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TRICHOTILLOMANIA
This article is published for general information. It is not intended as an aid to self diagnosis. If you are suffering this condition, professional advice should be sought. The Society lists practitioners in some countries.
Symptoms: Thinning hair or balding patches which may present as:
i) red indurated or excoriated scalp with visible hair follicles.
ii) normal scalp bearing short hairs which have escaped epilation.
Trichotillomania is a rare form of alopecia caused by the recurrent uncontrolled self inflicted epilation of hair e.g. scalp hair, eyelashes, eyebrows or other body hair.
Scalp hair is most commonly involved. This may produce noticeable hair losses e.g.one or more bald patches or sparse hair covering over large areas of scalp.
General comment.
Patients may experience a sense of tension immediately before bouts of epilation, or when attempting to resist the behavior.
The act of epilation itself may promote:
i) Sensations of pleasure and gratification.
ii) Clinical distress initiated by the uncontrollability of the habit or the visible damage caused.
Aetiology
The onset in boys occurs at age 7-9 years, and in girls at age 10+. Females are generally more prone to the disease which may be associated with stress levels at home or at school.
Of concern to trichologists: scalp hairs repeatedly epilated may eventually fail to regrow.
Treatment
Stop doing it ! - which is far easier said than done.
Treatment should be directed at any identified underlying cause - not the symptom. Many children outgrow the habit without major intervention. With others the habit more seriously continues into adult life. There may be deep psychological implications in many such cases which could benefit from referral to a hospital specialist e.g. psychotherapy. In general recovery requires a willing patient.
The Society lists practising trichologists who may be consulted.
© 2002 - Barry Stevens FTTS
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FURTHER CONSIDERATIONS by Carly Kent
Trichotillomania.
Trichotillomania is an impulse control disorder characterized by the repetitive pulling of hair. It may involve areas of the scalp, eyebrows, eyelashes, facial or pubic hair.
This disorder was first described by French dermatologist, Francois Henri Hallopeau in 1885. In 1889 the condition was termed ‘Trichotillomania’ deriving from the Greek for ‘trich’ meaning hair, ‘till’ meaning to pull and ‘mania’ representing an insanity.
‘Trichotillomania’ is the plucking of hairs from the eyelashes, eyebrows and scalp.
Trichotillomania will generally resemble habit or addiction. However, it has been classified as an impulse control disorder along with syndromes such as pyromania, kleptomania and also nail biting. There has also been a clinical association made between obsessive compulsive disorder, or OCD, trichotillomania and bipolar. Due to the nature of this condition it is considered to be best treated by psychiatrists.
The disorder can be seen in males and females of all ages, from children through to adults across all ethnic groups. It is typically most prevalent in female adults and adolescents with women being four times more likely to be affected, yet there is an equal sex distribution across children. Recent statistics suggest that it affects one to four percent of the population.
Cause.
Trichotillomania can be subdivided into two categories automatic, or subconscious and focused, conscious hair pulling.
Automatic hair pulling is most commonly seen amongst children and will often occur during times of relaxation for example, whilst watching television, reading or writing. The individual will be unaware of hair pulling and it almost becomes comforting.
Focused or conscious hair pulling is associated with relief often preceded by a mounting sense of pressure or stress. This can be stimulated by an overwhelming sense of anxiety or depression. Such type of hair pulling is predominant in adolescents and adults and can be a result of stress due to work situations, exams or for various social and personal reasons.
Research has suggested that trichotillomania is a psychological problem caused by abnormalities in levels of serotonin and dopamine. Seratonin, or 5-hyydroxytryptamine and dopamine act as neurotransmitters within the brain. Reduced levels of serotonin are responsible for causing depression whilst increased levels promote feelings of anxiety and stress. This makes it the focus of many studies for the treatment of trichotillomania due to connections between chemical imbalances in the brain and hair pulling.
Diagnosis.
An early diagnosis is essential for successful treatment. It is important to understand that many patients will be embarrassed about their condition and will try to conceal or deny it whilst others will be unaware as to the true extent of their disorder.
It is important to differentiate between the possibility of alopecia areata and trichotillomania. This is most successfully achieved by a simple hair pull test. If hairs surrounding the bald area are not removed easily the test is negative and discards the possibility of alopecia areata or loose anagen syndrome.
The image above shows a single bald spot caused as a result of ‘hair pulling’. Its appearance is identical to that of ‘alopecia areata’ which is why correct diagnosis is essential.
Trichotillomania may present in multiple or single areas, ranging from just a few centimetres to possible involvement of the entire scalp. These will very often appear in a well defined geometrical shape. Due to the habitual nature of hair pulling, sufferers will tend to concentrate on the same areas.
On closer inspection the patient may exhibit hair of varying lengths with a combination of broken, shortened or tapered hairs in amongst early re-growth.
Sufferers may also complain of an itching sensation caused by continual hair pulling and eventual irritation to the scalp, this is referred to as pruritis.
Treatment.
The treatment of trichotillomania is best achieved by way of behaviour modification processes such as habit reversal training, stimulus control and self monitoring procedures. With any of these therapies the patient must be motivated with success also being age related. They may be applied as individual courses of treatment or as combination therapies.
Self monitoring is a slightly more complicated process in which the patient is required to establish an awareness of their hair pulling whilst noting any behavioural patterns. This is achieved by manually recording the frequency of hair pulling and monitoring when, where, how they felt and what they were doing at the time it occurred. This allows therapists to work alongside patients to avoid such situations and focus on redirecting the sense of relief created by hair pulling
Stimulus control is particularly effective in younger children with the aid of parental intervention. This treatment simply requires keeping the hands busy in order to reduce times at which hair pulling is most likely to occur for example, whilst watching television. It is a process designed to eliminate, avoid or alter activities or environmental issues, routines or circumstances related to and that may instigate hair pulling.
Habit reversal training has been found to be the most effective form of cognitive behavioural therapy, particularly amongst adolescents and adults. This method allows patients to recognise their hair pulling habits and redirect it by applying a competing response such as fist clenching. The patient is taught specific relaxation techniques to reduce the effects of stress. Habit reversal training may be used alongside a self monitoring process to initially establish the times at which hair pulling is likely to occur.
There is ongoing research into possible forms of medication for trichotillomania, however to date none have been entirely successful. BBC News recently reported on the possibility of a pill containing N-acetylcysteine, an amino acid which acts upon the basal ganglia, the nerve signal transmission system of the brain. Trials are still in the early stages but the success rate is documented to be high.
Antidepressants and hypnotherapy have offered relief to some sufferers; however these have a limited success rate.
Prognosis.
The prognosis for trichotillomania is good if the condition is diagnosed early and the correct and most effective form of treatment is implemented. Medications are generally considered futile whilst behavioural therapies carry a ninety percent success rate if continued to prevent a relapse.
If the disorder is successfully diagnosed in childhood the prognosis is excellent. Any form of intervention is rarely required and the condition resolves itself over a period of time.
Adolescents and adults who have suffered from hair pulling since childhood carry a poor prognosis as habit reversal is very difficult to correct after long periods of time. Behavioural therapies may be successful if the patient is motivated. This also applies to adults who have recently developed this condition and with an early diagnosis hair pulling is reversible.
It is possible for those suffering from trichotillomania to also develop a condition known as trichophagia. This is an extremely dangerous disorder in which the sufferer ingests the plucked hairs. Trichophagia will eventually result in the appearance of hairballs in the stomach or large intestine.
© 2010 Carly Kent
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