Trichotillomania

Trichotillomania

Trichotillomania is a disorder characterized by the compulsive need to pull and play with hair and body hair. Plucking eyelashes or eyebrows is also part of this disorder. There may also be repeated attempts to reduce or stop the plucking, and significant work, social, and interpersonal discomfort or dysfunction due to the symptom. Although it can occur at any age, it is most common in children and adolescents. Trichotillomania is a disorder that has been included in the chapter “Obsessive Compulsive and Related Disorders” in the DSM-5 due to its specific features.

The prevalence of trichotillomania in the general population is estimated to be 1-2%. Women are more affected than men by a ratio of about 10:1.

Symptoms of trichotillomania

The characteristic symptoms of trichotillomania are related to the recurrent and compulsive behavior of pulling body hair. Often, but not always, the first areas where this compulsive behavior is concentrated are the scalp and face. The most common areas are

  • the scalp
  • the eyebrow area
  • the eyelashes

Trichotillomania can affect any part of the body where there is hair or hair growth. Although rare, the disorder can also affect other parts of the body, such as the pubic area, arms, neck and legs, etc. Typically, people with trichotillomania use their own nails, tweezers, or other tools to remove hair. In severe cases, trichotillomania can lead to permanent hair loss or skin damage.

Often, but not always, compulsive episodes are preceded by high levels of internal tension. The compulsive behavior is performed in solitude, sometimes while watching television, reading, talking on the phone, or driving. Sometimes pulling hair is a conscious and deliberate behavior, but more often it is unconscious and automatic.

In trichotillomania, hair pulling is often anticipated by ritual behaviors such as combing the hair, feeling each hair between the fingers, pulling, and visually examining the area. Hair or hairs are not pulled at random, but are often selected based on tactile or visual characteristics.

Behavior after pulling is also clinically relevant. While some people simply throw the torn hair away, others roll it between their fingers, inspect it, bite it, or even ingest it (a behavior called trichophagy).

Causes of trichotillomania

The causes of trichotillomania are not fully understood and are related to numerous factors. Although the causes of the disorder are unclear, some risk factors have been identified:

  • Genetic basis: Studies have shown that familiarity is a risk factor for trichotillomania (Ramot, 2013).
  • Prolonged anxiety and stress: Those who are exposed to stressful events over a long period of time or experience chronic anxiety may develop trichotillomania.
  • Acute stressful events: Any dramatically stressful event can promote the onset of the disorder.
  • Psychiatric comorbidities: Trichotillomania may occur in comorbidity with other psychiatric disorders such as personality disorders, obsessive-compulsive disorder, mood disorders, anorexia nervosa, or bulimia.

Environmental context of trichotillomania

Situational variables that may fuel the impulse are usually sedentary situations, such as watching television, reading a book, or getting ready in front of the mirror.

The act of plucking hair, eyebrows, etc. may also occur during contemplative activities.

Finally, there may be times of day when the risk of trichotillomania is greatest, such as in the evening, during the night, when one is alone, tired, or before falling asleep.

Emotional context of trichotillomania

The emotional context that may induce the tearing behavior is characterized by disturbing emotions such as anxiety, boredom, anger, and sadness. It is usually associated with a feeling of increasing tension in the person.

Hair pulling and tugging may provide a momentary sense of relief from tension: in fact, some individuals report a tingling or itching sensation on the scalp that is relieved only by the pulling behavior.

Finally, people with trichotillomania repeatedly try to reduce or avoid pulling their eyebrows, hair, or scalp because of the significant discomfort associated with the behavior.

Trichotillomania in children

Trichotillomania can affect anyone at any age. However, it is true that those who suffer from this disorder tend to start manifesting the disorder when they were children. In fact, the peak incidence of trichotillomania in children is between the ages of 2 and 6. However, at this stage of children’s growth, the symptoms of the disorder may be transient.

On the other hand, when they occur in pre-adolescence or adolescence, the disorder tends to be more pervasive and long-lasting. Typically, critical transitions can be particularly stressful for both children and adolescents. For example, the transition from elementary school to middle school, the onset of puberty, and the relationship dynamics of adolescence can cause stress and promote symptoms of trichotillomania in predisposed individuals.

Consequences of trichotillomania

There are many consequences of trichotillomania:

  • One consequence is alopecia, which is the progressive loss of hair until it disappears permanently. Depending on the severity and duration of the disorder, this loss may be temporary or permanent.
  • In addition, trichophagia (the swallowing of hair after it has been pulled out), if present, leads to the appearance of bezoars, clusters of hair that can block gastrointestinal function.
  • Skin damage is also associated with trichotillomania, particularly dermatitis of the scalp and target areas where hair is pulled. In addition, scalp pain may develop from inflammation of hair follicles damaged by the compulsive behavior.

In addition to the physical damage, there is also psychosocial damage. In fact, the compulsive behaviors of trichotillomania often cause the sufferer to feel ashamed of his or her physical appearance (especially alopecia) and to reduce his or her social contacts. The sense of shame and reduced relationships can fuel psychological distress by creating a vicious cycle of avoidance.

Styles of trichotillomania

Recent studies have also distinguished different styles of trichotillomania, which may correspond to different triggers. Two styles of pulling have been identified: automatic and conscious.

Automatic tearing

Automatic tearing occurs unconsciously, often during moments of rest. It becomes conscious only when one notices the consequences (e.g., a clump of hair).

Conscious tearing

Conscious tearing, on the other hand, appears to be a process that serves various purposes, such as the pleasure of tearing. It may be used to reduce negative emotions, to remove hair that seems out of place, or to remove hair that has certain characteristics.

Some research suggests that conscious tearing may be an attempt to regulate negative emotions or thoughts.

