Trichotillomania (Hair-Pulling Disorder)

What is Trichotillomania (Hair-Pulling Disorder)?

Obsessive-compulsive disorders (OCD) represent a range of different disorders linked by a common thread of recurring thoughts and actions. In simpler terms, OCD often involves recurring thoughts, referred to as obsessions, or repetitive actions, known as compulsions. One form of OCD is trichotillomania, otherwise known as the hair-pulling disorder. This condition, first recognized in ancient Greece and named in the late 18th century, involves people pulling out their hair from anywhere on their body, leading to noticeable hair loss.

However, this hair loss isn’t due to any health issue, but is the direct result of action taken by the patient. Since trichotillomania can significantly alter a person’s appearance, it often attracts societal judgement, which can lead patients to avoid reporting it. Often, people with this disorder try to hide their condition and may initially seek help from a skin specialist, or dermatologist, rather than or before seeing a psychiatrist.

What Causes Trichotillomania (Hair-Pulling Disorder)?

Trichotillomania is a condition connected to Obsessive Compulsive Disorder (OCD), rooted mainly in anxiety disorders. It’s believed to be inherited, as evidence has been found in genetic studies. Some research has also discovered brain structure changes linked to Trichotillomania. However, it’s important to note that research in this area isn’t very extensive and conclusive yet.

More recent research has focused on certain parts of the brain, particularly the grey and white areas. It’s been found that people diagnosed with Trichotillomania may have a reduction in the quality of white matter. This is especially seen in areas related to actions and emotions such as the anterior cingulate, the pre-supplementary motor area, and the right and left temporal cortex. It has also been noted that certain brain changes may become even more severe with longer and severe cases of the condition. Some imaging tests like PET and SPECT have shown increased metabolic rates in the cerebellum and the right parietal cortex, and decreased blood flow in the temporal lobes.

When it comes to understanding the chemicals in the brain related to Trichotillomania, researchers have seen a relationship with a specific brain receptor called serotonin 2A receptor. Most of this research is drawn from observing how patients react to therapies that adjust these brain chemicals. For instance, therapies involving Selective Serotonin Reuptake Inhibitors (SSRIs, a type of antidepressant) have shown mixed results. Other brain chemicals like dopamine also seem involved. Some studies have shown improvements with medications like olanzapine and aripiprazole, as well as with an antidepressant called clomipramine.

Besides these biological factors, Trichotillomania is also influenced by psychological aspects. Many patients report going through a stressful situation before they started pulling their hair. Some also say that they felt bored before showing this behavior. This points to a pattern where negative emotions like stress or boredom leads to hair-pulling, which gives relief, reinforcing the hair-pulling behavior. Some also connect Trichotillomania to depression symptoms, since some people respond to SSRI treatment. However, it’s difficult to point out one specific psychological trigger for everyone with this condition. Currently, the main approach to treat Trichotillomania is through behavioral therapy.

Risk Factors and Frequency for Trichotillomania (Hair-Pulling Disorder)

Trichotillomania (TTM), a disorder where people often pull out their own hair, may affect as many as 3.5% of individuals starting in their teenage years. It’s important to note that not all of these adolescents meet the exact criteria for TTM as outlined by a major psychiatric handbook (DSM-V), but they do exhibit some of its symptoms. The disorder is more often reported in females, with the reported ratio being approximately 9 to 1, female to male. However, it’s thought that the stigma associated with TTM may lead to less reporting overall.

TTM can start affecting individuals in their teenage years.
As many as 3.5% people might experience symptoms of TTM in their lifetime.
These individuals might not fit the exact diagnosis guidelines, but still experience some symptoms of TTM.
The disorder is more commonly reported in females, at a ratio of about 9 to 1 compared to males.
However, the stigma of TTM might cause underreporting of the disorder in general.

Signs and Symptoms of Trichotillomania (Hair-Pulling Disorder)

When someone seeks help for a mental health issue, the starting point is usually an introductory diagnostic interview. Certain established techniques, which have been developed from older standards, can be used to assess if they have Trichotillomania (TTM), a condition where a person feels compelled to pull their hair out. However, no such method has been set for the current DSM-V psychiatric manual.

According to the DSM-V manual, there are five essential criteria that have to be met for a TTM diagnosis:

Criteria A: The person is pulling out hair from any part of their body, whether from a specific area or widely distributed, resulting in areas of thinning hair or bald patches.
Criteria B: The person has made attempts to stop or cut down on the hair-pulling.
Criteria C: The hair-pulling causes them considerable distress or interferes significantly with at least one aspect of their life.
Criteria D: There isn’t another medical condition (like alopecia areata or tinea capitis) causing the hair loss.
Criteria E: The hair pulling can’t be better understood as a symptom of some other mental disorder.

During the interview, it’s also important to screen for other mental health symptoms.

For patients who see healthcare practitioners who aren’t psychiatrists, the examination should still include careful history-taking and physical examination. Hiding hair loss or the habit of pulling out hair is not rare due to the stigma associated with this behavior. This reluctance could cause patients to mention other psychiatric symptoms or even digestive complaints, possibly from accumulation in the stomach or intestines called trichobezoar.

