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The Informed Parent

Trichotillomania: Compulsive Hair Pulling

by Sandra Smith, Ph.D.
Published on Apr. 09, 2001

Recently, a bright, talented and seemingly happy 15-year-old girl was brought to my office for symptoms of uncontrollable hair pulling. She believes that this behavior started when she was either eight or nine years old. She described episodes of hair pulling, which gradually left several near-bald spots on her head, as follows: “I always pulled out ONE hair at a time. As soon as I thought about it, pulling the hair, I knew I would actually do it, eventually. It was always as though I had no power AT ALL to stop it. Once I thought of it, I could not focus on anything else until I had pulled a hair from my scalp.”

This young lady, we’ll call her Linda, had a condition known as trichotillomania, or compulsive hair pulling. Linda’s condition gradually worsened, in that she began to compulsively knead each of the hairs she pulled between her fingers until it formed a minute knot. She noticed that the knotted hair had a sort of “burning” smell, and decided to taste it. The escalating behavioral pattern eventually required that she ingest each hair. When she came to my office, she was two months post surgery for removal of a hairball, the size of a small grapefruit, from her stomach.

Trichotillomania—What Is It, Exactly?

Trichotillomania, often abbreviated to “trich” in conversation, is a disorder. It occurs when an individual experiences a compulsive urge to pull out hairs, from the head, eyebrows, eyelashes, pubic areas and any other place where hair grows. This “pulling” results in noticeable hair loss; in Linda’s case from her scalp. In other individuals, the loss may be apparent in other bodily areas. Trichotillomania most often starts at around 12 or 13 years of age, although it is not uncommon for it to start at a much younger, or older age. For this reason alone, it should be a subject of some interest to most informed parents.

Virtually all sufferers of trichotillomania experience some tension or urges associated with their disorder. Most individuals also describe the pulling as resulting in a lessening of the tension they experienced. Unfortunately, subsequent worry (e.g., of becoming bald, or unable to grow eyelashes back) may actually heighten anxiety.

Many “pullers” play with their hair in some way. They may touch the root of the hair to their mouth, or pull it through their hands or mouth. Some bite the root off, and some, like Linda, eat the entire hair. This is called trichophagy. In rare cases, like Linda’s, an indigestible hairball must be removed from the stomach.

Some trich sufferers describe a compulsion to pull out hairs that “feel wrong”. They may spend considerable time searching for the “right hair” to pull. Others tend to select a favorite area of the scalp, or other bodily area, to pull from. And the location may change periodically. As described, any area of hair growth is a potential site for pulling.

Most sufferers do not describe the pulling as painful. The number of hairs that are pulled during each episode varies. It may be a few, or a few dozen. It may take from moments to hours for the episode to conclude. Most often pulling occurs when one is alone.

According to the current psychiatric diagnostic manual (DSM-IV), the diagnosis of trichotillomania requires the following:

  1. Recurrent pulling of one’s hair which results in noticeable hair loss.
  2. An increasing sense of tension immediately before pulling out the hair, or when attempting to resist the behavior.
  3. Pleasure, gratification or relief when pulling out the hair.
  4. 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)
  5. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

Is Trichotillomania New? I Haven’t Heard Of It.

NO! Rather, the condition has “come to light” in recent years because of the focus on the diagnosis and treatment of Obsessive Compulsive Disorder, OCD. Eventually, it was recognized that there are distinct differences between OCD and trich, although there is also enough of an overlap that compulsive hair pulling is commonly included in what many authors term the “obsessive compulsive spectrum disorders”. That is, those conditions that seem related to OCD, but do not meet the actual OCD diagnostic criteria. Currently, trichotillomania is classified as a disorder of impulse control.

Most experts in this field agree that compulsive hair pulling has probably been around as long as there have been living beings with hair to pull. In the Old Testament of the Bible, Ezra describes hair pulling in verse 9.3 He states: “…and when I hear this thing, I rent my garment and my mantle, and plucked off the hair of my head and of my beard.” A French dermatologist by the name of Hallepeau coined the term trichotillomania in 1889. He derived the term from the Greek words for hair (thrix), to pull out (tillein) and insanity (mania), to describe his treatment of a young man with symptoms of compulsive hair pulling.

Perhaps the most promising news of all is the fact that, since trich has come out of the closet, more people have been able to come forward and seek treatment. In the past, sufferers were as likely to seek help from dermatologists as psychiatrists because of the shame of feeling "crazy”, or out of control. Although many individuals with trich continue to describe profound feelings of shame, hopelessness, depression and embarrassment, more and more also describe a sense of community and universality which has been the direct result of better education and treatment options. Each media effort about trich education results in a deluge of requests for more information.

How---And When---Does It Get Started?

As noted above, people frequently begin to start compulsive hair pulling at 12 or 13 years of age. However, it often starts earlier, as in Linda’s case, as well as later, even early adulthood.

