Hair pulling disorder (trichotillomania): Genes, neurobiology, and a model for understanding impulsivity and compulsivity

Hair pulling disorder (trichotillomania) affects at least 3.7 million people in the United States and results in marked functional impairment. This article reviews empirical research investigating the genetics and neurobiology of hair pulling disorder (HPD). We also discuss recent advances in the characterization of this phenotype which have led to evidence supporting the existence of at least two disparate pulling styles-automatic and focused pulling. These pulling styles exhibit facets of behavioral processes, impulsivity and compulsivity, characteristic of several classes of disorders (e.g., obsessive-compulsive spectrum disorders, impulse control disorders). Available genetic, neurobiological, and clinical data support the importance of impulsivity for conceptualizing HPD. Impulsivity alone is insufficient to fully understand this complex phenotype. Characterizations of both automatic and focused pulling as well as preliminary findings from affective neuroscience across species highlight the importance of compulsivity for understanding HPD. Opposing and complementary aspects to impulsivity–compulsivity provide a more comprehensive conceptualization of HPD and supports HPD's potential importance for advancing scientific inquiry in relation to the pathogenesis and treatment of related phenotypes. This review concludes with a description of areas—phenotype, neurobiology, and genes—in need of further study.