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Trichotillomania (Hair-Pulling Disorder)

Definition :
For better or worse, hair is often associated with beauty and vitality. That's why trichotillomania can be so emotionally painful for those who struggle to overcome the condition.

Trichotillomania is a type of mental illness in which people have an irresistible urge to pull out their hair, whether it's from their scalp, their eyebrows or other areas of their body. Hair pulling from the scalp often leaves them with patchy bald spots on their head, which they may go to great lengths to disguise.

Trichotillomania (trik-o-til-o-MAY-ne-uh) is sometimes called hair-pulling disorder, trich or pulling. Although trichotillomania may seem like an obsession or compulsion, it's actually classified as a type of impulse control disorder — a disorder in which you can't resist a temptation or drive to perform an act that's harmful to you or someone else. Behavior therapy can help you gain awareness about your hair-pulling habits and learn techniques to avoid pulling.

Causes :
Causes of trichotillomania are still being researched, and no specific cause has yet been found. Causes may include :
  • Genes. In 2006, researchers reported finding mutations in a specific gene that may give rise to trichotillomania. This mutation may cause neurons in the brain to develop faulty connections that trigger an urge to pull out your hair. However, these gene mutations are thought to play a role in only a few trichotillomania cases.
  • Neurochemical problems. Some studies suggest that abnormalities in the natural brain chemicals serotonin and dopamine may play a role in trichotillomania.

Risk Factor :
Best estimates suggest that anywhere from less than 1 percent to 3.4 percent of the population has trichotillomania. Both children and adults can develop the disorder. Trichotillomania typically develops very early in childhood, such as before age 2, or around the time of adolescence. In adults, the disorder often first develops in their 20s.

Certain factors that may increase the risk of developing or continuing trichotillomania include :

  • Hair features. Some people who pull out their hair say that a particular color, such as gray hairs, a particular shape, such as curly hairs, or a particular texture, such as coarse hairs, triggers an urge to pull out those hairs.
  • Certain thoughts. Thinking that gray hairs are bad or that your eyebrows aren't symmetrical may prompt you to pull them out.
  • Negative moods. Anxiety, tension, loneliness, fatigue, frustration and similar moods may trigger hair pulling.
  • Situations. People are more likely to engage in hair pulling while watching television, talking on the phone, reading, sitting at work or in a classroom, driving, or being in the bathroom.
  • Positive reinforcement. Because some people find that rubbing pulled hair against their face or lips feels good, or that pulling out hair feels satisfying, they may continue to pull their hair to seek that kind of positive reinforcement.
  • Negative reinforcement. Hair pulling can be a way to distract yourself from unpleasant or negative thoughts, such as stress, tension, anxiety or boredom. Because this distraction feels better than experiencing negative thoughts or moods, it encourages continued hair pulling.

When to seek medical advice :
Most adults with trichotillomania are aware that they're pulling their hair out, even if they don't understand what drives them to do it. Unfortunately, many people with the disorder live in secret shame and fear. They may avoid situations that could lead to discovery, such as swimming or windy days. They may wear wigs, style their hair in a way to disguise bald patches or wear false eyelashes. Their relationships and social lives may suffer.

If you can't control your hair pulling and it's affecting your quality of life, talk to one of your health care providers for help. In some cases, people first pay a visit to their dermatologist for help because they don't know why they've developed hair loss.

Symptoms :
Signs and symptoms of trichotillomania include :
  • Patchy bald areas on the scalp or other areas of the body
  • Sparse or missing eyelashes or eyebrows
  • Chewing or eating pulled out hair
  • Playing with pulled-out hair
  • Rubbing pulled-out hair across the lips or face

Most people with trichotillomania pull hair from their scalp. But eyebrows and eyelashes may also be pulled, as well as hair from the legs, arms, pubic area or other parts of the body. Hair pulling is usually done with the fingers. But sometimes tools are used, such as tweezers, brushes and combs.