The physical check-up should pay special attention to areas of hair loss, which might only be slightly visible in some cases. There could be hair loss on any body part where hair grows, and the spots could have hair of different lengths and stages of regrowth. If any skin rash or other changes are noted, they could indicate another diagnosis. To evaluate if hair can regrow, the skin at the hair roots has to be checked for scarring. The examination should also look for signs of possible trichobezoar, such as abdominal masses, pain, or blockages in the digestive tract.

Testing for Trichotillomania (Hair-Pulling Disorder)

If your doctor suspects you have trichotillomania (TTM), a condition where a person can’t resist the urge to pull out their hair, they usually diagnose it through an examination and learning about your medical history. Although it’s not necessary, a punch biopsy (a small sample taken from the scalp) can assist in the diagnosis. The doctor can look at your hair under a microscope, which often shows signs of hair regrowing in the area.

The level of hair loss can help determine the severity of your condition. Doctors sometimes use photographs as a way to track changes over time and measure how well a treatment is working.

Your doctor may also evaluate the behavioral aspects of hair-pulling, such as identifying triggers that lead to the pulling. These triggers can be either external, like certain situations, or internal, like emotions. Observing the consequences of hair-pulling, like feelings of guilt, poor self-image, or feeling relief from bad emotions, can provide additional information to guide treatment. Though it’s not required for diagnosis, this information can help them create the best treatment plan for you.

Your doctor could also use various rating scales to assess the condition. These scales are not necessary for diagnosis, but can provide a more detailed view of the situation. Some of these scales include: the NIMH trichotillomania scale; Yale-Brown obsessive-compulsive scale-trichotillomania; psychiatric institute trichotillomania scale; Massachusetts General Hospital hair-pulling scale; trichotillomania scale for children; and Milwaukee inventory for styles of trichotillomania (available in adult and child versions).

Treatment Options for Trichotillomania (Hair-Pulling Disorder)

Trichotillomania is a complex condition where you have an irresistible urge to pull out your hair. It often involves a team of healthcare professionals, including your primary care physician, a skin doctor (dermatologist), a mental health doctor (psychiatrist), and a licensed clinical psychologist. Your treatment would likely include therapy techniques and potentially some medications.

Currently, the most studied therapy techniques for trichotillomania are cognitive behavioral therapy (CBT) and habit reversal training. CBT helps you understand and then change the thoughts leading to your hair-pulling. Habit reversal training is a part of CBT and focuses on breaking the link between stressful situations (like group activities at work) and the urge to pull your hair. It is shown to be an effective and low-risk treatment for this condition.

Habit reversal therapy consists of three parts; awareness, a competing response, and social support. First, you are trained to recognize when you start pulling hair and what situations or feelings trigger it. Once you’ve got a good grasp of that, you’re taught alternative behaviors to do instead of pulling your hair. Lastly, encouraging friends or family can significantly improve the outcomes by praising you when you successfully use the new techniques and reminding you when you forget.

Research also indicates that specific medications may be helpful in treating trichotillomania. Selective serotonin reuptake inhibitors (a type of antidepressant) may have some positive effects, especially when combined with therapy. Also, some medicines typically used for psychiatric conditions (such as olanzapine, aripiprazole, and quetiapine) have had preliminary positive results in a few studies, but more research is needed to confirm these effects. Another medicine, clomipramine, from the antidepressant medication class called tricyclics, has also shown promising results. Finally, though not yet proven by large-scale studies, a supplement called N-acetylcysteine has demonstrated positive results in some small case studies.

When diagnosing hair loss, doctors need to consider a list of different possible causes aside from the usual suspects. Possible causes can include:

Traction alopecia: a type of hair loss caused by pulling on the hair
Male pattern baldness: a common type of hair loss in men
Pressure alopecia: hair loss caused by constant pressure on the scalp
Alopecia areata: a condition in which hair falls out in patches
Tinea capitis: a fungal infection of the scalp
Short-term habit: certain habits like rough handling could lead to hair loss
Obsessive-compulsive disorder: sometimes, people with OCD might pull out their hair
And other illnesses like cancer, lupus, having an underactive thyroid (hypothyroidism), and self-induced hair loss (factitious disorder).

It’s important for the treating doctor to rule out these possibilities before confirming on a diagnosis.

What to expect with Trichotillomania (Hair-Pulling Disorder)

It’s far more beneficial for everyone if an illness is identified and treated as early as possible. Typically, the sooner the disease is caught and treatment is started, the better the outlook. Plus, individuals who fall sick at a younger age generally have a better chance of recovery.

Possible Complications When Diagnosed with Trichotillomania (Hair-Pulling Disorder)

The illness can result in long-term complications, with one of the most common being permanent hair loss. This is primarily seen in people who have a habit of pulling out their hair and continues this habit into adulthood. People who ingest the hair, either entirely or parts of it, risk developing a trichobezoar (hairball in the stomach).

