Keywords: Trichotillomania, Obsessive–compulsive disorder, Homoeopathy
Trichotillomania, which is classified as an impulse control disorder by DSM-IV, is the compulsive urge to pull out one's own hair leading to noticeable hair loss, distress, and social or functional impairment. It is often chronic and difficult to treat. The hair-pulling behaviour can occur during both relaxed and stressful times, but people with Trichotillomania often experience a mounting sense of tension before hair pulling occurs or when attempting to resist the behaviour. Hair pulling was first described in the literature in 1885,  and the term Trichotillomania was coined by the French dermatologist François Henri Hallopeau in 1889.1
The cause of Trichotillomania is unclear. But like many complex disorders, it was thought it is a combination of genetic and environmental factors. has been hypothesized to lie on the obsessive–compulsive spectrum, it was included in the group of obsessive–compulsive disorder, nail biting and skin picking, tic disorders and eating disorders. It is associated with irresistible urges to perform unwanted repetitive behaviour.
Magnetic resonance imaging (MRI) studies have demonstrated that some individuals with Trichotillomania have abnormalities of the lenticulate. Abnormal brain metabolism ,serotonin deficiency,: Positron emission tomography (PET) scans have revealed that some individuals with Trichotillomania have a high metabolic glucose rate in the global, bilateral, cerebellar, and right superior parietal areas.
The lifetime prevalence is estimated to be between 0.6% (overall) and may be as high as 1.5% (in males) to 3.4% (in females).
Trichotillomania usually develops during adolescence ,most often between the ages of 11 and 13 — and is often a lifelong problem. Younger Children of 5 years age also can be prone to hair pulling, but this is usually mild and goes away on its own without treatment. Although far more women than men are treated for Trichotillomania 1
Signs and symptoms:
Trichotillomania is usually confined to one or two sites,  but can involve multiple sites. The scalp is the most common pulling site, followed by the eyebrows, eyelashes, face, arms, legs, and pubic hairs.2The classic presentation is the "Friar Tuck" form of vertex and crown alopecia . Most oftentimes, hairs are removed when the mind is occupied and the hands are idle like lying in bed, reading, watching television, etc.
Hair pulling occurs in a "trance-like" state; hence, Trichotillomania is subdivided into "automatic" and "focused" hair pulling. Children are more often in the automatic, or subconscious, subtype and may not consciously remember pulling their hair. Other type is focused, or conscious, rituals associated with hair pulling, including seeking specific types of hairs to pull, pulling until the hair feels "just right", or pulling in response to a specific sensation. Knowledge of the subtype is helpful in determining treatment strategies.
Anagen - Growth Phase - Approximately 85 percent of the hair on head is in the growing phase at any given time. This phase can last 2 to 6 years. Hair can grow at the rate of approximately 5 inches per year. Catagen - Transitional phase. When the Anagen growth phase comes to an end, hair enters into a Catagen phase which lasts about one or two weeks. During this transitional phase, the hair follicle shrinks to about 1/6th of the normal diameter. The "root" is diminished and the dermal papilla breaks away and rests below the scalp. Telogen - Resting Phase. After the catagen phase, hair goes into a resting phase known as Telogen. This period can last five to six weeks. Although the hair does not grow during this stage, the dermal papilla stays in the resting phase below the scalp. Approximately 10 to 15 percent of all hairs on head are in this resting phase at any given moment.
In Trichotillomania Telogen hairs are easily plucked .Anagen hairs appear broken off and twisted, as it is difficult to extracting Anagen hairs out. In Trichotillomania hair pull test may be negative. in the affected area all Telogen hairs would have already been removed.1, 2
Areas of active plucking can convert hairs from Anagen over to catagen then to Telogen. Because catagen hairs only account for approximately 1% of hairs on the scalp, the presence of 2 to 3 catagen hairs in a specific biopsy can be suggestive of a diagnosis.
Hair pulling is a way of dealing with negative or uncomfortable feelings, such as stress, anxiety, tension, loneliness, fatigue or frustration. Leading to Social problems.
