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TRICHOTILLOMANIA
BY:
Danny Duke &
Mary Keeley
What is Trichotillomania?
Trichotillomania is a disorder
characterized by the chronic compulsion of
pulling out one’s own hair.
The word trichotillomania is derived from
the Greek thrix (trich), hair; tillein (tillo), to
pull; and mania, madness or frenzy (mania).
Trichotillomania has historically been
thought of as a rare condition.
Trichotillomania
However, a college survey completed by
Christensen et al in 1991 found that 3.4% of
college females and 1.5% of college males
engaged in hair pulling behaviors.
A similar survey of 700 fresh college
students found that 11 % pulled their hair on
a regular basis for other than cosmetic
reasons. (Rothbaum, 1993)
Trichotillomania
Surveys have reported many different
prevalence rates depending on the how strict
a criteria was used.
Using the more conservative of these two
examples and given a United States
population approaching 300 million, we can
estimate that over seven million people
experience this condition in the U.S. alone.
Trichotillomania
 The manifestation of trichotillomania can
be grouped into three subtypes:
1) A transient form that most often occurs in
young children between 2-6 years of age.
2) A habit form wherein the individual pulls
their hair in an unaware state, usually
while engaged in sedentary activities.
Trichotillomania
3) A form akin to obsessive compulsive
disorder. In this type the individual feels a
compulsion to pull that often leads to seeking
out and consciously pulling hair to relieve a
building sense of tension or anxiety.
In this last form the individual may feel a
compulsion to engage in an associated ritual.
Trichotillomania
Common rituals include:
A need to extract an intact hair bulb.
A need to bite or mince the hair or hair bulb.
Tactile stimulation of lips or face with the hair shaft.
A need to pull the hair in a particular manner.
Placing, saving, or discarding hairs in a ritualistic way.
Twirling, rolling, or examination of the hair.
Searching for hairs that don’t feel right (i.e. too coarse).
Searching for hairs that don’t look right (i.e. color).
A compulsion to make their hairline absolutely even.
Eating (swallowing) their hair
And others.
Trichotillomania
Children:
Occurs about equally for each gender in young
children, then increasingly more girls as they age.
Average age of onset is about 12 years of age.
Children less often report a mounting tension
and release, while more often pulling during
sedentary activities such as watching television,
reading, and lying in bed before falling asleep.
Children are more likely to pull hair from
another person, pets, or dolls.
Trichotillomania
Body areas where pulling can occur along with
associated percentages:
Scalp 75%
Eyelashes 53%
Eyebrows 42%
Pubic area 17%
Beard/face 10%
Mustache 7%
Arm 10%,
Leg 7%
Chest 3%
Abdomen 2%.
Trichotillomania
Trichophagy (injesting hair) can cause
serious medical complications.
Injesting hair can result in trichobezoars
(hairballs) which can cause intestinal
obstruction necessitating surgical removal.
Teeth can become grooved due to the
repeated sliding of hair shafts between them.
Trichotillomania
Most report that pulling of hair does not cause
pain.
Some have thought that those who pull their
hair may have a higher pain threshold. Some
work in this area has found that they do not.
In those that do experience pain it is thought
that such pain may act as an anxiety or tension
reducer through satisfying the CNS need for
stimulation.
Trichotillomania
Trichotillomania has also been thought to be
refractory to treatment.
However with the emergence of cognitive
behavioral therapy (CBT), effective treatment
for trichotillomania now exists. Particularly
when using the behavioral approach, habit
reversal therapy (HRT; Azrin & Nunn, 1973,
1977).
Trichotillomania
An important barrier to treatment is that
those who pull their hair often experience
extreme embarrassment, often failing to seek
treatment.
Most often they neither realize that
effective treatments exist, nor do they realize
that this condition is not uncommon.
Trichotillomania
Many individuals with Trichotillomania
will go to great lengths to hide the evidence
of their condition.
Wigs, elaborate hairstyles, creative
cosmetics, hats, avoidance of water and
wind, etc.
Avoidance behaviors can take the form of
avoiding social situations such as dating, for
fear of being “found out”.
Trichotillomania
Trichotillomania is commonly associated
with young children and adolescents, having
an average age of onset at about 12 years of
age, yet it can begin in adulthood or even in
the elderly.
Trichotillomania is currently classified as an
impulse control disorder, although some argue
that it does not fit into this classification well.
Trichotillomania
 Why? What would cause a person to pull
out their hair.
Some theorize that hair pulling is an innate
complex grooming behavior (complex motor
program) that is triggered by stress.
Hair pulling does have similar counterparts in
animals (Moon-Fanelli et al., 1999)
Psychogenic alopecia in cats.
Acral lick dermatitis in dogs
Psychogenic feather picking
Flank biting in horses.
Trichotillomania
Hair pulling tends to occur more frequently
within families, suggesting it has biological, or
hereditary origins.
Hair pulling is thought to occur due to
dysregulation of neurotransmitters, in
particular, serotonin and dopamine.
Neuroimaging shows that the frontal-basil
ganglia pathway is of particular importance in
hair pulling.
