To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Challenges in the Classification and Treatment of Trichotillomania
Available formats

Send article to Dropbox

To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

Challenges in the Classification and Treatment of Trichotillomania
Available formats

Send article to Google Drive

To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

Challenges in the Classification and Treatment of Trichotillomania
Available formats

Reply to: Submit a response

Please enter your response.

Your details

Please enter a valid email address.

Conflicting interests

Do you have any conflicting interests? *