{"id":293,"date":"2020-07-16T12:15:44","date_gmt":"2020-07-16T12:15:44","guid":{"rendered":"https:\/\/courses.lumenlearning.com\/abnormalpsych\/chapter\/trichotillomania-hair-pulling-disorder\/"},"modified":"2022-07-26T20:05:50","modified_gmt":"2022-07-26T20:05:50","slug":"trichotillomania-hair-pulling-disorder","status":"publish","type":"chapter","link":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/chapter\/trichotillomania-hair-pulling-disorder\/","title":{"raw":"Trichotillomania (Hairpulling Disorder)","rendered":"Trichotillomania (Hairpulling Disorder)"},"content":{"raw":"<div class=\"textbox learning-objectives\">\r\n<h3>Learning Objectives<\/h3>\r\n<ul>\r\n \t<li>Describe the symptoms and diagnosis of trichotillomania<\/li>\r\n<\/ul>\r\n<\/div>\r\n<b>Trichotillomania<\/b>\u00a0(<b>TTM<\/b>), also known as\u00a0hairpulling disorder\u00a0or\u00a0compulsive hairpulling, is a psychological\u00a0disorder\u00a0characterized by a long-term urge that results in the\u00a0pulling out\u00a0of one's\u00a0hair.<sup id=\"cite_ref-Fran2011_2-3\" class=\"reference\"><\/sup>\u00a0This occurs to such a degree that\u00a0hair loss\u00a0can be seen.<sup id=\"cite_ref-Fran2011_2-4\" class=\"reference\"><\/sup>\u00a0A brief positive feeling may occur as hair is removed and efforts to stop pulling hair typically fail.<sup id=\"cite_ref-DSM5_1-5\" class=\"reference\"><\/sup>\u00a0Hair removal may occur anywhere; however, the head and around the eyes are most common.<sup id=\"cite_ref-DSM5_1-6\" class=\"reference\"><\/sup>\u00a0The hairpulling is to such a degree that it results in distress.\r\n\r\n[caption id=\"\" align=\"alignright\" width=\"300\"]<img src=\"https:\/\/upload.wikimedia.org\/wikipedia\/commons\/thumb\/4\/45\/Trichotillomania_1.jpg\/300px-Trichotillomania_1.jpg\" alt=\"Trichotillomania showing the back of a man's head with lots of missing hair.\" width=\"300\" height=\"421\" \/> <strong>Figure 1<\/strong>. A pattern of incomplete hair loss on the scalp of a person with trichotillomania.[\/caption]\r\n\r\nTTM may run in families. The disorder occurs more commonly in those with\u00a0obsessive-compulsive disorder or anxiety disorders, and episodes of pulling may be triggered by\u00a0anxiety.\u00a0People usually acknowledge that they pull their hair and on examination, broken hairs may be seen.\u00a0Other conditions that may be present\u00a0include\u00a0body dysmorphic disorder; however, in that condition, people remove hair to try to improve what they see as a problem in how they look.\r\n\r\nTrichotillomania is estimated to affect between 1%-4% of people.<sup id=\"cite_ref-Fran2011_2-5\" class=\"reference\"><\/sup><sup id=\"cite_ref-Huynh2013_3-4\" class=\"reference\"><\/sup>\u00a0The lifetime\u00a0prevalence\u00a0of trichotillomania is estimated to be between 0.6% and 4.0% of the overall population.\u00a0With a 1% prevalence rate, 2.5 million people in the United States may have trichotillomania at some time during their lifetimes. Trichotillomania most commonly begins in childhood or adolescence.\u00a0Women are affected about 10 times more often than men.\r\n<h2><span id=\"Signs_and_symptoms\" class=\"mw-headline\">Signs and Symptoms<\/span><\/h2>\r\nTrichotillomania is usually confined to one or two\u00a0areas of the body,\u00a0but can involve multiple sites. The scalp is the most common pulling site, followed by the eyebrows, eyelashes, face, arms, and legs.<sup id=\"cite_ref-Sah_8-0\" class=\"reference\"><\/sup>\u00a0Some less common areas include the pubic area, underarms, beard, and chest.<sup id=\"cite_ref-9\" class=\"reference\"><\/sup>\u00a0The classic presentation is the <em>Friar<\/em> <em>Tuck\u00a0<\/em>form of vertex and crown alopecia.<sup id=\"cite_ref-10\" class=\"reference\"><\/sup>\u00a0Children are less likely to pull from areas other than the scalp.<sup id=\"cite_ref-Sah_8-1\" class=\"reference\"><\/sup>\r\n\r\nPeople who suffer from trichotillomania often pull only one hair at a time and these hairpulling episodes can last for hours at a time. Trichotillomania can go into remission-like states where the individual may not experience the urge to pull for days, weeks, months, and even years.<sup id=\"cite_ref-11\" class=\"reference\"><\/sup>\r\n\r\nIndividuals with trichotillomania exhibit hair of differing lengths; some are broken hairs with blunt ends, some new growth with tapered ends, some broken mid-shaft, or some uneven stubble. Scaling on the scalp is not present, overall hair density is normal, and a hair-pull test is negative (the hair does not pull out easily). Hair is often pulled out leaving an unusual shape. Individuals with trichotillomania may be secretive or shameful of the hairpulling behavior.\u00a0If patients attempt to disguise their symptoms, it can make diagnosis difficult as symptoms are not always immediately obvious, or have been deliberately hidden to avoid disclosure.<sup id=\"cite_ref-Sah_8-2\" class=\"reference\"><\/sup>\r\n\r\nAn additional psychological effect can be low\u00a0self-esteem, often associated with being shunned by peers and the fear of socializing, due to appearance and negative attention they may receive.\u00a0Some people with trichotillomania wear hats, wigs, false eyelashes, eyebrow pencil, or style their hair in an effort to avoid such attention. TTM seems to have a strong\u00a0stress-related component. In low-stress environments, some exhibit no symptoms (known as <em>pulling<\/em>) whatsoever. This pulling often resumes upon leaving the low-stress environment.\u00a0Some individuals with trichotillomania may feel they are the only person with this problem due to low rates of reporting.\r\n\r\nFor some people, trichotillomania is a mild problem, merely a frustration. But for many, shame and embarrassment about hairpulling causes painful isolation and results in a great deal of emotional distress, placing them at risk for a co-occurring psychiatric disorder, such as a mood or anxiety disorder. Hairpulling can lead to great tension and strained relationships with family members and friends. Family members may need professional help in coping with this problem.