Trichophagia (Ingesting hair) is common in persons who pull out their hair. This chewing or mouthing behaviour can frequently lead to the formation of trichobezoars (i.e., hair casts) in the stomach or small intestines 2
On the scalp, there are multiple, broken off hairs in irregular patches in varying lengths. Biopsy can be confirmatory.
1. Recurrent pulling of one’s hair leading to noticeable hair loss, an increasing sense of tension immediately before pulling out the hair or when attempting to resist the behaviour
2. Pleasure, gratification, or relief when pulling out the hair
3. The condition not attributable to another mental disorder or medical condition
4. The disturbance causing clinically significant distress in social, professional, or personal areas of functioning.
Acknowledgements: I thank my patient for her co operation in above said article.
C A S E
Patient by name Ms B, 15Years, sex F, Student, came on 21/04/2010 with following complaints
1) Hair pulling 6year duration
2) Pain head
History of presenting complaints:
Hair pulling 6year duration, while on computer,
Pain in abdomen during menses
White discharge before menses
Eruptions over forehead
• Past history : Nothing Particular
• Treatment history : took allopathic treatment without any benefit
• family history : Nothing Particular
• Personal history: Appetite: moderate, Thirst: moderate bowels: regular. Sleep: difficulty
• Life space investigation: patient is a one of the two female children to well educated working parents, good childhood, good primary, not satisfactory middle and higher secondary education; of late she has become loner by spending more available time with PC.
• Physical examination & Systemic examination: thin built flat chest, dull looking weight 37 kgs,Heart S1S2 heard no murmurs, liver and spleen not enlarged, abdomen soft,
Scalp : hair growth is uniform short hair , no eruptions, no scales ,multiple patches of broken hair,
• Investigations: no investigations were done earlier
Clinical diagnosis: Trichotillomania ( diagnosed by local Dermatologist)
FEMALE GENITALIA/SEX - MENSES - late, too
FEMALE GENITALIA/SEX - MENSES - painful, dysmenorrhoea
FEMALE GENITALIA/SEX - LEUKORRHEA - menses – before
BACK - PAIN - Lumbar region - menses – before
FACE - ERUPTIONS - acne – Forehead
Result of Repertorisation:
Sepia 52/18, Sulphur 47/18, Cal carb 40/18, Nat Mur35/18
Remedy selected Sepia on built of patient and on reportorial analysis
210410 Sepia200C 3doses were given with 15 days placebo
050510 no change in symptoms, 15 days placebo was given
210510 no change in hair symptoms, irritability. complained of pain in abdomen with white discharge, Sepia200C 3doses were given with 15 days placebo
050610 sleeps was good, irritability reduced, no change in other symptoms. 15 days placebo
210610 hair plucking is less, with bitter taste in mouth 15 days placebo
070710 better but hair plucking was persisting Sepia 1M 2doses were given with 15 days placebo.
170710 as menstrual bleeding was copious, the following investigation were done Hb % was 10.5 gm, U S Scan was done of whole abdomen: impression was no abnormality only endometriam was 8mm. Hamamelis 1m, one dose was given and 15 days placebo was given.
280710 no hair plucking but hair growth was minimum ,weakness was present Ferum phos 3X 4grains twice a day was given along with iron rich diet.
110810 she came with history of diarrhoea for two day history Aloes 30c 7doses were given 15 days placebo and asked her to report after 3days.
250910 she came with mild pain in abdomen with white discharge, with occasional stress induced hair plucking Sepia 1M 2doses were given with 15 days placebo and Ferum phos 3X 4grains twice a day was given.
28 032011 she came along with her Hb % was 12.5 gm, U S Scan was done of whole abdomen : impression was no abnormality only endometriam was 6mm, her general condition was good no stress induced hair plucking , periods were normal .Thuja 200C 3doses were given along with 15 days placebo and Ferum phos 3X 4grains twice a day..
CASE SUMMARY: Hair pulling 6year duration took conventional medicines without any benefit, Sepia gave good results, she took 6 -7 months treatment and stopped for six months the problem didn’t recur. She gained weight her physical and psychological well being was noticed.