What is Trichotillomania?
Trichotillomania (TTM) or hair-pulling, has been observed for thousands of years as an aberrant behaviour that often occurs in times in stress, boredom, or frustration. Initially characterized as a rare, untreatable disorder, TTM is now recognized as a relatively common disorder for which several treatment options exist.
TTM is classified in the Diagnostic and Statistical Manual of Mental Disorders (4th edition) (DSM-IV) as an “impulse-control disorder not elsewhere classified” (APA, 1994, p609), and is characterized by the repeated pulling out of one’s hair from any part of the body resulting in noticeable hair loss.
The most common hair-pulling sites are the scalp, eyelashes, eyebrows, pubes, face and extremities. Anxiety virtually always accompanies the illness, with many people describe the hair-pulling as relieving this anxiety.
On the other hand, complications such as fear of losing control and becoming completely bald can cause an extreme heightening of their anxiety. The hair-pulling is generally not painful and may be engaged in from minutes to hours a day and is often done when alone.
TTM has a reported prevalence of 2.0% to 2.5% in the United States. Despite increasing research and clinical focus on TTM locally, the prevalence of TTM in South Africa is not known. Nevertheless, the true prevalence of TTM worldwide may in fact be higher than the US rates indicate as many patients with TTM are very secretive about the disorder.
TTM seems to be more common in women than men: 75% to 93% of clinic patients with TTM are women. This female preponderance may be due (in part) to women’s greater willingness to seek medical care. While TTM can begin at any age, the common age of onset is puberty.
Parents or other family members rarely understand the truly compulsive nature of the problem (saying something like “why don’t you just stop?” or in fact punishing them for hair-pulling) and can add to the person’s feelings of low self-worth.
In addition to the shame and humiliation felt over the inability to control the urges to pull their hair, the sufferer may have to endure ridicule by others – often leading to their avoidance of intimate relationships for fear of having their shameful secret exposed.
As such, TTM contributes to a lifetime of significantly decreased quality of life. Furthermore, TTM appears to be commonly associated with other problematic behaviours (such as nail biting, skin picking, picking at acne, nose picking, lip biting and cheek chewing) as well as other mood, anxiety and substance use disorders.
What causes hairpulling?
There is no one certain cause of TTM. Onset of hair-pulling has been suggested to be associated with a stressful life event such as illness, injury or parental divorce. However, in many cases there is no identified traumatic event or precipitating factor. Family dynamics and modelling may also play a role in the initiation of this disorder. The role of genetic factors in the aetiology of TTM is also being investigated. More recent work suggests that there may be some disruption in the system involved with one or more of the chemical messengers (i.e. serotonin, dopamine) between the nerve cells of the brain. Involvement of the serotonergic and dopaminergic neurotransmitter systems is currently being investigated locally and internationally. This investigation of a genetic basis for TTM is further encouraged by recent findings that genetic variants play a role in disorders with significant phenomenological and neurobiological similarities with TTM, e.g. obsessive-compulsive disorder.
How is Trichotillomania treated?
At this stage, different treatments may need to be tried before finding the one that works. Treatments can be divided into three major groups: medication, behavioural techniques, and hypnotherapy.
The so-called selective serotonin reuptake inhibitors (SSRI’s) have been the most extensively studied medications in TTM, and are currently the first-line pharmacotherapy.
Unfortunately, it has been suggested that the effectiveness of SSRI’s in patients with TTM may wane with time, i.e. treatment with SSRI’s is often associated with a high relapse rate. Still, SSRI’s are a reasonable first-line agent because of their efficacy in several patients, their favourable side-effect profile, and their efficacy in treating comorbid conditions such as depression and obsessive-compulsive disorder.
Several lines of evidence suggest that the anticonvulsant topiramate might also be effective in the treatment of TTM. The efficacy of this medication is currently under investigation.
In terms of behaviour therapy, habit reversal is the treatment of choice. This method consists of behavioural monitoring, relaxation training, and competing reaction training (substituting a competing behaviour such as clenching a fist in response to the urge to pull hair). One study has suggested that behaviour therapy may be superior to treatment with SSRI’s for reducing the symptoms of TTM.
Hypnotherapy has been used in the treatment of TTM, either alone or in combination with another form of therapy, and it has been suggested that hypnosis can bring effective results. Hypnotherapy commonly includes regression to the age of TTM onset to uncover hidden conflicts, relaxation to relive tension, and suggestion to increase awareness and control of hair-pulling.
This treatment method may provide a useful alternative for the patient who refuses medication or is unable to comply with behavioural therapy. It is very important that the therapist implementing hypnotherapy should be adequately trained.
Importantly, even if medical or behavioural treatments are successful in stopping the hair-pulling, the psychological complications (mentioned above) often also require healing with group and/or individual psychotherapy.
As mentioned previously, currently there is a research project undertaken at the MRC Research Unit on Anxiety Disorders (Dept of Psychiatry, Tygerberg), which primarily focuses on the issue of genetic factors in different psychiatric disorders (including TTM) and to the question of susceptibility to these conditions after streptococcal infection. More specifically, this study aims to identify specific genes that contribute to the development of TTM and other similar conditions.
If you need more information on TTM, or are interested in research and want to discuss the matter of participation, the Mental Health Information Centre (MHIC) can be contacted at +27 21 938 9229/9029.
Resources are readily available for patients who wish to learn more about their condition and the available methods for treatment:
Stein DJ, Christenson GA, Hollander E. Trichotillomania. Washington DC: American Psychiatric Press; 1999.
Keuthen NJ, Stein DJ, Christenson GA. Help for Hair pullers. Oakland, CA: New Harbinger Publications: 2001.
Goldfinger GR. The Hairpulling Habit and You: How to Solve the Trichotillomania Puzzle. Washington, DC: Writers’ Cooperative of Greater Washington; 1999.
Amanda’s Trichotillomania Guide
Written by Christine Lochner (Clinical Psychologist), MRC Unit for Anxiety Disorders