<sup id=\"cite_ref-15\" class=\"reference\"><\/sup>\r\n\r\n[caption id=\"attachment_1391\" align=\"alignleft\" width=\"300\"]<img class=\"wp-image-1391 size-medium\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/5351\/2020\/07\/31180316\/1600px-Trichotillomania-300x206.jpg\" alt=\"Girl scratching and pulling at hair on the back of her head.\" width=\"300\" height=\"206\" \/> <strong>Figure 2<\/strong>. Children may not consciously remember pulling their hair.[\/caption]\r\n<h3><span style=\"color: #373d3f; font-weight: 400;\">Trichotillomania is often n<\/span><span style=\"color: #373d3f; font-size: 1em; font-weight: 400;\">o<\/span><span style=\"color: #373d3f; font-size: 1rem; font-weight: 400; text-align: initial;\">t a focused act, but rather hairpulling occurs in a trance-like state;<\/span><sup id=\"cite_ref-Tay_19-4\" class=\"reference\" style=\"color: #373d3f; font-weight: 400; text-align: initial;\"><\/sup><span style=\"color: #373d3f; font-size: 1rem; font-weight: 400; text-align: initial;\">\u00a0hence, trichotillomania is subdivided into \"automatic\" versus \"focused\" hairpulling.<\/span><sup id=\"cite_ref-Sah_8-11\" class=\"reference\" style=\"color: #373d3f; font-weight: 400; text-align: initial;\"><\/sup><span style=\"color: #373d3f; font-size: 1rem; font-weight: 400; text-align: initial;\">\u00a0Children are more often in the automatic, or unconscious subtype, and may not consciously remember pulling their hair. Other individuals may have focused, or conscious, rituals associated with hairpulling, including seeking specific types of hairs to pull, pulling until the hair feels \"just right,\" or pulling in response to a specific sensation.\u00a0<\/span><sup id=\"cite_ref-Sah_8-12\" class=\"reference\" style=\"color: #373d3f; font-weight: 400; text-align: initial;\"><\/sup><span style=\"color: #373d3f; font-size: 1rem; font-weight: 400; text-align: initial;\">Knowledge of the subtype is helpful in determining treatment strategies.<\/span><\/h3>\r\n<h3>Epidemiology<\/h3>\r\nTrichotillomania (TTM), or human compulsive hairpulling, is one of the most common psychiatric disorders, affecting approximately 3.5% of women, or 3.7 million people in the United States. TTM patients experience pronounced psychological distress with considerable negative impact in their quality of life.[footnote]Vieira, G., Lossie, A. C., Lay, D. C., Jr, Radcliffe, J. S., &amp; Garner, J. P. (2017). Preventing, treating, and predicting barbering: A fundamental role for biomarkers of oxidative stress in a mouse model of Trichotillomania. <em>PloS one<\/em>, 12(4), e0175222. https:\/\/doi.org\/10.1371\/journal.pone.0175222[\/footnote]\r\n\r\nTrichotillomania has an estimated lifetime prevalence of approximately 0.5%-1%, and peak age of onset in adolescence (12\u201313\u00a0years of age) and\u00a0is typically associated with impairment across domains of social, occupational, academic, and psychological functioning.[footnote]Chamberlain, S. R., Harries, M., Redden, S. A., Keuthen, N. J., Stein, D. J., Lochner, C., &amp; Grant, J. E. (2018). Cortical thickness abnormalities in trichotillomania: international multi-site analysis. <em>Brain imaging and behavior<\/em>, 12(3), 823\u2013828. https:\/\/doi.org\/10.1007\/s11682-017-9746-3[\/footnote]\r\n\r\nTrichotillomania is more common in women than in men, and is currently classified as an OCD-related disorder.\u00a0However, unlike the repetitive compulsive acts observed in OCD, repetitive behaviors in trichotillomania are not generally driven by intrusive thoughts.[footnote]Isobe, M., Redden, S. A., Keuthen, N. J., Stein, D. J., Lochner, C., Grant, J. E., &amp; Chamberlain, S. R. (2018). Striatal abnormalities in trichotillomania: a multi-site MRI analysis. NeuroImage. Clinical, 17, 893\u2013898. https:\/\/doi.org\/10.1016\/j.nicl.2017.12.031[\/footnote]\r\n\r\nPatients with trichotillomania can come across a range of medical settings, including family doctors, dermatologists, neurologists, psychiatrists, pediatricians, endocrinologists, and geneticists.[footnote]Chamberlain, S. R., Harries, M., Redden, S. A., Keuthen, N. J., Stein, D. J., Lochner, C., &amp; Grant, J. E. (2018). Cortical thickness abnormalities in trichotillomania: international multi-site analysis. <em>Brain imaging and behavior<\/em>, 12(3), 823\u2013828. https:\/\/doi.org\/10.1007\/s11682-017-9746-3[\/footnote]\r\n<h3>Etiology<\/h3>\r\n<p id=\"p0025\" class=\"p p-first\">Very little is known about the neurobiological basis of this disorder in humans, but in one study that reviewed available clinical and imaging studies of trichotillomania, previous work suggested an ABC model of trichotillomania, emphasizing the dysfunction of pathways involved in affect regulation, behavioral control, and cognition. In keeping with this, studies have found that trichotillomania is associated with impairment on response inhibition tests\u00a0and phenomenological studies have found relationships between emotional states (dysphoria, anxiety) and the severity of the hairpulling symptoms.[footnote]Isobe, M., Redden, S. A., Keuthen, N. J., Stein, D. J., Lochner, C., Grant, J. E., &amp; Chamberlain, S. R. (2018). Striatal abnormalities in trichotillomania: a multi-site MRI analysis. NeuroImage. Clinical, 17, 893\u2013898. https:\/\/doi.org\/10.1016\/j.nicl.2017.12.031[\/footnote]<\/p>\r\nOne study suggests that hormones may be a potential cause. In a study of adolescent girls with trichotillomania, researchers found that lower progesterone was associated with worse hairpulling severity (NIMH Trichotillomania Symptom Severity Scale, NIMH-TSS), and that lower levels of all three hormones were associated with greater psychosocial dysfunction (Sheehan Disability Scale, SDS). Progesterone is believed to modulate the adaptive response to stress, mainly through the effect of its neurosteroid metabolite allopregnanolone on GABAA receptor activity.