Trichotillomania
Hair pulling may have behavioral origins.
Thought to begin via a classical
conditioning paradigm and subsequently
maintained through operant conditioning
principles.
It is likely that several of these factors play a
role in the emergence and maintenance of
Trichotillomania.
Trichotillomania
Puberty is associated with the age of onset. It is
possible that neuroendocrine maturational changes may
be related to the development of trichotillomania in
some women.
Premenstrual exacerbation of hair pulling symptoms
has been shown in several studies, suggesting that
hormonal variations, particularly gonadotropin levels
may exacerbate some patient’s symptoms. Occasionally
birth control pills have ameliorated symptoms.
DSM-IV Criteria
Recurrent pulling out of one's hair
resulting in noticeable hair loss.
An increasing sense of tension
immediately before pulling out the hair or
when attempting to resist the behavior.
Pleasure, gratification, or relief when
pulling out the hair.
DSM-IV Criteria
The disturbance is not better accounted for by
another mental disorder and is not due to a
general medical condition (e.g., a dermatological
condition).
The disturbance causes clinically significant
distress or impairment in social, occupational, or
other important areas of functioning.
DSM-IV Criteria
What is wrong with these criteria, based on the
earlier description of trichotillomania symptoms?
DSM-IV Criteria
What is wrong with these criteria, based on the
earlier description of trichotillomania symptoms?
Both an increasing sense of tension
immediately before pulling out the hair or when
attempting to resist the behavior, and pleasure,
gratification, or relief when pulling out the hair
are not present in about 40% of those who pull
their hair.
DSM-IV Criteria
These individuals still suffer clinically
significant distress or impairment in social,
occupational, or other important areas of
functioning, which many believe should be
the determining criteria.
Trichotillomania
Comorbidity
%
Depression
57
Generalized Anxiety Disorder
27
Simple Phobia
19
Obsessive Compulsive Disorder
13
Social Phobia
11
Alcohol Abuse
19
Substance Abuse
16
Christenson, 1995
Trichotillomania
Other reported habits or rituals that seem to
occur with greater frequency in those who
engage in hair pulling:
Nail biting
Skin picking
Thumb sucking
Knuckle cracking
Nose picking
Treatment Keys
 Both external and internal factors affect hair
pulling.
 Five modalities are thought to work together to
maintain hair pulling (Mansueto,1999):
1.
2.
3.
4.
5.
Cognitive (thoughts and beliefs)
Affective (emotional state)
Motoric (physical actions)
Sensory (sight, touch, etc.)
External (environment)
 Any or all of these factors may be in play.
Study
Trichotillomania (TTM) is understudied.
Most epidemiological data cited in the literature
is derived from few, and mostly small studies.
If we accept that habit based hair-pulling is an
important subtype of TTM, then understanding its
true prevalence is important to future revisions of
diagnostic criteria.
Further understanding of TTM will increase the
efficacy of treatment. For example, TTM that is
habit-based may respond differently to treatment
than tension release (OCD related) type.
Study
Understanding the prevalence of associated
rituals will inform treatment.
The prevalence of co-morbid symptoms such as
depression, and anxiety are important to
understand, both because they highlight the
importance of this disorder, as well as to inform
treatment.
Understanding this disorder’s impact on selfesteem is important to patient treatment.
Measures
Beck Depression Inventory (BDI).
Center for Epidemiological Studies Depression
scale (CES-D).
State Trait Anxiety Inventory.
Rosenberg Self-esteem scale.
Trichotillomania version of the Y-BOCS.
Trichotillomania specific questionnaire.
Preliminary Findings
Presently: n = 132. 18.9% Male.
Current hair pulling in 9.94% of sample.
Past Pulling in 7.5%. Mean age of onset – 14.8 yrs
Of those who pull:
11% are Male
69% are White, 13% Asian, 13% Hispanic, 7.5%
African American, 7.5% Other.
Preliminary Findings
76.9% sometimes pull their hair in an unaware
state.
23% know of a relative that pulls their hair.
Average age of onset – 13.2 years.
Pulling sites: Scalp – 61.5%, Eyebrows - 46%,
Face - 23%, Legs – 15.4%, Pubic – 7.6%,
Arms – 7.6%.
Preliminary Findings
Rituals:
Drop hair to the floor - 38%
Examine the root – 31%
Must pull out the root – 23%
Twist out the hair - 8%
Pull hair because:
It doesn’t look right - 23%
Feels coarse - 23%
Is straight - 23%
It doesn’t feel right - 15%
Wrong Color - 15%
Is curly - 15%
Preliminary Findings
Depression:
Average score on the CES-D for normal
population is 9.25, range 0-60. Standard cut-off
score of 16 is typically used to distinguish clinically
depressed from non-depressed individuals
(Comstock & Helsing, 1976). Range in this
population, 3-29. Mean score 16.75. Fifty-three
percent of scores exceeded the cut-off score of 16.
On the BDI, scores ranged from 3-26 with a
mean score of 11.23. 53% of scores exceeded 10.
QUESTIONS