OBJECTIVE: DSM-IV defines trichotillomania as an impulse disorder with rising tension followed by relief or gratification. Alternative formulations view trichotillomania as an internalizing disorder or variant of obsessive-compulsive disorder (OCD). This study addresses this controversy by examining the phenomenology, comorbidity, and family genetics of childhood trichotillomania. METHOD: Fifteen chronic hair-pullers (13 girls), aged 9 through 17 years (mean 12.3 +/- 2.3 years), were systematically assessed. Child Behavior Checklist (CBCL) profiles of the hair-pulling girls were compared with those of 37 girls from a general child psychiatry clinic and of 15 girls with OCD. RESULTS: All the hair-pullers had impairing cosmetic disfigurement; however, 4 subjects (26.7%) denied rising tension or relief. All three groups had comparable global CBCL problem scores. The CBCL symptom profile of the hair-pulling group differed significantly from that of the general clinic group but strongly resembled that of the OCD group. The hair-pulling group, however, had few obsessions or compulsions aside from hair-pulling; two (13%) subjects met criteria for OCD. As a group, hair-pulling subjects had substantial comorbid psychopathology, and a parental history of tics, habits, or obsessive-compulsive symptoms was common. CONCLUSIONS: These findings lend only partial support to the notion of trichotillomania as an OCD-spectrum disorder. Rising tension followed by relief or gratification may not be an appropriate diagnostic criterion for trichotillomania.
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