What is trichotillomania?
Trichotillomania, also known as trich or hair pulling disorder, is a mental disorder characterized by the compulsive urge to pull out one’s own hair. This condition causes people to have less hair than normal, or in more extreme cases, to be completely bald. The hair pulling is often focused on the scalp, but can occur on any part of the body where hair grows. Trichotillomania is classified as an obsessive-compulsive disorder (OCD) and body-focused repetitive behavior. It affects between 0.6% and 3.4% of the population at some point during their lifetime.
What causes trichotillomania?
The exact cause of trichotillomania is unknown, but it is likely due to a combination of genetic, neurological and environmental factors. Here are some of the possible causes:
– Genetics – there appears to be a genetic component, as trichotillomania tends to run in families. First-degree relatives of someone with trich have a higher risk of also developing trich. Certain genes relating to emotional regulation may play a role.
– Brain chemistry – people with trich have been found to have abnormalities in certain neurotransmitters like serotonin and dopamine. These neurotransmitters regulate mood, impulse control and repetitive behaviors.
– Stress and trauma – onset or worsening of trich is often tied to stressful life events or trauma. Trich may start as a coping mechanism.
– Obsessive-compulsive disorder – over 30% of people with trich also have OCD. The compulsive hair pulling may be related to overlapping brain circuitry.
– Body-focused repetitive behaviors – trich is classified as a BFRB, along with skin picking, nail biting, cheek chewing and other repetitive self-grooming behaviors. The urge and gratification from pulling hair shares similarities with these conditions.
– Emotion regulation – for many, hair pulling provides a way to manage anxiety, boredom, tension, loneliness, fatigue or other unpleasant emotions. This momentary mood boost reinforces the behavior.
What are the signs and symptoms of trichotillomania?
People with trichotillomania exhibit the following signs and symptoms:
– Recurrent hair pulling – this is the core symptom. People feel an irresistible urge to pull out hair from their scalp, eyebrows, eyelashes or other parts of the body.
– Feelings of tension – tension, anxiety or stress builds until the person pulls their hair, which provides temporary relief.
– Ritualistic hair pulling habits – people may pull their hair in certain patterns, styles or routines without full awareness. Hair pulling becomes an automatic behavior.
– Sense of gratification, pleasure or relief after pulling out hair – this sensation reinforces the hair pulling behavior.
– Playing with, nibbling on or swallowing pulled out hairs – some people engage in hair-play rituals.
– Varying amounts of hair loss – this depends on severity; ranges from thinning hair to large bald patches to being completely bald. The scalp is often most affected.
– Hiding bald spots – people may cover up bald patches on head or eyebrows with hats, wigs, make-up or other concealers.
– Significant distress or problems in daily functioning due to hair pulling – impacts self-esteem, social life or work performance.
What are trichotillomania urges and rituals like?
The irresistible urges and ritualistic qualities of trichotillomania can manifest in various ways:
– Building tension until pulling out a “right” hair – searching the scalp or body while feeling mounting anxiety until finding and plucking a specific “coarse” or “out of place” hair, which brings relief.
– Pulling out hairs in a specific pattern or order – having a habitual pulling sequence, like starting from one side of the head and working to the other.
– Examining and touching hairs – running fingers through hair checking for hairs that feel irregular to target. Twirling or sliding pulled hairs between fingertips.
– Biting, chewing, swallowing pulled hairs – placing plucked hairs in mouth and manipulating them with teeth, tongue and lips. Accidentally or intentionally ingesting them.
– Playing with pulled hairs – rolling them between fingers, tying them in knots, winding them around fingers, making piles and other rituals.
– Pulling with non-dominant hand – using the non-dominant hand to pull hair allows simultaneously watching TV or reading while pulling.
– Needing things to “feel right” – keeping pulling until an area feels smooth, all hairs are extracted, or a sense of balance is achieved between two sides.
– Zoning out – entering a trance-like dissociated state while pulling for an extensive period of time.
What are common trichotillomania triggers?
Trichotillomania symptoms are often triggered or worsened by certain situations and emotional states:
– Stress – increased anxiety, change, transitions, pressure, uncertainty or frustrations commonly lead to more hair pulling.
– Boredom – lack of activity or mental stimulation can trigger trich urges.
– Fatigue – being tired lowers mental stamina to resist hair pulling.
– Negative emotions – feelings of sadness, depression, loneliness, anger, guilt or shame increase hair pulling.
– Idleness – inactive times like reading, watching TV or being online provide opportunity to mindlessly pull hair.
– Cognitive tasks – concentration on activities like studying, computer work or driving enable hands to pull hair without full awareness.
