Trichotillomania

Definition

Trichotillomania is a psychiatric condition in which an individual has an uncontrollable desire to pull out his own body hair. It is generally considered to be an impulse control disorder but is sometimes classified as either a subtype or variant of obsessive-compulsive disorder (OCD).

Description

Trichotillomania is the most common cause of hair loss in children. First described in 1889, trichotillomania is a psychiatric disorder, the result of which is alopecia or hair loss, caused by repeated pulling of one's hair from, most often the head, followed by the eyelashes and eye brows. But the hair of any part of the body may be pulled and multiple sites may be involved. The individual with trichotillomania will have bald spots on the head or missing eyelashes or eyebrows.

There is an immense amount of embarrassment and denial associated with trichotillomania. It is common for individuals with this disorder to deny their behavior and attempt to hide their hair loss. The hair loss may be disguised by wearing wigs, hats, scarves or hair clips, or by applying make-up or even by tattooing. The act of hair pulling is a private one. Rarely does the hair pulling occur in the presence of another, except for close family members. Because of this fact, social alienation is common in trichotillomania.

The hair pulling may occur either when the individual is relaxed or under stress. For some individuals with trichotillomania, certain situations, such as watching TV, lying in bed, or talking on the phone, will trigger the behavior. The individual either may focus intensely on the hair pulling or the pulling may be done unconsciously. Immediately before pulling hair, the individual with trichotillomania feels a mounting tension. This tension is relieved as a hair root is successfully pulled. Since a tingling sensation is felt upon successfully pulling a hair follicle completely from its root, a neurodermatologic connection may reinforce hair pulling as a means of tension relief. When the hair root remains intact and the hair shaft is broken, this sensation is not felt and the patient may repetitively pull hairs until successful. After pulling the hair, patient may carefully examine the hair root, and the hair bulb may be rubbed along the lips for further stimulation. The hairs may be ingested by some patients.

The amount of time each day that the patient engages in hair pulling may consist of either several brief periods, or a longer intense period. The typical trichotillomania patient will spend one to three hours daily pulling hairs. The urge to pull can be so intense that the individual with trichotillomania cannot think of anything except hair pulling. Thus, social life and work production often suffer with trichotillomania.

The act of hair pulling in trichotillomania is often ritualistic. The necessary implements, such as tweezers, are collected, the location where this is to be performed is determined, the preferred texture or color to be pulled may be planned as well as disposal of the hairs.

Rarely, the individual with trichotillomania may attempt to pull the hairs of others. The hairs of a pet or doll or the fibers of an inanimate object, such as sweater, may be pulled as well. In addition to hair pulling, the hair may be bitten off or twisted or twirled.

Co-existing psychiatric diagnoses such as anxiety , depression, and addictive disorders are common in trichotillomania. Tics , borderline personality disorders , and OCD are all more prevalent in trichotillomania than in the general population. The hair pulling in trichotillomania can be differentiated from that in OCD in that the hair pulling in trichotillomania is an impulse behavior where in OCD it is a repetitive act performed as part of an obsession. The individual with OCD is aware of his or her actions, while the individual with trichotillomania is not always conscious that he or she is pulling hairs.

Trichotillomania is not the underlying cause of hair pulling if there is a medical reason for the hair loss or if another co-existing psychiatric disorder such as hallucination provokes the hair pulling.

Demographics

Trichotillomania usually begins in the preteens but has been reported in children as young as one year old and has been seen first in adults over 50 years old. Patients in their seventies may suffer from trichotillomania. The mean age of onset is 12 years of age in girls and eight years of age in boys. This condition is seven times more common in children than in adults. Among young children there is no gender preference. But among adults, it is reported up to 10 times more often in females than in males. This may be skewed because females are more likely to seek attention for a medical problem, and because it is easier for males to disguise their compulsions, e.g. by shaving or because of social acceptance of male pattern hair loss.

