TRICHOTILLOMANIA

BY: Danny Duke & Mary Keeley

What is Trichotillomania? Trichotillomania is a disorder characterized by the chronic compulsion of pulling out one’s own hair. The word trichotillomania is derived from the Greek thrix (trich), hair; tillein (tillo), to pull; and mania, madness or frenzy (mania). Trichotillomania has historically been thought of as a rare condition.

Trichotillomania However, a college survey completed by Christensen et al in 1991 found that 3.4% of college females and 1.5% of college males engaged in hair pulling behaviors. A similar survey of 700 fresh college students found that 11 % pulled their hair on a regular basis for other than cosmetic reasons. (Rothbaum, 1993)

Trichotillomania Surveys have reported many different prevalence rates depending on the how strict a criteria was used. Using the more conservative of these two examples and given a United States population approaching 300 million, we can estimate that over seven million people experience this condition in the U.S. alone.

Trichotillomania The manifestation of trichotillomania can be grouped into three subtypes: 1) A transient form that most often occurs in young children between 2-6 years of age. 2) A habit form wherein the individual pulls their hair in an unaware state, usually while engaged in sedentary activities.

Trichotillomania 3) A form akin to obsessive compulsive disorder. In this type the individual feels a compulsion to pull that often leads to seeking out and consciously pulling hair to relieve a building sense of tension or anxiety. In this last form the individual may feel a compulsion to engage in an associated ritual.

Trichotillomania Common rituals include: A need to extract an intact hair bulb. A need to bite or mince the hair or hair bulb. Tactile stimulation of lips or face with the hair shaft. A need to pull the hair in a particular manner. Placing, saving, or discarding hairs in a ritualistic way. Twirling, rolling, or examination of the hair. Searching for hairs that don’t feel right (i.e. too coarse). Searching for hairs that don’t look right (i.e. color). A compulsion to make their hairline absolutely even. Eating (swallowing) their hair And others.

Trichotillomania Children: Occurs about equally for each gender in young children, then increasingly more girls as they age. Average age of onset is about 12 years of age. Children less often report a mounting tension and release, while more often pulling during sedentary activities such as watching television, reading, and lying in bed before falling asleep. Children are more likely to pull hair from another person, pets, or dolls.

Trichotillomania Body areas where pulling can occur along with associated percentages: Mustache 7% Arm 10%, Leg 7% Chest 3% Abdomen 2%. Scalp 75% Eyelashes 53% Eyebrows 42% Pubic area 17% Beard/face 10%

Trichotillomania Trichophagy (injesting hair) can cause serious medical complications. Injesting hair can result in trichobezoars (hairballs) which can cause intestinal obstruction necessitating surgical removal. Teeth can become grooved due to the repeated sliding of hair shafts between them.

Trichotillomania Most report that pulling of hair does not cause pain. Some have thought that those who pull their hair may have a higher pain threshold. Some work in this area has found that they do not. In those that do experience pain it is thought that such pain may act as an anxiety or tension reducer through satisfying the CNS need for stimulation.

Trichotillomania Trichotillomania Trichotillomania has also been thought to be refractory to treatment. However with the emergence of cognitive behavioral therapy (CBT), effective treatment for trichotillomania now exists. Particularly when using the behavioral approach, habit reversal therapy (HRT; Azrin & Nunn, 1973, 1977).

Trichotillomania An important barrier to treatment is that those who pull their hair often experience extreme embarrassment, often failing to seek treatment. Most often they neither realize that effective treatments exist, nor do they realize that this condition is not uncommon.

Trichotillomania Many individuals with Trichotillomania will go to great lengths to hide the evidence of their condition. Wigs, elaborate hairstyles, creative cosmetics, hats, avoidance of water and wind, etc. Avoidance behaviors can take the form of avoiding social situations such as dating, for fear of being “found out”.

Trichotillomania Trichotillomania is commonly associated with young children and adolescents, having an average age of onset at about 12 years of age, yet it can begin in adulthood or even in the elderly. Trichotillomania is currently classified as an impulse control disorder, although some argue that it does not fit into this classification well.

Trichotillomania Why? What would cause a person to pull out their hair. Some theorize that hair pulling is an innate complex grooming behavior (complex motor program) that is triggered by stress. Hair pulling does have similar counterparts in animals (Moon-Fanelli et al., 1999) Psychogenic alopecia in cats. Acral lick dermatitis in dogs Psychogenic feather picking Flank biting in horses.

