Associated features

Hair pulling is typically accomplished by grasping individual hairs between the thumb and index finger, (3) although some patients utilize tweezers or other devices to pull out hair. Hair which is coarse, kinky, or in other ways texturally distinct may be preferentially targeted. For some patients the examination of the hair in general, or root in particular, is an important aspect of their behaviour. Half of hair pullers rub the pulled hair over their lips or bite off the hair end or root; approximately 10 per

Fig. 1 Tonsure pattern of hair loss in trichotillomania.

cent admit to hair ingestion (trichophagy).(4)

Trichotillomania is typically painless.(4) Increased pain tolerance (and/or thresholds) has been proposed as a permissive factor to the development of trichotillomania, but this has not been verified. A minority of patients describe pain as pleasurable. (3)

A distinction between 'automatic' versus 'focused' hair pulling has been proposed. (4) Automatic hair pulling occurs with little or no awareness, and as a parallel behaviour to other mental or behavioural activity. Automatic hair pulling typically occurs during 'sedentary contemplative' activities such as reading, watching TV, working at a desk, driving, speaking on the phone, or lying in bed at night. In contrast, during 'focused' hair pulling attention is centred on the hair pulling itself. Focused hair pulling may involve certain rules (for example symmetrical pulling) or goals (for example obtain a hair with intact root) and shares greater similarities to compulsions. Of all patients with trichotillomania 75 per cent report their primary style of hair pulling as being automatic, with the remainder reporting the focused style as primary.(3) However, many, if not most, patients report engaging in both styles to some degree.(3)

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