[footnote]Grant, J. E., &amp; Chamberlain, S. R. (2018). Salivary sex hormones in adolescent females with trichotillomania. <em>Psychiatry research<\/em>, 265, 221\u2013223. https:\/\/doi.org\/10.1016\/j.psychres.2018.05.012[\/footnote]\r\n\r\nSome studies which included neuroimaging showed that\u00a0individuals with trichotillomania had increased grey matter density in several brain regions involving affect regulation, motor habits, and cognition<strong>.\u00a0<\/strong>Additionally, other studies examine the negative reinforcement people have when pulling; when emotional regulation is measured, those with\u00a0trichotillomania have a harder time with emotional control that those without the disorder. Triggers for pulling include boredom, perfectionism, and frustration (to name a few) and hairpulling may be a way of relieving some of the stress and tension associated with these negative feelings.[footnote]Grant, J. E., &amp; Chamberlain, S. R. (2016). Trichotillomania. <em>The American journal of psychiatry<\/em>, 173(9), 868\u2013874. https:\/\/doi.org\/10.1176\/appi.ajp.2016.15111432[\/footnote]\r\n<h2>Causes and Comorbidity<\/h2>\r\nEnvironment is a large factor that affects hairpulling.<sup id=\"cite_ref-Tay_19-0\" class=\"reference\"><\/sup>\u00a0Sedentary activities such as being in a relaxed environment, or bored, are conducive to hairpulling.\u00a0<sup id=\"cite_ref-Tay_19-1\" class=\"reference\"><\/sup><sup id=\"cite_ref-Diefenbach_20-0\" class=\"reference\"><\/sup>A common example of a sedentary activity promoting hairpulling is lying in a bed while trying to rest or fall asleep.<sup id=\"cite_ref-Tay_19-2\" class=\"reference\"><\/sup>\u00a0An extreme example of automatic trichotillomania is found when some patients have been observed to pull their hair out while asleep.\u00a0<sup id=\"cite_ref-Tay_19-3\" class=\"reference\"><\/sup>This is called sleep-isolated trichotillomania.<sup id=\"cite_ref-21\" class=\"reference\"><\/sup>\r\n\r\nAnxiety,\u00a0depression, and\u00a0OCD are more frequently encountered in people with trichotillomania.<sup id=\"cite_ref-Chamberlain_7-2\" class=\"reference\"><\/sup><sup id=\"cite_ref-pmid8698680_22-0\" class=\"reference\"><\/sup>\u00a0Trichotillomania also has a high overlap with\u00a0post-traumatic stress disorder, and some cases of trichotillomania may be triggered by stress. Another school of thought emphasizes hairpulling as addictive or negatively reinforcing, as it is associated with rising tension beforehand and relief afterward.<sup id=\"cite_ref-Chamberlain_7-3\" class=\"reference\"><\/sup>\u00a0A neurocognitive model\u2014the notion that the\u00a0basal ganglia\u00a0plays a role in habit formation and that the\u00a0frontal lobes\u00a0are critical for normally suppressing or inhibiting such habits\u2014sees trichotillomania as a habit disorder.<sup id=\"cite_ref-Chamberlain_7-4\" class=\"reference\"><\/sup>\r\n\r\nThe most common age of onset of trichotillomania is between ages nine and 13,\u00a0and a notable peak at ages 12\u201313. In this age range, trichotillomania is usually chronic and continues into adulthood. Trichotillomania that begins in adulthood most commonly arises from underlying psychiatric causes.<sup id=\"cite_ref-:0_27-1\" class=\"reference\"><\/sup>\r\n<h2><span id=\"Psychotherapy\" class=\"mw-headline\">Psychotherapy<\/span><\/h2>\r\nTreatment is based on a person's age. Most preschool age children outgrow the condition if it is managed conservatively. In young adults, establishing the diagnosis and raising awareness of the condition is an important reassurance for the family and patient. Non-pharmacological interventions, including\u00a0behavior modification\u00a0programs, are often the first-line mediation; referrals to psychologists or psychiatrists may be considered when other interventions fail. When trichotillomania begins in adulthood, it is often associated with other psychological\u00a0disorders, and referral to a psychologist or psychiatrist for evaluation or treatment is considered best. The hairpulling may resolve when other conditions are treated.\r\n<div class=\"textbox examples\">\r\n<h3>Watch It<\/h3>\r\nWatch at least the first four minutes of this video (or the whole thing if you have time) to learn more about\u00a0Aneela Idnani's experience with a body-focused repetitive behavior.\r\n\r\n<iframe src=\"\/\/plugin.3playmedia.com\/show?mf=5572641&amp;p3sdk_version=1.10.1&amp;p=20361&amp;pt=375&amp;video_id=WkfBtT4VbI4&amp;video_target=tpm-plugin-1wv2gsul-WkfBtT4VbI4\" width=\"800px\" height=\"450px\" frameborder=\"0\" marginwidth=\"0px\" marginheight=\"0px\"><\/iframe>\r\n\r\nYou can view the <a href=\"https:\/\/course-building.s3-us-west-2.amazonaws.com\/Abnormal+Psychology\/transcripts\/OvercomingTrichotillomaniaThePowerOfAwareness_transcript.txt\" target=\"_blank\" rel=\"noopener\">transcript for \"Overcoming Trichotillomania: The Power of Awareness | Aneela Idnani | TEDxFargo\" here (opens in new window)<\/a>.\r\n\r\n<\/div>\r\n<div class=\"textbox key-takeaways\">\r\n<h3>Key Takeaways:\u00a0Trichotillomania<\/h3>\r\n<iframe title=\"Trichotillomania\" src=\"https:\/\/lumenlearning.h5p.com\/content\/1291225597709582998\/embed\" width=\"1088\" height=\"822\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><script src=\"https:\/\/lumenlearning.h5p.com\/js\/h5p-resizer.js\" charset=\"UTF-8\"><\/script>\r\n\r\n<\/div>\r\n<div class=\"textbox tryit\">\r\n<h3>Try It<\/h3>\r\nhttps:\/\/assess.lumenlearning.com\/practice\/5b685f3a-0e8c-4d8c-a783-b6158dcde258\r\n\r\n<\/div>\r\n<div class=\"textbox learning-objectives\">\r\n<h3>Glossary<\/h3>\r\n<b>habit reversal training<\/b>\u00a0<strong>(HRT):\u00a0<\/strong>multicomponent behavioral treatment package originally developed to address a wide variety of repetitive behavior disorders\r\n\r\n<b>trichotillomania<\/b>\u00a0<strong>(TTM):<\/strong> also known as\u00a0hairpulling disorder\u00a0or\u00a0compulsive hairpulling<b>;<\/b>\u00a0a psychological\u00a0disorder\u00a0characterized by a long-term urge that results in pulling one's\u00a0hair out\r\n\r\n<\/div>","rendered":"<div class=\"textbox learning-objectives\">\n<h3>Learning Objectives<\/h3>\n<ul>\n<li>Describe the symptoms and diagnosis of trichotillomania<\/li>\n<\/ul>\n<\/div>\n<p><b>Trichotillomania<\/b>\u00a0(<b>TTM<\/b>), also known as\u00a0hairpulling disorder\u00a0or\u00a0compulsive hairpulling, is a psychological\u00a0disorder\u00a0characterized by a long-term urge that results in the\u00a0pulling out\u00a0of one&#8217;s\u00a0hair.