Trichotillomania

Descriptive Characteristics and Phenomenology

File photo. [Credit: Your TeenOpens in new window]

Due to persistent hair pulling from the scalp, the disorder often leaves behind patchy bald spots, which causes significant despondency and distress, interfering with an individual’s social or work functionality.

Indeed, the phrase “I could pull my hair out!” is a common idiom in our culture, although the exact origin of this phrase is unknown. A biblical account of hair pulling exists, in reference to the prophet Ezra: “And when I heard this thing, I rent my garment and my mantle, and plucked off the hair of my head and of my beard, and sat down astonished” (Ezra 9:3).

Interestingly, people with this disorder try tooth and nail to disguise the loss of hair as much as they can. In the case of a few, this disorder may be mild and generally manageable. In the cases of some, this disorder brings about a strong compulsive urge to pull out the hair. This urge is so strong in them that it renders the individuals powerless in the face of the disorder. Treatment options have helped people reduce their urge or even completely stop pulling out their hair.

DSM-IV Diagnostic Criteria

Trichotillomania is included in DSM-IV under the general category of “Impulse-Control Disorders Not Elsewhere Classified,” which includes other disorder characterized by impulsiveness (American Psychiatry Association, 1994). As such, trichotillomania shares association with such diverse syndromes as pyromaniaOpens in new window, kleptomaniaOpens in new window, pathological gamblingOpens in new window, and intermittent explosive disorderOpens in new window.

These disorders are defined by the presence of mounting tension prior to the pathological behavior and gratification derived from the release of tension following the behavior. Impulse-control disorders are also characterized as ego-syntonic, that is, consistent with the will of the individual at the time.

During the drafting of DSM-IV, trichotillomania was considered for inclusion as an anxiety disorder because of presumed similarities with obsessive-compulsive disorder (OCD)Opens in new window. It was also considered for inclusion within disorders first presenting in childhood or adolescence.

Mansueto (cited in Kaplan 1992) has suggested that a new diagnostic category, “displacement activity disorder,” be considered, with inclusion of trichotillomania, face picking, nail biting, and other “nervous habits” with body foci when they reach clinical levels of severity. At least for now, however, trichotillomania remains within the Impulse-Control Disorders Not Elsewhere Classified category.

Onset

Trichotillomania can arise at any age; however, the average age at onset is approximately 13 years (Christenson et al., 1995b). Although often persistent in adults, trichotillomania is subject to great fluctuations in severity, with exacerbations related to environmental stressors, increased opportunities to pull, or other factors.

Little is known about the genesis of hair pulling. A recurrent theme in the trichotillomania literature is that trichotillomania often develops in the context of loss or perceived loss, but many other precipitating factors have been reported. Trichotillomania onset has been described as being associated with the following:

• Childhood illness or injury (Greenberg & Sarner 1965; Oranje et al. 1986).
• Death or illness of or injury to a family member (Cordle & Long 1980)
• Change in residence
• Alienation or separation from friends
• Entrance into school
• Academic difficulties or school tensions
• Onset of menarche
• Parental divorce
• Brief separation from parents
• Medically necessitated forced immobility
• Birth of a sibling or sibling rivalry (with resultant decreased attention leading to hair-pulling behavior).

Gender Ratio

Research on trichotillomania has supported the traditional view that the disorder affects females far more often than males. Of 186 patients with trichotillomania presenting to a trichotillomania clinic, 92.5% were female (Christenson 1995b). Cohen and colleagues (1995) reported that 93% of the children, adolescents, and adults with hair pulling identified in a survey (N = 123) were female.

Hair Pulling Method

Trichotillomania is a heterogeneous disorder; nonetheless, certain shared features are observed. Although hair may be pulled out in clumps, it is far more characteristic that hairs are pulled out one by one. Virtually any body hair is vulnerable, with the most commonly affected sites being scalp, lashes, brows, pubes, face, and extremities, in descending order of frequency.

Nasal, perianal, ear, and abdominal hair may also be affected, and most patients pull from more than one site. Pulling from the lashes and/or brows may leave these areas totally denuded, or “patchy” in appearance, as may pulling hair from the pubic area.

Obviously, the potential for individual variations in pulling patterns and resultant damage is endless. In some, but relatively few, instances, damage to the skin may occur; the hair pulling may damage the skin matrix or create sites for infection, or the patient may damage the skin by scratching or picking with fingernails, pins, tweezers, or other implements (Christenson 1995a). Change in hair color to white or gray has also been noted can persist long after hair pulling has ceased. In addition, textural changes can occur, typified by normally straight hair becoming thick and curly.

Infrequently, patients may also pull hair from spouses, parents, siblings, or others (Oranje et al., 1986). Pulling from pets has also been encountered. An occasional clue to the etiology of hair loss in young children is a similar pattern of hair loss on their dolls.

A general interest in fibers or the need to manipulate minute objects or to receive tactile stimulation via the fingertips may be characteristics associated with individuals with trichotillomania.

