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In Epidemics I, the ancient Greek physician Hippocrates (c.460 - c.377 BC) suggested that hair pulling was a symptom that the physician should assess routinely.
"Then we must consider his speech, his mannerisms, his silences, his thoughts, his habits of sleep or wakefulness and his dreams, their nature and time. Next, we must note whether he plucks his hair, scratches or weeps." (Lloyd 1983, P. 100)
In Epidemics III, Hippocrates described a case of hair pulling where the patient was depressed and grieving.
"At Thasos the wife of Delearces, who lay on the level ground, took a high fever with shivering as the result of grief. From the start she used to wrap herself up, always remaining silent while she groped about, scratching and plucking out hair, and alternately wept and laughed". (Lloyd 1983, p. 137)
There are other reports of 'clinically relevant' hair pulling in more recent medical literature, viz. Baudamant (1777-1778); and D'Hauteville (1813).
In 1889, the physician Hallopeau described a young man who pulled out all of his body hair. Five years later, Hallopeau published a description of another case, and on that occasion he tried application of mentholated camphor and wrapping the patient in rubber; but this was ineffective.
He concluded that the essential features of trichotillomania were,
1) itching extending to all the hairy parts of the body,
2) a "type of insanity" that drives the patient to seek relief from itching
via hair pulling,
3) normal appearance of skin and hair,
4) long duration, and
5) lack of cure
The diagnostic criteria have subsequently been revised, and Trichotillomania is now included under "Impulse-Control Disorders Not Elsewhere Classified", where it shares company with such syndromes as pyromania, kleptomania and pathological gambling.
These disorders are defined by the presence of mounting tension prior to the behaviour, and gratification derived from the release of tension following the behaviour. They are also characterised as consistent with the will of the individual at the time.
There has been consideration to classification as an anxiety disorder because of apparent similarities with obsessive-compulsive disorder. Mansueto (Kaplan 1992) has suggested that a new diagnostic category, "displacement activity disorder", be considered, with the inclusion of trichotillomania, face picking, nail biting, and other body focused "nervous habits" when they become severe. But, at the moment, Trichotillomania remains under "Impulse-Control Disorders Not Elsewhere Classified". More on the DSM-IV diagnostic criteria for trichotillomania.
It is thus interesting, and important, to note that the condition is not yet fully understood. It is difficult, if not impossible, to provide diagnostic criteria which will cover all cases, and clearly distinguish it from other medical conditions.
Acknowledgement
The above article relies on material drawn from the essay by Gary A.
Christenson and Charles S. Mansueto, "Trichotillomania: Descriptive
characteristics and phenomenology"; chapter in the book "Trichotillomania",
edited by Dan J. Stein, Gary A. Christenson, and Eric Hollander. American
Psychiatric Press, 1999. Readers are referred to this book chapter for
details of the medical references.