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Trichotillomania

Trichotillomania, also known as hair pulling disorder (HPD), is a psychiatric illness affecting up to 4% of the population. The disorder is most notably categorized by repetitive, noncosmetic removal of hair that is accompanied by distress and/or functional impairment. The onset for trichotillomania is typically in early adolescence. Symptoms wax and wane over time and the disorder is typically chronic. Behavioral therapies and medication can help manage symptoms.

Trichotillomania is a body-focused repetitive behavior (BFRB) disorder that involves repetitive removal of body hair. Patients often pull their hair with a mix of different styles, and these styles can change over time. Individuals may pull their hair with less conscious awareness (often accompanied by sedentary activity) or pull due to uncomfortable emotions or sensations. The disorder commonly co-occurs with other BFRBs (i.e., skin picking), obsessive-compulsive disorder (OCD), depression, substance use, and anxiety.

Major Characteristics

There are five main criteria that one must meet to formally be diagnosed with trichotillomania, according to the DSM-5:

• Noncosmetic hair removal: The main criterion for this disorder is that one must repetitively remove hair from anywhere on the body for noncosmetic reasons.

• Multiple attempts to decrease/stop pulling: An individual who pulls his or her hair must have made repeated attempts to decrease or stop hair pulling in order to receive a formal diagnosis of trichotillomania.

• Distress and/or functional impairment: For one to formally be diagnosed with trichotillomania, one must also endorse subjective distress and/or functional impairment as a result of his or her pulling behaviors. Individuals sometimes experience very high levels of distress from their pulling, noting that these behaviors may cause embarrassment, shame, or self-consciousness. If one is not distressed about his or her pulling, there must be evidence of some impairment in one or more areas of life functioning (i.e., work, school, and/or social functioning).

• Not caused by another medical condition: The presence of an underlying medical etiology as the cause of any hair-pulling behavior or depilated areas of the body must be ruled out. For instance, patients may pull hair or scratch certain areas because of dermatological conditions such as psoriasis or eczema, which can cause hair loss. In cases such as these, a diagnosis of trichotillomania would be inappropriate.

• Not caused by another mental disorder: In some cases, individuals will present with hair pulling behavior that resembles trichotillomania; however, the underlying cause will be another mental disorder. For instance, sometimes individuals with OCD will pull out their hair as part of a superstitious ritual to prevent something bad from happening. In cases such as these, one would not diagnose trichotillomania.

Causes

There is no single known cause for trichotillomania. Genetics, as well as environmental factors, likely play a role in the development of the disorder.

What Can Be Done?

Cognitive behavioral approaches are the first-line treatment for trichotillomania and have consistently demonstrated efficacy in research trials. Specifically, Habit Reversal Therapy (HRT) in tandem with stimulus control is utilized.

In a typical course of HRT + stimulus control for trichotillomania, patients will:

• Try to understand the triggers that cause them to pull their hair;

• Develop a competing response that they can do instead of pulling at their hair;

• Identify someone in their life who can serve as a support person (or persons) in encouraging them to engage in this alternative response to pulling;

• Use stimulus control strategies, which include reducing environmental or behavioral triggers that lead to pulling (e.g., disposing of tweezers, not watching TV, covering areas of the body where one is susceptible to pulling hair), making it more difficult to pull (e.g., using Band-Aids or hats) and/or providing alternative sensory reinforcement (e.g., playing with a Koosh ball).

Other behavioral therapy techniques, such as Acceptance and Commitment Therapy (ACT) and Dialectical Behavior Therapy (DBT), likely enhance treatment outcomes by facilitating acceptance of the negative and aversive feelings that give rise to pulling and improved emotion regulation. These strategies are especially important when pulling behavior occurs secondary to uncomfortable internal experiences.

Finally, some medications have been shown to be helpful in treating trichotillomania, although the research is limited. N-acetylcysteine (NAC), a health supplement that can be purchased over the counter and has minimal side effects, has been shown to be effective in treating hair pulling. Antipsychotic medications have also been shown to be effective in some studies; however, given the fact that these medications often have significant side effects, they should typically be utilized only in cases where other treatments have not been helpful. Finally, the type of antidepressants known as SSRIs are often used for individuals with trichotillomania; although they have not necessarily been shown to be effective in cases where hair pulling is the only problem, they can be useful in cases where the individual is also suffering from depression or anxiety, or in cases of treatment failure.

 

Additional Resources

• A compendium of possible tricks at https://www.bfrb.org/learn-aboutbfrbs/treatment/self-help/104-50-ways-to-stop-pulling-your-hair;

• Rubber bands, especially when coupled with some additional mechanism, as described at https://www.psychologytoday.com/us/blog/the-danceconnection/ 201010/unwanted-thoughts-snap-the-rubber-band;

• Consult a self-help book, such as this one featured on ABCT’s Self-Help Book Recommendations: https://www.abct.org/SHBooks/?shTab=1&action=11&vBookID=32;

• And, for some, reducing either the anxiety, stress, or sleep-deprivation that may all contribute to the compensating hair pulling.

 

Getting Help

• Trichotillomania Learning Center (TLC) website (Find a Therapist Section): http://www.bfrb.org/find-help-support/find-a-therapist

• International OCD Foundation website to find a provider that can effectively treat trichotillomania and other BFRBs: https://iocdf.org/find-help

• ABCT’s Find a CBT Therapist: http://www.findcbt.org

• Anxiety and Depression Association of America:

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