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 considered a rare condition.

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

Trichotillomania  Researchers have reported various prevalence rates depending on how strict a criteria they used to define hair-pulling.  If we consider a conservative 1%, and given a United States population approaching 300 million, we can estimate that over three 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 tension-release type 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 compelled 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. coarse).  Searching for hairs that don’t look right (i.e. color).  Feel compelled to make their hairline absolutely even.  Swallowing their hair.

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

Trichotillomania Children:  Occurs about equally for each gender in young children, then increasingly higher prevalence rate for girls as they age.  Average age of onset is about 13 years of age.  Children less often report tension and release, and more often report 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  Scalp 75%  Eyelashes 53%  Eyebrows 42%  Pubic area 17%  Beard/face 10%  Mustache 7%  Arm 10%,  Leg 7%  Chest 3%  Abdomen 2%. Body areas where pulling can occur along with associated percentages:

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.  However, it is thought that the experience of pain may act as an anxiety or tension reducer through satisfying the CNS need for stimulation.

Trichotillomania  Trichotillomania has also been thought to be refractory to treatment.  However with the emergence of cognitive behavioral therapy (CBT) and Habit Reversal Therapy (HRT), effective treatment for trichotillomania now exists. (Azrin & Nunn, 1973, 1977)

Trichotillomania  An important barrier to treatment is that those who pull their hair often experience extreme embarrassment and consequently do not 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 not participating in common social situations such as dating, for fear of being “found out”.

Trichotillomania  Trichotillomania is commonly associated with young children and adolescents, 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 then 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 often associated with the age of onset. It’s thought 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.

Trichotillomania  Certain genes may be associated with increased risk of hair-pulling.  A study by Duke University Medical Center found two mutations in genetic marker SLITRK1 in some family members with Trichotillomania and not in other family members without Trichotillomania.  This gene is thought to play an important role in the formation of neuronal connections. Mutations may disrupt the normal formation of neural connections. Molecular Psychiatry, October 2006

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?  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 Comorbidities% Depression57 Generalized Anxiety Disorder27 Simple Phobia19 Obsessive Compulsive Disorder13 Social Phobia11 Alcohol Abuse19 Substance Abuse16 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  Both external and internal factors affect hair pulling.  Five modalities are thought to work together to maintain hair pulling (Mansueto,1999): 1.Cognitive (thoughts and beliefs) 2.Affective (emotional state) 3.Motoric (physical actions) 4.Sensory (sight, touch, etc.) 5.External (environment)  Any or all of these factors may be pulling cues.

QUESTIONS