Trichotillomania

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Trichotillomania

Definition

Individuals with trichotillomania repetitively pull out their own hair. Trichotillomania is an impulse-control disorder, although some researchers view it as a type of affective or obsessive-compulsive disorder. Nail-biting, skin-picking, and thumb-sucking are considered to be related conditions.

Description

Trichotillomania involves hair-pulling episodes that result in noticeable hair loss. Although any area of the body can be a target, the most common areas are the scalp, followed by the eyelashes, eyebrows, and pubic region. Hair-pulling can occur without the individual’s awareness but is frequently preceded by a sense of increasing tension and followed by a sense of relief or gratification, common features of behavioral addiction disorders. The resulting hair loss can be a source of embarrassment or shame. Because of a tendency to hide symptoms and because professionals are relatively unfamiliar with the disorder, individuals either may not seek or are not offered treatment. Untreated trichotil-lomania can result in impaired social functioning, reduced quality of life, and medical complications.

Causes and symptoms

Causes

Psychoanalytic theories explain compulsive hair-pulling behavior as a way of dealing with unconscious conflicts or childhood trauma (such as sexual abuse). Behavioral theories assume that symptoms are learned, that a child may imitate a parent who engages in hair-pulling. The behavior may also be learned independently if it serves a purpose. For example, hair-pulling may begin as a response to stress and

then develop into a habit. Biological theories address a genetic basis. For instance, people with trichotillomania often have a first-degree relative with an obsessive-compulsive spectrum disorder.

Researchers have also evaluated similarities between trichotillomania and Tourette’s syndrome. One group at Duke noted that the parent of a patient with Tourette’s syndrome in one of their studies displayed symptoms of trichotillomania. The researchers identified a link between mutations in a specific gene and the incidence of Tourette’s syndrome among the families in this study. Intrigued because the parent carried the mutation but did not exhibit symptoms of Tourette’s, the researchers completed a study analyzing the potential link between carrying the gene and having trichotillomania. They confirmed a link between the hair-pulling behavior and the mutant form of the gene, called SLITRK1, which is involved in the formation of connections among brain cells (called neurons). Two mutations in this gene appear to be linked to trichotillomania, and the researchers suggested that the mutant protein that results may cause missed connections among neurons, leading to the hair-pulling urges.

Symptoms

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), produced by the American Psychiatric Association and used by most mental health professionals in North America and Europe to diagnose mental disorders, the following conditions must be present for a diagnosis of trichotillomania:

noticeable hair loss (alopecia) due to recurrent hair-pulling
tension immediately before hair-pulling, or when attempting to resist hair-pulling
reduction of tension, or a feeling of pleasure or gratification, immediately following hair-pulling
significant distress or impairment in social, occupational, or other important areas of functioning

In addition, the DSM-IV-TRrequires that the patient’s hair-pulling not be due to another medical or mental disorder. The tension-release requirement is controversial because 17% of people who otherwise qualify for this diagnosis do not experience this.

Symptoms usually emerge in early adolescence. Episodes may last a few minutes or a few hours during periods of stress or relaxation. Those with trichotillo-mania may prefer hairs with unique textures or qualities. The pulling may include rituals, such as twirling hair off or examining the root. Half of those individuals with trichotillomania engage in oral behaviors—running hair across the lips or through the teeth, biting off the root (trichophagy), or eating hair (trichophagia). They usually try to control their behavior in the presence of others and may hide the affected areas. Symptoms may come and go for weeks, months, or years at a time.

Demographics

Once regarded as rare, trichotillomania is now considered more common, affecting 1-4% of people in the general population. When the tension-release requirement is excluded, trichotillomania occurs in adult females (3.4%) more often than adult males (1.5%). Among children, both genders are affected equally. Nonclinical levels of hair-pulling behavior may be as high as 15.3% among university students.

Diagnosis

Other possible causes of symptoms must first be ruled out. Hair loss may have a medical cause, such as a dermatological condition. Hair-pulling may have another psychological cause, such as a delusion or hallucination in schizophrenia.

If individuals deny symptoms, hair-pulling behavior can be assessed by objective measures such as the presence of short, broken hairs or damaged follicles. Some psychological assessment instruments are also available. These include the Massachusetts General Hospital Hair Pulling Scale (MGH-HPS), a seven-item, self-report measure of the symptoms of hair-pulling. Also the Alopecia Rating assesses the level of hair loss, and the Trichotillomania Interference Checklist interviews patients to assess the effects of pathological hair-pulling on various quality-of-life and health parameters.

