Do you have a habit of twirling or pulling your hair, possibly indicating trichotillomania (hair-pulling disorder)?

Diagnosis and Management of Trichotillomania in a 17-Year-Old Girl

The most appropriate question to ask this patient is "Do you twirl or pull your hair?" as this directly addresses the likely diagnosis of trichotillomania based on the clinical presentation.

Clinical Features Supporting Trichotillomania

The patient's presentation strongly suggests trichotillomania (hair-pulling disorder):

• Widened hair part with decreased hair density
• Coarse hair of different lengths in the affected area
• Negative hair pull test (hairs remain firmly anchored)
• Light brown scales on the scalp
• Varying lengths of eyelashes
• Patient's lack of concern despite parental worry (common in trichotillomania)

Distinguishing Trichotillomania from Other Conditions

Trichotillomania has specific features that differentiate it from other causes of hair loss:

• Broken hairs firmly anchored in the scalp - Unlike alopecia areata where "exclamation mark" hairs are easily pulled out, in trichotillomania the hairs remain in the growing (anagen) phase 1
• Incomplete nature of hair loss - Patchy distribution with hairs of varying lengths 1
• Coarse texture of remaining hairs - Characteristic finding due to traumatic damage
• Varying lengths of eyelashes - Suggests pulling behavior extends beyond the scalp

Diagnostic Approach

Asking about hair pulling or twirling is essential because:

1. It directly addresses the core behavior in trichotillomania
2. Many patients with trichotillomania may not initially volunteer this information
3. The question helps establish whether the behavior has the core clinical features of tics, including suppressibility, distractibility, suggestibility, and variability 1

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifies trichotillomania as a body-focused repetitive behavior disorder within the obsessive-compulsive and related disorders category 1, 2. The diagnosis requires:

• Recurrent pulling out of one's hair resulting in hair loss
• Repeated attempts to decrease or stop the behavior
• Clinically significant distress or impairment
• Not attributable to another medical condition or mental disorder

Why Other Questions Are Less Appropriate

• "Have you had a perm recently?" - The clinical features (varying hair lengths, coarse texture) are not typical of chemical damage from perms
• "Do you color your hair?" - Hair coloring typically causes diffuse damage rather than patchy hair loss with varying lengths
• "Do you have a desire to eat paper or dirt?" - This question screens for pica, which is not related to the current presentation

Management Approach

1. Establish diagnosis through direct questioning

   • Ask about hair pulling/twirling behaviors
   • Assess awareness level, triggers, and associated behaviors 2

2. Behavioral interventions (first-line)

   • Habit reversal training and awareness training 2
   • Teaching specific physical actions that make hair pulling impossible 2

3. Pharmacological options (if needed)

   • N-acetylcysteine has shown promise in treating severe cases 2, 3
   • Clomipramine has demonstrated efficacy in clinical trials 4, 5
   • SSRIs are commonly prescribed despite limited evidence 5

4. Psychological support

   • Cognitive-behavioral therapy approaches 6
   • Family education and support 3
   • Avoid negative feedback or punishment for hair pulling 3

Important Clinical Considerations

• Trichotillomania often begins in childhood or adolescence 6
• The condition can be associated with significant functional impairment and psychiatric comorbidity 6
• Many patients with trichotillomania report that much of their plucking occurs outside of awareness 7
• Monitoring devices that enhance awareness may be helpful adjuncts to treatment 7

By asking "Do you twirl or pull your hair?", you directly address the most likely diagnosis while opening a non-judgmental conversation about this often-hidden behavior.