Editing Trichotillomania (section)

== Signs and symptoms ==
Trichotillomania is usually confined to one or two sites,<ref name="Chamberlain"/> but can involve multiple sites. The scalp is the most common pulling site, followed by the eyebrows, eyelashes, face, arms, and legs.<ref name="Sah"/> Some less common areas include the pubic area, underarms, beard, and chest.<ref>What is Trichotillomania {{cite web |url=http://bfrb.org/learn-about-bfrbs/trichotillomania |title=What is Trichotillomania (Hair Pulling Disorder)? |access-date=2016-07-12 |url-status=live |archive-url=https://web.archive.org/web/20160702155050/http://www.bfrb.org/learn-about-bfrbs/trichotillomania |archive-date=2016-07-02 }}. 2016</ref> The classic presentation is the "[[Friar Tuck]]" form of crown [[Hair loss|alopecia]] (loss of hair at the "crown" of the head, also known as the "vertex").<ref>{{cite book|author1=James, William |author2=Berger, Timothy |author3=Elston, Dirk |year= 2005 |title= Andrews' Diseases of the Skin: Clinical Dermatology |edition= 10th |publisher= Saunders |isbn= 978-0-7216-2921-6 |page=62}}</ref> Children are less likely to pull from areas other than the scalp.<ref name="Sah"/>

People with trichotillomania often pull only one hair at a time and these hair-pulling episodes can last for hours at a time. Some individuals may experience more satisfaction after pulling an [[Hair follicle#Anagen phase|anagen phase hair]] with the gel-like [[inner root sheath]] still surrounding the base of the hair. Trichotillomania can go into [[Remission (medicine)|remission]]-like states where the individual may not experience the urge to "pull" for days, weeks, months, or even years.<ref>{{cite web |url=http://www.pullfreeatlast.com/trichotillomania-facts/trichotillomania-information.html |title=Trichotillomania: 12 Facts You Should Know About Trich |publisher=Pullfreeatlast.com |access-date=2013-02-22 |url-status=live |archive-url=https://web.archive.org/web/20130228014405/http://www.pullfreeatlast.com/trichotillomania-facts/trichotillomania-information.html |archive-date=2013-02-28 }}</ref>

Individuals with trichotillomania exhibit hair of differing lengths; some are broken hairs with blunt ends, some new growth with tapered ends, some broken mid-shaft, or some uneven stubble. [[Scale (dermatology)|Scaling]] on the scalp is not present, overall hair density is normal, and a hair pull test is negative (the hair does not pull out easily). Hair is often pulled out leaving an unusual shape. Individuals with trichotillomania may be secretive of the hair pulling behavior, which is often associated with feelings of shame.<ref name="Sah"/>

An additional psychological effect can be low [[self-esteem]], often associated with being shunned by peers and the fear of socializing, due to appearance and negative attention they may receive.<ref>{{cite web |last1=Chamberlain |first1=Samuel |title=Trichotillomania |url=https://rarediseases.org/rare-diseases/trichotillomania/ |website=National Organization for Rare Disorders |access-date=12 June 2019 |archive-date=3 June 2019 |archive-url=https://web.archive.org/web/20190603071103/https://rarediseases.org/rare-diseases/trichotillomania/ |url-status=dead }}</ref> Some people with trichotillomania wear hats, wigs, false eyelashes, use makeup such as an [[eyebrow pencil]], or style their hair in an effort to avoid such attention.<ref name="Huynh2013"/> There seems to be a strong [[Stress (biological)|stress]]-related component. In low-stress environments, some exhibit no symptoms (known as "pulling") whatsoever, and this "pulling" often resumes upon leaving this environment.<ref name="Christenson91">{{cite journal | vauthors = Christenson GA, Mackenzie TB, Mitchell JE | title = Characteristics of 60 adult chronic hair pullers | journal = The American Journal of Psychiatry | volume = 148 | issue = 3 | pages = 365–370 | date = March 1991 | pmid = 1992841 | doi = 10.1176/ajp.148.3.365 | s2cid = 26010143 }}</ref> Some individuals with trichotillomania may feel isolated, as if they are the only person with this problem, due to low rates of reporting.<ref>{{cite journal | vauthors = Christenson GA, MacKenzie TB, Mitchell JE | title = Adult men and women with trichotillomania. A comparison of male and female characteristics | journal = Psychosomatics | volume = 35 | issue = 2 | pages = 142–149 | year = 1994 | pmid = 8171173 | doi = 10.1016/S0033-3182(94)71788-6 }}</ref>