Trichotillomania patients have been noted to pick at blanket fuzz, carpet fibers, or blades of grass. More than half of patients preferentially pull at hairs possessing certain textural qualities described as “wiry,” “thick,” “coarse,” “stubby,” or “kinky”. Since recurrent hair pulling can lead to textural hair changes, initial pulling of normal hair may promote future pulling via the production of increasing numbers of “target” hairs (Christenson 1995a).

Touching or stroking of hair typically precedes actual pulling (Mansueto 1990). Hair pulling is generally accomplished by grasping the hair between the tips of the thumb and index finger or by wrapping the hair around the index finger prior to pulling. The dominant hand is used by 38% to 50% of hair pullers, with 32% to 38% incorporating the nondominant hand and 18% to 23% using both hands.

Tweezers were used in a noncosmetic fashion by 43% of patients in a large clinical sample (Christenson et al. 1991a), although the actual amount of hair pulling by an individual utilizing this method is usually small. Mansueto (1990) reported that a quarter of patients use tweezers at least part of the time.

Other methods of hair removal, such as rubbing, entangling hair in combs or brushes, or grasping with an eyelash-epilating forceps, have been described but can be considered atypical.

Time Expanded in Hair Pulling

Hair pullers can devote great amounts of time to their behavior. In a sample of 44 patients, Mansueto (1990) found that approximately 47% reported pulling out hair for more than an hour per day.

Twenty-four percent of Mansueto’s patients reported pulling out more than 100 hairs per day, while about half reported pulling fewer than 50 hairs per day. Ninety-five percent of the patients acknowledged that “bingeing” described at least some episodes of hair pulling.

Koran et al., (1992) noted several patients who pulled from 2 to 8 hours daily. On the other hand, many patients with trichotillomania have severe alopecia resulting from infrequent hair-pulling episodes of minimal duration. Repetitive and prolonged hair pulling can lead to the development of cuts and calluses of the fingertips or even result in carpal tunnel syndrome and other musculoskeletal maladies (Christenson 1955a; O’Sullivan et al. 1996).

Hair Disposition

Hair is often manipulated or played with before being discarded. At times, the hair is examined for the presence of an intact root; some patients identify the procurement of roots as strong incentives for pulling hair (Mansueto 1990). Roots are often broken or bitten off. Occasionally, hair is saved. Rarely, hair has been used later as a substitute for dental loss. Mansueto (1990) found that only 9% of the patients in his sample quickly discarded pulled hair; 43% acknowledged that they manually manipulated the hair shafts or roots.

Associated Activities

Trchotillomania occurs in association with several “high risk” situations. Typical situations include reading, watching television, speaking on the phone, grooming, driving, or laying in bed at night (Azrin et al., 1980; Christenson et al., 1991a; Mansueto 1990). In addition, the pulling of pubic hair often occurs while the individual is sitting on the toilet.

Resistance

Nearly all patients have attempted to resist or limit hair pulling at some time. One-third of patients have used a barrier (e.g., scarf, wig, hat, glasses) to prevent their hands from coming into contact with hair. One-fifth have worn gloves or mittens to prevent their getting a good grip.

Other methods include ceasing associated activities (e.g., stopping reading), occupying hands (e.g., knitting), sitting on hands, taping fingers together, cutting fingernails short or growing them long, hiding tweezers, and applying petroleum jelly to hands or hair (to reduce grip).

Several patients have described such severe interventions as cutting off or shaving all of their hair or typing their hands down. In general, most of these “home remedies” prove ineffective and are rapidly abandoned. (Christenson et al., 1991a; Schlosser et al., 1994).

Emotional Consequences

Patients with trichotillomania may describe an array of personal and emotional problems as a consequence of the disorder.

Self-esteem often appears compromised in patients with trichotillomania. Often they report feeling shame, humiliation and embarrassment. They may experience low self-esteem, depression, and anxiety. Embarrassment because of hair loss may lead patients to avoid social activities and job opportunities.

People with trichotillomania may wear wigs, style their hair to disguise bad patches or wear false eyelashes. Some people may avoid intimacy for fear that their condition will be discovered.

Interventions

Overcoming hair pulling urges may involve a type of behavioral therapy called habit substitution, taking medicine, or a combination of both.

In therapy, people with trichotillomania learn about urges. They learn how urges fade on their own when people don’t give in to them, and how urges get stronger and happen more often when people do give in. In addition, patients may learn to identify situations, places, or times they usually have an urge to pull.

Typically, therapists teach patients with trichotillomania how to plan a replacement habit they can do when they feel a strong urge to pull hair. Replacement habits might be things like squeezing a stress ball, handling textured objects, or drawing. The therapist guides the person on how to use the new habit to resist the urge to pull hair. With practice, a person gets better at resisting the urge to pull. Thus, the urge becomes weaker and easier to resist.

Sometimes medicines can help the brain deal better with urges, making them easier to resist. A therapist may also help people with trichotillomania learn to manage stress, deal with perfectionism, or work out other compulsive habits they may have, like nail biting.

There is no proven way to prevent trichotillomania, but getting treatment as soon as symptoms start can be a big help.