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Trichotillomania

Trichotillomania, or pathological hair pulling, is a popular mental health disorder that is often defined as an underdiagnosed psychological disorder.


What Is Trichotillomania?

Trichotillomania
Trichotillomania


Trichotillomania (TTM) is a psychiatric disorder marked by the repetitive pulling out of hair, resulting in noticeable hair loss along with clinically notable academic, social, and/or occupational impairment. People with TTM feel a strong urge to pull out their hair. Many sufferers may not recognize it as a diagnosable condition as they consider it as a mere bad habit of pulling hair. It is also known as “hair-pulling disorder,” which is a type of impulse control disorder where the affected person repeatedly pulls out, twists out, or breaks off hair from any part of the body for non-cosmetic reasons. While the person is aware of the fact that the habit or the urge can do damage, he/she often can’t control the impulse. Such people pull out their hair when they’re stressed as a way to calm themselves. Individuals with TTM may pull out hair from their scalp, eyelashes, eyebrows, underarms, pubic, chin, chest, or leg areas. They may pull out their hair intentionally or unconsciously.

According to a study 1 , “trichotillomania (TTM) is a chronic impulse control disorder characterized by pulling out one’s own hair, resulting in noticeable hair loss.” The study states that while extensive, large-scale epidemiological studies are yet to be conducted, TTM is considered by smaller studies to inflict 1-3.5% of late adolescents and young adults. However, the prevalence rates among younger children 2 , unfortunately, remain unknown. During the development period of this disorder, patients can experience other complications such as skin irritations at the pulling site, infections, and repetitive-use hand injuries.

Understanding Trichotillomania

Trichotillomania is a relatively new concept in the field of psychology. As of yet, there are several theories about the causes of this disorder without any proven conclusion. Researchers are yet to understand whether it is a psychological condition or a biological condition, caused by a fluctuation in hormone levels. Research suggests that 0.5 to 2 percent 3 of people have TTM. The most important aspect of this condition is pulling out hair from any part of the body as a response to manage stress. The person first feels the stress and then feels a sense of pleasure or relief once he or she starts pulling out the hair, followed by guilt, embarrassment, self-loathing, or shame. In some cases, people pull hair out of their habit rather than any emotional trigger, however, the cycle of pleasure, relief, guilt, and shame remains the same.

Due to the urge of pulling hair, especially from the scalp, patchy bald spots start appearing which causes distress severe enough to interfere with social or work functioning. In such cases, people go to great lengths to disguise their hair loss. While for some, the condition may be mild and manageable, for others it might prove to be overwhelming. There are treatment options that have helped to reduce the hair-pulling urges entirely. Trichotillomania is classified in the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as an obsessive-compulsive spectrum disorder. The condition is characterized by:

  • Repetitive pulling out of one’s hair, resulting in hair loss
  • Repeated efforts to limit or stop hair pulling
  • A sense of embarrassment or distress that can affect a person’s social or professional functioning
  • Hair pulling or hair loss independent of any cosmetic care or another medical condition or mental disorder

The condition usually develops during the adolescent years and once it starts, it can continue for several years through adulthood. It affects males and females equally during childhood but can affect females more often during adulthood. A 2018 study 4 states that hormonal changes in a woman’s body during their menstrual cycle may have an impact on symptoms of this disorder. However, the researchers are not yet aware of the reason. In fact, in a study of 462 individuals, 94% of women were inflicted with TTM.

Read More About DSM 5 Here.

Symptoms Of Trichotillomania

Symptoms Of Trichotillomania
Trichotillomania


The common signs and symptoms of TTM often include:

  • Repeatedly pulling out hair, especially from scalp, eyebrows, or eyelashes, and at times from other body parts such as underarm, pubic, legs, etc
  • A growing sense of tension before pulling, or when the person tries to resist pulling
  • A sense of satisfaction or relief after pulling the hair
  • Striking hair loss marked by bald patches, thinning of hair or shortened hair, or sparse or missing eyelashes and eyebrows
  • Preference for particular types of hair followed by rituals that accompany hair pulling, or patterns of hair pulling
  • Biting, chewing, or eating pulled-out hair
  • Frolicking with pulled-out hair or rubbing it across the lips or face
  • Failed attempts to stop pulling out hair or trying to do it less often without much success
  • Notable trouble or problems at work, school, or in social situations related to pulling out of hair

Additionally, there are people with the disorder who also pick their skin, bite their nails, or chew their lips. They also find a sense of satisfaction by pulling hairs from their pets, dolls, or from materials such as clothes or blankets. Also, such patients try to pull hair in private and generally hide the disorder from others.

