Sleep-Isolated Trichotillomania: A Survey of Dermatologists

Abstract

Study objectives:

To determine whether sleep-isolated trichotillomania has been recognized or suspected by dermatologists.

Methods:

Eight-hundred and seven practicing dermatologists in the Midwest were identified through the American Academy of Dermatologists website database. A 10-question multiple-choice survey regarding trichotillomania was mailed to each. Responses were anonymously returned by fax.

Results:

A total of 107 (13%) of the 807 dermatologists surveyed responded. Twelve (11%) reported having seen patients with trichotillomania that occurred solely during sleep. In cases of unexplained hair loss, 21(20%) suspected hair-pulling occurred only in sleep.

Seventy-six subjects (71%) said they had seen patients with unexplained hair loss; 67 (88%) of those respondents said they would ask those patients if they pull their hair. Only 16 (24%) said they would ask patients who deny hair pulling while awake if they pull their hair during sleep. Twenty (19%) said they ask patients diagnosed with trichotillomania if hair pulling also occurs in sleep.

Conclusions:

Although sleep-isolated trichotillomania has only recently been reported, some dermatologists report having recognized this entity in their own practices. When dermatologists see patients with unexplained hair loss, only a small percentage consider trichotillomania isolated to sleep. Increased physician awareness of this disorder may allow diagnosis and treatment of many patients.

Citation:

Murphy C; Redenius R; O'Neill E; Zallek S. Sleep-isolated trichotillomania: a survey of dermatologists. J Clin Sleep Med 2007;3(7):719–721.

Trichotillomania is an impulse control disorder that creates an irresistible urge to pull out one's own body hair. Hair pulling sites may include the scalp, eyebrows, eyelashes, pubic hair, and arm hair.¹ Areas subjected to hair pulling will exhibit irregular patches of alopecia and blunt-tipped hairs of different lengths.³ The estimated lifetime prevalence is 1.5% for males and 3.4% for females.⁷ The sex ratio is more equal in younger patients, with typical age of onset of 9–13 years.²

The onset of trichotillomania can be triggered by a psychological stressor, such as a divorce of parents, birth of a sibling, sibling rivalry, or moving to a new home.² Fifty-five percent of adults with trichotillomania have a comorbid psychiatric diagnosis, 23% have major depression, 23% have generalized anxiety disorder, and 26% have an obsessive-compulsive disorder.⁶

Hair pulling commonly occurs when the subject is alone and in a relaxed environment. Some patients have been observed pulling hair while asleep.²

The most effective treatment of trichotillomania is a combination of pharmacotherapy and behavioral therapy. Serotonin reuptake inhibitors and tricyclic antidepressants are the most commonly used agents.³

Recently, a case was reported of a 24-year-old woman who pulled her eyebrows and eyelashes only during sleep.⁵ She was unaware of the behavior when she did it, did not awaken directly from it, and did not recall it upon awakening the following morning. She was aware of the behavior only because she would find lash and brow hairs on her pillow in the morning, and because her mother witnessed it. She did not pull hair while awake at all. This behavior was not associated with vocalization, ambulation, or other movements. The patient had no other unusual or unwanted sleep related behavior. She had no history of anxiety, depression, eating disorders, or other mental health conditions. There was no family history of trichotillomania. The subject's trichotillomania responded well to imipramine, as do some other NREM sleep parasomnias.

While dermatologists and other specialists may see unexplained hair loss, many may not consider the possibility of a sleep-isolated behavior in the differential diagnosis.

The aim of this study was to determine whether dermatologists recognize or suspect sleep-isolated trichotillomania (SITTM).

METHODS

Practicing dermatologists in the Midwest (within 150 mile radius of the following cities: Peoria IL, Springfield IL, Moline IL, Chicago IL, Madison WI, Iowa City IA, St. Louis MO, and Indianapolis IN), were identified through the American Academy of Dermatologists by its publicly available website database. Each of the 807 dermatologists identified was sent a 10-question multiple choice survey regarding sleep-related trichotillomania. Responses were anonymously returned through fax, unless the subject opted to provide contact information.

RESULTS

Of the 107 respondents, the average number of cases of trichotillomania of any type seen each year was 2.2; 19% (n=20) of respondents said they ask patients diagnosed with trichotillomania if hair pulling also occurs during sleep.

Respondents were asked to select their typical method of treatment for patients diagnosed with trichotillomania: 47% (n=74) said they would refer a patient to a psychiatrist/psychologist, 34% (n=56) recommended behavioral therapy, and 12% (n=19) prescribed medication (specific medications were not identified) (Figure 1).

Figure 1.

Treatments Prescribed for Patients with Trichotillomania

Seventy-one percent (n=76) of respondents said they had seen patients with unexplained hair loss (Figure 2); sites included the scalp (n=59), eyelashes (n=28), eyebrows (n=35), limbs (n=10), and pubic hair (n=7) (respondents were asked to check all that applied from a list of sites). Eighty-eight percent (n=67) of subjects who reported having seen unexplained hair loss said they would ask those patients if they pull their hair. Twenty-four percent (n=16) of those said they would ask patients with unexplained hair loss who deny hair pulling while awake if they pull their hair during sleep.

Figure 2.

Respondents who Explore SITTM in Patients with Unexplained Hair Loss

Twenty percent (n=21) of respondents suspected hair pulling occurred only in sleep in their patients with unexplained hair loss.

Eleven percent (n=12) of respondents had seen patients with trichotillomania that occurred solely during sleep (Figure 3). Sites reported included the scalp (n=12), eyelashes (n=3), eyebrows (n=2), and pubic hair (n=1).

Figure 3.

Respondents Who Report Having Seen Trichotillomania Exclusivly in Sleep

Of the 12 respondents who believe they have seen patients who pull hair only in sleep, 67% (n=8) would ask other patients with unexplained hair loss if they pull hair in sleep, while 17% (n=10) of those who did not believe they had seen it would ask.

DISCUSSION

Although sleep-isolated trichotillomania has only recently been reported, a number of dermatologists surveyed (11% of respondents) report having recognized this entity in their own practices. Only one in five respondents said they would even consider trichotillomania isolated to sleep as an explanation for unexplained hair loss. Many more may have seen the disorder but not considered it.

Since patients may not be aware of this disorder, dermatologists must consider it in order to make the diagnosis. Those who had seen it before were more likely to consider it in other patients. However, most had neither seen it nor considered it at all.

These authors speculate that SITTM may be better classified as a parasomnia than a manifestation of a psychological condition. Accordingly, treatment may differ from standard treatments for trichotillomania. Dermatologists and other physicians who see unexplained hair loss must be aware of both the existence of this condition and that treatment may differ from other forms of trichotillomania if these patients are to be diagnosed and treated.

With the information available from the first case report of this disorder and the present study, physicians may now consider SITTM in the differential diagnosis of unexplained hair loss. Further studies to better characterize this disorder and determine effective treatment are needed.

Limitations of the Study

The response rate of 13% is low, so the prevalence of SITTM may have been different with more respondents. Physicians with an interest in or previous experience with SITTM may have been more likely to respond to this survey. This survey required subjective recall of clinical experience and is less reliable than prospective data. Aside from unexplained hair loss, reasons for suspected hair pulling in sleep were not investigated.