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Trichotillomania (Chronic, Repetitive Hair Pulling)

Trichotillomania (TTM) is characterized by chronic, repetitive pulling of bodily hair. The sites of hair pulling include the scalp, eyelashes, eyebrows, axillary, body, and pubic area. Hair pulling tends to occur in episodes, exacerbated by stress, or sometimes by relaxation (when reading a book or watching television, for example). All other causes of hair loss, including medical and dermatological problems, must be considered and ruled out before the diagnosis of trichotillomania is confirmed. People with TTM experience an increasing sense of tension immediately before pulling out a hair or when attempting to resist hair-pulling. When the hair is pulled, they experience immediate feelings of pleasure, gratification, and relief.

Once thought to be rare with a prevalence of only .05 percent to .6 percent, recent studies estimate a prevalence of 2 percent to 3 percent of the population. As with obsessive-compulsive disorder (OCD), people with TTM are often highly secretive about their symptoms. They may hide their symptoms by pulling hair from areas not easily visible or wear wigs or hair styles that conceal the areas where their hair is pulled.

Children with trichotillomania demonstrate a male to female ratio of 1:1. By adulthood however, more women are diagnosed with TTM. The onset usually occurs in childhood or adolescence, although it can begin before the age of one or as late as middle age. There appears to be a subgroup of TTM with an onset before the age of five.

Trichotillomania is often co-morbid with other psychiatric disorders, including anxiety disorders, depression, eating disorders, attention deficit disorder (ADD), Tourette disorder, and body dysmorphic disorder. Interestingly, one study observed a significantly higher rate of hair pulling in patients with both Tourette disorder and OCD than in patients with either Tourette disorder or OCD alone.

Complications of TTM are alopecia (baldness), infection, and scarring at hair extraction sites, slowed or stopped hair growth, and changes of hair texture or color. Some people eat the hair they have pulled and are at risk for stomach pain, gasto-intestinal obstruction, peritonitis, and in rare cases, even death. The repetitive arm and hand movements involved in hair pulling can cause carpal tunnel syndrome and other neuromuscular problems.

What causes trichotillomania?

No one knows for sure what causes trichotillomania, but evidence is growing that brain function and structure may be involved. The abnormalities found in the brains of people with TTM overlaps with those found in OCD and Tourette disorder. Dr. Susan Swedo and her colleagues have proposed that strep infections may be involved in some cases of early onset hair pulling .

Trichotillomania can be effectively managed with medication and behavior therapy. The most widely studied and used behavioral technique is habit reversal training (HRT). It involves several components, including:

  • Awareness training. Monitor for one week all urges to pull, actual occurrences of pulling, when and where it occurs, emotions just prior to pulling, and feelings immediately after pulling.
  • Identifying response precursors. What do you do with your arms and hands just before starting to pull? Do you touch or stroke your hair? Touch your face, eye lashes?
  • Response detection procedure. Describe and experience the muscles you use when pulling, using the following exercise: Extend arm straight and hold for 10 seconds. Slightly tighten muscles in arm. Then, begin moving clenched arm slowly toward head. At one quwarter, stop and hold for 10 seconds. At half-way, stop and hold for 10 seconds. At three-quarters way, stop and hold for 10 seconds. When your hand is at the top of your head, stop and hold for 10 seconds (do not touch the hair). Repeat entire sequence until the urge to pull subsides.
  • Competing response training. Choose an incompatible behavior, one that prevents hair-pulling. It must be a physically inconspicious activity, such as muscle tightening, hand grasping, clasping, or clenching an object, your belt or a Koosh ball, for example. Practice for three minutes, then release for one minute. Then repeat five more times.
  • Identifying habit-prone situations. Talking on the phone, watching TV, driving the car, for example. These are situations that typically trigger pulling. Practice competing responses in situations most likely to trigger pulling.
  • Relaxation training. Training in deep muscle relaxation, deep breathing exercises. Use these when urge to pull strikes, or when stress is high.
  • Positive attention (overcorrection). If pulling should occur, practice positive hair care by extensive brushing or repairing eye make-up. This is intended as a mildly aversive behavior. If done consistently, it makes hair-pulling less satisfying.
  • Prevention training. Practice a competing response when and where pulling is likely to occur.Other Methods for Managing TTM

Other Methods for Managing TTM

Hair collecting is a mildly aversive technique and requires that the sufferer collect all of the hair that has been pulled. Cognitive-behavior therapy has also been used to help counteract maladaptive thought patterns that precede hair pulling. Case studies of the use of hypnosis with TTM indicate that hypnotic techniques can benefit some hair pullers (please note that hypnosis has been proven of little value with classic OCD). The focus of the hypnotic techniques is on enhancing habit awareness and reinforcing behavioral control of the hair pulling.

More research is presently being done on this disorder and there is much hope.

Trichotillomania Web Resources

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