For some people, trichotillomania is a mild, if frustrating, problem. But for many, embarrassment about hair pulling causes isolation and results in a great deal of [[emotional distress]], placing them at risk for a co-occurring psychiatric disorder, such as a mood or anxiety disorder. Hair pulling can lead to tension and strained relationships with family members and friends. Family members may need professional help in coping with this problem.<ref>"What is Trichotillomania" {{cite web |url=http://bfrb.org/learn-about-bfrbs/trichotillomania |title=What is Trichotillomania (Hair Pulling Disorder)? |access-date=2016-07-12 |url-status=live |archive-url=https://web.archive.org/web/20160702155050/http://www.bfrb.org/learn-about-bfrbs/trichotillomania |archive-date=2016-07-02 }}. 2016</ref>

Other medical complications include [[infection]], permanent loss of hair, [[repetitive stress injury]], [[carpal tunnel syndrome]], and gastrointestinal obstruction as a result of [[trichophagia]].<ref name="Chamberlain"/> In trichophagia, people with trichotillomania also ingest the hair that they pull; in extreme (and rare) cases this can lead to a hair ball ([[trichobezoar]]).<ref name="Sah"/> [[Rapunzel syndrome]] is an extreme form of trichobezoar in which the "tail" of the hair ball extends into the intestines and can be fatal if misdiagnosed.<ref name="Sah"/><ref>{{cite journal | vauthors = Ventura DE, Herbella FA, Schettini ST, Delmonte C | title = Rapunzel syndrome with a fatal outcome in a neglected child | journal = Journal of Pediatric Surgery | volume = 40 | issue = 10 | pages = 1665–1667 | date = October 2005 | pmid = 16227005 | doi = 10.1016/j.jpedsurg.2005.06.038 }}</ref><ref>{{cite journal | vauthors = Pul N, Pul M | title = The Rapunzel syndrome (trichobezoar) causing gastric perforation in a child: a case report | journal = European Journal of Pediatrics | volume = 155 | issue = 1 | pages = 18–19 | date = January 1996 | pmid = 8750804 | doi = 10.1007/bf02115620 | s2cid = 20876626 }}</ref><ref>{{cite journal | vauthors = Matejů E, Duchanová S, Kovac P, Moravanský N, Spitz DJ | title = Fatal case of Rapunzel syndrome in neglected child | journal = Forensic Science International | volume = 190 | issue = 1–3 | pages = e5–e7 | date = September 2009 | pmid = 19505779 | doi = 10.1016/j.forsciint.2009.05.008 }}</ref>

Environment is a large factor which affects hair pulling.<ref name="Tay"/> Sedentary activities such as being in a relaxed environment are conducive to hair pulling.<ref name="Tay"/><ref name="Diefenbach">{{cite journal | vauthors = Diefenbach GJ, Mouton-Odum S, Stanley MA | title = Affective correlates of trichotillomania | journal = Behaviour Research and Therapy | volume = 40 | issue = 11 | pages = 1305–1315 | date = November 2002 | pmid = 12384325 | doi = 10.1016/S0005-7967(02)00006-2 }}</ref> A common example of a sedentary activity promoting hair pulling is lying in a bed while trying to rest or fall asleep.<ref name="Tay"/> An extreme example of automatic trichotillomania is "sleep-isolated" trichotillomania, where patients pull their hair out while asleep.<ref name="Tay"/><ref>{{cite web|url=http://www.trichotillomania.co.uk/_working/about.html|access-date=August 20, 2010|title=What is Trichotillomania?|url-status=dead|archive-url=https://web.archive.org/web/20100713141220/http://www.trichotillomania.co.uk/_working/about.html|archive-date=July 13, 2010}}</ref>