<sup id=\"cite_ref-Fran2011_2-3\" class=\"reference\"><\/sup>\u00a0This occurs to such a degree that\u00a0hair loss\u00a0can be seen.<sup id=\"cite_ref-Fran2011_2-4\" class=\"reference\"><\/sup>\u00a0A brief positive feeling may occur as hair is removed and efforts to stop pulling hair typically fail.<sup id=\"cite_ref-DSM5_1-5\" class=\"reference\"><\/sup>\u00a0Hair removal may occur anywhere; however, the head and around the eyes are most common.<sup id=\"cite_ref-DSM5_1-6\" class=\"reference\"><\/sup>\u00a0The hairpulling is to such a degree that it results in distress.<\/p>\n<div style=\"width: 310px\" class=\"wp-caption alignright\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/upload.wikimedia.org\/wikipedia\/commons\/thumb\/4\/45\/Trichotillomania_1.jpg\/300px-Trichotillomania_1.jpg\" alt=\"Trichotillomania showing the back of a man's head with lots of missing hair.\" width=\"300\" height=\"421\" \/><\/p>\n<p class=\"wp-caption-text\"><strong>Figure 1<\/strong>. A pattern of incomplete hair loss on the scalp of a person with trichotillomania.<\/p>\n<\/div>\n<p>TTM may run in families. The disorder occurs more commonly in those with\u00a0obsessive-compulsive disorder or anxiety disorders, and episodes of pulling may be triggered by\u00a0anxiety.\u00a0People usually acknowledge that they pull their hair and on examination, broken hairs may be seen.\u00a0Other conditions that may be present\u00a0include\u00a0body dysmorphic disorder; however, in that condition, people remove hair to try to improve what they see as a problem in how they look.<\/p>\n<p>Trichotillomania is estimated to affect between 1%-4% of people.<sup id=\"cite_ref-Fran2011_2-5\" class=\"reference\"><\/sup><sup id=\"cite_ref-Huynh2013_3-4\" class=\"reference\"><\/sup>\u00a0The lifetime\u00a0prevalence\u00a0of trichotillomania is estimated to be between 0.6% and 4.0% of the overall population.\u00a0With a 1% prevalence rate, 2.5 million people in the United States may have trichotillomania at some time during their lifetimes. Trichotillomania most commonly begins in childhood or adolescence.\u00a0Women are affected about 10 times more often than men.<\/p>\n<h2><span id=\"Signs_and_symptoms\" class=\"mw-headline\">Signs and Symptoms<\/span><\/h2>\n<p>Trichotillomania is usually confined to one or two\u00a0areas of the body,\u00a0but can involve multiple sites. The scalp is the most common pulling site, followed by the eyebrows, eyelashes, face, arms, and legs.<sup id=\"cite_ref-Sah_8-0\" class=\"reference\"><\/sup>\u00a0Some less common areas include the pubic area, underarms, beard, and chest.<sup id=\"cite_ref-9\" class=\"reference\"><\/sup>\u00a0The classic presentation is the <em>Friar<\/em> <em>Tuck\u00a0<\/em>form of vertex and crown alopecia.<sup id=\"cite_ref-10\" class=\"reference\"><\/sup>\u00a0Children are less likely to pull from areas other than the scalp.<sup id=\"cite_ref-Sah_8-1\" class=\"reference\"><\/sup><\/p>\n<p>People who suffer from trichotillomania often pull only one hair at a time and these hairpulling episodes can last for hours at a time. Trichotillomania can go into remission-like states where the individual may not experience the urge to pull for days, weeks, months, and even years.<sup id=\"cite_ref-11\" class=\"reference\"><\/sup><\/p>\n<p>Individuals with trichotillomania exhibit hair of differing lengths; some are broken hairs with blunt ends, some new growth with tapered ends, some broken mid-shaft, or some uneven stubble. Scaling on the scalp is not present, overall hair density is normal, and a hair-pull test is negative (the hair does not pull out easily). Hair is often pulled out leaving an unusual shape. Individuals with trichotillomania may be secretive or shameful of the hairpulling behavior.\u00a0If patients attempt to disguise their symptoms, it can make diagnosis difficult as symptoms are not always immediately obvious, or have been deliberately hidden to avoid disclosure.<sup id=\"cite_ref-Sah_8-2\" class=\"reference\"><\/sup><\/p>\n<p>An additional psychological effect can be low\u00a0self-esteem, often associated with being shunned by peers and the fear of socializing, due to appearance and negative attention they may receive.\u00a0Some people with trichotillomania wear hats, wigs, false eyelashes, eyebrow pencil, or style their hair in an effort to avoid such attention. TTM seems to have a strong\u00a0stress-related component. In low-stress environments, some exhibit no symptoms (known as <em>pulling<\/em>) whatsoever. This pulling often resumes upon leaving the low-stress environment.\u00a0Some individuals with trichotillomania may feel they are the only person with this problem due to low rates of reporting.<\/p>\n<p>For some people, trichotillomania is a mild problem, merely a frustration. But for many, shame and embarrassment about hairpulling causes painful isolation and results in a great deal of emotional distress, placing them at risk for a co-occurring psychiatric disorder, such as a mood or anxiety disorder. Hairpulling can lead to great tension and strained relationships with family members and friends. Family members may need professional help in coping with this problem.<sup id=\"cite_ref-15\" class=\"reference\"><\/sup><\/p>\n<div id=\"attachment_1391\" style=\"width: 310px\" class=\"wp-caption alignleft\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-1391\" class=\"wp-image-1391 size-medium\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/5351\/2020\/07\/31180316\/1600px-Trichotillomania-300x206.jpg\" alt=\"Girl scratching and pulling at hair on the back of her head.\" width=\"300\" height=\"206\" \/><\/p>\n<p id=\"caption-attachment-1391\" class=\"wp-caption-text\"><strong>Figure 2<\/strong>. Children may not consciously remember pulling their hair.