Hair Pulling in Medical Literature

The first ever reference made to hair pulling in a medical context was by the father of modern medicine, Hippocrates around 400 B.C.  In Epidemics, Book III he lists hair plucking as one of the many signs and symptoms a doctor must consider when assessing a patient in order to identify the disease.  I very much doubt if such an item would be on many doctors’ checklist today!  Most interestingly he gives an account of a patient in Thasos, referred to as the wife of Delearces.   She is suffering with a high fever that involves shivering.  Her illness is thought by Hippocrates to be brought on by grief.  Her hair pulling is accompanied by her falling silent and scratching too.  She also cannot sleep and is constipated.  

      Amazingly, it will be almost 2000 years later before another mention is made of hair pulling in the medical literature.  In 1777-8 a French surgeon named Baudamant finds masses of hair in the stomach of a teenage boy indicating hair pulling and hair ingestion.  But it is not until 1889 in a medical report by the French physician Francois Henri Hallopeau that hair pulling receives its first formal diagnostic label.  Hallopeau gave it the name trichotillomania, from the Greek words thrix (hiar), tillein (to pluck or pull) and mania (an abnormal love for).  This name remains today, though mostly it is referred to simply as hair pulling disorder.  Hallopeau’s first report in 1889 described a young man who pulled out all of his body hair.  Another more detailed report by Hallopeau in 1894 identified the key features of hair pulling as:

1) itching sensation extending to all the hairy parts of the body
2) a “type of insanity” that drives the patient to seek relief from pruritus via hair pulling
3) normal appearance of skin and hair
4) long duration
5) lack of cure

Hallopeau had sought to cure hair pulling by applying mentholated camphor and wrapping the patient in rubber.  But when the method proved ineffective he declared the disorder incurable.
     Since this time, doctors have found establishing a diagnostic criteria for hair pulling very problematic.  It remains a poorly understood disorder and it varies in its particular manifestations which include:

(a) hair can be pulled from different sites of the body
(b) hair may or may not be chewed and the root eaten and/or the hair ingested
(c) there may or may not be a tingling itchy sensation prior to pulling etc
(d) pulling may occur consciously or unconsciously.  

To date trichotillomania evades a fully inclusive medical definition.  But according to DSM IV (American Psychiatric Association, 1994) the criteria for hair pulling includes:

A. Recurrent pulling out of one's hair resulting in noticeable hair loss.
B. An increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior.
C. Pleasure, gratification, or relief when pulling out the hair. [- but not always the case]

D. The disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (e.g., a dermatological condition).
E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

It is currently classified in the category Impulse Control Disorders Not Otherwise Specified though this may change in time (for the very latest current definition see DSM V).

     Considering that records of hair pulling go back as far as the writings of Hippocrates, not to mention featuring in the Bible, Homer’s Iliad and in Shakespeare (more on these references in future posts) it is extraordinary to reflect that in the 21st Century psychologists and psychiatrists continue to struggle to find a meaningful diagnostic category that might help to shed light on an age old enigma of psychology.

References:
American Pschiatric Associaton, DSM IV, (1994)

Christenson, G.A. and Mansueto, C.S. (1999), "Trichotillomania: Descriptive characteristics and phenomenology". Chapter in the book "Trichotillomania", edited by D.J. Stein et al. 1999.