Editor's Note: In her new book Life Is Trichy: Memoir of a Mental Health Therapist With a Mental Health Disorder, behavioral therapist Lindsey M. Muller, MS, writes about her own struggles with trichotillomania, a condition in which patients uncontrollably pull out their hair. The disorder is more common than you might think, and Medscape recently interviewed Ms Muller on what exactly trichotillomania is and how to manage it.
Background
Medscape: What is trichotillomania?
Ms Muller: According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), the symptoms of trichotillomania are:
Recurrent pulling out of one's hair, resulting in hair loss;
Repeated attempts to decrease or stop hair-pulling;
The hair-pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning;
The hair-pulling or hair loss is not attributable to another medical condition (eg, a dermatologic condition); and
The hair-pulling is not better explained by the symptoms of another mental disorder (eg, attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder).
Medscape: Can you briefly review the history of the condition? When was it first described, and how has understanding of it has evolved over the years?
Ms Muller: The name of the disorder was coined by French dermatologist François Hallopeau in 1889 and comes from the Greek words trich (hair), tillein (to pull), and mania (madness). However, the disorder was not formally introduced as a disorder and added to the DSM-III-R until 1987.
Classification of the disorder has been vague and questioned by many researchers and clinicians; it has been conceptualized as an obsessive-compulsive spectrum disorder, anxiety disorder, and an impulse control disorder, and most recently it appears under "Obsessive-Compulsive and Related Disorders" in DSM-5. The understanding of the disorder as sometimes present without reported feelings of anxiety and with inclusion of a sensory processing component has greatly altered how the disorder is presented in various DSM versions. From the DSM-IV-TR to the DSM-5, the following changes were made:
Trichotillomania moved from the impulse control disorder category to the obsessive-compulsive and related disorders category;
Criterion B, "an increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior" was removed; and
Criterion C, "pleasure, gratification, or relief when pulling out the hair" was also removed.
Medscape: Whom does trichotillomania affect, and how widely?
Ms Muller: The lifetime prevalence of trichotillomania is estimated to be between 1% and 4% of the overall population. It is expected that this percentage is probably higher owing to the shame and stigma associated with the disorder. Even with increased research and media exposure to shed light on this disorder, many people are still unaware that there is a name for the behavior of hair-pulling.
With regard to gender distribution, the female-to-male ratio is 3 to 1. Again, this statistic is questionable, given that men may underreport symptoms because they shave to "manage" the behavior.
Causes and Treatment
Medscape: Do we know anything about what causes trichotillomania? Are there associated risk factors?
Ms Muller: The etiology of trichotillomania is still unknown. However, we do know there are various factors to consider. Neurobiological research via brain scans demonstrates the structure and functioning of persons with trichotillomania to differ from that of control participants, persons with attention-deficit/hyperactivity disorder (ADHD), persons with tic disorder, and persons with obsessive-compulsive disorder (OCD). There is a genetic component in some cases; we have identified families in which trichotillomania is diagnosed in parent and child, or siblings.
Personality traits (low tolerance to stress, perfectionism, low tolerance to anxiety) are apparent. Sensory processing, such as overstimulation or understimulation from an environmental or physical standpoint, is also relevant when discussing etiology. As in all other mental health disorders, there are exceptions. Additional areas of further research that have been reported include the relationship between pulling urges and sugar consumption, caffeine consumption, and lack of sleep.
Risk factors include family history; age (peak onset is most often between age 11 and 13 years); poor coping mechanisms for emotional regulation; premorbid mental health diagnoses, such as ADHD, OCD, tic disorder, an eating disorder, an anxiety disorder, or depressive disorder; and the personality traits mentioned above.
Medscape: How is trichotillomania treated and managed?
Ms Muller: Empirically validated treatment for trichotillomania includes cognitive-behavioral therapy (CBT) and acceptance and commitment therapy (ACT), which is the third wave of treatment approaches and a branch of CBT. ACT teaches patients to recognize, accept, and embrace urges without acting on them. Behavioral approaches, such as habit reversal, stimulus control, and awareness training, are also used and are efficacious.
Regarding medication, research is not overwhelmingly positive on prescribing medication for trichotillomania. Some patients benefit from use of a selective serotonin reuptake inhibitor in conjunction with psychotherapy, whereas others do not.
There is no cure for trichotillomania, but freedom from it is possible by recognizing the behavior, increasing awareness of the thoughts and feelings driving the urges, understanding that urges are different from behaviors, breaking the habitual cycle of pulling with behavioral interventions, increasing positive coping skills, and incorporating sensory regulation methods.
A Personal Account
Medscape: If you are comfortable doing so, can you tell us a bit about your own struggle with the condition?
Ms Muller: I started with skin-picking and nail-biting from a young age (approximately 4). Over time, these behaviors subsided, and I began pulling my hair in seventh grade until 2008 (when I was 24 years old). It was a daily and constant struggle as I tried to fight the urges day after day. Each time, I would lose the fight. The more I focused on not pulling, the more I pulled.
I tried CBT, many medications, hypnosis, and wearing something on my head at all times. Each tactic seemed to work in the beginning (the placebo effect), but the results never lasted. It was frustrating and disheartening. I felt alone, ashamed, guilty, damaged, and lost.
In 2008, I found freedom from hair-pulling when I came to understand that pulling was a choice. I could not choose whether or not I had an urge, but I could choose what to do with that urge. I waited several years until I felt enough distance and separation from my own struggle before I opened my doors to patients.
Medscape: Do you have any final thoughts for a clinician audience on how to approach this condition and discuss it with their patients?
Ms Muller: For clinicians who may not be familiar with treatment of trichotillomania, it is important to recognize that this disorder is not treated like OCD, but requires specialized understanding and treatment approaches.
And for all clinicians, I would like to share that trichotillomania is almost always a symptom of something else. Treating the behavior as "just a behavior, or just a habit" is not going to address what is underlying the behavior. To really make progress, the following questions should be explored and answered: "What is driving the urges? Where are they coming from?" When treating patients, I tend to view trichotillomania as a messenger or a red flag that something is out of alignment or has gone awry.
Finally, patients may get worse before they get better as personal experiences, deep-rooted emotions, and core beliefs are brought to the surface.
