Trichotillomania (Hair Pulling Disorder)

Trichotillomania is often a debilitating psychiatric condition that is characterized by repetitive pulling out of one’s own hair. This recurrent practice eventually leads to hair loss and marked functional impairment. Similar to obsessive-compulsive disorder (OCD), the suffering individual experiences a senseless and uncontrollable urge to pull on their hair. The emotions and sensory stimuli that trigger this behavior vary from person to person. 

Trichotillomania is an impulse disorder that occurs episodically and is unfortunately in most cases chronic and difficult to treat. It typically leaves the affected individual with a compromised body image and a low quality of life. 

How common is this disorder?

According to experts on average 5 to 10 million individuals in the United States (roughly 3.5% of the population) meet the clinical criteria for the diagnosis of trichotillomania. Children presenting symptoms early in life may have a benign and self-limiting disorder compared to individuals presenting in late childhood. The male-to-female ratio in children is almost equal, and increases up to 1:4 in adulthood, although a greater population of females seek medical aid, compared to males. 

The typical age of onset of the condition is consistently reported in multiple studies to be 10–13 years. 

What is the clinical picture of trichotillomania?

Signs of trichotillomania can be observed in any hairy region of the body, but the scalp remains the most common site (72.8%) followed by the eyebrows (56.4%) and the pubic region (50.7%). Patients describe multiple triggers that cause them to pull on their hair, such as: 

  • Sensory stimulus: for example, hair thickness, length, location, and physical sensation of hair on the scalp, 
  • Emotional stimulus: for example, anxiety, boredom, stress, or anger, and 
  • Cognitive stimulus: for example, concerns about hair and appearance, rigid thinking, and cognitive errors, etc. 

According to research, typically most individuals report a variety of these trigger which may even change day to day. Some individuals also report a phenomenon called Automatic pulling or focused pulling, where they are not even aware of their hair pulling behaviour. 

Patients suffering from trichotillomania may also experience low self-esteem, pychosocial dysfunction, and social anxiety, all which further contribute to the habbit. Sadly, studies document that nearly one third of trichotilliomanic sufferers have a low or very low quality of life.  

Trichotillomania is also found to exist with a variety of other psychiatric disorders, such as major depressive disorder (39%−65%), anxiety disorders (27%−32%), and substance abuse disorders (15%−19%). A survey conducted on 894 individuals with trichotillomania reported that 6.0% of the participants used illegal drugs, 17.7% tobacco products, and 14.1% sought alcohol to relieve negative feelings associated with hair pulling. Additionally, 83% of the participants reported anxiety and 70% exhibited signs and symptoms of depression secondary to trichotillomania.  

What complications arise secondary to trichotillomania?

Complications are reported at a very low incidence in patients suffering from trichotillomania, but when they do arise, they are generally secondary infections born as a result of picking and scratching the scalp. Over 20% of the patients swallow their pulled hair (trichophagia) and may experience abdominal discomfort, nausea, vomiting, pallor, or weight loss. The presence of a hairball (trichobezoar) in the gastrointestinal tract can also cause obstruction that may require surgical intervention and be fatal if misdiagnosed.

What are the treatment options?

The treatment of trichotillomania is generally difficult as most of the patients refuse to acknowledge the fact that they have a medical problem and refuse to seek help. Another reason for not seeking treatment is social embarrassment or the misconception that their condition is untreatable. A large-scale study followed 1,048 individuals who met the criteria for the diagnosis of trichotillomania and found that only 39.5% of the subjects had sought treatment from a therapist and only 27.3% had sought treatment from a psychiatrist.  

The appropriate treatment approach is decided upon the age of onset of symptoms, for example in the pre-school age group simple awareness and guidance is offered to parents and that, most of the times, is enough to resolve the situation. On the other hand, in preadolescents to young adults, home therapies may come handy to increase awareness of hair pulling activities, such as for example the use of Band‐Aids on distal index fingers. 

If the patients are unable to benefit from these interventions, treatment modalities including pharmacotherapy, and non-pharmacological therapies such as the behavioral technique of habit reversal, hypnosis, etc, are offered. With timely diagnosis and early and appropriate intervention 50% of individuals experience symptom reduction at least in the short term. 

Pharmacological therapy

Currently, no medication is considered to be the first line of attack in the management of trichotillomania. 

The class of anti-depressants commonly prescribed for trichotillomania is tricyclic antidepressants (TCA) with clomipramine being its most promising agent. A recent review of randomized trials concluded that clomipramine demonstrates some benefit for trichotillomania, however, strong evidence of treatment effects for the SSRIs are still inconclusive. In another double‐blinded study, clomipramine was prescribed to 14 women with severe trichotillomania. The results documented a significant decrease in symptoms over 10 weeks of medication use.

Other agents proposed to be beneficial for trichotillomania include antipsychotic medications (Olanzapine), glutamatergic agents (N-acetylcysteine (NAC), and cannabinoid agonists (dronabinol).

Psychotherapy

Evidence exhibits behavioral therapy to be the preferred form of psychotherapy to tackle trichotillomania. Generally, habit reversal therapy and its components of acceptance and commitment therapy and dialectical behavior therapy show improved outcomes in such patients. 

Habit reversal therapy was initially introduced for the treatment of nervous habits and tics, however, it is now also employed to manage conditions such as OCD and trichotillomania. The two key aspects of habit reversal therapy include self-monitoring, (where the patient is asked to keep track of his/her hair pulling, picking, etc.), and second awareness training, (modifying the environment that reduces cues for hair pulling). This therapy produces results that are generally maintained from 3 to 6 months. Although several combination therapies are typically applied in a clinical setting, the statistical data supports habit reversal therapy as the first-line psychotherapy treatment for trichotillomania. A retrospected review of 63 patients suffering from trichotillomania managed via psychotherapy demonstrated quality scores that were in the moderate to good range.

Adult‐onset trichotillomania may often be associated with other psychiatric disorders, and benefits from the treatment carried out for the co-existing condition. 

 

 

References: 

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