The authors review the many ways in which trichotillomania can be manifested, information that is vital to all health practitioners, since women with trichotillomania (90 percent of patients are female) typically suffer in silence rather than admit that their bald spots or lack of eyelashes are the result of their own hair pulling.

After a comprehensive presentation of the clinical features of trichotillomania in children and adults, the authors review the neurobiologic underpinnings of the condition, including theories of specific regional dysfunction and possible neurotransmitter abnormalities. Animal models are introduced as a means of suggesting new avenues of research. Moon-Fanelli, Dodman, and O'Sullivan suggest parallels between trichotillomania and aberrant self-grooming. This chapter is intriguing but would be more interesting to the general reader if the authors had provided commentary and critique. For example, why is allogrooming the equivalent of trichotillomania when nonspecific displacement reactions (including grooming behavior, among others) are more reliably exacerbated by environmental sources of stress (as is the case with trichotillomania)?

The greatest strength of Trichotillomania is the section on treatment. The editors sought out the world's experts on pharmacologic, behavioral, hypnotic, and psychotherapeutic treatments for trichotillomania. Each of these experts gives a clear, concise description of the methods used in the treatment of compulsive hair pulling. They also provide a realistic assessment of the risks and benefits of the therapies, thus allowing clinicians to offer their patients the best treatment options. Since most patients with trichotillomania require combination therapy (e.g., cognitive behavior therapy and selective serotonin-reuptake inhibitors), practitioners will appreciate that specific guidelines are presented for multimodal therapies. Given the fact that 1 percent of Americans have trichotillomania, every health care professional should read this clear, concise guidebook.

Reviewed by Susan E. Swedo, M.D.
Copyright © 1999 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

The phenomenon of trichotillomania, or hair pulling, has been observed for centuries. The ancient Greek physician Hippocrates noted hair pulling as one of the many symptoms that the physician was advised to assess as a routine matter. In our present time and culture, "pulling one's hair out" is more typically referred to in the context of depression, frustration, boredom, or other emotional turmoil.

In truth, hair pulling is a highly prevalent behavior that may be associated with significant morbidity.

Edited by experts in the field, Trichotillomania addresses the importance of the study of hair pulling from both a clinical and a research perspective. Documenting the clinical phenomenology, morbidity, and management of trichotillomania, it discusses the phenomenology of childhood trichotillomania, providing a comprehensive description of its symptoms and sequelae. Of particular value for the clinician are contributions on the assessment of trichotillomania and a detailed cognitive-behavioral treatment plan. The uses of medication, the place of a psychodynamic perspective, the value of behavioral interventions, and the role of hypnotherapy are also thoroughly discussed.

This discerning text further documents the significance of research on trichotillomania for obtaining a broader understanding of complex brain-behavior relationships. While recent research has suggested that hair pulling lies on the spectrum of obsessive-compulsive disorder, a range of evidence is presented that indicates important differences between trichotillomania and OCD. As such, attention by clinicians to hair pulling may be of enormous value to patients, whose condition was previously unrecognized, while leading to a better understanding of the range of OCD-like disorders.