The total number of Americans who pull their own hair at some point in their lifetime may be as high as 11 million. The prevalence of trichotillomania has been estimated to be as high as 2 percent of the general population. Among college students surveyed, more than 10 percent of college students pull their hair at some point, although only 1 percent meets the criteria for trichotillomania.

Causes and symptoms

There is no clear cause of trichotillomania, but there are psychoanalytical, behavioral, or biological theories for this disorder. Some of the more commonly accepted theories for trichotillomania are:

• childhood trauma
• stressful events
• neurochemical imbalance

The psychoanalytic model purports that trichotillomania occurs in an attempt to resolve a childhood trauma, the most common of which is sexual abuse. According to this model an unconscious unresolved past conflict triggers hair pulling.

The behavioral theory for trichotillomania states that a stressful event, such as moving or the loss of a loved one, or a family conflict precedes the onset of hair pulling and that hair pulling begins in an attempt to relieve tension caused by a stressful event. This behavior continues beyond the initial stimulus and eventually becomes habitual. Later the patient may not be aware of this initial trigger. For a child, the stressor may not be just a single event, but may occur in response to what a child may perceive as excessive demands from an authoritarian or an overbearing parent.

Biological theories for trichotillomania include a neurochemical imbalance, such as a serotonin imbalance. Drugs that correct for serotonin imbalance improve symptoms in many with this disorder. Altered dopamine levels may also play a role in trichotillomania. It is not clear if genetic factors are involved in the development of trichotillomania, although some studies report an increased percentage of relatives with various psychiatric disorders.

The most common symptom of trichotillomania is hair loss. The pattern of alopecia in trichotillomania varies among patients and the degree of hair loss will range from a barely noticeable thinning to total loss of hair. Some patients pull out hairs without regard for symmetry, while others will attempt to follow a pattern or pull out hairs in an effort to maintain symmetry of appearance. Usually, the hair loss on the head is patchy or poorly defined. There are neither scars nor any inflammation in the area of scalp hair loss. The top is the most affected region of the head. Tonsure trichotillomania is a pattern hair loss of the scalp in which hair is present only at the nape and on the outer edge of the scalp. The eyelashes and eyebrows may be plucked off, and hair loss may be noted on the arms, legs, and body. Pubic hair may be sparse.

When to call the doctor

Any continuous pulling of hair or hair loss should be reported to a medical professional, as there are medical causes for hair pulling and hair loss, and if trichotillomania is the underlying cause for this problem, then medical and psychiatric treatment needs to be initiated as soon as possible, since the earlier the intervention, the greater the likelihood that the behavior can be controlled. It is important to realize that the occasional or infrequent twisting, pulling, or chewing of hair in a child does not constitute trichotillomania and does not require medical attention.

Diagnosis

The diagnosis of trichotillomania is made by history and interview, along with histological examination of the hairs in the area of hair loss as well as skin tissue in the area. All other medical causes of hair loss must be eliminated. Since patients are adept at disguising and denying the symptoms of trichotillomania, the condition may go on for years without detection or treatment. Most patients are embarrassed to admit to hair pulling and the resultant sequelae, and elicitation of this behavior is difficult. The patient will not usually report pain . All of this makes the diagnosis of trichotillomania difficult. The patient must be made to feel comfortable admitting to and then discussing the behavior.

The clinician may use rating scales to assist in the diagnosis of trichotillomania and to assess the degree to which a patient has trichotillomania. These scales include the Psychiatric Institute Trichotillomania Scale, National Institutive of Mental Health-Trichotillomania Severity Scale, Yale-Brown Obsessive Scale modified for Trichotillomania, the National Institute of Mental Health-Trichotillomania Impairment Scale, and the Minnesota Trichotillomania Assessment Inventory.

According to the American Psychiatric Association there are five criteria which must be met in order for trichotillomania to be diagnosed. They are as follows:

• The hair pulling is recurrent and a noticeable pattern of hair loss is observed.
• The patient feels increased tension prior to the hair pulling.
• This tension is relieved upon pulling hairs.
• The pulling is not associated with another mental condition, and there is no medical cause for the hair pulling.
• The behavior interferes with or disrupts the patient's social and work activities.

