Trichotillomania is a disorder in which the sufferer experiences the irresistible urge to pull out the hair on the scalp and potentially other body sites. The severity of the urges varies amongst sufferers. For some, the urges are persistent, intrusive and compulsive and can severely affect their ability to function. For others, the urges are less severe and can be managed. It is difficult to determine exactly how many people are affected by trichotillomania, because many sufferers do not seek help for the condition. It is estimated that up to 2% of the population may suffer from the disorder. More women than men seek medical help.
Risk Factors
Several risk factors for the development of trichotillomania have been identified. These risk factors include:
- Anxiety, frustration, tension and stress are significant risk factors. For sufferers, pulling out hair can be a way to relieve these emotions. By alleviating these feelings, the behaviour of pulling out the hair acts as a form of positive reinforcement, which encourages the hair-pulling to continue. Sufferers of trichotillomania frequently have comorbidities such as obsessive-compulsive disorder, anxiety disorders and depression.
- Many cases of trichotillomania begin at puberty, generally between the ages of 11 and 13.
- There is evidence to suggest that there is a genetic (inherited) component to trichotillomania. Those with parents, siblings and other close relatives with the disorder are at a heightened risk of developing the disorder.
Diagnostic Criteria
Trichotillomania is a disorder relating to the inability to control impulses, much like kleptomania (an inability to control the urge to steal items). It is categorised in the DSM-V (Diagnostic and Statistical Manual of Mental Disorders, Edition 5- American Psychiatric Association), as an obsessive-compulsive related disorder. The diagnostic criteria outlined in the DSM-5 include:
- Loss of hair caused by the individual pulling out their own hair
- Frequent, repeated attempts by the patient to limit or cease the problem behaviour
- There is no underlying dermatological or other disorder to explain the hair loss
- The pulling of hair does not fit better with another psychiatric illness, such as body dysmorphic disorder
- The pulling of hair impacts on the individual’s daily functioning, such as socialisation and the ability to work
Signs & Symptoms
Patients suffering from trichotillomania can present in different ways. The most obvious sign of trichotillomania is hair loss that is due to the compulsive pulling of hair. It is not uncommon for sufferers to deny acts of hair pulling and may present with unexplained hair loss. Although the condition has an underlying psychiatric aetiology, patients often present to dermatologists. It may take some time to exclude other possible causes to reach a diagnosis of trichotillomania. Children, in particular, will deny that they are pulling their hair. Friends and family often do not realise that the sufferer is pulling their own hair, as the behaviour tends to occur in private. Patients may not be aware that they are even pulling their hair initially; some sufferers are in a daze whilst performing the behaviour. Hair loss may not only be from the scalp, other regions that may be affected include the underarms, limbs, eyebrows and pubic area.
Stress and anxiety are also common symptoms and are often an exacerbating factor. The behaviour of hair-pulling is a means of alleviating stress and tension in sufferers; and by relieving these unpleasant feelings, the behaviour is positively reinforced (it acts somewhat like a reward). The sufferer thus becomes conditioned to repeat the behaviour in times of stress and anxiety. Although the behaviour is commonly associated with stress, it can still occur when the individual is relaxed. As the hair-pulling is often performed in private, some sufferers may begin to avoid social situations and activities to avoid the embarrassment and shame of pulling out their hair in front of others. Such situations may also be avoided if the individual is concerned about their appearance if the hair loss is affecting their self-esteem and body image.
In some cases, sufferers of trichotillomania may pull hair off other people, animals and objects, such as rugs. Children suffering from the condition may pull the hair out of dolls and toys. This is not observed in all people suffering from the condition. Sufferers may also have other compulsive, body-focused behaviours such as biting their nails or picking at their skin.
The pattern of hair loss in trichotillomania sufferers differs from other forms of alopecia. The affected areas of hair are mainly comprised of short, rough bristles of actively growing hairs (anagen hairs). The patches of hair loss are also often asymmetrical. The anagen hairs in the affected areas tend to be of varying lengths. Any hairs in the resting phase of growth (telogen hairs) easily fall out. Often, the edges of the scalp are spared. Sufferers of trichotillomania may style their hair to cover any bald patches.
Patients may also present with other physical symptoms. Some patients complain of an itchy scalp. Others may present with gastrointestinal complaints, such as constipation, nausea, vomiting and in severe cases, bowel obstruction. This is because swallowing of the hair can lead to the formation of hair casts/hair balls (known as trichobezoar) within the gastrointestinal tract that can block part of the tract and produce the aforementioned symptoms.
Treatment
Cognitive behaviour therapy is an important element of treatment for the disorder. Cognitive behaviour therapy is a widely used treatment in psychiatry that is successful in the treatment of a range of disorders, including depression, anxiety and phobias, to name a few. The aim of cognitive behaviour therapy is to change underlying maladaptive thoughts and behaviours. By restructuring these thoughts and behaviours, patients are trained to find alternative ways to cope with their stressors, rather than pulling at their hair. It is also important to understand other psychosocial factors which are contributing to trichotillomania and to find a method to resolve these to aid recovery.
There are also medications which can be used in the treatment of trichotillomania. Fluoxetine, olanzapine and clomipramine are medications which have been successful in reducing hair-pulling behaviours. Fluoxetine is a medication which is more commonly known by the brand name Prozac. It is a serotonin reuptake inhibitor that is used in the treatment of depression, anxiety and obsessive-compulsive disorders. Olanzapine is an atypical anti-psychotic agent that is used in the management of schizophrenia and bipolar disorder. Clomipramine is a tricyclic antidepressant that is used in the treatment of obsessive-compulsive disorder, major depression and panic disorder. In patients who also suffer from attention deficit hyperactivity disorder, methylphenidate is also somewhat effective. Methylphenidate is more commonly known and Ritalin and it is a drug that acts by stimulating the central nervous system.