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Trichotillomania from Patients' Perspectives

“Usually, I'm not even aware that I've been pulling my hair until after it is over… I look at my school books and find hairs all over them. Now I realize that doing my homework usually starts out in an ordinary way, but if I come across a problem that I can't easily figure out, I usually rest my head on my hand out of frustration. Before, I used to not notice that this was also the time when my other hand would start to trail toward my head. My fingers would wind and twirl around my hair. I would zone out and relax a little. Then usually something would break the “spell“ like my mom or sister coming into the room. I'd quickly sit up straight. I would always be surprised at the number of hairs on my book - how long had I been at it? I would quickly swipe the hairs onto the floor - ashamed to have others know what I was doing.“

“I now notice that I usually pull when I feeling really overwhelmed…when I'm behind a few reports at work and I feel like my boss is breathing down my neck. When I get home, I have trouble letting go of the day. I should have accomplished more…where did all the time go…I'll need to work even harder tomorrow to catch up. I start feeling jittery and nervous as I'm sitting on my sofa reviewing my day. The only thing that helps me let go is when I am able to move my focus to my hair. It starts innocently enough…I'm thinking about my day as I'm stroking my hair and feeling its soft texture. Then, I'll come across one that feels wrong, it's wiry. I isolate it as best I can, and tug it out. When I look at it in my fingers, I feel this sense of accomplishment that I have eliminated this rogue hair from my head. I put my hand back in my hair…trying to see if there are any more in there. Got another. It feels good. Like a search and destroy mission. My day fades away…“.

Trichotillomania - Prevalence Rates and Course of the Disorder

There has been little research into how many people suffer from trichotillomania. However, it appears that about 2-3% of adults in the United States may suffer from this problem. It seems that more women than men may suffer from this problem, but this is also inconclusive since women are more likely than men to seek treatment. In addition, for men it is often easier to hide the problem (e.g., shave if they pull facial hair, blame patchy hair on going bald, etc.).

The two most common age ranges for people to develop trichotillomania are between 11 - 15 and 6 - 10 years old. Although many people report not knowing why the onset occurred, others are able to link the onset of their trichotillomania with a stressful time in their life. Because many people are embarrassed to reveal to others that they pull their hair and because pulling is often done in private, if you notice hair loss in your child, the first step should be to take them to a medical doctor to rule out the existence of a dermatological problem.

What Causes Trichotillomania?

It is unknown what causes trichotillomania. However, like other psychological difficulties, it is likely due to a combination of many factors, including biological as well as life experience and stressors.

It is not uncommon for people with trichotillomania to report having family members who also pull their hair. However, while it is possible that genetics play some role in determining who develops trichotillomania, research studies not have found hair pulling to “run in families“.

General Information

Most people pull their hair when they are alone. Some are “automatic“ pullers - they pull when their attention is focused elsewhere (usually on another activity). Others are “focused“ pullers where their attention is totally focused on the pulling itself. It is not uncommon for some people to be a mix of the two - with some automatic and some focused pulling.

Common areas where hairs are pulled from include: scalp, eyelashes, eyebrows, pubic area, arms, and legs. Sometimes, people select hairs based on certain characteristics such as their color, texture, location, or thickness. Many people report that it “feels good“ to pull their hair out - sometimes giving them relief from life stresses or helping them to deal with other emotions (such as being angry, anxious, tense, or bored). Many people also report that the sensations of pulling out their hair or their “achievement“ at pulling out certain types of hairs gives them a sense of satisfaction. In addition to having certain rituals for what types of hairs are pulled and how they are pulled, it is also common to have a ritual for what to do with the hair once it has been pulled out (e.g., bite on hair bulb, save it, etc.). In addition, people frequently try to hide the damage they have done to themselves using various different methods (e.g., wigs, “spray on“ hair, eye glasses, false eyelashes, shaving head).

Although many people report trying methods to stop pulling their hair, trichotillomania tends to be a chronic problem that does not remit without treatment. Some people tend to pull hairs in the same area throughout the course of the problem, while others “add“ new places to pull hairs from. However, it seems that once an area has been a “favorite“ place to pull from, people rarely completely discontinue pulling from that area.

What are the Symptoms of Trichotillomania?

Currently, Trichotillomania is categorized in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), as an impulse control disorder. However, trichotillomania has many features in common with Obsessive-Compulsive Disorder, so many consider it to be an Obsessive-Compulsive Spectrum Disorder.