Causes Of Trichotillomania

The exact cause of TTM is not known or well-understood. However, it is assumed that it results from several factors occurring at the same time, including genetic and environmental factors. It is considered that a few people may have a genetic predisposition to developing the disorder. However, it must be noted that while first-degree family members of someone with TTM are at increased risk of developing the disorder themselves, the majority of such individuals do not. Additionally, anxiety and arousal levels can play a role in the onset. According to a study 5 , the condition occurs with a variety of other disorders such as major depressive (39-65%), anxiety (27-32%), and substance use (15-19%) disorders. Among 894 individuals with TTM, 6% used illegal drugs, 17.7% used tobacco products, and 14.1% used alcohol to relieve negative feelings associated with pulling hair. Additionally, 83% of subjects reported anxiety and 70% reported depression.

Some scientists believe that trichotillomania falls under obsessive-compulsive disorder (OCD), which may be caused due to certain chemical imbalances in the brain. Rates of co-occurring OCD are significantly higher in individuals with TTM (13-27%) than those found in the community (1-3%). Moreover, the rates among individuals with OCD ranges from 4.9% to 6.9% which is greater than the rate of 0.5%-2.0% found in the community. The repeated motor symptom of hair pulling shares some similarities with the repetitive compulsive rituals in OCD.

Read More About Obsessive-Compulsive Disorder Here.

Risk Factors Associated With Trichotillomania

The determinants that tend to increase the risk of TTM are:

1. Family History

As mentioned previously, genetics 6 may play a role in the evolution of this condition. It may develop in those who have a close relative with the disorder

2. Age

It usually develops before teenage years or during the early teens, generally falling between the age bracket of 10 and 13 years, and it’s often a lifelong problem. Infants can also develop the disorder of hair pulling, however, this is usually moderate and goes away without any treatment

3. Other Disorders

People suffering from this condition may also have other disorders, such as depression, anxiety, or obsessive-compulsive disorder (OCD) Extremely stressful situations or events may trigger TTM in some people

Read More About Major Depressive Disorder ( Depression ) Here.

Complications Associated With Trichotillomania

Although it may not seem unusually serious, this condition can leave some major negative impact on one’s life. Complications may include:

1. Emotional Distress

Many people with this disorder have expressed their feelings of shame, humiliation, and embarrassment. They may experience low self-esteem, despair, stress while getting involved in alcohol or street drug use because of their condition.

2. Social & Work Functioning Issues

People with trichotillomania feel embarrassed due to their hair loss which further leads to avoiding social activities and job opportunities. They may also avoid intimacy for fear that their condition will be revealed.

3. Skin & Hair Damage

Constant hair pulling causes scarring and other damage along with scalp infection or the specific area where the hair is pulled and can permanently impair hair growth.

4. Hairballs

Eating hair may lead to large, matted hairballs (trichobezoar 7 ) in the digestive tract. Over time, the hairball can cause weight loss, vomiting, intestinal obstruction, and even death.

Diagnosis Of Trichotillomania

The diagnosis of TTM may include the following activities.

  • Examining the amount of loss
  • Asking questions about hair loss and discussing the same
  • Eliminating other possible reasons for hair pulling or hair loss through tests determined by the doctor
  • Distinguishing any physical or mental health problems that may be connected with hair pulling

According to the DSM-5, a person must meet the following criteria to get diagnosed with trichotillomania:

  • Repeated pulling out of hair, resulting in hair loss
  • Repeated efforts to decrease or stop hair pulling
  • Hair pulling must cause clinically notable distress or impairment in social, occupational, or other important areas of functioning
  • Hair pulling or hair loss that is not connected to another medical condition
  • Hair pulling is not better explained by the symptoms of another mental disorder

The doctor will eliminate any other causes of hair loss and may send the concerned person to a dermatologist.