Severity of symptoms is also important. Twisting or playing with hair when nervous does not qualify as trichotillomania. If symptoms are minor or undetectable, a diagnosis should be given only if the individual expresses significant distress. Children should be given the diagnosis only if symptoms persist because hair-pulling may be a temporary phase, much like thumb-sucking.

Treatments

Treatment usually starts by determining the current frequency and severity of symptoms. This information, which serves as a measure of progress, is gathered by (a) self-report, (b) reports from significant others, (c) objective measures, such as saving pulled hairs, videotapes, or measuring areas of hair loss, or (d) a combination of these methods.

Primarily, three categories of therapy have been used in the treatment of trichotillomania:

Psychoanalysis focuses on childhood experiences and unresolved conflicts during early development.
Medications. Those typically used are antidepressants with serotonergic properties (also used with obsessive-compulsive disorders). Clomipramine (Anafranil) has proven most effective. The selective serotonin reup-take inhibitors (SSRIs) have had mixed results. Some researchers recommend low doses of antipsychotic drugs (neuroleptics) in conjunction with SSRIs. Medications are usually combined with behavior therapy.
Behavior therapy. Habit-reversal training is the most accepted approach. It teaches individuals to monitor their hair-pulling and substitute it for healthier behaviors. Alternative forms of behavior therapy include biofeedback and hypnosis.

Prognosis

The effects of trichotillomania can be very serious. Associated feelings of shame may result in avoidance of social situations; chewing hair can result in dental erosion; and eating hair may result in hairballs (tricho-bezoars) becoming lodged in the stomach or large intestine, which can lead to anemia, abdominal pain, nausea and vomiting, hematemesis (vomiting blood), or bowel obstruction or perforation.

Studies show low success rates with medications and traditional psychoanalysis. Behavioral therapy has reported long-term success rates of 90% or more. Follow-up sessions are encouraged to prevent relapse. A major issue in prognosis is whether an individual receives treatment. Professionals may not recognize or

KEY TERMS

Alopecia —Hair loss (also, loss of feathers or wool in animals).

Selective serotonin reuptake inhibitors (SSRIs) — Commonly prescribed drugs for treating depression. SSRIs affect the chemicals that nerves in the brain use to send messages to one another. These chemical messengers (neurotransmitters) are released by one nerve cell and taken up by others. Neurotransmitters not taken up by other nerve cells are taken up by the same cells that released them. This process is termed “reuptake.” SSRIs work by inhibiting the reuptake of serotonin, an action that allows more serotonin to be taken up by other nerve cells.

Serotonergic —Containing, activating, or otherwise involving serotonin, which is a chemical that aids in the transmission of nerve impulses.

Trichobezoar —A hairball that results from a buildup of swallowed hairs becoming lodged in the digestive system.

Trichophagia —Eating hair.

Trichophagy —Biting hair.

know how to treat trichotillomania effectively. Conversely, individuals with the disorder may be too embarrassed to address their symptoms.

Prevention

No specific information is available regarding prevention.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., Text rev. Washington D.C.: American Psychiatric Association, 2000.

Keuthen, Nancy J., Dan J. Stein, and Gary A. Christenson. Help for Hair Pullers: Understanding and Coping with Trichotillomania. Oakland, CA: New Harbinger Publications, 2001.

Stein, Dan J., Gary A. Christenson, and Eric Hollander, eds. Trichotillomania. Washington D.C.: American Psychiatric Press, 1999.

PERIODICALS

Diefenbach, Gretchen J., et al. “Trichotillomania: Impact on Psychosocial Functioning and Quality of Life.” Behavior and Research Therapy 43 (2005): 868–84.

Diefenbach, Gretchen J., David Reitman, and Donald A. Williamson. “Trichotillomania: A Challenge to Research and Practice.” Clinical Psychology Review 20.3 (2000): 289–309.

Elliot, Amy J., and R. Wayne Fuqua. “Trichotillomania: Conceptualization, Measurement, and Treatment.” Behavior Therapy 31 (2000): 529–45.

ORGANIZATIONS

Trichotillomania Learning Center, Inc. 303 Potrero No. 51, Santa Cruz, CA 95060. (831) 457-1004. http://www.trich.org

OTHER

News release: “Hair-pulling Disorder Caused by Faulty Gene in Some Families.” http://www.dukehealth.org/news/9887

Duke’s Trichotillomania Genetics Research and Information About the Disorder, Including Ongoing Clinical Trials: http://www.chg.duke.edu/diseases/ttm.html

Sandra L. Friedrich, MA

Emily Jane Willingham, PhD

The Gale Encyclopedia of Mental Health