Often, a stressful event is associated with the onset of trich. In some cases, however, there is no clear precipitant. Whether stress is a cause or a coincidence of the onset is not known. The hormonal changes associated with adolescence may also trigger the onset, as suggested by the fact that the disorder typically begins in adolescence. Over months and years, there may be periods of lessening or even disappearance of the disorder. Probably, relapses tend to occur with subsequent, stressful events in the sufferer’s life.

What Is The Cause?

There is no certain cause. It may well be that there are a combination of factors—such as a genetic predisposition, and an aggravation by stress or circumstances—as is the case in many illnesses. It may be that the problem is heterogeneous, i.e., trich could be a symptom caused by different factors in different people, just as a cough can be caused by a number of different medical problems. More research is needed. Currently, however, the most popular way of looking at trichotillomania is as a medical illness. One biological theory is that there is a disruption in the system that involves one of the chemical messengers between nerve cells in certain parts of the brain.

Is Trich Related To Other Illnesses Or Disorders?

Many people with trich also describe obsessive-compulsive behavior such as checking or counting. There are enough similarities between those with trich and those with Obsessive Compulsive Disorder, OCD, that some consider trich a subtype, or variant, of OCD. The fact that the two problems tend to occur in the same families strengthens this possibility. In addition, medications used to treat OCD are sometimes helpful in the treatment of trich. Tourette syndrome, a disorder that is characterized by tics, repetitive movements and utterances, also tends to run in the same families, which have OCD and trich sufferers.

Depression is a frequent by-product of trich sufferers. There may be a direct neuro-biochemical relationship, or the depression may be secondary to the low self-esteem, which occurs with hair pulling.

What Is The Treatment For Trich?

Treatment of trichotillomania is generally considered to be empirical; that is, different treatments may need to be attempted before finding one that works. To date, the two types of treatments which have been researched and which have been found to be effective are behavioral therapy and medications.

Behavioral therapy teaches the trich sufferer to use a structured method to keep track of symptoms and associated behaviors. This increases awareness of pulling, and teaches the individual incompatible behaviors and other techniques designed to reverse the habit of pulling. Some OCD studies have indicated that behavioral treatment can actually change the biological functioning of the brain.

Medications have, however, received the most research attention in the treatment of trich. Some research indications that symptoms are likely to return when one ceases using medication, unless one also uses behavioral techniques. Hence, the most effective treatment may well be a combination treatment approach; behavioral techniques and medication. Some of the medications currently being used include: Prozac, Zoloft, Anafranil, Lithobid and Eskalith, Luvox, Paxil and Depakote.

Group psychotherapy can be enormously helpful. Often, feelings of isolation and self-loathing are reduced as soon as the sufferer realizes that she is not the only one who has this strange compulsion. Even when behavioral and medical treatment is effective in stopping the pulling, psychological complications may persist, and require healing through the psychotherapeutic process. Groups are an especially powerful method of relieving the shame and isolation that generally accompanies this illness.

How Can I Get More Information, And Learn About My local Resources?

Contact:

  1. The Trichtillomania Learning Center, Inc.
    1215 Mission Street
    Santa Cruz, CA 95060
    (831) 457-1004
    FAX: (831) 426-4383

    The Center is staffed on Monday, Tuesday and Wednesday from 9:00 a.m. to 3:00 p.m. During this time, telephone calls are answered and information is provided. The Center provides possible support contacts, treatment referrals and a chance to talk.

    The Center also publishes a quarterly newsletter, In Touch, which includes letters and articles by members of the growing trich community. For a contribution of $15.00 the Center will mail you a comprehensive information packet.

  2. The Obsessive-Compulsive Foundation: (203) 878-5669

    This Foundation maintains a large, national referral list, organized by states, of practitioners who treat OCD. Although these specialists may or may not sub-specialize in the treatment of trich, they can probably refer you to specialists in your area.

  3. The Association for the Advancement of Behavior Therapy (AABT): (212) 647-1890

    Again, practitioners may sub-specialize in the treatment of trich, or they can refer you to someone who does.

Summary

Trichotillomania is a condition that is characterized by compulsive hair pulling. Because of the research and attention given to the treatment of Obsessive Compulsive Disorder over the past several years, this condition has begun to receive attention, as well. Although the disorder generally has its onset in adolescence, it may be earlier or later. People who pull invariably describe feelings of shame and even self-loathing. It is most often a tremendous relief to learn that there are other sufferers.

Research to date has focused primarily on the use of medication. Some of the same medications that work for those with OCD also work for trich sufferers. There has also been considerable focus on behavioral therapy as a possible key to long lasting relief from pulling. The Trichotillomania Learning Center, Inc. provides a wealth of information about this condition, and how to get help. Treatment is available, although you may have to do some searching, depending on the area in which you live.




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