Common Long-Term Complications:

Permanent hair loss
Trichobezoar

Preventing Trichotillomania (Hair-Pulling Disorder)

It’s beneficial for patients to steer clear of stress-causing situations and anything that triggers their urge to pull out hair. For those dealing with Trichotillomania (TTM), a condition where people feel compelled to pull out their hair, certain activities tend to be linked with an increase in hair-pulling episodes. Activities such as driving, reading, handling paperwork, watching television, and talking on the phone commonly instigate such episodes.

Therefore, it’s highly recommended for these individuals to limit the time they spend on these activities whenever they can. Additionally, increasing the amount of physical activity they engage in may also help to manage this hair-pulling behavior. By staying physically active, not only do patients distract themselves from hair-pulling but also maintain their overall well-being.

Frequently asked questions

The prognosis for Trichotillomania (Hair-Pulling Disorder) is generally better if the illness is identified and treated early. Individuals who develop the disorder at a younger age have a better chance of recovery.

Trichotillomania (Hair-Pulling Disorder) can be inherited and is often connected to Obsessive Compulsive Disorder (OCD) and anxiety disorders. It can also be influenced by psychological factors such as stress and boredom.

Signs and symptoms of Trichotillomania (Hair-Pulling Disorder) include: - Pulling out hair from any part of the body, resulting in areas of thinning hair or bald patches. - Attempts to stop or cut down on the hair-pulling. - Hair-pulling causing considerable distress or interfering significantly with at least one aspect of life. - Absence of another medical condition causing the hair loss. - Hair pulling not being better understood as a symptom of another mental disorder. In addition to these criteria, it is important to screen for other mental health symptoms during the diagnostic interview. Patients may hide hair loss or the habit of pulling out hair due to the associated stigma, which could lead to the manifestation of other psychiatric symptoms or even digestive complaints like trichobezoar. During the physical examination, special attention should be given to areas of hair loss, which may only be slightly visible in some cases. Hair loss can occur on any body part where hair grows, and the spots may have hair of different lengths and stages of regrowth. Any skin rash or other changes noted during the examination could indicate another diagnosis. The examination should also check for signs of possible trichobezoar, such as abdominal masses, pain, or blockages in the digestive tract. The presence of scarring at the hair roots can help evaluate if hair can regrow.

The types of tests that may be ordered to properly diagnose Trichotillomania (Hair-Pulling Disorder) include: 1. Examination and medical history: The doctor will examine the patient and learn about their medical history to make a preliminary diagnosis. 2. Punch biopsy: A small sample taken from the scalp can assist in the diagnosis by examining the hair under a microscope, which may show signs of hair regrowth in the affected area. 3. Photographs: Doctors may use photographs to track changes over time and measure the effectiveness of treatment. 4. Behavioral evaluation: The doctor may evaluate the behavioral aspects of hair-pulling, such as identifying triggers and observing the consequences of hair-pulling, to gather additional information for treatment planning. 5. Rating scales: Various rating scales, such as the NIMH trichotillomania scale and Yale-Brown obsessive-compulsive scale-trichotillomania, can provide a more detailed view of the condition but are not necessary for diagnosis.

The doctor needs to rule out the following conditions when diagnosing Trichotillomania (Hair-Pulling Disorder): - Traction alopecia - Male pattern baldness - Pressure alopecia - Alopecia areata - Tinea capitis - Short-term habit - Obsessive-compulsive disorder - Other illnesses like cancer, lupus, having an underactive thyroid (hypothyroidism), and self-induced hair loss (factitious disorder)

When treating Trichotillomania (Hair-Pulling Disorder), there are potential side effects that can occur. These include: - Permanent hair loss: People who have a habit of pulling out their hair and continue this habit into adulthood may experience permanent hair loss. - Trichobezoar: Ingesting hair, either entirely or in parts, can lead to the development of a trichobezoar, which is a hairball in the stomach.

A team of healthcare professionals, including a primary care physician, a dermatologist, a psychiatrist, and a licensed clinical psychologist, should be involved in the treatment of Trichotillomania (Hair-Pulling Disorder).

As many as 3.5% people might experience symptoms of TTM in their lifetime.

Trichotillomania (Hair-Pulling Disorder) is typically treated through a combination of therapy techniques and potentially some medications. The most studied therapy techniques for this condition are cognitive behavioral therapy (CBT) and habit reversal training. CBT helps individuals understand and change the thoughts leading to hair-pulling, while habit reversal training focuses on breaking the link between stressful situations and the urge to pull hair. This therapy consists of three parts: awareness, a competing response, and social support. Medications such as selective serotonin reuptake inhibitors and certain psychiatric medicines have shown positive effects when combined with therapy. Additionally, clomipramine, a tricyclic antidepressant, and N-acetylcysteine, a supplement, have demonstrated promising results in some studies.

Trichotillomania, also known as the hair-pulling disorder, is a form of obsessive-compulsive disorder (OCD) characterized by the repetitive action of pulling out one's hair from any part of the body, resulting in noticeable hair loss.

Mental Health Obsessive Compulsive Disorder