<\/p>\n<\/div>\n<h3><span style=\"color: #373d3f; font-weight: 400;\">Trichotillomania is often n<\/span><span style=\"color: #373d3f; font-size: 1em; font-weight: 400;\">o<\/span><span style=\"color: #373d3f; font-size: 1rem; font-weight: 400; text-align: initial;\">t a focused act, but rather hairpulling occurs in a trance-like state;<\/span><sup id=\"cite_ref-Tay_19-4\" class=\"reference\" style=\"color: #373d3f; font-weight: 400; text-align: initial;\"><\/sup><span style=\"color: #373d3f; font-size: 1rem; font-weight: 400; text-align: initial;\">\u00a0hence, trichotillomania is subdivided into &#8220;automatic&#8221; versus &#8220;focused&#8221; hairpulling.<\/span><sup id=\"cite_ref-Sah_8-11\" class=\"reference\" style=\"color: #373d3f; font-weight: 400; text-align: initial;\"><\/sup><span style=\"color: #373d3f; font-size: 1rem; font-weight: 400; text-align: initial;\">\u00a0Children are more often in the automatic, or unconscious subtype, and may not consciously remember pulling their hair. Other individuals may have focused, or conscious, rituals associated with hairpulling, including seeking specific types of hairs to pull, pulling until the hair feels &#8220;just right,&#8221; or pulling in response to a specific sensation.\u00a0<\/span><sup id=\"cite_ref-Sah_8-12\" class=\"reference\" style=\"color: #373d3f; font-weight: 400; text-align: initial;\"><\/sup><span style=\"color: #373d3f; font-size: 1rem; font-weight: 400; text-align: initial;\">Knowledge of the subtype is helpful in determining treatment strategies.<\/span><\/h3>\n<h3>Epidemiology<\/h3>\n<p>Trichotillomania (TTM), or human compulsive hairpulling, is one of the most common psychiatric disorders, affecting approximately 3.5% of women, or 3.7 million people in the United States. TTM patients experience pronounced psychological distress with considerable negative impact in their quality of life.<a class=\"footnote\" title=\"Vieira, G., Lossie, A. C., Lay, D. C., Jr, Radcliffe, J. S., &amp; Garner, J. P. (2017). Preventing, treating, and predicting barbering: A fundamental role for biomarkers of oxidative stress in a mouse model of Trichotillomania. PloS one, 12(4), e0175222. https:\/\/doi.org\/10.1371\/journal.pone.0175222\" id=\"return-footnote-293-1\" href=\"#footnote-293-1\" aria-label=\"Footnote 1\"><sup class=\"footnote\">[1]<\/sup><\/a><\/p>\n<p>Trichotillomania has an estimated lifetime prevalence of approximately 0.5%-1%, and peak age of onset in adolescence (12\u201313\u00a0years of age) and\u00a0is typically associated with impairment across domains of social, occupational, academic, and psychological functioning.<a class=\"footnote\" title=\"Chamberlain, S. R., Harries, M., Redden, S. A., Keuthen, N. J., Stein, D. J., Lochner, C., &amp; Grant, J. E. (2018). Cortical thickness abnormalities in trichotillomania: international multi-site analysis. Brain imaging and behavior, 12(3), 823\u2013828. https:\/\/doi.org\/10.1007\/s11682-017-9746-3\" id=\"return-footnote-293-2\" href=\"#footnote-293-2\" aria-label=\"Footnote 2\"><sup class=\"footnote\">[2]<\/sup><\/a><\/p>\n<p>Trichotillomania is more common in women than in men, and is currently classified as an OCD-related disorder.\u00a0However, unlike the repetitive compulsive acts observed in OCD, repetitive behaviors in trichotillomania are not generally driven by intrusive thoughts.<a class=\"footnote\" title=\"Isobe, M., Redden, S. A., Keuthen, N. J., Stein, D. J., Lochner, C., Grant, J. E., &amp; Chamberlain, S. R. (2018). Striatal abnormalities in trichotillomania: a multi-site MRI analysis. NeuroImage. Clinical, 17, 893\u2013898. https:\/\/doi.org\/10.1016\/j.nicl.2017.12.031\" id=\"return-footnote-293-3\" href=\"#footnote-293-3\" aria-label=\"Footnote 3\"><sup class=\"footnote\">[3]<\/sup><\/a><\/p>\n<p>Patients with trichotillomania can come across a range of medical settings, including family doctors, dermatologists, neurologists, psychiatrists, pediatricians, endocrinologists, and geneticists.<a class=\"footnote\" title=\"Chamberlain, S. R., Harries, M., Redden, S. A., Keuthen, N. J., Stein, D. J., Lochner, C., &amp; Grant, J. E. (2018). Cortical thickness abnormalities in trichotillomania: international multi-site analysis. Brain imaging and behavior, 12(3), 823\u2013828. https:\/\/doi.org\/10.1007\/s11682-017-9746-3\" id=\"return-footnote-293-4\" href=\"#footnote-293-4\" aria-label=\"Footnote 4\"><sup class=\"footnote\">[4]<\/sup><\/a><\/p>\n<h3>Etiology<\/h3>\n<p id=\"p0025\" class=\"p p-first\">Very little is known about the neurobiological basis of this disorder in humans, but in one study that reviewed available clinical and imaging studies of trichotillomania, previous work suggested an ABC model of trichotillomania, emphasizing the dysfunction of pathways involved in affect regulation, behavioral control, and cognition. In keeping with this, studies have found that trichotillomania is associated with impairment on response inhibition tests\u00a0and phenomenological studies have found relationships between emotional states (dysphoria, anxiety) and the severity of the hairpulling symptoms.<a class=\"footnote\" title=\"Isobe, M., Redden, S. A., Keuthen, N. J., Stein, D. J., Lochner, C., Grant, J. E., &amp; Chamberlain, S. R. (2018). Striatal abnormalities in trichotillomania: a multi-site MRI analysis. NeuroImage. Clinical, 17, 893\u2013898. https:\/\/doi.org\/10.1016\/j.nicl.2017.12.031\" id=\"return-footnote-293-5\" href=\"#footnote-293-5\" aria-label=\"Footnote 5\"><sup class=\"footnote\">[5]<\/sup><\/a><\/p>\n<p>One study suggests that hormones may be a potential cause. In a study of adolescent girls with trichotillomania, researchers found that lower progesterone was associated with worse hairpulling severity (NIMH Trichotillomania Symptom Severity Scale, NIMH-TSS), and that lower levels of all three hormones were associated with greater psychosocial dysfunction (Sheehan Disability Scale, SDS). Progesterone is believed to modulate the adaptive response to stress, mainly through the effect of its neurosteroid metabolite allopregnanolone on GABAA receptor activity.