– Perfectionism – the perceived imperfections of irregular hairs may trigger trich urges.
– Mirrors – seeing reflections of hair can draw attention to “flaws” and trigger pulling.
– Tactile sensations – hair textures, tugging sensations, and clothes brushing hair can prompt pulling.
What are the stages of the trichotillomania hair pulling cycle?
Trichotillomania follows a cyclical pattern with several stages:
– Trigger – something like a stressful event, boredom, certain setting or activity sparks the initial urge to pull hair.
– Mounting tension – tension builds as the desire to pull hair intensifies but is resisted. Distressing thoughts about needing to pull hair occur.
– Hair pulling – finally giving in to the overwhelming urge and pulling hair, which provides relief. This may occur in a focused or automatic, zoning-out manner.
– Instant gratification – a pleasurable sensation of relief from tension is felt immediately after pulling hair. This reinforces the behavior.
– Examining hairs – looking closely at and touching the extracted hairs, sometimes engaging in rituals like twirling them.
– Regret and distress – after the momentary gratification, negative emotions set in, like shame, guilt, sadness or frustration.
– Attempting to stop – the person may try to fight the urges and stop pulling, often unsuccessfully.
– Concealing – efforts made to hide or camouflage hair loss, like with make-up, hats, wigs or specific hairstyles.
– Repeat process – the cycle begins again as urges to pull hair recur.
How does trichotillomania typically progress?
Trichotillomania tends to follow certain patterns of progression:
– Onset in childhood or adolescence – about 85% of cases begin before age 18, with a mean age of onset around 13 years old.
– Fluctuating course – symptoms usually wax and wane over time. There may be periods of remission. Stress often exacerbates symptoms.
– Chronic long-term condition – trich is chronic for over 80% of adults with the disorder, often lasting decades. But severity levels can change.
– Pulling focused on different sites over time – common to shift pulling from scalp to eyebrows to body.
– Most intense in adolescence and early adulthood – symptoms often peak during the teens and 20s then improve somewhat with age.
– Remission is possible – about 30% of people recover completely later in life. This usually occurs by the 30s.
– Potential hair regrowth – hair sometimes regrows normally after pulling ceases. But permanent balding can occur in severe, long-term cases.
– Reduced life quality – trich often causes significant life impairment in school, work, socially and mentally. But degree varies.
– OCD and depression can develop – these commonly co-occurring disorders can worsen without proper treatment.
What are common complications of trichotillomania?
Trichotillomania can lead to various complications when severe and left untreated:
– Permanent bald patches – repeated pulling over time damages the hair follicles, preventing regrowth and causing permanent balding. This is more common after 10+ years of pulling.
– Skin damage – this includes skin irritation, infections and sores from chronic pulling on scalp and body sites.
– Anxiety and depression – trich sufferers are at higher risk of developing clinical anxiety or depressive disorders due to social isolation, shame and low self-esteem.
– Body-focused repetitive behaviors – trich sufferers are more prone to develop related problems like compulsive skin picking, nail biting or cheek chewing.
– Dental damage – those who chew and swallow pulled hairs risk dental erosion, cavities, tooth fractures and gum damage.
– Intestinal obstruction – accumulation of swallowed hairballs over months or years can obstruct the intestines, requiring surgery. This is rare.
– Interference with daily life – trich can severely impact school performance, work, relationships and mental health when uncontrolled.
– Social withdrawal – those with noticeable hair loss often avoid activities and isolate themselves due to embarrassment or shame.
What are the long term effects of trichotillomania?
The long term effects of trichotillomania for those with chronic, severe symptoms include:
Physical effects
– Permanent hair loss – sustained pulling over years damages follicles leading to irreversible bald patches on the scalp, eyebrows, eyelashes or body.
– Skin damage – long term picking and pulling creates skin discoloration, infections, scarring and lesions.
– Vision effects – lack of eyelashes makes eyes vulnerable to dust and debris leading to irritation. Light sensitivity and impaired vision can occur.
– Gastrointestinal problems – trichobezoar or hairball accumulation in the stomach and intestines from swallowing hair for years. May require surgery.
– Carpal tunnel syndrome – sustained hair pulling with wrists bent can inflame tendons causing numbness or weakness in wrists and hands.
Psychological effects
– Low self-esteem – chronic hair loss often leads to poor self-image, feelings of ugliness, shame and lack of confidence.
– Depression – long term trich is linked to clinical depression, which can worsen if not properly treated. Depression is both a cause and effect.
– Anxiety disorders – generalized anxiety, social anxiety, and OCD are common comorbidities that compound over many years.
