Makes you want to pull your hair out: Treating trichotillomania

One of the saddest, but more treatable, causes of hair loss in patients is trichotillomania, the impulse control disorder in which a person repeatedly pulls out hair from their body for non-cosmetic reasons. While some people have never even heard of trichotillomania, according to the Trichotillomania Learning Center, as many as ten million Americans (or 4% of the U.S. population) suffer from the disorder.

According to the Diagnositic and Statistical Manual of Mental Disorders (DSM), there are five particular attributes of trichotillomania:

  • Recurrent pulling out of one’s hair resulting in noticeable hair loss.
  • An increasing sense of tension immediately prior to pulling out the hair or when attempting to resist the behavior.
  • Pleasure, gratification, or relief when pulling out the hair.
  • The disturbance is not better accounted for by another mental disorder and is not due to a general medical condition such as alopecia areta (patchy hair loss).
  • The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Physical characteristics of trichotillomania can be harder to spot. Individuals with trichotillomania exhibit hair of differing lengths: broken hairs with dulled ends; new, tapered growth; broken strands; and uneven stubble. Scaling is rarely present. Beyond the physical symptoms, deep psychological scars can take hold, with low self-esteem and fear of socializing. Some with trichotillomania also wear hats, wigs, wear false eyelashes, eyebrow pencil, or style their hair to avoid attention that might be put on their hair loss.

Because trichotillomania can resemble other medical conditions associated with hair loss such as alopecia areta, diagnosis of trichotillomania often requires consultation with both dermatological and psychiatric professionals. In some cases, the onset of trichotillomania is caused by alopecia areata itself. Sufferers of trichotillomania may also feel shame about their behavior, thus preventing them from disclosing the condition to those who might best help.

While trichotillomania is thought by many to be a subset of OCD, as with any unique medical condition, there are a number of theories about what the root cause might be.

The Pittsburgh Tribune Review spoke to a number of those who suffer from trichotillomania for a 2007 article. One sufferer, Joan Kaylor, herself a therapist, disputed that trichotillomania should be classified as a subset of Obsessive Compulsive Disorder:

“It is not obsessive-compulsive disorder. When people pull, it’s because they enjoy pulling and they get something out of it. There’s pleasure attached to this. Folks with OCD don’t want to do what they are doing.”

In fact, that same article cited research studies showing that hair pullers experienced a rush of dopamine, the brain’s pleasure chemical. Given this theory, it would be the rush of dopamine that would account for the repeated behavior. Others interviewed cited the easing of anxiety and even thought their own diet might be a contributing factor.

If trichotillomania remains undiagnosed and undisclosed by the sufferer, it can take quite a while for anyone else to recognize it. Those with the disorder tend to pluck one strand at a time, often very gradually over time, so it’s not as if the missing hair presents itself as an immediate missing patch.

Once those suffering from trichotillomania beyond childhood (where it is more common and considered less of a mental disorder) can recognize and share their disorder, it can be treated, if not entirely cured, through a number of measures. According to the Trichotillomania Learning Center (TLC), these have proven to be the most effective techniques:

Cognitive-Behavioral Therapy (CBT). A form of therapy that seeks to alter behavior by identifying the precise factors that trigger hair pulling and learning the skills necessary to interrupt and redirect responses to those triggers. CBT is based on learning theory, which has shown repeating a learned pattern can change the brain’s structure itself. Over time, the learned behavior becomes an automatic response. An example of this would be having a sufferer put bandages on their fingers to impede the pulling. Any CBT should be performed by a psychologist who specializes in CBT.

Medication. As the TLC site states, while no “magic pill” exists for trichotillomania, there are a number of medications that can produce a positive response in sufferers, especially when administered in conjunction with CBT. This can start many of those with trichotillomania on a slow road to recovery that reduces the urge to pull, perhaps eventually leading to total termination of the activity. As with any type of medication, the result can be different for every person, and even short-term cessation doesn’t necessarily guarantee complete inhibition of pulling. Finally, this is definitely one route not recommended for children suffering from trichotillomania.

Alternative treatments. The TLC also suggests dietary changes, meditation, hypnosis, prayer, yoga, and herbal remedies, all of which have been reported to help stem pulling for many individuals. While not proving to meet the same rigorous medical standards as CBT or prescribed medication, each of these has helped sufferers in the past and may well help those in the future. The TLC suggests asking the following questions when considering alternative treatments:

“What do I want to achieve through this treatment (or tool or diet, etc.)?”

“Can it do me any harm? (Please note: Sometimes the answer to this question isn’t obvious. It is especially important to do your own research and consult a doctor if you are going to ingest any medication, herb, vitamin, or alter your diet. Even seemingly benign substances can have harmful effects if ingested in too great a quantity or in combination with certain other conditions or medications.)”

“On what basis do I believe that this treatment will help me?”

“What is the likelihood of this method being useful compared to other options?”

“Can I afford the money, time, or emotional energy involved in pursuing this idea?”

Support Groups. Just about every emotional or psychiatric problem can be helped by talking about it, and trichotillomania is no different. There are many support groups that exist for those who pull their hair to talk about what they are experiencing and finding others who face same struggles. There are even support groups for family members of those with trichotillomania. You can find the support group closest to you on the Trichotillomania Learning Center website.

Again, whether any problem is physical or psychological, the first key in finding a solution is admitting a problem exists, not being ashamed of it, and realizing that solutions exist to impede pulling and eventually eliminate the behavior altogether.

Edwin Suddleson is a surgeon and Assistant Medical Director of Bosley Beverly Hills.

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