<a class=\"footnote\" title=\"Grant, J. E., &amp; Chamberlain, S. R. (2018). Salivary sex hormones in adolescent females with trichotillomania. Psychiatry research, 265, 221\u2013223. https:\/\/doi.org\/10.1016\/j.psychres.2018.05.012\" id=\"return-footnote-293-6\" href=\"#footnote-293-6\" aria-label=\"Footnote 6\"><sup class=\"footnote\">[6]<\/sup><\/a><\/p>\n<p>Some studies which included neuroimaging showed that\u00a0individuals with trichotillomania had increased grey matter density in several brain regions involving affect regulation, motor habits, and cognition<strong>.\u00a0<\/strong>Additionally, other studies examine the negative reinforcement people have when pulling; when emotional regulation is measured, those with\u00a0trichotillomania have a harder time with emotional control that those without the disorder. Triggers for pulling include boredom, perfectionism, and frustration (to name a few) and hairpulling may be a way of relieving some of the stress and tension associated with these negative feelings.<a class=\"footnote\" title=\"Grant, J. E., &amp; Chamberlain, S. R. (2016). Trichotillomania. The American journal of psychiatry, 173(9), 868\u2013874. https:\/\/doi.org\/10.1176\/appi.ajp.2016.15111432\" id=\"return-footnote-293-7\" href=\"#footnote-293-7\" aria-label=\"Footnote 7\"><sup class=\"footnote\">[7]<\/sup><\/a><\/p>\n<h2>Causes and Comorbidity<\/h2>\n<p>Environment is a large factor that affects hairpulling.<sup id=\"cite_ref-Tay_19-0\" class=\"reference\"><\/sup>\u00a0Sedentary activities such as being in a relaxed environment, or bored, are conducive to hairpulling.\u00a0<sup id=\"cite_ref-Tay_19-1\" class=\"reference\"><\/sup><sup id=\"cite_ref-Diefenbach_20-0\" class=\"reference\"><\/sup>A common example of a sedentary activity promoting hairpulling is lying in a bed while trying to rest or fall asleep.<sup id=\"cite_ref-Tay_19-2\" class=\"reference\"><\/sup>\u00a0An extreme example of automatic trichotillomania is found when some patients have been observed to pull their hair out while asleep.\u00a0<sup id=\"cite_ref-Tay_19-3\" class=\"reference\"><\/sup>This is called sleep-isolated trichotillomania.<sup id=\"cite_ref-21\" class=\"reference\"><\/sup><\/p>\n<p>Anxiety,\u00a0depression, and\u00a0OCD are more frequently encountered in people with trichotillomania.<sup id=\"cite_ref-Chamberlain_7-2\" class=\"reference\"><\/sup><sup id=\"cite_ref-pmid8698680_22-0\" class=\"reference\"><\/sup>\u00a0Trichotillomania also has a high overlap with\u00a0post-traumatic stress disorder, and some cases of trichotillomania may be triggered by stress. Another school of thought emphasizes hairpulling as addictive or negatively reinforcing, as it is associated with rising tension beforehand and relief afterward.<sup id=\"cite_ref-Chamberlain_7-3\" class=\"reference\"><\/sup>\u00a0A neurocognitive model\u2014the notion that the\u00a0basal ganglia\u00a0plays a role in habit formation and that the\u00a0frontal lobes\u00a0are critical for normally suppressing or inhibiting such habits\u2014sees trichotillomania as a habit disorder.<sup id=\"cite_ref-Chamberlain_7-4\" class=\"reference\"><\/sup><\/p>\n<p>The most common age of onset of trichotillomania is between ages nine and 13,\u00a0and a notable peak at ages 12\u201313. In this age range, trichotillomania is usually chronic and continues into adulthood. Trichotillomania that begins in adulthood most commonly arises from underlying psychiatric causes.<sup id=\"cite_ref-:0_27-1\" class=\"reference\"><\/sup><\/p>\n<h2><span id=\"Psychotherapy\" class=\"mw-headline\">Psychotherapy<\/span><\/h2>\n<p>Treatment is based on a person&#8217;s age. Most preschool age children outgrow the condition if it is managed conservatively. In young adults, establishing the diagnosis and raising awareness of the condition is an important reassurance for the family and patient. Non-pharmacological interventions, including\u00a0behavior modification\u00a0programs, are often the first-line mediation; referrals to psychologists or psychiatrists may be considered when other interventions fail. When trichotillomania begins in adulthood, it is often associated with other psychological\u00a0disorders, and referral to a psychologist or psychiatrist for evaluation or treatment is considered best. The hairpulling may resolve when other conditions are treated.<\/p>\n<div class=\"textbox examples\">\n<h3>Watch It<\/h3>\n<p>Watch at least the first four minutes of this video (or the whole thing if you have time) to learn more about\u00a0Aneela Idnani&#8217;s experience with a body-focused repetitive behavior.<\/p>\n<p><iframe loading=\"lazy\" src=\"\/\/plugin.3playmedia.com\/show?mf=5572641&amp;p3sdk_version=1.10.1&amp;p=20361&amp;pt=375&amp;video_id=WkfBtT4VbI4&amp;video_target=tpm-plugin-1wv2gsul-WkfBtT4VbI4\" width=\"800px\" height=\"450px\" frameborder=\"0\" marginwidth=\"0px\" marginheight=\"0px\"><\/iframe><\/p>\n<p>You can view the <a href=\"https:\/\/course-building.s3-us-west-2.amazonaws.com\/Abnormal+Psychology\/transcripts\/OvercomingTrichotillomaniaThePowerOfAwareness_transcript.txt\" target=\"_blank\" rel=\"noopener\">transcript for &#8220;Overcoming Trichotillomania: The Power of Awareness | Aneela Idnani | TEDxFargo&#8221; here (opens in new window)<\/a>.<\/p>\n<\/div>\n<div class=\"textbox key-takeaways\">\n<h3>Key Takeaways:\u00a0Trichotillomania<\/h3>\n<p><iframe loading=\"lazy\" title=\"Trichotillomania\" src=\"https:\/\/lumenlearning.h5p.com\/content\/1291225597709582998\/embed\" width=\"1088\" height=\"822\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><script src=\"https:\/\/lumenlearning.h5p.com\/js\/h5p-resizer.js\" charset=\"UTF-8\"><\/script><\/p>\n<\/div>\n<div class=\"textbox tryit\">\n<h3>Try It<\/h3>\n<p>\t<iframe id=\"assessment_practice_5b685f3a-0e8c-4d8c-a783-b6158dcde258\" class=\"resizable\" src=\"https:\/\/assess.lumenlearning.com\/practice\/5b685f3a-0e8c-4d8c-a783-b6158dcde258?iframe_resize_id=assessment_practice_id_5b685f3a-0e8c-4d8c-a783-b6158dcde258\" frameborder=\"0\" style=\"border:none;width:100%;height:100%;min-height:300px;\"><br \/>\n\t<\/iframe><\/p>\n<\/div>\n<div class=\"textbox learning-objectives\">\n<h3>Glossary<\/h3>\n<p><b>habit