Trichotillomania (Hair-Pulling Disorder)

Definition:
Trichotillomania (Hair Pulling) is an irresistible urge to pull out hair from your scalp, eyebrows or other areas of your body. Hair pulling from the scalp often leaves patchy bald spots, which people with trichotillomania may go to great lengths to disguise.

It is classified as an impulse control disorder by DSM-IV, is the compulsive urge to pull out one’s own hair leading to noticeable hair loss, distress, and social or functional impairment. It is often chronic and difficult to treat.

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Trichotillomania may be present in infants, but the peak age of onset is 9 to 13. It may be triggered by depression or stress. Due to social implications the disorder is often unreported and it is difficult to accurately predict its prevalence; the lifetime prevalence is estimated to be between 0.6% (overall) and may be as high as 1.5% (in males) to 3.4% (in females).

For some people, trichotillomania may be mild and generally manageable. For others, the urge to pull hair is overwhelming and can be accompanied by considerable distress. Some treatment options have helped many people reduce their hair pulling or stop entirely.

The name, coined by French dermatologist François Henri Hallopeau, derives from the Greek: trich- (hair), till(en) (to pull), and mania (“an abnormal love for a specific object, place, or action”).

Classification:
Trichotillomania is defined as a self-induced and recurrent loss of hair. It is classified in DSM-IV as an impulse control disorder with pyromania, pathological gambling and kleptomania, and includes the criterion of an increasing sense of tension before pulling the hair and gratification or relief when pulling the hair. However, some people with trichotillomania do not endorse the inclusion of “rising tension and subsequent pleasure, gratification, or relief” as part of the criteria;   because many individuals with trichotillomania may not realize they are pulling their hair, patients presenting for diagnosis may deny the criteria for tension prior to hair pulling or a sense of gratification after hair is pulled.

Trichotillomania has been hypothesized to lie on the obsessive–compulsive spectrum, which is proposed to encompass obsessive–compulsive disorder, nail biting (onychophagia) and skin picking (dermatillomania), tic disorders and eating disorders. These conditions may share clinical features, genetic contributions, and possibly treatment response; however, differences between trichotillomania and OCD are present in symptoms, neural function and cognitive profile. In the sense that it is associated with irresistible urges to perform unwanted repetitive behavior, trichotillomania is akin to some of these conditions, and rates of trichotillomania among relatives of OCD patients is higher than expected by chance. However, differences between the disorder and OCD have been noted including differing peak ages at onset, rates of comorbidity, gender differences, and neural dysfunction and cognitive profile. When it occurs in early childhood, it can be regarded as a distinct clinical entity.

Because trichotillomania can present in multiple age groups, it is helpful in terms of prognosis and treatment to approach three distinct subgroups by age: preschool age children, preadolescents to young adults, and adults.

Trichotillomania is often not a focused act, but rather hair pulling occurs in a “trance-like” state; hence, trichotillomania is subdivided into “automatic” versus “focused” hair pulling. Children are more often in the automatic, or subconscious, subtype and may not consciously remember pulling their hair. Other individuals may have focused, or conscious, rituals associated with hair pulling, including seeking specific types of hairs to pull, pulling until the hair feels “just right”, or pulling in response to a specific sensation. Knowledge of the subtype is helpful in determining treatment strategies

Symptoms:
Trichotillomania is usually confined to one or two sites, but can involve multiple sites. The scalp is the most common pulling site, followed by the eyebrows, eyelashes, face, arms, legs, and pubic hairs. The classic presentation is the “Friar Tuck” form of vertex and crown alopecia. Children are less likely to pull from areas other than the scalp.

Individuals with trichotillomania exhibit hair of differing lengths; some are broken hairs with blunt ends, some new growth with tapered ends, some broken mid-shaft, or some uneven stubble. Scaling on the scalp is not present, overall hair density is normal, and a hair pull test is negative (the hair does not pull out easily). Hair is often pulled out leaving an unusual shape; individuals with trichotillomania may be secretive or shameful of the hair pulling behavior.

An additional psychological effect can be low self-esteem, often associated with being shunned by peers and the fear of socializing due to appearance and negative attention they may receive. Some people with TTM wear hats, wigs, wear false eyelashes, eyebrow pencil, or style their hair in an effort to avoid such attention. There seems to be a strong stress-related component. In low-stress environments, some exhibit no symptoms (known as “pulling”) whatsoever. This “pulling” often resumes upon leaving this environment. Some individuals with TTM may feel they are the only person with this problem due to low rates of reporting.

Other medical complications include infection, permanent loss of hair, repetitive stress injury, carpal tunnel syndrome, and gastrointestinal obstruction as a result of trichophagia. In trichophagia, people with trichotillomania also ingest the hair that they pull; in extreme (and rare) cases this can lead to a hair ball (trichobezoar). Rapunzel syndrome, an extreme form of trichobezoar in which the “tail” of the hair ball extends into the intestines, can be fatal if misdiagnosed.

Environment is a large factor which affects hair pulling. Sedentary activities such as being in a relaxed environment are conducive to hair pulling. A common example of a sedentary activity promoting hair pulling is lying in a bed while trying to rest or fall asleep. An extreme example of automatic TTM is found when some patients have been observed to pull their hair out while asleep. This is called sleep-isolated trichotillomania.

Signs and symptoms of trichotillomania often include:

*Repeatedly pulling your hair out, typically from your scalp, eyebrows or eyelashes, but it can be from other body areas as well
*A strong urge to pull hair, followed by feelings of relief after the hair is pulled
*Patchy bald areas on the scalp or other areas of your body
*Sparse or missing eyelashes or eyebrows
*Chewing or eating pulled-out hair
*Playing with pulled-out hair
*Rubbing pulled-out hair across your lips or face

Causes:-
The cause of trichotillomania isn’t known. Most experts believe it’s a type of obsessive-compulsive disorder, but there may be a hereditary element. Some blame environmental pollution, streptococcal infections, or even deficiencies of brain or body chemicals and nutrients.

