Trichotillomania: Compulsive hair-pulling

[David Baxter PhD]

Trichotillomania (hair-pulling disorder)
By Mayo Clinic Staff
Jan. 24, 2009

Trichotillomania (trik-o-til-o-MAY-ne-uh) is an irresistible urge to pull out hair from your scalp, eyebrows or other areas of your body. Hair pulling from the scalp often leaves patchy bald spots, which people with trichotillomania may go to great lengths to disguise.

Hair is often associated with beauty and vitality. That's why trichotillomania ? also called hair-pulling disorder, trich or pulling ? can be so emotionally painful for people with the condition.

For some people, trichotillomania may be mild and generally manageable. For others, the urge to pull hair is overwhelming. Some treatment options have helped many people reduce their pulling or stop entirely.

Symptoms
Signs and symptoms of trichotillomania include:

• Patchy bald areas on the scalp or other areas of your body
• Sparse or missing eyelashes or eyebrows
• Chewing or eating pulled-out hair
• Playing with pulled-out hair
• Rubbing pulled-out hair across your lips or face

Most people with trichotillomania pull hair from their scalp, especially the crown. This can lead to what's known as a Friar Tuck sign ? a balding pate surrounded by a fringe of hair. Eyebrows and eyelashes may also be pulled, as well as hair from the legs, arms, pubic area and other parts of the body. Most people pull hair with their fingers, but sometimes tools are used, such as tweezers, brushes and combs.

For some people, hair pulling is intentional and focused. They're aware that they're pulling their hair out and may even develop elaborate rituals for doing so. Other people pull their hair unconsciously.

Causes
Possible causes of trichotillomania are being researched, but like most disorders, it probably results from a combination of genetic and environmental factors:

• Genes. Mutations in a gene called SLITRK1 have been linked to trichotillomania as well as to Tourette syndrome, a neurological disorder that causes a person to make unusual movements and sounds.
• Neurochemical problems. Some studies suggest that abnormalities in the natural brain chemicals serotonin and dopamine may play a role in trichotillomania.

Risk factors
These factors may increase your risk of trichotillomania:

• Family history. Trichotillomania tends to run in families. If someone in your family engages in hair pulling, you're more likely to do it too.
• Age. Trichotillomania usually develops in adolescence ? most often around age 12 ? and is often a lifelong problem. It may be triggered initially by a stressful event, such as moving, changing schools or the death of a parent. It may also be triggered by hormonal changes that occur during the teen years. Children younger than age 5 can also be prone to hair pulling, but this is usually mild and goes away on its own without treatment. Young children tend to pull their hair at bedtime or nap time, whereas older children with trichotillomania pull their hair to relieve stress.
• Your sex. Although far more women than men are treated for trichotillomania, this may be because women are more likely to seek medical advice. In early childhood, boys and girls appear to be equally affected.
• Hair characteristics. Some people who pull out their hair say that they do so because they're bothered by hair that's a particular texture or color.
• Negative emotions. For many people with trichotillomania, hair pulling is a way of dealing with negative or uncomfortable feelings, such as stress, anxiety, tension, loneliness, fatigue or frustration. People who have trichotillomania may also have other emotional disorders, including depression, obsessive-compulsive disorder or eating disorders.
• Positive reinforcement. Some people find that rubbing pulled hair against their faces or lips feels good, or that pulling out hair feels satisfying. As a result, they continue to pull their hair to maintain these positive feelings.

Complications
Although it may not seem particularly serious, trichotillomania can have a great impact on your life. Complications include:

• Hair loss. Constant hair pulling can destroy hair follicles, so your hair doesn't regrow normally. You may also have abrasions and other damage to the skin on your scalp.
• Carpal tunnel syndrome. Carpal tunnel syndrome can result from the repetitive motions involved in habitual hair pulling.
• Hair balls. It's possible to develop a large, matted hairball ? technically called a trichobezoar ? when you eat hair that you've pulled from your scalp. Over a period of years, the hairball can cause weight loss, vomiting, intestinal obstruction and even death.
• Lifestyle restrictions. Some people learn to live with trichotillomania, while others may find their lives greatly changed by the disorder. They may experience shame and fear, avoiding swimming, haircuts and windy weather. They may wear wigs, style their hair to disguise bald patches or wear false eyelashes. Their relationships may suffer; some people may shy away from intimacy for fear that their condition will be discovered.
• Emotional distress. Many people with trichotillomania feel shame, humiliation and embarrassment and experience low self-esteem, depression and anxiety. Some consider suicide.

Preparing for your appointment
These suggestions may help make your appointment easier:

• Write down all the symptoms you're experiencing, even if they seem unrelated to hair pulling. Trichotillomania can cause both physical and psychological distress. Note which factors trigger your hair pulling, how you've tried to deal with the problem, and factors that make it better or worse.
• Write down key personal information, including any major stresses or recent life changes and whether hair pulling runs in your family.
• Make a list of all medications, as well as any vitamins or supplements, that you're taking. Include on your list the specific name and dose of these medications, and how long you've been taking them.