reversal training<\/b>\u00a0<strong>(HRT):\u00a0<\/strong>multicomponent behavioral treatment package originally developed to address a wide variety of repetitive behavior disorders<\/p>\n<p><b>trichotillomania<\/b>\u00a0<strong>(TTM):<\/strong> also known as\u00a0hairpulling disorder\u00a0or\u00a0compulsive hairpulling<b>;<\/b>\u00a0a psychological\u00a0disorder\u00a0characterized by a long-term urge that results in pulling one&#8217;s\u00a0hair out<\/p>\n<\/div>\n\n\t\t\t <section class=\"citations-section\" role=\"contentinfo\">\n\t\t\t <h3>Candela Citations<\/h3>\n\t\t\t\t\t <div>\n\t\t\t\t\t\t <div id=\"citation-list-293\">\n\t\t\t\t\t\t\t <div class=\"licensing\"><div class=\"license-attribution-dropdown-subheading\">CC licensed content, Original<\/div><ul class=\"citation-list\"><li>Modification, adaptation, and original content. <strong>Authored by<\/strong>: Christina Hicks for Lumen Learning. <strong>Provided by<\/strong>: Lumen Learning. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by\/4.0\/\">CC BY: Attribution<\/a><\/em><\/li><\/ul><div class=\"license-attribution-dropdown-subheading\">CC licensed content, Shared previously<\/div><ul class=\"citation-list\"><li>Trichotillomania. <strong>Provided by<\/strong>: Wikipedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/en.wikipedia.org\/wiki\/Trichotillomania\">https:\/\/en.wikipedia.org\/wiki\/Trichotillomania<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><li>Girl pulling hair. <strong>Authored by<\/strong>: Vitalicecila. <strong>Provided by<\/strong>: Wikipedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Trichotillomania.jpg\">https:\/\/commons.wikimedia.org\/wiki\/File:Trichotillomania.jpg<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><li>Preventing, treating, and predicting barbering: A fundamental role for biomarkers of oxidative stress in a mouse model of Trichotillomania. <strong>Authored by<\/strong>: Giovana de L. T. Vieira,1 Amy C. Lossie, Donald C. Lay, Jr., John S. Radcliffe, and Joseph P. Garner. <strong>Provided by<\/strong>: PLoS One. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"\"><\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/about\/cc0\">CC0: No Rights Reserved<\/a><\/em><\/li><li>Cortical thickness abnormalities in trichotillomania: international multi-site analysis. <strong>Authored by<\/strong>: Samuel R. Chamberlain, Michael Harries, Sarah A. Redden, Nancy J. Keuthen, Dan J. Stein, Christine Lochner, and Jon E. Grant. <strong>Provided by<\/strong>: Brain Imaging Behavior. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC5640149\/\">https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC5640149\/<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by\/4.0\/\">CC BY: Attribution<\/a><\/em><\/li><li>Striatal abnormalities in trichotillomania: A multi-site MRI analysis. <strong>Authored by<\/strong>: Masanori Isobe, Sarah A. Redden,Nancy J. Keuthen, Dan J. Stein, Christine Lochner, Jon E. Grant, and Samuel R. Chamberlain. <strong>Provided by<\/strong>: Neuroimage Clinical. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC5836997\/\">https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC5836997\/<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by\/4.0\/\">CC BY: Attribution<\/a><\/em><\/li><\/ul><div class=\"license-attribution-dropdown-subheading\">All rights reserved content<\/div><ul class=\"citation-list\"><li>Overcoming Trichotillomania: The Power of Awareness. <strong>Authored by<\/strong>: Aneela Idnani. <strong>Provided by<\/strong>: TEDxFargo. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/www.youtube.com\/watch?v=WkfBtT4VbI4\">https:\/\/www.youtube.com\/watch?v=WkfBtT4VbI4<\/a>. <strong>License<\/strong>: <em>Other<\/em>. <strong>License Terms<\/strong>: Standard YouTube License<\/li><li>Overcoming Trichotillomania: The Power of Awareness | Aneela Idnani | TEDxFargo. <strong>Provided by<\/strong>: Tedx. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/www.youtube.com\/watch?v=WkfBtT4VbI4&#038;feature=emb_logo\">https:\/\/www.youtube.com\/watch?v=WkfBtT4VbI4&#038;feature=emb_logo<\/a>. <strong>License<\/strong>: <em>Other<\/em>. <strong>License Terms<\/strong>: Standard YouTube License<\/li><\/ul><div class=\"license-attribution-dropdown-subheading\">Public domain content<\/div><ul class=\"citation-list\"><li>Image of Trichotillomania. <strong>Authored by<\/strong>: Robodoc. <strong>Provided by<\/strong>: Wikimedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/en.wikipedia.org\/wiki\/Trichotillomania#\/media\/File:Trichotillomania_1.jp\">https:\/\/en.wikipedia.org\/wiki\/Trichotillomania#\/media\/File:Trichotillomania_1.jp<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/about\/pdm\">Public Domain: No Known Copyright<\/a><\/em><\/li><\/ul><\/div>\n\t\t\t\t\t\t <\/div>\n\t\t\t\t\t <\/div>\n\t\t\t <\/section><hr class=\"before-footnotes clear\" \/><div class=\"footnotes\"><ol><li id=\"footnote-293-1\">Vieira, G., Lossie, A. C., Lay, D. C., Jr, Radcliffe, J. S., &amp; Garner, J. P. (2017). Preventing, treating, and predicting barbering: A fundamental role for biomarkers of oxidative stress in a mouse model of Trichotillomania. <em>PloS one<\/em>, 12(4), e0175222. https:\/\/doi.org\/10.1371\/journal.pone.0175222 <a href=\"#return-footnote-293-1\" class=\"return-footnote\" aria-label=\"Return to footnote 1\">&crarr;<\/a><\/li><li id=\"footnote-293-2\">Chamberlain, S. R., Harries, M., Redden, S. A., Keuthen, N. J., Stein, D. J., Lochner, C., &amp; Grant, J. E. (2018). Cortical thickness abnormalities in trichotillomania: international multi-site analysis. <em>Brain imaging and behavior<\/em>, 12(3), 823\u2013828. https:\/\/doi.org\/10.1007\/s11682-017-9746-3 <a href=\"#return-footnote-293-2\" class=\"return-footnote\" aria-label=\"Return to footnote 2\">&crarr;<\/a><\/li><li id=\"footnote-293-3\">Isobe, M., Redden, S. A., Keuthen, N. J., Stein, D. J., Lochner, C., Grant, J. E., &amp; Chamberlain, S. R. (2018). Striatal abnormalities in trichotillomania: a multi-site MRI analysis. NeuroImage. Clinical, 17, 