In this article, I will be talking about the impulse control disorder known as trichotillomania. Here, its causes, symptoms, and characteristics will be described in fullest detail, as well as its history, incidence, prevalence, and all of its known treatments.
In 1889, a French physician named Francois Hallopeau described a young man who pulled out all of his body hair. This description is how hair pulling became an identified medical syndrome. Hallopeau coined the name trichotillomania, deriving it from three Greek words – thrix, meaning hair, tillein, meaning to pull, and mania, which has several meanings, but most often implies insanity or frenzy (Christenson & Mansueto, 1999).
However, hair pulling existed long before Hallopeau first observed it. There are even cultures and events in which the behavior is sanctioned. The early Greeks would tear out, shave off, or cut off their hair from their heads and lay it upon a corpse or funeral pile of a friend or relative. Today, some monastic sect members in the Jain community of India regularly pluck all the hair from their heads to show their detachment from pain. In the African Ila tribe, new brides pluck all their husband’s pubic and chin hairs after the consummation of their marriage. Tweezers have been found in the tombs of common citizens in ancient Egypt (Christenson & Mansueto, 1999).
There are also dozens of literary accounts of hair pulling. Shakespeare’s play Troilus and Cressida, Homers The Iliad, even in the Bible in Ezra 9:3. Hippocrates wrote about hair pulling in Epidemics I and Epidemics III (Christenson & Mansueto, 1999).
So obviously, hair pulling has existed for hundreds, probably even thousands of years. So now that the history of this strange behavior has been covered, let us delve deeper into its characteristics . . .
Today, trichotillomania is listed in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision [DSM-IV-TR American Psychiatric Association (APA)] as an impulse control disorder, and it lists the criteria for a proper diagnosis:
A: Recurrent pulling out of one’s own hair that results in noticeable loss.
B: An increasing sense of tension immediately before pulling out the hair or attempting to resist the behavior.
C: Pleasure, gratification, or relief when pulling out the hair.
D: The disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (e.g. a dermatological condition).
E: The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The cause of trichotillomania is not yet known. Some researchers speculate that it has biological roots, such as an imbalance of hormones or neurotransmitters. Others believe that is has psychological foundations. And still yet others, as Linda Bayer notes, it may be a grooming ritual “gone haywire" (2001, p. 72).
Hair pulling episodes can vary from person to person. Some individuals may have episodes that are brief and frequent throughout the day, and others may pull out their hair less frequently but for longer periods of time, and sometimes these episodes will last for hours. The way the hair is pulled can also vary. Some people will use their thumb and forefinger, some will use tweezers, or twirl the hair around their finger or a foreign objects (e.g. a hairbrush or a pencil), and some will scratch or rub the hair out. Some cases have shown individuals who even use needles and other sharp objects to dig the hair from under their skin. These episodes often occur in states of relaxation, such as when the individual is reading or watching television, (Brody, 1995) but they can also occur in states of stress as well. People suffering from this disorder generally do not report experiencing pain when pulling out the hair, but some describe an itching sensation that prompts the hair pulling (Bayer, 2001), and most report feeling tension just before pulling the hair.
The majority of the time spent in these episodes, however, is not pulling the hair out, but rather manipulating the hair after it’s been pulled. “Examining the hair root, twirling the root off, putting the strand of hair between the teeth or under the fingernails, and eating the hair" (Bayer, 2001) are just a few of the ways the hair can be manipulated. Eating the hair, known as trichophagia, can cause additional medical problems, such as hair balls, anemia, abdominal pain, nausea and vomiting, or bowel obstruction (Bayer, 2001). Other problems found with trichotillomania are anxiety and mood disorders, eating disorders, and drug abuse (Kress, Kelly, & McCormick), and physical injuries as well. These injuries range from mild to serious, and can include calluses on the fingertips, repetitive strains of the neck, back, shoulder, and elbow
muscles, and tendonitis due to bending and twisting the wrists when pulling. People can also suffer from eye and eyelid irritation and infection, and dental problems caused by excessive wear of the tooth enamel from chewing hairs, or grooves cut into the enamel from drawing hairs between the teeth. Women who pull pubic hairs sometimes avoid regular visits to the gynecologist and develop health problems. Those who pull eyelashes or eyebrows may avoid going for regular eye checkups or corrective lenses (Penzel, 2003).
The behavior usually does not occur in front of people, with the exception of immediate family members who are already aware of the person’s problem. Most individuals are embarrassed of their behavior and try to hide their hair loss, through makeup, large hats or glasses, wigs, scarves, etc. Because of their embarrassment and the fear that their secret will be found out, most of these people will avoid social situations in which their problem may be noticed (e.g. standing outside on a windy day, going swimming).