For some people, hair pulling is intentional and focused. They're aware that they're pulling their hair out while they're doing it, and they may even develop elaborate rituals around hair pulling. But for others, hair pulling is so automatic or habitual that they may do it unconsciously — they don't realize that they're doing it.

Diagnosis :
Your health care provider will perform a thorough evaluation to determine if you have trichotillomania. Some people aren't aware that they're plucking out their own hair. They may visit their dermatologist because they believe there's something wrong with their hair. Others know they pull but try to hide their behavior from their doctor out of shame. Your dermatologist may need to take a biopsy of your hair or skin to try to pinpoint the problem. A biopsy that shows certain patterns of damage to your hair offers clues about how it's being damaged. Your dermatologist or primary care doctor may also refer you to a mental health professional for further evaluation and treatment.

To help diagnose trichotillomania, your doctor will ask you questions about your hair-pulling habit, such as frequency, duration and amount of hair loss. Your doctor may also check for other related medical problems, such as depression, anxiety or repetitive-strain injuries from repeated pulling.

To be diagnosed with trichotillomania, someone must meet the criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health professionals to diagnose mental conditions and by insurance companies to reimburse for treatment.

Criteria for diagnosis of trichotillomania include :

  • Repeatedly pulling out your hair, resulting in noticeable hair loss
  • An increasing sense of tension before pulling, or when you try to resist pulling
  • Pleasure or relief when pulling
  • Your hair loss isn't attributed to another medical or dermatologic condition
  • Hair pulling causes you significant distress

However, there is some debate among mental health professionals about these criteria, and it's possible they could change in the future.

Complications :
Although it may seem hard to believe, trichotillomania can actually be life-threatening in rare cases. That's because some people with the disorder eat their hair after pulling it from their scalp. This hair is indigestible and may lodge in the stomach. Over a period of years, it may cause a trichobezoar — a large, matted hairball. This hairball can cause weight loss, vomiting, intestinal obstruction and even death.

Other complications are more common, however. Physically, the most noticeable complication is hair loss. Hair pulling can result in permanent damage to hair follicles, which means the hair may not be able to regrow normally. Scalp irritation and sores also are possible. In addition, trichotillomania can result in repetitive-strain injuries, such as carpal tunnel syndrome, because of the repetitive movements involved in pulling out hair.

Many people with trichotillomania learn to live with and accept the condition. But for others, trichotillomania can ruin their quality of life. They may avoid social outings, swimming, getting haircuts and windy weather, for fear of being found out. Many people with trichotillomania also have a great deal of shame, humiliation and embarrassment, as well as low self-esteem, depression, anxiety and feelings of being unattractive. Some may consider suicide.

There's little research about treatment of trichotillomania because it's only been formally recognized as a disorder since the late 1980s. However, two main treatments stand out :

  • Psychotherapy. Studies have shown that a form of psychotherapy called cognitive behavior therapy (CBT) is the most effective treatment for trichotillomania. CBT teaches you to become more aware of pulling, helps you monitor your pulling habits and helps you reverse the habit of pulling. You also learn about what emotions and triggers are involved in hair pulling. When you gain awareness of pulling, you can learn to substitute other behaviors instead.
  • Medications. Medications such as antidepressants are sometimes used to treat trichotillomania. In particular, some studies have shown clomipramine (Anafranil) to be the most effective medication. Clomipramine is a tricyclic antidepressant approved to treat the obsessions and compulsions of obsessive-compulsive disorder (OCD), but it's often used to treat other conditions as well. Studies have shown that medications may work best when combined with cognitive behavior therapy.

Treatment of trichotillomania can be challenging. It can be difficult to overcome the urge to pull, but ultimately you may be able to regain control to reduce or stop your hair pulling.

Because the exact cause of trichotillomania isn't known, there's no specific way to prevent it from developing. Researchers are beginning to identify mutations in genes that may play a role, and this eventually may lead to prevention or better treatments. Getting treatment at the earliest sign of a problem may help prevent the condition from worsening.

Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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