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Trichotillomania (Hair-Pulling Disorder): Symptoms and Treatment

Trichotillomania (Hair-Pulling Disorder)

What is Trichotillomania?

The main feature of trichotillomania (hair-pulling disorder) is the repeated pulling out of one’s own hair. They do not do this for cosmetic reasons, but because of an irresistible urge to pull out their hair. This happens to such a degree that there is hair loss and the person can feel distressed. A brief feeling of relief can occur as you pull out the hair. Hair pulling most commonly occurs on the head and around the eyes, though it can occur anywhere. Hair pulling can occur in brief episodes throughout the day or sometimes for several hours.

The disorder may run in families. It is common in those with obsessive compulsive disorder (OCD). Anxiety can trigger trichotillomania episodes. People usually admit that they have the problem. Many people put the hair in their mouths after pulling it. Examination reveals broken hairs.

Trichotillomania affects 1 to 4 percent of people. Women are about 4 times more likely to be affected than men. It most commonly starts in childhood or adolescence.

The symptoms of trichotillomania are manageable in some people. But for others, the symptoms can be overwhelming. The course of the disorder is chronic, though some can have waxing and waning of symptoms. Treatment is mainly with habit reversal training. Clomipramine can be helpful.

Symptoms of Trichotillomania

The primary symptom is repeated pulling of one’s own hair. The most common areas of hair pulling are the head, eyebrows, and eyelids. Less commonly it can occur in facial, pubic, and peri-rectal regions.

Other symptoms can include:
  • They usually do hair pulling in private
  • It can involve multiple sites on the body
  • Exhibit hair of differing lengths; hairs may be with blunt ends, some new growth with tapered ends, some broken mid-shaft, or some uneven stubble
  • Repeated failed attempts to stop pulling the hair
  • Hair pulling can be conscious and focused or automatic
  • Feeling of tension before or when trying to resist pulling
  • Feel pleasure or relief after pulling
  • Obvious hair loss
  • Playing with, biting, chewing, or eating pulled hair
  • Hair balls in the stomach (trichobezoars) can form if they swallow the pulled out hairs, posing a risk of bowel obstruction
  • Rubbing pulled hair across the face or skin
  • Attempt to camouflage bald spots with hats, makeup, wigs, clothing, etc.
  • They may have other repetitive behaviors, such as skin picking, nail biting, and lip chewing
  • Distress and impairment in social, occupational, and/or other areas of functioning
  • It can lead to strained relationships with family members and friends
  • They may avoid activities and social situations which may lead them to being “discovered”
  • Physical effects such as severe itching, infection, and repetitive motion injuries to the muscles or joints could result

Causes of Trichotillomania

We do not know the cause of trichotillomania. The following increase the risk of trichotillomania:
  • Family history: Genetics may play a role because it runs in families.
  • Presence of other mental disorders: Anxiety, depression, or OCD.
  • Stress: Exposure to severe stress can trigger it in some people.

Diagnosis of Trichotillomania

DSM-5 lists the following diagnostic criteria for trichotillomania:
  • Repeated pulling out of one’s hair, resulting in hair loss.
  • Repeated attempts to reduce or stop hair pulling.
  • Clinically significant distress or impairment in social, occupational, and/or other important areas of functioning.
  • Not because of another medical condition (e.g., a dermatological condition).
  • Not better explained by the symptoms of another mental disorder (e.g., body dysmorphic disorder).

Treatment of Trichotillomania

Conservative management helps children. In young adults, behavior modification programs can be useful, but referrals to psychologists or psychiatrists may be necessary sometimes. When trichotillomania begins in adulthood, other mental disorders can also be present. Treating these mental disorders can resolve the hair pulling.

Psychotherapy for Trichotillomania

Habit reversal training (HRT) is most effective in treating trichotillomania. HRT is also a successful adjunct to medication. In HRT, the therapist trains one to recognize their impulse to pull and to redirect this impulse. Therapist teaches patient replacement habits they can do when they feel a strong urge to pull hair. Replacement habits might be things like clenching fists, snapping an elastic band on the wrist, drawing, squeezing a stress ball, or handling textured objects. With practice, the sufferer gets better at resisting the urge to pull. The urge, with time, becomes weaker and easier to resist.

Symptoms can also be improved by hypnosis, biofeedback, and cognitive-behavioral therapy. You can learn to accept your hair-pulling urges without acting on them with acceptance and commitment therapy.

Medication for Trichotillomania

The FDA has approved no medications for trichotillomania treatment. However, clomipramine, a tricyclic antidepressant, can improve symptoms. Naltrexone, fluoxetine and other SSRIs can help in treating trichotillomania.

Devices for Trichotillomania

Technology can augment HRT. Several mobile apps exist to help log behavior and strategize treatment. Wearable devices exist that track a user’s hands. They issue notifications so that users can track frequency of these events.

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