– Body dysmorphic disorder – BDD or abnormal obsession over perceived flaws in physical appearance affects up to 10% of those with long term trich.
– Social isolation – chronic trich sufferers often withdraw from school, work and social interactions leading to loneliness.
Functional effects
– School/work impairment – long term trich that begins in childhood often causes learning difficulties. Trich impedes concentration and performance.
– Unemployment – trich patients have higher unemployment rates and dependence on disability services. Many struggle to perform work duties.
– Relationship difficulties – poor self-image, depression, and isolation caused by trich can hinder meaningful connections and strain relationships.
– Reduced quality of life – longtime trich sufferers report markedly lower life satisfaction, purpose and participation in activities they enjoy.
– Substance abuse – those with chronic trich have elevated rates of substance use disorders and addiction, which compounds problems.
What percentage of trichotillomania patients improve with treatment?
Studies show that around 50-60% of trichotillomania patients demonstrate significant improvement with appropriate treatment:
– Habit reversal training – 50% saw reduced hair pulling in 12 weeks with this behavioral therapy.
– Cognitive behavioral therapy – 56% achieved mild to moderate improvement in symptoms with CBT.
– Acceptance and commitment therapy – 60% had nearly full remission after ACT treatment.
– N-acetylcysteine – 56% taking NAC supplements improved more than placebo group.
– Olanzapine – 72% taking olanzapine medication reduced trich symptoms by over 35%.
– Clomipramine – 55% taking clomipramine antidepressant experienced remission.
However, trichotillomania is difficult to treat and improvements may gradually relapse once treatment is discontinued. Consistent, long-term treatment is usually needed to maintain gains. Approximately 10-20% of cases are highly resistant to intervention.
Can children outgrow trichotillomania?
Trichotillomania often begins in childhood or early teens, which raises the question of whether kids eventually outgrow the disorder. Studies indicate:
– About 30% remit by adulthood – Spontaneous remission does occur, but is not the norm. Of those whose trich begins in childhood, approximately 30% will outgrow it and achieve full remission by their 30s.
– Remission more likely before age 13 – Younger age of onset predicts greater chance of remission. 77% of kids who started trich before age 13 went into remission compared to only 39% of those starting after 13.
– Chronic hair pulling often persists – Around 70% of pediatric trich cases continue into adulthood as a chronic condition if untreated. Average duration is over 15 years.
– Trich may relapse in adulthood – Those who appear to overcome childhood trich can experience recurrence of symptoms later in life during periods of stress.
– Early intervention helps – Behavior therapy in childhood offers the best chance to halt progression of trich and reach remission sooner.
While it’s possible for pediatric trich to abate over time, professional treatment is recommended to help bring about remission and prevent hair pulling from becoming a lifelong problem.
What percentage of trichotillomania patients relapse after therapy?
It is unfortunately very common for trichotillomania to return after a period of improvement with treatment. Relapse statistics indicate:
– 50% relapse within 6 months after therapy – Half of patients regress within 6 months of ending treatment, even if they made significant gains during therapy.
– 75% relapse within 1 year – Within one year of discontinuing treatment, three-fourths of trich patients experience recurrence of moderate to severe hair pulling symptoms.
– 95% relapse within several years – Almost all patients have some level of relapse within a few years if not engaging in continued maintenance therapy.
Relapse occurs because trich is wired in as a habitual behavior pattern strengthened over many repetitions. Main factors leading to relapse include:
– Discontinuing medication – Medication like SSRIs often successfully control trich urges during use, but symptoms return after stopping medication.
– Stopping behavior therapy – CBT and habit reversal training teach skills to resist urges, but old habits can creep back in without ongoing practice.
– Re-exposure to triggers – Stress, anxiety, boredom, and familiar pull-sites reactivate trich behaviors if coping strategies are not maintained.
– Loss of accountability – Lacking the accountability and support system of a therapist can undermine progress.
To reduce risk of relapse, trich experts emphasize the need for long-term management using medications, therapy, lifestyle changes and support systems. Though challenging, lifelong diligent maintenance offers the best results.
Conclusion
Trichotillomania is a complex hair pulling disorder that exerts significant long term physical, psychological and functional impacts on the majority of sufferers. Chronic trich often leads to permanent baldness, skin damage, gastrointestinal issues, depression, anxiety, social isolation, career impairment and reduced quality of life. While treatment can help many patients achieve remission or control of symptoms, trichotillomania is prone to relapse and difficult to fully overcome. Consistent adherence to long term therapy, lifestyle adjustments, and habit changes provide the best chance for managing trich. Increased awareness and research around trich are still needed to improve treatment outcomes and quality of life for those battling this challenging disorder.