There is a subgroup of hair-pullers who do not meet the second and third criteria listed above. These individuals are less likely to hide their behavior and do not suffer from low self-esteem as frequently as those who meet all of the above criteria. There is some debate about whether these people have trichotillomania and about whether these criteria for diagnosis of trichotillomania are too restrictive.

Histological examination of hair follicles and skin biopsies also help in the diagnosis of trichotillomania. In the areas of hair loss in trichotillomania there will be a mixture of short and longer hairs in the area of hair loss. Trichomalacia or distortion of the hair follicles is often present in trichotillomania.

Trichotillomania must be differentiated from medical causes of hair loss and these include: skin conditions such as psoriasis ; trauma, such as that from radiation; endocrine disorders such as hypothyroidism ; infectious diseases such as herpes zoster; inflammation such that of the lids margins, called blepharitis; and tinea capitis, a fungal infection of the scalp. Other psychiatric disorders, such as schizophrenia , must also be ruled out.

Treatment

Usually, the patient with trichotillomania does not present for treatment until, on average, two years after the hair pulling has begun. Traditional treatment for trichotillomania involves psychological or behavioral therapy, or medication. Behavior modification, especially with children, helps the child to increase his or her awareness of the hair pulling. Behavioral therapy may be as simple as acknowledging the problem and instituting a plan for desensitization of the behavior.

Habit reversal training (HRT), a cognitive behavioral therapy, has been successfully used in the treatment of trichotillomania. Under HRT treatment the patient acquires increased awareness of his or her actions and learns alternative behavior to the hair pulling. HRT has been employed in group therapy. Addressing the behavior of trichotillomania in a group setting is helpful so the patients realize that they are not the only ones with this problem. This experience also improves social interaction, as isolation is common among patients with trichotillomania.

Medication to correct biochemical imbalances in the brain is a common component of trichotillomania treatment. But since drug trials in children and adolescents have been limited, behavioral therapy is often instituted alone first, prior to using medication. But for some with trichotillomania, behavioral therapy is more successful when drug therapy helps reduce the urge to pull hair. For these individuals, relapses are more frequent when pharmacotherapy is reduced or discontinued.

There are no FDA drugs which specifically treat trichotillomania. The drugs used to treat this disorder have been developed for treatment of other psychiatric problems. The drug which has been the most successful in treatment of trichotillomania is clomipramine (Anafranil), a tricyclic antidepressant.

Since it is hypothesized that serotonin activity is abnormal in trichotillomania, selective serotonin reuptake inhibitors (SSRIs) are commonly given to improve symptoms. Prozac is a common SSRI. Drugs in this class given to treat trichotillomania in children include sertraline (Zoloft), fluvoxamine (Luvox), and clomioramine. The effectiveness of a given drug varies considerably from person to person. If one SSRI drug is not successful in controlling trichotillomania in a given individual, another drug in this class may work. Risperdone and clonazepam, which address a dopamine imbalance, can be added to SSRIs if an SSRI drug does not satisfactorily control symptoms. But these drugs, called neuroleptics, have more side effects in children than in adults.

Since those with trichotillomania do not report pain, drugs to decrease pain thresholds have been tried as well. Other drugs that are given to treat this disorder include buspirone, lithium (Lithobid), naltrexone, paroxetine (Paxil), valproate, and the antipsychotic drug, quetiapine.

Treatment of the resultant medical complications of hair pulling must be addressed. Carpal tunnel can develop from repetitive pulling. Infections at the site of the hair pulling and blepharitis at the eyelid margins can occur, both of which are treated with topical antibiotics and corticosteroids. If there is significant eyelash and eyebrow loss, called madarosis, blepheropigmentation or surgical tattooing can be performed. Although not done often, transplantation of hairs to these areas is possible.

Topical application of colladion can help with regrowth of hair but will not be successful long term unless the underlying behavior is controlled. If the hair pulling continues for long periods without treatment, the alopecia may be permanent.

