Trichotillomania

Trichotillomania (TTM), or "trich" as it is commonly known, is an impulse control disorder characterized by the repeated urge to pull out scalp hair, eyelashes, facial hair, nose hair, pubic hair, eyebrows or other body hair, resulting in noticeable bald patches. Trichotillomania is classified in the DSM-IV as an impulse control disorder, but there are still questions about how it should be classified. It may seem, at times, to resemble a habit, an addiction, a tic disorder or an obsessive-compulsive disorder. Due to social implications the disorder is often unreported and it is difficult to accurately predict prevalence of trichotillomania; 2.5 million in the U.S. may have TTM, with a 1% prevalence rate.^[1]

TTM seems to strike most frequently in the pre- or early adolescent years. The typical first-time hair puller is 12 years old, although TTM has affected people as young as one and as old as seventy. It is thought that ninety percent of those with TTM are women, but research is inconclusive and it may simply be the case that men are less likely to seek treatment and can more easily hide their symptoms. A form of TTM that affects very young children appears to occur in males and females at an equal rate and seems to be more benign in nature.

The name derives from Greek tricho- (hair) plus mania.

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Characteristics

Individuals with trichotillomania can live relatively normal lives; however, they may have bald spots on their head, among their eyelashes, pubic hair, or brows. An additional psychological effect can be low self-esteem, often associated with being shunned by peers and the fear of socializing due to appearance and negative attention they may receive. Some people with TTM wear hats, wigs or style their hair in an effort to avoid such attention. There seems to be a strong stress-related component. In low-stress environments, some exhibit no symptoms (known as 'pulling') whatsoever. This 'pulling' often resumes upon leaving this environment.^[2]

Many clinicians classify TTM as a habit behavior, in the same family as nail biting (onychophagia) or compulsive skin picking (dermatillomania). These disorders are a cross between mental disorders, such as obsessive compulsive disorder (OCD) because the sight or feel of a body part causes the individual anxiety, and physical disorders such as stereotypic movement disorder because the person performs repetitive movements without being bothered by or completely aware of them. The current classification of trich as an impulse disorder with pyromania, pathological gambling and kleptomania, has been called into question as inadequate and in need of revision.^[3] One study showed that individuals with TTM have decreased cerebellar volume.^[4] Like people with other OCD-related disorders (for example, body dysmorphic disorder, impulse control disorder, kleptomania, Tourette syndrome), people with TTM have a reduced ability to transport serotonin at the presynaptic level.^[5] Anxiety, depression and OCD are more frequently encountered in people with TTM.^[6] People with TTM may also eat/chew the roots of the hair that they pull, referred to as trichophagia. In extreme cases this can lead to Rapunzel syndrome, and even death.^[7][8][9] Some individuals with TTM may feel they are the only person with this problem due to low rates of reportage.^[10]

Treatment

Trichotillomania is a chronic problem; although one can recover from it, there is currently no specific cure, although OCD medications are highly effective.^{[citation needed]} It can be stubborn, but with proper treatment and persistence, picking and/or pulling hairs can be greatly reduced and even brought under control (often called "hibernation").

Habit Reversal Training or HRT, has been shown to be a successful adjunct to pharmacotherapy as a way to treat TTM.^[11] Many patients who pull their hair don’t realize that they are doing this; it is a conditioned response.^{[citation needed]} With Habit Reversal Training, doctors train the individual to learn to recognize their impulse to pull and also teach them to redirect this impulse. As a part of the behavioral record-keeping component of HRT, patients are often instructed to keep a journal of their hair-pulling episodes. They may be asked to record the date, time, location, and number of hairs pulled, as well what they are thinking or feeling at the time. This can help the patient learn to identify situations where they commonly pull out their hair and develop strategies for avoiding episodes.

Selective serotonin reuptake inhibitors are effective in the treatment of obsessive-compulsive disorder and are commonly used in the treatment of trichotillomania. Clomipramine treatment was shown to significantly improve symptoms when tested in a doubled-blind study.^[12]

Fluoxetine and other similar drugs have limited usefulness in treating TTM, and can often have significant side effects.^[13] According to F. Penzel, antidepressants can even increase the severity of the TTM.^[3]

Epidemiology

Sixty-five percent of those afflicted are female.^[10] Evidence now points to a genetic predisposition.^[14][15]

The number of reported trichotillomania cases has increased throughout the years, possibly due to a reduced stigma around the condition. Estimates of the number of persons with TTM range from 1–3%^[16] up to 5%^[15] of the world's population. This prevalence data is based on the DSM-IV criteria which include reported increased tension preceding, and relief following, pulling, which has found to be inapplicable in some cases. Without the presence of these criteria the prevalence is much higher.^{[citation needed]}

See also

• Dermatillomania
• Onychophagia
• Dermatophagia

References

Further reading

• Keuthen, Stein, Christensen & Christenson (2001) Help for Hair Pullers: Understanding and Coping With Trichotillomania; New Harbinger Publications, ISBN 1-57224-232-9
• Parker (Ed.) (2004) Trichotillomania - A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References ; Icon Health Publications, ISBN 0-597-84664-2
• Stein (Ed.), Christenson (Ed.) & Hollander (Ed.) (1999) Trichotillomania; American Psychiatric Press, ISBN 0-88048-759-3