The answer probably lies somewhere between pleasant habit and a reaction to stress, at least in terms of the initial trigger. People often start by pulling out damaged hairs to relieve an itch or a follicle, but as the habit progresses they may lose any reason for it.

Risk Factors:
These factors tend to be associated with trichotillomania:

*Family history. Susceptibility to trichotillomania may be inherited.

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*Age. Trichotillomania usually develops during adolescence — most often between the ages of 11 and 13 — and is often a lifelong problem. Children younger than age 5 also can be prone to hair pulling, but this is usually mild and goes away on its own without treatment.

*Sex. Although far more women than men are treated for trichotillomania, this may be because women are more likely to seek medical advice. In early childhood, boys and girls appear to be equally affected.

*Negative emotions. For many people with trichotillomania, hair pulling is a way of dealing with negative or uncomfortable feelings, such as stress, anxiety, tension, loneliness, fatigue or frustration.

*Positive reinforcement. People with trichotillomania often find that pulling out hair feels satisfying and provides a measure of relief. As a result, they continue to pull their hair to maintain these positive feelings.

*Other disorders. People who have trichotillomania may also have other disorders, including depression, anxiety, obsessive-compulsive disorder or eating disorders. Nail biting and skin picking have also been associated with trichotillomania.

 

Diagnosis:
Patients may be ashamed or actively attempt to disguise their symptoms. This can make diagnosis difficult as symptoms are not always immediately obvious, or have been deliberately hidden to avoid disclosure. If the patient admits to hair pulling, diagnosis is not difficult; if patients deny hair pulling, a differential diagnosis must be pursued. The differential diagnosis will include evaluation for alopecia areata, tinea capitis, traction alopecia, and loose anagen syndrome. In trichotillomania, a hair pull test is negative.

A biopsy can be performed and may be helpful; it reveals traumatized hair follicles with perifollicular hemorrhage, fragmented hair in the dermis, empty follicles, and deformed hair shafts (trichomalacia). Multiple catagen hairs are typically seen. An alternative technique to biopsy, particularly for children, is to shave a part of the involved area and observe for regrowth of normal hairs.

Treatment:
Treatment is based on a person’s age. Most pre-school age children outgrow it if the condition is managed conservatively. In young adults, establishing the diagnosis and raising awareness of the condition is an important reassurance for the family and patient. Non-pharmacological interventions, including behavior modification programs, may be considered; referrals to psychologists or psychiatrists are considered when other interventions fail. When trichotillomania begins in adulthood, it is often associated with other psychiatric disorders, and referral to a psychologist or psychiatrist for evaluation or treatment is considered best. The hair pulling may resolve when other conditions are treated.

Psychosocial:
Habit Reversal Training (HRT) has the highest rate of success in treating trichotillomania. HRT has been shown to be a successful adjunct to medication as a way to treat TTM. With HRT, doctors train the individual to learn to recognize their impulse to pull and also teach them to redirect this impulse. In comparisons of behavioral versus pharmacologic treatment, cognitive behavioral therapy (including HRT) have shown significant improvement over medication alone. It has also proven effective in treating children. Biofeedback, cognitive-behavioral methods, and hypnosis may improve symptoms.

Medication:
Medications can be used. Treatment with clomipramine (Anafranil), a tricyclic antidepressant, was shown in a small double-blind study to significantly improve symptoms, but results of other studies on clomipramine for treating trichotillomania have been inconsistent. Fluoxetine (Prozac) and other selective serotonin reuptake inhibitors (SSRIs) have limited usefulness in treating TTM, and can often have significant side effects. Behavioral therapy has proven more effective when compared to fluoxetine or control groups. Dual treatment (behavioral therapy and medication) may provide an advantage in some cases, but robust evidence from high-quality studies is lacking.[1] Acetylcysteine treatment stemmed from an understanding of glutamate’s roll in regulation of impulse control

Prognosis:
When it occurs in early childhood (before five years of age), the condition is typically self-limiting and intervention is not required. In adults, the onset of trichotillomania may be secondary to underlying psychiatric disturbances and symptoms are generally more long-term.

Secondary infections may occur due to picking and scratching, but other complications are rare. Individuals with trichotillomania often find that support groups are helpful in living with and overcoming the disorder.

Epidemiology:
Although no broad-based population epidemiologic studies had been conducted as of 2009, the lifetime prevalence of trichotillomania is estimated to be between 0.6% (overall) and as high as 1.5% (in males) to 3.4% (in females). With a 1% prevalence rate, 2.5 million people in the U.S. may have TTM at some time during their lifetimes.

TTM is diagnosed in all age groups; onset is more common during preadolescence and young adulthood, with mean age of onset between 9 and 13 years of age, and a notable peak at 12–13. Among preschool children the genders are equally represented; there appears to be a female predominance among preadolescents to young adults, with between 70% and 93% of patients being female. Among adults, females typically outnumber males by 3 to 1.

“Automatic” pulling occurs in approximately three-quarters of adult patients with trichotillomania

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

 

Resources:

http://www.bbc.co.uk/health/physical_health/conditions/hairpull.shtml
http://en.wikipedia.org/wiki/Trichotillomania
http://www.mayoclinic.com/health/trichotillomania/DS00895

http://www.wattzinternational.com/testimony_j.htm

http://www.noellesalon.com/hair-salon-boston.php?tag=trichotillomania&page=2

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