Trichotillomania: Modifying the Diagnostic Criteria from DSM IV TR to DSM V

Trichotillomania in the DSM 5

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is an authoritative guide to the diagnosis of mental disorders. It is used by health care professionals throughout the world.  The DSM contains detailed criteria for diagnosing mental disorders, including descriptions and symptoms.   

Every few years the DSM undergoes revisions. The purpose of such revisions is to make the diagnostic criteria more reliable and to further enhance the communication between physicians regarding mental disorders.


DSM 5 Criteria for Trichotillomania (TTM)

Trichtillomania (TTM) is a hair pulling disorder whereby affected individuals pull out their own hair. 3-4 % of the world experiences trichotillomania at some point in their lives making it a common disorder. In 2013, the DSM underwent a revision from the previous DSM - IV TR to the DSM 5. And with these revisions, the new manual had proposed new criteria for TTM.


The DSM IV-TR criteria for TTM (2000)

The earlier DSM IV TR criteria for TTM included the following:

A. Recurrent pulling out of one's hair resulting in noticeable hair loss. 

B. An increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior. 

C. Pleasure, gratification, or relief when pulling out the hair. 

D. The disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (e.g., a dermatological condition). 

E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Copyright 2000 American Psychiatric Association




The DSM 5 criteria for TTM (2013)

With the revisions of the DSM 5 in 2013, criteria B and C above were removed.  There is no longer a requirement for diagnosed individuals to show urges to pull and subsequent relief after pulling. These criteria showed the lowest relatedness to the underlying TTM construct. The new criteria are:

  • Recurrent pulling out of one’s hair, resulting in hair loss

  • Repeated attempts to decrease or stop the hair-pulling behavior

  • The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

  • The hair pulling or hair loss cannot be attributed to another medical condition (eg, a dermatologic condition)

  • The hair pulling cannot be better explained by the symptoms of another mental disorder (eg, attempts to improve a perceived defect or flaw in appearance, such as may be observed in body dysmorphic disorder)



American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 5th ed. Washington, DC: American Psychiatric Association; 2013. 251-4.

Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887

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