Hair pulling is not always limited to just the sufferer. Some individuals may pull hairs from pets, dolls, sweaters, carpets, and other fibrous materials. Some may also pull hairs from other people, usually under some sort of pretense (e.g. pulling “stray" hairs from a friend’s head, or plucking someone else’s eyebrows to make them appear more “groomed.") (Bayer, 2001). Dr. Fred Penzel refers to this as “trichotillomania by proxy."
According to Victoria E. White Kress and her colleagues, trichotillomania has been estimated to affect 2.5 million people in the United States. In a 1991 study by Dr. Gary Christenson, it was found that the lifetime rate is 3.4 percent of adult females and 1.5 percent of adult males are affected by this disorder (Penzel, 2003). This prevalence may be underestimated because it is sometimes overlooked due to the secrecy of some sufferers, especially with men, since male baldness is so common it makes it easier for men to hide their problem. Trichotillomania may also be comorbid with other disorders, which also adds to this underestimation.
While the prevalence in the adult populations is mostly female, the child population is nearly equal among boys and girls. In a survey of 36 children aged 12 and under with trichotillomania, 50 percent of those children were male . . . In a sample of 52 preschoolers, 46.2 percent of those preschoolers were female (Miltenberger, Rapp, & Long, 2001). It is generally accepted that trichotillomania begins in childhood or early adolescence. In the studies conducted by Dr. Gary Christenson and his colleagues, the most common age for trichotillomania to begin to take place is between eleven and fifteen years of age, with thirteen being the average age. The next most susceptible age group is children ages six to ten (Miltenberger, et. al., 2001). Some children go through phases of benign hair pulling, in which the pulling is self-limited and stops on its own, usually in a matter of weeks or months, and some very young children have been observed pulling their hair out during their sleep (Miltenberger, et.al., 2001). “Frequently, a stressful event can be associated with the onset, such as: change of schools, abuse, family conflict, or the death of a parent. The symptoms also may be triggered by pubertal hormonal changes" (http://www.ocdhope.com/trich.htm).
There is hope for trichotillomania sufferers. Until about forty years ago, trichotillomania was barely even heard of. Therefore, many individuals felt isolated, as though they were the only ones with the disorder. Treatments were very limited, and even more limited were the number of clinicians who were experience in treating these patients. Luckily, today there are many treatments, and more and more clinicians are becoming more aware of the problem in today’s population. Now, each of these treatments will be discussed in depth.“One common treatment for trichotillomania is a behavior therapy technique called habit reversal" (Izenberg & Dowshen, 2001, p. 392). When using habit reversal training, the individual first learns to notice the urge to pull hair before the compulsion becomes too strong to resist. Then the person learns to do something else entirely different, something that makes hair pulling impossible (e.g. squeezing a tennis ball, clenching a fist or clasping hands) until the urge to pull grows weaker and passes. This technique can often be more difficult than it sounds because the individual may feel an increase in tension and anxiety while doing the alternate activity and resisting the urge to pull. However, over time the brain learns to adjust and can react differently to these urges, and the person can control their behavior (Izenberg & Dowshen, 2001). Certain medications can help to reduce the strength of these urges, making it easier for one to resist them.
Pharmacotherapy is another popular treatment method. The medications that are most commonly and widely researched and used to treat trichotillomania are generally classified as antidepressants. These fall into two major categories: Serotonin Re-uptake Inhibitors (SRI’s) that include the subgroup Tricyclic antidepressants (TCA’s), and Serotonin Specific Re-uptake Inhibitors (SSRI’s). There are some newer medication, but these newer ones remain unclassified (Penzel, 2003). The most popular medications used today are Prozac, Zoloft, Paxil, and Anafranil. Antipsychotic drugs are used only when several other medications have failed. These are not widely used because of the risk of developing tardive dyskinesia (TD), an irreversible neurological side effect (Penzel 2003). Monoamine Oxidase Inhibitors (MAOI’s) are another class of antidepressants, though these are rarely used in the treatment of trichotillomania. There are no controlled studies of the use of MAOI’s as a treatment of this disorder to date, although there are a few isolated case reports indicating some success. These are used only when TCA’s, SSRI’s, antipsychotics, and other drugs have failed (Penzel, 2003).
Cognitive therapy is a form of treatment used to make the patient familiar with the thoughts and feelings, the internal cues and external cues, that they associate with their hair pulling (Kress, et. al., 2004). “[This] type of treatment . . .has been in use for about the last forty years" (Penzel, 2003, p. 106). Although it does have the same success as behavioral therapy for the treatment of obsessive-compulsive disorder, and is also effective with depression and anxiety, it is not as useful in the treatment of trichotillomania. “While a cognitive therapy approach . . .does not work directly on the hair-pulling itself, it can help with all the things that help a person to engage in therapy, to persist at it, and to ultimately be successful at it" (Penzel, 2003, p. 107). Cognitive therapy is best used when paired with another form of treatment, most commonly with behavioral therapy. When these two treatments are paired together, it forms a type of “talk therapy component for the types of philosophical and emotional issues that behavioral therapy cannot alone address" (Penzel, 2003, p. 107). Combining cognitive therapy with habit reversal training is also effective, because once the person is aware of his or her external cues to pull hair, that person can begin their alternate activity.
