Trichotillomania (TM) is a disorder of recurrent hair pulling.  It is included in the Diagnostic and Statistical Manual of Mental Disorders (fourth edition) (DSM-IV) under “impulse control disorders not elsewhere classified.”  The condition has previously been considered rare, but recent studies indicate that it may be more common than once believed.  Clinically relevant hair pulling may occur in approximately 2% of the population.  Most patients with recurrent and/or chronic hair pulling are too embarrassed to volunteer the problem.  TM is often not obvious.
This condition appears to be more common among women.  Any body hair may be targeted, although the scalp is the most common site followed by eyelashes and eyebrows.  Hair pulling commonly occurs during sedentary and contemplative activities such as reading or watching television.  Most patients do not pay attention to what they are doing and do not report anxiety while engaged in hair pulling (one of several characteristics that seem to distinguish TM from obsessive-compulsive disorder).  The onset of TM is typically in childhood or adolescence.  The mean age at onset is 13 years.  Some research suggests that if, at the time of presentation in children, hair pulling has been present less than 6 months, the prognosis for recovery with minimal intervention is good; otherwise a chronic pattern of hair pulling is typical.
By definition, TM results in noticeable hair thinning or bald spots of the involved area.  At times patients adapt hairstyles or wear scarves, hats, and wigs.  Attempts to hide hair loss may lead to avoidance of situations in which the scalp would be visible.  Hair pulling from any site may lead to avoidance of intimate relationships.  Oral manipulation of hair is reported in 48% of TM cases.  This may involve chewing the end of the hair, rubbing hair along the mouth, or complete ingestion of hair.  For this reason, it is important to inquire about hair ingestion or gastrointestinal pain in the assessment so as not to miss a connected hair mass in the stomach or bowel (i.e., trichobezoar).  This is a serious and life-threatening condition that needs immediate medical attention.  TM is frequently associated with psychiatric comorbidity such as mood (65%), anxiety (57%), chemical use (22%), and eating disorders (20%).
Hair pulling onset has been associated with loss or perceived loss or trauma, such as divorce of parents, family move, change of schools, or physical abuse.  More recently, it has been speculated that TM belongs?

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