According to the DSM-IV, the criteria for trichotillomania are the following:

1. Recurrent hair pulling, resulting in noticeable hair loss.

2. Having a sense of tension before pulling out the hair (or when the urge to pull is resisted).

3. Having a sense of satisfaction, pleasure, or relief after pulling the hair out.

4. The hair pulling causes significant distress or impairment in the person's life.

As there is more and more research on trichotillomania, it seems that there are some problems with the criteria requiring tension before pulling and relief or gratification afterward -- many people who pull their hair do not experience these emotions. Therefore, some people believe that the criteria itself should be changed to just include the first criterion -- recurrent pulling out of one's hair.

** Professional evaluation may be necessary to differentiate Trichotillomania from Obsessive-Compulsive Disorder (OCD) or Body Dysmorphic Disorder (BDD). Typically, those with OCD or BDD do not experience gratification from the hair pulling itself, and the pulling is usually accompanied by continual obsessive thoughts. In OCD and BDD, pulling is usually a response to try to calm the anxiety created by these disturbing thoughts.

Treatment for Trichotillomania

Both medications as well as therapy have been found to be effective for trichotillomania. Generally, selective serotonin reuptake inhibitors (SSRIs) are tried first, but then other drug classes (such as tricyclics or dopamine blockers) or combinations of medications might be tried to find the ideal medication. People respond very differently to each medication, so it is unfortunately a trial-and-error process to find the right medication or medications.

Only one type of therapy has been scientifically found to be effective for Trichotillomania -- Cognitive-Behavioral Therapy (CBT). For most people with hair pulling, a combination of medications and CBT are often necessary to help them fight the urges to pull.

CBT for hair pulling involves several steps - with the most integral one being the steps of “habit reversal“. In habit reversal, the first step is typically awareness training. This is a fancy term for the individual being taught how to monitor their behaviors. This is frequently very helpful in determining which situations a person is most likely to pull, what environmental or emotional triggers may initiate pulling, and what types of situations produce the strongest urge to pull. Frequently, people find that they pull in some situations that they were not really aware of or they are surprised to find that their pulling is limited to just a few types of situations. On occasion, people might even be asked to save and bring in their pulled hairs as another form of monitoring. Sometimes, this basic intervention is successful in helping people substantially reduce their hair pulling.

In addition, people with trichotillomania are also taught how to monitor the steps in their “behavioral chain“ - in other words, learning what the first behavior is that leads to hair pulling. For example, someone might notice that the thing that first triggers their pulling is a feeling of frustration, which then leads to leaning their head on their hand, then twirling their hair, and eventually leads to pulling out a strand of hair.

Once they are aware of when the pulling occurs, people with trichotillomania are then taught a competing response. In other words, they are taught how to engage in another behavior that prevents them from pulling their hair. They are taught to engage in this response until the urge to do the pulling decreases. For example, if the urge to pull arises in the car, people are taught the competing response of gripping the steering wheel hard until the urge passes. Different competing behavioral responses can be designated for different situations.

In addition, many people with impulses to pull find learning relaxation techniques to be very helpful. Techniques such as breathing retraining and progressive muscle relaxation often help to control the distressing emotions and general stress level that led to the pulling in the first place. When real stressors exist, it is often helpful to engage in problem solving techniques to explore additional ways of better coping with these life stressors. In addition, using techniques to analyze daily thoughts and stresses are often a very helpful adjunct to habit reversal - these techniques help people better deal with the stresses of life so that they are less likely to resort to pulling to help relieve any stresses that occur in the future.

In addition, it is often helpful for people to write a list of all the ways in which hair pulling has caused them any inconvenience or embarrassment and to keep this list with them. Many people also find that rewards help to keep them motivated with treatment. First, rewards are given for successfully reducing and then eliminating hair pulling. It is often easier to provide rewards to children who pull their hair, since parents have more control over incentives like magazines, gum, video games, etc. For adults, it is slightly more difficult to control rewards; however, many adults also find it helpful to agree to treat themselves to a specific item or activity for their work in reducing or eliminating pulling.

If you are interested in learning more about anxiety disorders and their treatment, and you live in the Los Angeles area, contact Dr. Nelson at (310) 963-4891 or e-mail her at