Anemia, malnutrition , and digestive disorders, including bowel obstructions, can develop, if trichotillomania develops into trichotillophagia or eating of the hairs. Trichobezoars, or hairballs, can form when the hair is bitten off and ingested.

For many with trichotillomania, hair pulling is not an activity that can be stopped at will. For some, however, the suppression of hair pulling may be possible, even if the underlying urge persists. The family needs to be a part of therapy since familial stressors may have triggered trichotillomania.

Because of the shame involved with hair pulling the patient may have other medical problems which go untreated because he or she will not seek any medical care at all, for fear that hair pulling and its associated stigmata will be uncovered. Thus, it is important that once trichotillomania is diagnosed that the healthcare provider inquire into any other medical concerns that the patient may have.

Alternative treatment

Hypnosis has been used in treatment of childhood trichotillomania. The Erickson approach of hypnosis helps the child to substitute hair pulling for a stroking behavior. Other approaches to hypnosis in trichotillomania teach the child that he or she has control over events in his or her life, including hair pulling. There are other hypnotic techniques that employ adverse conditioning, so that the hair pulling becomes associated with pain instead of pleasure.

Other techniques, consider alternative, used to trichotillomania include biofeedback, yoga , and exercise .

Prognosis

When trichotillomania appears in early childhood, the duration of time during which the child is afflicted, is limited. The remission rate for children diagnosed before age six is high. For many children with trichotillomania, the condition resolves by adulthood.

The prognosis is much more difficult for those who develop trichotillomania after age 13. These children have a higher rate of other co-existing psychiatric disorders. Unfortunately, among those individuals who need long-term treatment for trichotillomania, as is the case when the initial presentation occurs in late childhood or as in adolescence or in adulthood, there is a high relapse rate in spite of intervention. A lack of definitive cause for trichotillomania makes treatment difficult, and the prognosis for a total recovery is poor, although the behavior may be satisfactorily controlled with therapy.

Prevention

Since, as of 2004, the actual cause of trichotillomania was not known, there is no known means of prevention.

Parental concerns

Parents must realize that the earlier the treatment for trichotillomania is begun, the more likely that the hair pulling can be controlled. When trichotillomania strikes the adolescent it is especially important that the behavior be addressed and treated promptly. Adolescence is a time when self-esteem and independence are developing. If the adolescent does not have a positive body image, then fear or ridicule from family and peers can affect his or her ability to interact with others. Development of normal healthy relationships as an adult may be impaired if the family and such support mechanisms as therapy are not in place.

Since often the family dynamics provoke this behavior, parental involvement in therapy is essential. If necessary, the parents must be open to establishing new boundaries within the parent-child relationship.

It is important that parents to realize that trichotillomania is a complex and not completely understood behavior. But it is increasingly believed that trichotillomania has a biological basis, and thus parents must understand that they did not cause it and that they are not the only parents with a child who has trichotillomania. Support for trichotillomania may be found through the Trichotil- lomania Learning Center (available online at http://www.trich.org). Many larger cities may have local support groups. Healthcare providers may help with location of such groups locally.

See also Alopecia ; Obsessive-compulsive disorders .

Resources

BOOKS

Albert, Daniel M., et al. Principles and Practice of Ophthalmology , 2nd ed. Philadelphia: W. B. Saunders Co, 2000.

Burt, Vivien K., and Jeffery William Katzman. "Trichotillomania." In Kaplan & Sadock's Comprehensive Textbook of Psychiatry , vol. II. Edited by Benjamin J. Sadock and Virginia Sadock. Philadelphia: Lippinicott Williams & Wilkins, 2000.

Diagnostic and Statistical Manual of Mental Disorders , 4th ed. Washington, DC: American Psychiatric Association, 2000.

PERIODICALS

Bergfeld, Wilma, et al. "The Combined Utilization of Clinical and Histological Findings in the Diagnosis of Trichotillomania." Journal of Cutaneous Pathology 29 (2002): 207–14.