Group therapy, combined with habit reversal training, is a somewhat effective treatment method. It has been shown to increase the client's awareness of internal and external cues that are associated with their hair pulling and interrupt the sequence of their behavior, and then introduces alternative behaviors to incorporate in response to these urges (Kress, et. al, 2004), as well as provide a sense of belonging, support, and community to these individuals. Its effectiveness is limited, however. Most individuals resume their hair pulling shortly after treatment ends. More research is needed to determine its efficacy (Kress, et. al, 2004).
Hypnosis has also been used in the treatment of trichotillomania. While it shouldn’t be used as the sole medical or psychological treatment (Penzel, 2003), the use of hypnotic suggestion has been effective, though on a limited basis. As of present, it is speculated that hypnosis is best effective with highly suggestible patients.
The treatments that probably don’t work include traditional talk therapy, play therapy, energy therapy, homeotherapy, and special diets. Talk therapy is based on the psychoanalytic approach of free association. The reason that talk therapy doesn’t seem to work is because hair pulling is not a psychological problem that has roots in one’s upbringing or early experiences (Penzel, 2003). While a talking component incorporated into treatment programs can provide an insight into the problem, talking alone will not be of any significant help. Play therapy is used with only children. “It attempts to get children to express their feelings and concerns and to relate them to a therapist through play activities" (Penzel, 2003, p. 97). While it may be effective for certain childhood problems, very young children, and kids who cannot express themselves easily, it is about as effective as talk therapy is for adults. Also, there is no scientific evidence that play therapy should be even considered as an effective treatment.
Energy therapy is almost certainly a hoax. “At least one device is presently being marketed that claims to relieve the urge to pull hair by balancing the ‘bioelectricity’ of the scalp at ‘the cellular level’" (Penzel, 2003, p. 98). It supposedly sends static electricity to the scalp, similar to acupuncture. There is absolutely no scientific data and no verifiable statistics to back up the claim that this is an effective treatment for trichotillomania (Penzel, 2003).
Homeotherapy is an older form of pseudotreatment. Basically, any individual can walk into a health food store and find some kind of herb, extract, etc., that claims to cure almost any ailment. The reason that this treatment doesn’t work is because the herbs or other factors in the treatment is so diluted that it is impossible to produce any kind of effect (Penzel, 2003).
Lastly, special diets are considered fake treatments because when they are “put to the test of science . . . [they] are found to be no more helpful then a placebo diet" (Penzel, 2003, p. 99). It is more of a hassle than a help.
In conclusion, there is still much to be learned about trichotillomania. Even though its cause is not yet known, scientists and therapists have made many discoveries about its characteristics, prevalence, and made important breakthroughs in developing treatments.
References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders. (4th ed.) Washington: Author.
Bayer, Linda. (2001). Out of control: Gambling and other impulse control disorders. Philadelphia: Chelsea House Publishers.
Brody, Jane E. (1995, January 04). Personal health: Help but no sure cure for hair-pulling disorder. New York Times. pp. C.8
Christenson, Gary A., Hollander, Eric, and Stein, Dan J. (Eds). (1999). Trichotillomania.
Washington: American Psychiatric Press.
Izenberg, Neil, and Dowshen, Steven A. (Eds). (2001). Human diseases and conditions supplement 1: Behavioral health. Charles Schribner’s Sons.
Kress, Victoria E. White, Kelly, Brandy L., and McCormick, Laura J. (2004). Trichotillomania:
Assessment, diagnosis, and treatment. Journal of Counseling and Development, 82 (2)
185
National Mental Health Association. Other mental illnesses – Trichotillomania. Retrieved November 5, 2005, from the World Wide Web: http://www.nmha.org/infoctr/factsheets/92.cfm
OCD Resource Center of Florida. Trichotillomania. Retrieved November 5, 2005, from the World Wide Web: http://www.ocdhope.com/trich.htm
Penzel, Fred. (2003). The hair-pulling problem: A complete guide to trichotillomania. New
York: Oxford University Press.
Woods, Douglas W., and Miltenberger, Raymond G. (Eds.) (2001). Tic disorders, trichotillomania, and other repetitive behavior disorders: Behavioral approaches to analysis and treatment. Norwell: Kluwer Academic Publishers.
