Trichotillomania

Trichotillomania is a psychological disorder characterised by repetitive pulling out of one’s own hair, resulting in noticeable hair loss (DSM-IV; American Psychiatric Association, 1995). This can be from the scalp, eyelashes, eyebrows, pubic hair or other areas. It is a relatively unfamiliar condition, although it is more common than you might think, affecting 2-4% of the general population. This is about the same proportion of the population as those who suffer from either anorexia or bulimia.

Trichotillomania sufferers often pull hairs out at times when they are experiencing particularly strong emotions, such as anger or stress. However, at the other extreme episodes of pulling may occur at times when the person may feel bored or understimulated, such as when watching TV or lying in bed. At such times the sufferer may not even be aware that they are pulling hairs out.

People often report a feeling of tension or tingling immediately before or when attempting to resist pulling, accompanied by an urge to search for the “right hair” which may feel thicker or rougher than the rest. Pulling the hair out is often accompanied by an immediate release of tension, and feelings of relief or a sense of achievement.



However, this is often shortly followed by further tingling and a renewed urge to search for the next hair. Other behaviours or rituals that are often reported are examining the hair closely after it has been pulled out, rolling the bulb at the base of the hair between fingers or lips and biting it off with the teeth. Sufferers often feel shame as they think that these behaviours are unique to them, when in fact they are a relatively common feature of trichotillomania.

Depending on the number of hairs pulled out, trichotillomania can cause significant hair loss in the form of bald patches. Some people with longer hair are able to cover up these patches so they are not really noticeable, but can still feel incredibly self-conscious about them. It can also prevent them from joining in activities they previously enjoyed such as swimming. The hair loss resulting from prolonged pulling can have a huge impact in terms of feelings of shame, isolation, low self-confidence and problems with intimacy and relationships.

The exact cause of trichotillomania is not known. Some researchers think that it may have a genetic basis. Others propose that it is a normal grooming behaviour that has developed into a habit, the function of which may be to reduce tension or stress, to increase concentration or to combat boredom.

Some research suggests that people may be more likely to develop trichotillomania if they have perfectionist traits and beliefs which fit with an often reported need to pull out “bad” hairs. It has also been suggested that people with difficulty accepting and/or expressing emotions may be more likely to develop a behavioural strategy like trichotillomania. The onset of trichotillomania can often be linked to a particularly stressful life event such as the death of a relative but this is not always the case.

Habit reversal training (HRT) is currently the treatment of choice for trichotillomania and has been found to be more effective than drug treatment, supportive therapy and psychoanalytic therapy. The main components of HRT are self-monitoring, relaxation techniques and practising a competing response.

For the self-monitoring component, clients keep a diary to track their hair pulling episodes, recording details such as when and where they occur and how many hairs were pulled out. This helps build the client’s awareness of their pulling behaviour, and many people are surprised at the patterns that emerge. The diary can also be used to identify what situations trigger episodes of hair pulling so the client can work on eliminating or changing them.



Clients are taught relaxation and controlled breathing techniques to practice daily to reduce their general levels of tension and anxiety, and also to use when they experience an urge to pull. Finally, a competing response is developed together with the client. This is a physically incompatible activity to act as a substitute when the desire for hair pulling occurs, such as squeezing the hands into fists and putting them on the hips.

My approach to trichotillomania is to integrate the HRT techniques described above with what is known as “cognitive restructuring”. This involves working together with the client to identify, explore and challenge any deeply held dysfunctional beliefs they may have, such as that it is wrong to openly express angry feelings. Such beliefs may underlie the development of the trichotillomania itself as a strategy to control certain emotional states, and ironically they probably also contribute to increased levels of tension and stress.

By modifying such rigid, unhelpful beliefs into more balanced and helpful ones, clients can introduce flexibility into their deeper ideas and understandings about themselves, other people and their worlds. This, in turn, should result in improvements in their mood and behaviour.

Like any habit, it takes time and a significant amount of willpower on the part of the client to stop pulling altogether. However, using the above approach I would expect to help the sufferer reduce the frequency, duration and intensity of their pulling episodes to a negligible level in around 18 to 24 sessions.

References

American Psychiatric Association (1995). Diagnostic and Statistical Manual of Mental Disorders (4th edition, Text Revision). American Psychological Association: Washington, DC.

Bloch, M.H., Landeros-Weisenberger, A., Dombrowski, P., Kelmendi, B., Wegner, R., Nudel, J., Pittenberger, C., Leckman, J.F. and Coric, V. (2007). Systematic review: Pharmacological and behavioral treatment for trichotillomania. Biological Psychiatry, 62, 839-846.

Kraemer, P.A. (1999). The application of habit reversal in treating trichotillomania. Psychotherapy, 36, 298-304.

Pélissier, M-C. and O’Connor, K. (2004). Cognitive-behavioral treatment of trichotillomania, targeting perfectionism. Clinical Case Studies, 3, 57-69.