Trichotillomania

Trichotillomania (TTM) or "trich" is an impulse control disorder characterised by the repeated urge to pull out scalp hair, eyelashes, beard hair, nose hair, pubic hair, eyebrows or other body hair. It may be distantly related to obsessive-compulsive disorder, with which it shares some similarities.

Trichotillomania has been mentioned as a disorder in very early historical records. Onset generally occurs at puberty. There is a strong stress-related component, that is, in low-stress environments some stop pulling altogether. Pulling resumes when one leaves this environment.

80% of those afflicted are female.

Evidence is now starting to accumulate pointing to TTM as being genetic in origin (cf. Entrezgene (12-Aug-2006). Gene (UTF-8). NCBI.) Stimulant abuse has also been known to cause, or at least trigger episodes of, trichotillomania.

Most TTM sufferers live relatively normal lives, except for having bald spots on their head, among their eyelashes, or brows. Eyelashes have been reported to grow back thinner or in much lesser amounts.

An additional danger is from the low self-esteem which comes from being shunned by peers, and the fear of socializing due to appearance.

Many clinicians classify TTM as a mental disorder, though the classification is debatable. Some clinicians classify TTM as a form of obsessive-compulsive disorder. Some classify TTM as a form of self-harm. Some say it is neurobiological condition. Others say that TTM is no more a mental disorder than is any other habitual behavior, such as nail biting (onychophagia) or compulsive skin picking (dermatotillomania), while others say that it is a type of addiction. Many TTM sufferers have normal work and social lives; and TTM sufferers are not any more likely to have significant personality disorders than anyone else.

While there is no cure, there are some treatments. There have been a few small and not well-controlled clinical trials of drug treatment for trichotillomania, for example using such drugs as anafranil, prozac, and lithium. No one medication has been shown to have a particular advantage over any other, and drugs alone have not been shown to be particularly effective for many people. One should use care in choosing a therapist who has specific training, experience, and insight into the condition, lest one be overdiagnosed or overmedicated. Prozac and other similar drugs, which some professionals prescribe on a one-size-fits-all basis, tend to have limited usefulness in treating TTM, and can often have significant side effects.

A practice related to TTM is trichophagia, in which hairs are swallowed. In extreme cases, this can lead to the development of a hairball (trichobezoar) in the abdomen, a serious condition in humans; see Rapunzel syndrome. A trichobezoar can lead to intestinal blockage, which may only be relieved via surgery.

Treatment for Trichotillomania

Trichotillomania is unofficially classified by some as an Obsessive Compulsive Spectrum Disorder, although there is some question as to whether such a spectrum actually exists at all.

Habit Reversal Training

As of the present time, other than medication, the only treatment shown to have any documented effect on the symptoms of "trich" is a behavioral treatment known as Habit Reversal Training or HRT. This was developed by Dr. Nathan Azrin and colleagues and first published in 1973 in an article titled Habit Reversal: A Method of Eliminating Nervous Habits and Tics. The treatment focused on getting patients to increase their awareness of their behavior by recording and learning as much as possible about when, where, and how it occurred, and how to know ahead of time when it would occur. They were next trained to focus on, and reduce the tension that preceded the pulling. Finally, they were taught to perform a muscular movement that was inconspicuous, that was the opposite of, and incompatible with the behavior they wished to eliminate, and which would become an overlearned behavior.

Many patients who pull their hair don’t realize that they are doing this; it is a conditioned response. 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.

Trichotillomania is a chronic problem, meaning that although one can recover from it, there is currently no cure. It can be a stubborn problem, but with proper treatment and persistence, picking and or pulling hairs can be greatly reduced and even brought under control. Clinicians who are specialized in treating this problem are not always easy to find, but do have the techniques and training to bring about substantial improvement.

Medications

Selective serotonin reuptake inhibitors (SSRIs) are commonly used in the treatment of trichotillomania. Antidepressants have been shown to be effective in treating both Obsessive-Compulsive Disorder and trichotillomania. Cannabis has been known to relieve acute symptoms of trichotillomania, by inducing relaxation in the user, however its use as a long term treatment is not advised.

Stimulus Control Techniques

Stimulus Control is a well-known behavioral treatment that in the case of trichotillomania, seeks to help sufferers first identify, and then eliminate, avoid, or change the particular activities, environmental factors, states, or circumstances that trigger hair pulling. The goal is to consciously control these triggers (or stimuli or cues as they are also known) that lead to pulling, and to create new learned connections between the urge to pull, and new non-destructive behaviors. It is often combined with Habit Reversal Training, and utilizes the self-recorded information that is a part of that treatment.