Because of the great heterogeneity of this symptomatic condition, great care should be taken when diagnosing it.

Trichotillomania and differential diagnosis

Obsessive-Compulsive Disorder

The characteristics of the repetitiveness of the behavior and its place within the DSM-5 may cause this condition to be confused with OCD.

However, they are phenomenologically very different, primarily because of the pleasure derived from the ritualistic behavior. This is absent in the performance of compulsive rituals.

Also because of the absence of both intrusive thoughts and the variety of ritualistic behaviors, also very different from each other, that we find in OCD.

Dysmorphic Disorder (Dysmorphophobia)

Another feature to consider is the presence of shame and dissatisfaction with one’s appearance. This could lead to Dysmorphia Disorder, but the focus of the person’s attention and eventual tearfulness is on correcting a perceived aesthetic flaw.

Borderline Personality Disorder

Finally, some suggest similarities with those disorders involving emotional regulation and self-injurious behavior.

In borderline disorder, for example, tearfulness or self-injurious behaviors may regulate emotional states. However, they are explicitly aimed at experiencing pain, whereas this intentionality is not present in trichotillomania.

It is known, however, that patients with trichotillomania often report a reduction in anxiety, tension, and boredom after tearful episodes.

Treatment of trichotillomania

Treatment of trichotillomania may include medication, psychotherapy, or a combination of the two. At the psychotherapeutic level, there is no specific treatment; in general, trichotillomania is treated similarly to OCD, with which it shares some symptoms.

Cognitive behavioral therapy of trichotillomania

This conceptualization of the disorder can strengthen the therapeutic strategies available to cognitive behavioral therapy.

Empirical evidence has already shown good efficacy of some techniques, such as Habit Reversal Training and stimulus control interventions. These have been used successfully for the management of repetitive behaviors, along with cognitive techniques for identifying dysfunctional thoughts.

The interventions have shown excellent efficacy in managing the tearing behavior and in learning alternative and more adaptive behaviors. Indeed, they promote awareness of the automatic thoughts that may precede the tearing to cope adequately with the situation.

Habit Reverse Training

One of the approaches used to treat trichotillomania is habit reversal training (HRT, Rehm, 2015). HRT is based on the conceptualization that the main symptom of trichotillomania is a behavior that is conditioned by specific situations or events of which the subject is not fully aware.

Hair pulling would thus be a reinforced behavior that can be treated according to the principles of classical behaviorism. It is therefore necessary to understand the stressful situations in which the symptom occurs in order to promote the emergence of more functional behaviors.

Dialectical Behavior Therapy (DBT)

DBT facilitates awareness of emotions such as anger, boredom, and frustration. It addresses maladaptive emotional regulation strategies that reinforce and perpetuate tearful behavior. It helps replace them with new, more adaptive regulatory skills.

Mindfulness exercises train emotional and cognitive awareness and reduce reactivity to distressing emotions.

Acceptance and Commitment Therapy

Another form of cognitive behavioral psychotherapy is Acceptance and Commitment Therapy (ACT). The primary goal of ACT is to develop a nonjudgmental and welcoming attitude toward all internal emotional experiences, even those that are psychologically negative.

In fact, according to ACT, most suffering is related to the attempt to control unpleasant mental content (negative thoughts, feelings, sensations, and emotions).

References

  1. Anwar, S., & Jafferany, M. (2019). Trichotillomania: A psychopathological perspective and the psychiatric comorbidity of hair pulling. Acta Dermatovenerologica Alpina, Pannonica et Adriatica28(1), 33–36. https://doi.org/10.15570/actaapa.2019.7
  2. Grant, J. E. (2019). Trichotillomania (hair pulling disorder). Indian Journal of Psychiatry61(Suppl 1), S136–S139. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_529_18
  3. Lamothe, H., Baleyte, J.-M., Mallet, L., & Pelissolo, A. (2020). Trichotillomania is more related to Tourette disorder than to obsessive-compulsive disorder. Revista Brasileira de Psiquiatria (Sao Paulo, Brazil : 1999)42(1), 87–104. https://doi.org/10.1590/1516-4446-2019-0471
  4. Cisoń, H., Kuś, A., Popowicz, E., Szyca, M., & Reich, A. (2018). Trichotillomania and Trichophagia: Modern Diagnostic and Therapeutic Methods. Dermatology and Therapy8(3), 389–398. https://doi.org/10.1007/s13555-018-0256-z
  5. Melo, D. F., Lima, C. D. S., Piraccini, B. M., & Tosti, A. (2022). Trichotillomania: What Do We Know So Far? Skin Appendage Disorders8(1), 1–7. https://doi.org/10.1159/000518191
  6. Kalia, S., & Adams, S. P. (2005). Dermacase: Hair loss on the scalp. Canadian Family Physician51(APR.), 509–510.
  7. Eskeland, S. O., Moen, E., & Hummelen, B. (2018). Trikotillomani. Tidsskrift for Den Norske Laegeforening138(10). https://doi.org/10.4045/tidsskr.17.0599
  8. Harrison, J. P., & Franklin, M. E. (2012). Pediatric trichotillomania. Current Psychiatry Reports14(3), 188–196. https://doi.org/10.1007/s11920-012-0269-8
  9. Jafferany, M., & Patel, A. (2018). Therapeutic aspects of trichotillomania: A review of current treatment options. Primary Care Companion to the Journal of Clinical Psychiatry20(6). https://doi.org/10.4088/PCC.18nr02344
  10. Grant, J. E., & Chamberlain, S. R. (2016). Trichotillomania. American Journal of Psychiatry173(9), 868–874. https://doi.org/10.1176/appi.ajp.2016.15111432
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