893\u2013898. https:\/\/doi.org\/10.1016\/j.nicl.2017.12.031 <a href=\"#return-footnote-293-3\" class=\"return-footnote\" aria-label=\"Return to footnote 3\">&crarr;<\/a><\/li><li id=\"footnote-293-4\">Chamberlain, S. R., Harries, M., Redden, S. A., Keuthen, N. J., Stein, D. J., Lochner, C., &amp; Grant, J. E. (2018). Cortical thickness abnormalities in trichotillomania: international multi-site analysis. <em>Brain imaging and behavior<\/em>, 12(3), 823\u2013828. https:\/\/doi.org\/10.1007\/s11682-017-9746-3 <a href=\"#return-footnote-293-4\" class=\"return-footnote\" aria-label=\"Return to footnote 4\">&crarr;<\/a><\/li><li id=\"footnote-293-5\">Isobe, M., Redden, S. A., Keuthen, N. J., Stein, D. J., Lochner, C., Grant, J. E., &amp; Chamberlain, S. R. (2018). Striatal abnormalities in trichotillomania: a multi-site MRI analysis. NeuroImage. Clinical, 17, 893\u2013898. https:\/\/doi.org\/10.1016\/j.nicl.2017.12.031 <a href=\"#return-footnote-293-5\" class=\"return-footnote\" aria-label=\"Return to footnote 5\">&crarr;<\/a><\/li><li id=\"footnote-293-6\">Grant, J. E., &amp; Chamberlain, S. R. (2018). Salivary sex hormones in adolescent females with trichotillomania. <em>Psychiatry research<\/em>, 265, 221\u2013223. https:\/\/doi.org\/10.1016\/j.psychres.2018.05.012 <a href=\"#return-footnote-293-6\" class=\"return-footnote\" aria-label=\"Return to footnote 6\">&crarr;<\/a><\/li><li id=\"footnote-293-7\">Grant, J. E., &amp; Chamberlain, S. R. (2016). Trichotillomania. <em>The American journal of psychiatry<\/em>, 173(9), 868\u2013874. https:\/\/doi.org\/10.1176\/appi.ajp.2016.15111432 <a href=\"#return-footnote-293-7\" class=\"return-footnote\" aria-label=\"Return to footnote 7\">&crarr;<\/a><\/li><\/ol><\/div>","protected":false},"author":29,"menu_order":6,"template":"","meta":{"_candela_citation":"[{\"type\":\"cc\",\"description\":\"Trichotillomania\",\"author\":\"\",\"organization\":\"Wikipedia\",\"url\":\"https:\/\/en.wikipedia.org\/wiki\/Trichotillomania\",\"project\":\"\",\"license\":\"cc-by-sa\",\"license_terms\":\"\"},{\"type\":\"pd\",\"description\":\"Image of Trichotillomania\",\"author\":\"Robodoc\",\"organization\":\"Wikimedia\",\"url\":\"https:\/\/en.wikipedia.org\/wiki\/Trichotillomania#\/media\/File:Trichotillomania_1.jp\",\"project\":\"\",\"license\":\"pd\",\"license_terms\":\"\"},{\"type\":\"copyrighted_video\",\"description\":\"Overcoming Trichotillomania: The Power of Awareness\",\"author\":\"Aneela Idnani\",\"organization\":\"TEDxFargo\",\"url\":\"https:\/\/www.youtube.com\/watch?v=WkfBtT4VbI4\",\"project\":\"\",\"license\":\"other\",\"license_terms\":\"Standard YouTube License\"},{\"type\":\"cc\",\"description\":\"Girl pulling hair\",\"author\":\"Vitalicecila\",\"organization\":\"Wikipedia\",\"url\":\"https:\/\/commons.wikimedia.org\/wiki\/File:Trichotillomania.jpg\",\"project\":\"\",\"license\":\"cc-by-sa\",\"license_terms\":\"\"},{\"type\":\"cc\",\"description\":\"Preventing, treating, and predicting barbering: A fundamental role for biomarkers of oxidative stress in a mouse model of Trichotillomania\",\"author\":\"Giovana de L. T. Vieira,1 Amy C. Lossie, Donald C. Lay, Jr., John S. Radcliffe, and Joseph P. Garner\",\"organization\":\"PLoS One\",\"url\":\"Preventing, treating, and predicting barbering: A fundamental role for biomarkers of oxidative stress in a mouse model of Trichotillomania\",\"project\":\"\",\"license\":\"cc0\",\"license_terms\":\"\"},{\"type\":\"cc\",\"description\":\"Cortical thickness abnormalities in trichotillomania: international multi-site analysis\",\"author\":\"Samuel R. Chamberlain, Michael Harries, Sarah A. Redden, Nancy J. Keuthen, Dan J. Stein, Christine Lochner, and Jon E. Grant\",\"organization\":\"Brain Imaging Behavior\",\"url\":\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC5640149\/\",\"project\":\"\",\"license\":\"cc-by\",\"license_terms\":\"\"},{\"type\":\"cc\",\"description\":\"Striatal abnormalities in trichotillomania: A multi-site MRI analysis\",\"author\":\"Masanori Isobe, Sarah A. Redden,Nancy J. Keuthen, Dan J. Stein, Christine Lochner, Jon E. Grant, and Samuel R. Chamberlain\",\"organization\":\"Neuroimage Clinical\",\"url\":\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC5836997\/\",\"project\":\"\",\"license\":\"cc-by\",\"license_terms\":\"\"},{\"type\":\"copyrighted_video\",\"description\":\"Overcoming Trichotillomania: The Power of Awareness | Aneela Idnani | TEDxFargo\",\"author\":\"\",\"organization\":\"Tedx\",\"url\":\"https:\/\/www.youtube.com\/watch?v=WkfBtT4VbI4&feature=emb_logo\",\"project\":\"\",\"license\":\"other\",\"license_terms\":\"Standard YouTube License\"},{\"type\":\"original\",\"description\":\"Modification, adaptation, and original content\",\"author\":\"Christina Hicks for Lumen Learning\",\"organization\":\"Lumen Learning\",\"url\":\"\",\"project\":\"\",\"license\":\"cc-by\",\"license_terms\":\"\"}]","CANDELA_OUTCOMES_GUID":"1dd622ed-ebe5-4b58-a366-1f97d25d8e06, 4145c9e7-ca05-4178-8f6b-72cfab05eb15","pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-293","chapter","type-chapter","status-publish","hentry"],"part":138,"_links":{"self":[{"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/pressbooks\/v2\/chapters\/293","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/wp\/v2\/users\/29"}],"version-history":[{"count":33,"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/pressbooks\/v2\/chapters\/293\/revisions"}],"predecessor-version":[{"id":7490,"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/pressbooks\/v2\/chapters\/293\/revisions\/7490"}],"part":[{"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/pressbooks\/v2\/parts\/138"}],"metadata":[{"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/pressbooks\/v2\/chapters\/293\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/wp\/v2\/media?parent=293"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/pressbooks\/v2\/chapter-type?post=293"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/wp\/v2\/contributor?post=293"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/wp\/v2\/license?post=293"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}