TRICHOTILLOMANIA

by Fred Penzel, Ph.D.

Trichotillomania (TTM) is a disorder in which individuals compulsively pull out their own hair to the point of noticeable hair loss. Hair may be pulled from any area of the body the head, eyebrows, eyelashes, the beard or mustache, the torso, arms or legs, or the pubic area. Specific areas of hair may be pulled to the point of baldness, or pulling may take place over a wide area resulting in a general thinning of the hair. Although hair pulling may start in childhood or adolescence, it is not unusual for it to begin in adulthood. Many sufferers have come to believe that they are the only ones who pull out their own hair, however, it is estimated that about 1% of the population suffers from this problem.

The effects of this disorder upon the lives of sufferers can be quite severe. Those who pull from the scalp or the area of the face have the most conspicuous problems. They may have to resort to wearing wigs, eyeglasses that they don't need, elaborate hair arrangements, hats, or headscarves. Many of these sufferers avoid much that others take for granted, such as family social events, relationships, school, and even jobs. Simple activities such as going outside on a windy day, riding in a convertible or on a carnival ride, participating in sports, or swimming, can frequently be off limits. Poor self-image and depression are common among those with TTM. Some have gone as far as to resort to alcohol or drugs to relieve their unhappiness. Many confess to feeling like "freaks" or "weirdoes," and live secret lives. It is bad enough to be missing significant amounts of hair, but it is even worse to know or to have to explain to others that you have done this to yourself. There are sufferers who have gone so far as to tell others that they have cancer and have lost their hair due to chemotherapy.

Pulling may be done deliberately, where the sufferer knowingly stops all activities in order to concentrate upon this activity, or, it can be automatic, where it is done with little awareness while the puller engages in some other activity. This has led some to theorize that there may be two types of hairpulling disorders the deliberate type being more related to Obsessive-Compulsive Disorder, and the automatic type being related to tic disorders such as Tourette's Syndrome. Activities that are most likely to be accompanied by hairpulling would include talking on the phone, watching TV, working on the computer, reading, sitting in the car in heavy traffic, or lying in bed falling asleep. Sufferers commonly report that hairpulling does not produce pain, and that it actually feels pleasurable.

Hair pulling may actually be done for the purpose of self-regulation. It may serve two different functions, both related to helping individuals regulate the way their nervous systems deal with stimulation. When a sufferer is over-stimulated (stressed, or feeling a strong emotion) it can help to soothe the nervous system and help to achieve a more relaxed state. This happens when pullers focus so tightly on the act of pulling (in an almost trancelike way), that they are able to shut everything else out for a period of time. When they are under-stimulated (bored or inactive) it may provide a type of stimulation that their nervous system requires. Most of the areas where hairs grow most abundantly also tend to be rich in nerve endings, so hair pulling can be quite stimulating.

At the present time, there are two treatments that have been shown to be effective in relieving the symptoms of TTM. They are antidepressant medications, and behavioral therapy. Neither treatment is a cure, as TTM is a chronic problem. The potential for it to become active will always be present. The good news, though, is that with proper help, symptoms can be controlled allowing hair to once again grow to a normal length. Some claims have been made for special diets or hypnosis, but neither approach has ever been scientifically proven, and what little information we do have about them is not particularly convincing or promising. Medications used to treat TTM include such drugs as Prozac, Paxil, Luvox, Zoloft, Celexa, Serzone, Effexor, and Anafranil. Occasionally, these drugs may be augmented with a second medication to help them to work better. Augmenting agent such as Risperdal, Zyprexa, Seroquel, Geodon, and Abilify are frequently used for this purpose. The main limitation of medications is that although they seem to work well for some individuals,not everyone responds well to them. Also, if they are your only treatment and you stop taking them, the pulling behavior will soon return.

One main type of behavioral therapy used to treat TTM is known as Habit Reversal Training (HRT), a treatment developed back in 1973 by Dr. Nathan Azrin. It is composed of four steps:

1. Awareness training keeping detailed records of all pulling episodes and their surrounding circumstances.
2. Relaxation training learning to calm one's nervous system and to focus and center oneself.
3. Breathing retraining learning to breathe from the diaphragm to increase relaxation and focus.
4. Competing response training a method of tensing the forearms and hands that is incompatible with pulling.

Steps 2 through 4 make up the actual HRT response that is practiced whenever the sufferer gets the urge to pull. Other additional techniques designed to provide or relieve stimulation may also be incorporated along with HRT. Learning to use HRT can involve much work and practice, and involves a good deal of effort. It can also be used with children as young as eight or nine years old, but would probably be too difficult and frustrating to those who are younger.

TTM is a very complex problem with many inputs, and while HRT is a valuable technique, it is not comprehensive enough to accomplish the task of recovery on its own. For this reason, an approach known as Stimulus Control (SC) should also be employed. SC is a behavioral treatment that seeks to help sufferers identify, and then eliminate, avoid, or change particular activities, environmental factors, emotional states, or circumstances that trigger pulling. It is used to help sufferers consciously control these triggers, and then create new conncections between urges to pull and new, non-destructive behaviors. Using the records that are kept for HRT, information is gathered about these triggers, and then used to modify them, one step at a time. SC and HRT together would appear to make a very effective combination, and seem to be the most effective all-around approach..

The cause of TTM is unknown at this time. Some have theorized that it may be part of the Obsessive-Compulsive Spectrum of disorders, or that it may be an ancient grooming program that resides in the brain, and which has become inappropriately activated. Its basis may be genetic, but this, too, remains to be scientifically studied. Other problems that may be related to TTM include severe skinpicking and nailbiting. There is much that we have yet to learn about this disorder. Only further research will reveal the answers.

If you would like to read more of Dr. Penzel's writings on Trichotillomania, take a look at his self-help book, "The Hair-Pulling Problem: A Complete Guide to Trichotillomania," ) Oxford University Press, 2003. You can find out more about it at
www.trichbook.com