Treatment Options Of Trichotillomania

Research on the treatment of TTM is limited. However, there are a few treatment options that have helped many people reduce their hair pulling habit or stop it entirely. Here are a few treatment options for this disorder.

1. Therapy

A 2012 case study 8 shows that habit reversal therapy (HRT), a type of Cognitive Behavioral Therapy (CBT), might be useful in treating TTM. According to a 2011 review 9 , most experts acknowledge the fact that HRT should be the first-line treatment option for trichotillomania. HRT involves five steps as follows

A. Awareness Training

This is the first step of the therapy where the person recognizes the psychological and environmental factors that may trigger an episode of hair-pulling.

B. Competing Response Training

Through this training, the person learns to replace hair-pulling behavior with another behavior.

C. Motivation & Compliance

At this stage of the therapy, the person involves himself/herself in activities and behaviors that will remind him/her about the importance of sticking to HRT. This may entail receiving praise from family and friends for progress made during therapy.

D. Relaxation Training

Here, the person practices relaxation techniques such as meditation and deep breathing. These help to reduce stress leading to hair pulling.

E. Generalization Training

The person practices new skills for different situations so that the new behavior becomes habitual.

2. Other Therapies

The other forms of therapies that may also help alleviate the symptoms of trichotillomania are:

A. Cognitive Therapy

The therapy helps people to explore the distorted beliefs related to hair pulling. According to a recent 2020 study 10 , “To date, treatments based on cognitive behavior therapy (CBT) have been the most tested and are thus the most empirically validated, with researchers reporting promising results about their effectiveness.”

Read More About Cognitive Behavioral Therapy Here.

B. Self-Awareness Training

Through this therapy, the concerned person becomes more aware of his/her hair pulling patterns by keeping a track of it when he/she pulls it. The person also tries to understand the associated emotions and other important information.

C. Family Therapy

For children and adolescents, family therapy 11 is useful as it helps the parents to learn ways to manage the symptoms.

D. Group Therapy

TTM can make a person feel isolated. Group therapy can help a person to connect with others facing similar struggles, thereby, supporting each other in the same battle.

Read More About Group Therapy Here.

3. Medications

Although there are no medications approved by the Food and Drug Administration (FDA) for the treatment of trichotillomania, some medications may help control certain symptoms. A 2013 review examined the effectiveness of different medications in treating this condition. The review consisted of eight trials, seven of which were placebo-controlled. The drugs investigated across the eight trials comprised:

  • Selective serotonin reuptake inhibitors (SSRIs), which are a group of antidepressants
  • Olanzapine, which is an antipsychotic
  • Naltrexone, which is an opioid antagonist
  • Clomipramine, which is a tricyclic antidepressant
  • N-acetylcysteine

Through the review, it was identified that olanzapine, N-acetylcysteine, and clomipramine are the only drugs that have a significant treatment effect on trichotillomania. However, the studies have practiced using very small sample sizes and did not report information on side effects. Additional controlled clinical tests are required to discover the safest and most appropriate drug treatments for TTM.

Coping With Trichotillomania

Here are some simple tips that a person can make use of to cope with the condition and that may help reduce the urge of pulling hair out. These include:

  • Squeezing a stress ball or something similar
  • Forming a ball with the fist and tightening the muscles in that arm
  • Using a fidget toy
  • Wearing a bandana or a tight-fitting hat, such as a beanie
  • Indulging in a soothing bath to ease any stress or anxiety
  • Practicing deep breaths, meditation, or yoga until the urge to pull goes away
  • Regular exercise
  • Putting plasters on the fingertips
  • Getting a short haircut

Helping Someone With Trichotillomania

If you are close to someone suffering from TTM, here are some suggestions to help them fight the disorder.

1. Do Not Blame

As a caretaker, it is your first step to understanding the fact that the concerned person wants to stop the habit of pulling hair but it is difficult to bring it under control. Blaming him or her for not stopping will only add to the person’s stress and aggravate the disorder.

