“But the very hairs of your head are all numbered.” –  Bible, Matthew x. 30  

According to The Webster Dictionary trichotillomania (pronounced: trik-oh-till-oh-may-nee-ah) is an abnormal desire to pull out one’s own hair whether it be the scalp, eyebrows, eyelashes or other part of the body.  It leads to noticeable hair loss, significant distress, and can often result in both social and functional impairment.  It can vary greatly in severity and treatment response.  For many the hair pulling is highly focused and absolutely intentional.  They are completely aware of the behavior, and may develop highly sophisticated rituals for doing so.  Yet for others the hair pulling is done unconsciously.  For some hair pulling can be relatively mild and somewhat easily controlled with nothing more than awareness and additional concentration to cease the action.  For others however the urge to pull hair can be so intense and all-consuming that it becomes almost impossible to think about anything else.

Sufferers of this disorder generally pull hair in private, and will often take extreme measures in order to deny and hide their affliction by masking their hair loss by wearing hats and scarves, wearing false eyelashes, and even fake eyebrows.  The term, first used by the French dermatologist François Henri Hallopeau, comes from the Greek: trich- (hair), till(en) (to pull), and mania (An excessive or unreasonable enthusiasm or desire).  It is characterized as an Impulse Control Disorder, a group of disorders in which a person acts uncontrollably on a specific impulse that is potentially harmful, but they are powerless to resist.

The signs and symptoms of trichotillomania often include:

• An intense feeling of mounting tension before pulling hair, or when trying to resist the urge to do so.
• The repetitive pulling out of your hair from the scalp, eyebrows, eyelashes, or some other part of the body.
• The inability to resist the urge to pull out your own hair.
• A strong sense of relief or gratification either while and/or just after acting on the impulse to pull hair.
• Bare patches where hair has been pulled out including sparse or missing eyebrows and/or eyelashes.
• Playing with pulled out hair.
• Rubbing the pulled out hair across the face or lips.
• Pulling the hair between the teeth, chewing, or eating pulled out hair (known as trichophagia).

Although the specific cause of trichotillomania is not known it is believed to involve both behavioral and biological factors.  An imbalance in brain chemicals, known as neurotransmitters, which facilitate the sending of messages between nerve cells, appears to be at the root of the problem.  This imbalance, in particular areas of the brain, can affect the brains ability to control impulses thus leading to the hair pulling behaviors as well as other types of impulse control problems.  We also know that people with trichotillomania find the behavior to be self-soothing, not at all painful and thereby use it as a coping mechanism against anxiety and other challenging emotions.  Some sufferers also have other mental health disorders such as anxiety and depression.  Furthermore, the likelihood of developing trichotillomania is somewhat higher in individuals who have first degree relatives with the disorder.

The following have been linked to the development of trichotillomania:

• Gender – Although in childhood males and females appear to be equally afflicted, in adulthood women are much more likely to be treated for the disorder.  This, however, may be as a result of women being under greater social pressure relative to observable hair loss.
• Age – Trichotillomania typically develops during adolescence, and is often a lifelong struggle.
• Heredity – A family history of trichotillomania appears to increase the likelihood of acquiring the disorder.
• Negative feelings – Hair pulling helps sufferers deal with uncomfortable and negative feelings (anxiety, frustration, loneliness, etc.).
• Associated disorders – Other psychiatric disorders such as obsessive-compulsive disorder (OCD), depression, anxiety disorders, and eating disorders have been associated with trichotillomania.

As a result of the social stigma associated with the disorder, trichotillomania often goes unreported.  As such its lifetime prevalence can only be estimated to be approximately 1% overall with females being almost twice as likely to suffer from the disorder.  Although trichotillomania can occur at any age, including very young children, its onset is most often observed during pre-adolescence (ages 9-13).  The actual triggers for the disorder are widely varied, but oftentimes is the result of sensory experiences such as scratchy eyelashes, itchy scalp, or stressful life events.  It can develop over a long period of time, but can also occur rather suddenly.

Beyond the social stigma there are several complications that further negatively impact those who suffer from trichotillomania.  Constant hair pulling can often lead to skin abrasions, infections, and permanent hair loss.  For those who engage in trichophagia there is also the risk of developing trichobezoars (hair balls in the stomach and/or intestine) which can cause significant nausea and vomiting, pain, weight loss, bleeding, and even intestinal obstruction.  Trichobezoars may actually require surgery to remove.

Treatment of trichotillomania can often be difficult and lengthy.  Treatment options and interventions are often based on the patient’s age of onset.  Most very young patients, those in pre-school and early elementary school, are often managed rather conservatively as they will often outgrow the behavior without the need for significant intervention.  In older children and young adults accurate diagnosis, education, and reassurance, for both the patient and their family, are critical pieces of the treatment puzzle.  Adult onset of trichotillomania is very often associated with other psychiatric conditions and as such a thorough psychiatric evaluation should be strongly considered.

The use of Cognitive-Behavioral Therapy (CBT) and behavior modification interventions has been demonstrated to be very effective in this age group.  A specific form of behavioral therapy known as habit reversal training (HRT) has been demonstrated to be particularly effective in treating this disorder.  In utilizing habit reversal training the patient is first taught to identify where and when the hair pulling urge is experienced.  They are then instructed in specific relaxation techniques to diminish the tension associated with the desires to pull hair, thereby paving the way for the patient to develop different more effective behaviors, knows as a competing response, to apply when the urges appear.  In comparing the effectiveness of CBT, and HRT in particular, with medication treatments the behavioral therapies were shown to demonstrate significant improvement over the use of medication alone.  HRT has however been shown to be an effective add-on intervention to medication in treating trichotillomania.  Medications, in particular the selective serotonin re-uptake inhibitors (SSRIs), may be particularly effective in helping relieve the symptoms of the disorder.

There are a number of highly qualified and capable Cognitive-Behavioral therapists and psychiatrists within the Tri-Counties with extensive experience who can effectively assist in treating trichotillomania.