Diefenbach, Gretchen J., et al. "Trichotillomania: A Challenge to Research and Practice." Clinical Psychological Review 20, no. 3 (April 2000): 289–309.

du Troit, Pieter L., et al. "Characteristics and Phenomenology of Hair-Pulling: An Exploration of Subtypes." Comprehensive Psychiatry 42, no. 3 (May-June 2001): 247–56.

Enos, Stephanie, and Thomas Plante. "Trichotillomania: An Overview and Guide to Understanding." Journal of Psychosocial Nursing and Mental Health Services 39, no. 5 (May 2001): 10–18.

Iglesias, Alex. "Hypnosis as a Vehicle for Choice and Self-Agency in the Treatment of Children with Trichotillomania." American Journal of Clinical Hypnosis 46, no. 2 (October 2003): 129–37.

Jordan, D. R., and L. A. Mawn. "Trichotillomania." Canadian Journal of Ophthalmology 38, no. 4 (June 2003): 303–05.

Khouzam, Hani Raoul, et al. "An Overview of Trichotillomania and Its Response to Treatment with Quetiapine: A Case Report." Psychiatry Interpersonal and Biological Processes 65, no. 3 (Fall 2002): 262–70.

Nuss, Michelle A., et al. "Trichotillomania: A Review and Case Report." Cutis 72, no. 3 (September 2003): 191–96.

Child's scalp showing hair loss from trichotillomania.

(© NMSB/Custom Medical Stock Photo.)

O'Sullivan, Richard L., et al. "Characterization of Trichotillomania: A Phenomenological Model with Clinical Relevance to Obsessive-Compulsive Spectrum Disorders." The Psychiatric Clinics of North America 23, no. 3 (September 2000): 587–604.

Springer, Karyn, et al. "Common Hair Loss Disorders." American Family Physician 68, no. 1 (July 1, 2004): 93–102, 107–8.

WEB SITES

"About TTM & Treatment: Alternative Therapies." Trichotillomania Learning Center. Available online at http://www.trich.org/about-ttm/alttherapies.asp (accessed July 24, 2004).

"About TTM & Treatment: Introduction." Trichotillomania Learning Center. Available online at http://www.trich.org/about-ttm/intor.asp (accessed July 24, 2004).

"About TTM & Treatment: Medications." Trichotillomania Learning Center. Available online at http://www.trich.org/ttm/medication.asp (accessed July 24, 2004).

"For Kids and Teens: Will it Go Away?" Trichotillomania Learning Center. Available online at http://www.trich.org/forkidsteens/go-away.asp (accessed July 24, 2004).

"Other Mental Illnesses: Trichotillomania." National Mental Health Association . Available online at http://www.nmhaa.org/infoctr/factsheets/92.cfm (accessed July 24, 2004).

Martha Reilly, OD

KEY TERMS

Alopecia —The loss of hair, or baldness.

Dopamine —A neurotransmitter made in the brain that is involved in many brain activities, including movement and emotion.

Histology —The study of tissue structure.

Hypnosis —The technique by which a trained professional induces a trance-like state of extreme relaxation and suggestibility in a patient. Hypnosis is used to treat amnesia and identity disturbances that occur in dissociative disorders.

Obsessive-compulsive disorder —An anxiety disorder marked by the recurrence of intrusive or disturbing thoughts, impulses, images, or ideas (obsessions) accompanied by repeated attempts to supress these thoughts through the performance of certain irrational and ritualistic behaviors or mental acts (compulsions).

Remission —A disappearance of a disease and its symptoms. Complete remission means that all disease is gone. Partial remission means that the disease is significantly improved, but residual traces of the disease are still present. A remission may be due to treatment or may be spontaneous.

Serotonin —A widely distributed neurotransmitter that is found in blood platelets, the lining of the digestive tract, and the brain, and that works in combination with norepinephrine. It causes very powerful contractions of smooth muscle and is associated with mood, attention, emotions, and sleep. Low levels of serotonin are associated with depression.