Hair Pulling – Is It Taken Too Lightly?

Hair Pulling - Is It Taken Too Lightly

Hair pulling carries a tongue-twisting name: trichotillomania. The disorder is not widely recognized by the public or by mental health professionals. People with trichotillomania suffer in silence. They tend to avoid getting help because they feel ashamed. Many have had the problem since childhood or adolescence.

What is Trichotillomania?

Trichotillomania is considered an impulse control disorder. The person is unable to resist hair-pulling. People pull hair from their scalp, eyebrows, eyelashes or pubic area, which can leave noticeable bald spots. As with other impulse control problems, trichotillomania sufferers feel tension building up beforehand. Then they may feel a sense of relief from uncomfortable feelings or even pleasure when pulling their hair.

Trichotillomania ranges in severity from very mild to incapacitating and affects up to 3 in every 100 people. At the most severe end of the spectrum, a person pulls hair most or all of the time. Women seem twice as likely as men to have the disorder. But this may be an overestimate because men are probably half as likely as women to get treatment.

The symptoms of trichotillomania may come and go. There can be long periods where the disorder is quiet, only to return when a person is under stress.

Some people with trichotillomania report hard-to-describe sensations just from the area they are pulling from. Others say the sensation is more like an overall feeling of physical or mental anxiety. A significant number of people with trichotillomania pull all of the hair from the area they have targeted, causing total hair loss.

Shame – Perhaps the Worst Problem of All

Hair-pulling can be terrible to live with. Because it affects a person’s appearance, hair-pullers often feel very embarrassed. Some avoid close relationships, refuse to take vacations or go out in public. The illness can interfere with school and work performance. People with trichotillomania tend to have low self-esteem and feel less satisfied with their lives. Many become anxious or depressed, or they turn to cigarettes, alcohol or drugs for relief. Treatment can ease these problems, but all too often people who pull their hair suffer alone.

Besides the obvious hair loss and skin or scalp irritation, people with trichotillomania can experience other physical problems:

  • Carpal tunnel syndrome from repetitive hand and wrist motions
  • Dental problems resulting from eating pulled hair
  • A build-up of swallowed hair called a trichobezoar, which causes pain, nausea, vomiting, or — if it grows large enough — a dangerous obstruction requiring surgery; death, though very rare, can occur

What Causes Trichotillomania?

Researchers don’t know what causes trichotillomania, but many think it’s related to obsessive compulsive disorder (OCD). Neuroscientists have suggested that people with trichotillomania have trouble putting the brakes on motor behavior. They also may have more trouble than average shifting from one task to another — a capacity of the brain called “cognitive flexibility.” These observations suggest that there’s a problem in the connection between the frontal lobe — the part of the brain involved in planning and reasoning — and the striatum, which is involved in regulating action.

In one study, researchers found that people with trichotillomania have small differences in the size of the cerebellum, the part of the brain that looks as if it were suspended behind the brainstem. The cerebellum also helps regulate movement.

These findings are preliminary, but lend hope that we can better understand the biology of this behavior and develop effective treatments.

Does Treatment Work?

According to research, a form of cognitive behavior therapy called habit reversal training (HRT) is the most effective treatment at the moment for trichotillomania. An HRT therapist trains the individual to pay closer attention to the symptom, noting situations when hair-pulling is most likely to occur. The person then tries to replace the habit with a competing motion that makes the hair-pulling impossible, such as clenching the fist and pressing it against the side of the body. HRT can be supplemented by relaxation techniques, support and encouragement. Unfortunately, symptoms often come back after treatment ends.

Most psychiatrists treat trichotillomania with medications for OCD. They often start with selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac) and sertraline (Zoloft), or with the older tricyclic antidepressant, clomipramine. If one drug alone is not helpful, then the psychiatrist will usually try a combination of drugs, such as an SSRI plus clomipramine or an SSRI with an antianxiety drug, a mood stabilizer, an antipsychotic or even a stimulant.

Right now there is no evidence that one medication is better than another, or that any medication is better than a placebo (dummy pill). One recent article showed that a combination of psychotherapy and medication provided the most relief.

Psychiatrists may be pulling whatever they can out of their medicine bags to treat trichotillomania. But when trichotillomania is severe, the suffering makes it very difficult to live a productive or satisfying life. Even as neuroscientists work to learn more about the causes of the disorder, doctors and patients need to keep trying things that offer the possibility of relief, keeping in mind the risks or side effects.

Living with Trichotillomania

It is important not to underestimate the suffering this disorder causes.

Even if the hair-pulling itself is not significantly improved with treatment, the anxiety and depression that go along with trichotillomania can be effectively treated. Psychotherapy can lend support and help a person cope with shame. And in the age of the Internet, support groups, and other resources are easier to find.

Despite the limits of our knowledge about the causes and the treatment of trichotillomania, there does seem to be growing awareness of the problem, which brings hope that better treatments are on the way. In the meantime, getting past the shame and living a full life with the disorder may be the best treatment of all.

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