Trichotillomania Hair pulling tends to occur more frequently within families, suggesting it has biological, or hereditary origins. Hair pulling is thought to occur due to dysregulation of neurotransmitters, in particular, serotonin and dopamine. Neuroimaging shows that the frontal-basil ganglia pathway is of particular importance in hair pulling.

Trichotillomania Hair pulling may have behavioral origins. Thought to begin via a classical conditioning paradigm and subsequently maintained through operant conditioning principles. It is likely that several of these factors play a role in the emergence and maintenance of Trichotillomania.

Trichotillomania Puberty is associated with the age of onset. It is possible that neuroendocrine maturational changes may be related to the development of trichotillomania in some women. Premenstrual exacerbation of hair pulling symptoms has been shown in several studies, suggesting that hormonal variations, particularly gonadotropin levels may exacerbate some patient’s symptoms. Occasionally birth control pills have ameliorated symptoms.

DSM-IV Criteria Recurrent pulling out of one's hair resulting in noticeable hair loss. An increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior. Pleasure, gratification, or relief when pulling out the hair.

DSM-IV Criteria 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). The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

DSM-IV Criteria What is wrong with these criteria, based on the earlier description of trichotillomania symptoms?

DSM-IV Criteria What is wrong with these criteria, based on the earlier description of trichotillomania symptoms? Both an increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior, and pleasure, gratification, or relief when pulling out the hair are not present in about 40% of those who pull their hair.

DSM-IV Criteria These individuals still suffer clinically significant distress or impairment in social, occupational, or other important areas of functioning, which many believe should be the determining criteria.

Trichotillomania Comorbidity % Depression 57 Generalized Anxiety Disorder 27 Simple Phobia 19 Obsessive Compulsive Disorder 13 Social Phobia 11 Alcohol Abuse Substance Abuse 16 Christenson, 1995

Trichotillomania Other reported habits or rituals that seem to occur with greater frequency in those who engage in hair pulling: Nail biting Skin picking Thumb sucking Knuckle cracking Nose picking

Treatment Keys Both external and internal factors affect hair pulling. Five modalities are thought to work together to maintain hair pulling (Mansueto,1999): Cognitive (thoughts and beliefs) Affective (emotional state) Motoric (physical actions) Sensory (sight, touch, etc.) External (environment) Any or all of these factors may be in play.

Study Trichotillomania (TTM) is understudied. Most epidemiological data cited in the literature is derived from few, and mostly small studies. If we accept that habit based hair-pulling is an important subtype of TTM, then understanding its true prevalence is important to future revisions of diagnostic criteria. Further understanding of TTM will increase the efficacy of treatment. For example, TTM that is habit-based may respond differently to treatment than tension release (OCD related) type.

Study Understanding the prevalence of associated rituals will inform treatment. The prevalence of co-morbid symptoms such as depression, and anxiety are important to understand, both because they highlight the importance of this disorder, as well as to inform treatment. Understanding this disorder’s impact on self-esteem is important to patient treatment.

Measures Beck Depression Inventory (BDI). Center for Epidemiological Studies Depression scale (CES-D). State Trait Anxiety Inventory. Rosenberg Self-esteem scale. Trichotillomania version of the Y-BOCS. Trichotillomania specific questionnaire.

Preliminary Findings Presently: n = 132. 18.9% Male. Current hair pulling in 9.94% of sample. Past Pulling in 7.5%. Mean age of onset – 14.8 yrs Of those who pull: 11% are Male 69% are White, 13% Asian, 13% Hispanic, 7.5% African American, 7.5% Other.

Preliminary Findings 76.9% sometimes pull their hair in an unaware state. 23% know of a relative that pulls their hair. Average age of onset – 13.2 years. Pulling sites: Scalp – 61.5%, Eyebrows - 46%, Face - 23%, Legs – 15.4%, Pubic – 7.6%, Arms – 7.6%.  

Preliminary Findings Rituals: Drop hair to the floor - 38% Examine the root – 31% Must pull out the root – 23% Twist out the hair - 8% Pull hair because: It doesn’t look right - 23% Feels coarse - 23% Is straight - 23% It doesn’t feel right - 15% Wrong Color - 15% Is curly - 15%

Preliminary Findings Depression: Average score on the CES-D for normal population is 9.25, range 0-60. Standard cut-off score of 16 is typically used to distinguish clinically depressed from non-depressed individuals (Comstock & Helsing, 1976). Range in this population, 3-29. Mean score 16.75. Fifty-three percent of scores exceeded the cut-off score of 16. On the BDI, scores ranged from 3-26 with a mean score of 11.23. 53% of scores exceeded 10.

QUESTIONS