2. Identify Possible Stressors

Understand the factors or stressors that trigger the habit of pulling hair. This way you can help the person to control his/her habit of pulling hair. Such factors could include a number of things, such as dissatisfaction at the job, financial troubles, exam stress, tension in the relationship, etc. Identifying what provokes the behavior can help the person to make life changes in order to reduce the stress, and consequently, the compulsion.

3. Busy Hands

Come up with activities that will keep the person’s hand busy, thereby reducing the habit of pulling hair. For example, if the person is studying, tell him/her to write notes. Additionally, you can get a ball or small toy to squeeze which may help in reducing the habit.

4. Seek Help

As we have mentioned previously, therapy is the best way to control trichotillomania. Seeking help from a professional will help you with more ideas to deal with the condition and supporting the loved one. Online support groups are also available to comfort people with TTM who often feel isolated and lonely due to their behavior.

Trichotillomania Prevention

There is no proven way to stop the condition. However, getting early treatment can be a big help. Learning stress management is also a big help as stress often triggers hair-pulling behavior.

Overcoming TTM

Trichotillomania is often left undiagnosed as people with this condition tend to feel embarrassed or afraid to talk to their doctor about their experience. Symptoms may last for a few months while others for a few years. Even though the condition affects many people all over the world, it is a treatable mental health condition. There are many ways to manage it, ranging from therapy to medication. Thus, if you come across someone with this condition, help him/her to reach out to an expert to help the person to fight the condition with an early treatment plan.

References:
  1. Franklin, M. E., Zagrabbe, K., & Benavides, K. L. (2011). Trichotillomania and its treatment: a review and recommendations. Expert review of neurotherapeutics, 11(8), 1165–1174. https://doi.org/10.1586/ern.11.93 []
  2. Harrison, J. P., & Franklin, M. E. (2012). Pediatric trichotillomania. Current psychiatry reports, 14(3), 188–196. https://doi.org/10.1007/s11920-012-0269-8 []
  3. Grant, J. E., & Chamberlain, S. R. (2016). Trichotillomania. The American journal of psychiatry173(9), 868–874. https://doi.org/10.1176/appi.ajp.2016.15111432 []
  4. Grant, J. E., & Chamberlain, S. R. (2018). Salivary sex hormones in adolescent females with trichotillomania. Psychiatry Research, 265, 221-223. https://doi.org/10.1016/j.psychres.2018.05.012 []
  5. Grant, J. E., & Chamberlain, S. R. (2016). Trichotillomania. The American journal of psychiatry, 173(9), 868–874. https://doi.org/10.1176/appi.ajp.2016.15111432 []
  6. Chattopadhyay K. The genetic factors influencing the development of trichotillomania. J Genet. 2012 Aug;91(2):259-62. doi: 10.1007/s12041-011-0094-6. Erratum in: J Genet. 2012 Aug;91(2):263. Chatterjee, Koushik [corrected to Chattopadhyay, Koushik]. PMID: 22942103. []
  7. Gorter, R. R., Kneepkens, C. M., Mattens, E. C., Aronson, D. C., & Heij, H. A. (2010). Management of trichobezoar: case report and literature review. Pediatric surgery international, 26(5), 457–463. https://doi.org/10.1007/s00383-010-2570-0 []
  8. Gupta, S., & Gargi, P. D. (2012). Habit reversal training for trichotillomania. International journal of trichology, 4(1), 39–41. https://doi.org/10.4103/0974-7753.96089 []
  9. Franklin, M. E., Zagrabbe, K., & Benavides, K. L. (2011). Trichotillomania and its treatment: a review and recommendations. Expert review of neurotherapeutics, 11(8), 1165–1174. https://doi.org/10.1586/ern.11.93 []
  10. Bottesi, G., Ouimet, A. J., Cerea, S., Granziol, U., Carraro, E., Sica, C., & Ghisi, M. (2020). Comprehensive Behavioral Therapy of Trichotillomania: A Multiple-Baseline Single-Case Experimental Design. Frontiers in psychology, 11, 1210. https://doi.org/10.3389/fpsyg.2020.01210 []
  11. Lantz JE, Early JP, Pillow WE. Family aspects of trichotillomania. J Psychiatr Nurs Ment Health Serv. 1980 Aug;18(8):32-7. PMID: 6253626. []