Create a list of questions ahead of your appointment so that you can make the most of your time with your doctor. For example:

• What might have caused me to develop this disorder?
• How do you diagnose this condition?
• Is this something that will go away on its own? Is there anything I can do on my own to improve my symptoms?
• What treatments do you recommend for this disorder?
• What if I can't afford therapy?
• If I decide to take medications, how long will it take for my symptoms to improve?
• What are the side effects of the medications you're recommending?
• How much improvement can I realistically expect if I follow your treatment plan?
• What if nothing helps?

In addition to your prepared questions, don't hesitate to ask questions during your appointment if you don't understand something your doctor says.

Tests and diagnosis
Your doctor will perform a thorough evaluation to determine if you have trichotillomania. He or she may need to take a biopsy of your hair or skin to try to pinpoint the problem. A biopsy that shows certain patterns of damage to your hair offers clues as to how the damage occurred. Your dermatologist or primary care doctor may also refer you to a mental health provider for further evaluation and treatment.

To be diagnosed with trichotillomania, you must meet criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association.

DSM criteria for the diagnosis of trichotillomania include:

• Repeatedly pulling out your hair, resulting in noticeable hair loss
• An increasing sense of tension before pulling, or when you try to resist pulling
• Pleasure or relief when pulling
• Your hair loss isn't attributed to another medical or dermatologic condition
• Hair pulling causes you significant distress

There is some debate among mental health providers ? and people with trichotillomania ? about these criteria, and they may change in the future.

Treatments and drugs
There's little research about treatment of trichotillomania because it's only been formally recognized as a disorder since the late 1980s. Right now, two main treatments stand out:

• Psychotherapy. Studies have shown that a form of psychotherapy called cognitive behavior therapy (CBT) is an effective treatment for trichotillomania. CBT teaches you to become more aware of pulling, and helps you learn to reverse the habit. You also learn what emotions and triggers are involved in hair pulling and how to substitute other behaviors instead. Sometimes elements of other therapies may be blended with CBT. For instance, acceptance and commitment therapy (ACT) helps people learn to accept their hair-pulling urges while at the same time teaching them how to avoid acting on their impulses.
• Medications. Doctors sometimes use antidepressants to treat trichotillomania. But these drugs can have troublesome side effects, and some people can't tolerate them. Medications work best when combined with cognitive behavior therapy, not when used as the sole treatment.

Relapses are common, even when treatment is successful initially.

Alternative medicine
A handful of small studies and a number of anecdotal reports suggest that hypnotherapy may be a successful initial treatment for trichotillomania as well as effective in preventing relapses.

Biofeedback, a technique that teaches you how to control or change certain physical responses, also may help. For instance, biofeedback can teach you how to reduce muscle tension in your face, forehead and neck without resorting to pulling. It can also help reduce anxiety and draw attention away from unwanted behaviors.

Coping and support
Many people with trichotillomania can learn to control it or to live an enjoyable life in spite of the disorder.

Here are some steps that may make dealing with trichotillomania easier:

• Be aware of situations that typically lead to pulling, such as watching television, driving or reading.
• Engage in activities that keep your hands busy ? knitting or sketching, for instance.
• Wear gloves on your hands to discourage pulling.
• Join a support group to connect with others who face the same challenges. Support groups aren't for everyone, but some people find them extremely valuable.
• Get expert advice on purchasing a wig or applying makeup if you're bothered by your hair loss.
• Keep your hair short and take good care of it.
• Ask family and friends to alert you when you're unconsciously pulling your hair.
• Learn stress-reduction techniques other than pulling.

 

[DrMikeMiller]

CBT IS the tx therapists would use. However, a study published three years ago showed that 56% of people who took N-acetylcystene (NAC), an amino acid, reported dramatic improvements. I've seen people take 25% of the dose studied (2400 mg) and report greatly decreased urges. Last weekend at Trichotillomania Conference in Chicago, some are speculating, based on several functional MRI studies, that CSP and Trich may be due to abnormalities in the brain's processing of glutamate, which is why NAC is so often helpful.

For more info on NAC, Body Focused Repetetive Behaviors (BFRBs), trained providers, a free info pack, and more, go to trich.org.

These are increasingly treatable conditions. DON'T GIVE UP!!!

 

[GDPR]

I guess I didn't realize there was a name for what I do, which is pulling hair out of my eyebrows. I occasionally get sores from it, but mostly I just have small bald spots.

If it isn't that big of a problem, then there's really no need to seek help for it, right?

 

[DrMikeMiller]

Pulling out one's eyebrows IS a big problem to many. Some, including men, rely on applying make-up to cover up where they pulled. I'd encourage checking out trich.org, if you haven't already done so, so you know what your options are. Ultimately, it is up to you to decide how big of a problem it is to yourself. Best wishes.