Trichotillomania
Trichotillomania | |
---|---|
Other names | Trichotillosis, hair-pulling disorder, hairs-pulling disorder, obsessive compulsive disorder[1] |
Diagnostic method | Based on symptoms, seeing broken hairs[1] |
Differential diagnosis | Body dysmorphic disorder[1] |
Medication | Cognitive behavioral therapy, clomipramine[3] |
Frequency | ~2%[2][3] |
Trichotillomania (TTM), also known as hair-pulling disorder or compulsive hair pulling, is a
As of 2023, the specific cause or causes of trichotillomania are unclear. Trichotillomania is probably due to a combination of genetic and environmental factors.
Treatment is typically with cognitive behavioral therapy.[3] The medication clomipramine may also be helpful, as will keeping fingernails clipped.[3] Trichotillomania is estimated to affect one to four percent of people.[2][3] Trichotillomania most commonly begins in childhood or adolescence.[2] Women are affected about 10 times more often than men.[1] The name was created by François Henri Hallopeau in 1889, from the Greek θριξ/τριχ; thrix (meaning 'hair'), along with τίλλειν; tíllein (meaning 'to pull'), and μανία; mania (meaning 'madness').[7]
Signs and symptoms
Trichotillomania is usually confined to one or two sites,[8] but can involve multiple sites. The scalp is the most common pulling site, followed by the eyebrows, eyelashes, face, arms, and legs.[9] Some less common areas include the pubic area, underarms, beard, and chest.[10] The classic presentation is the "Friar Tuck" form of crown alopecia (loss of hair at the "crown" of the head, also known as the "vertex").[11] Children are less likely to pull from areas other than the scalp.[9]
People with trichotillomania often pull only one hair at a time and these hair-pulling episodes can last for hours at a time. Some individuals may experience more satisfaction after pulling an anagen phase hair with the gel-like inner root sheath still surrounding the base of the hair. Trichotillomania can go into remission-like states where the individual may not experience the urge to "pull" for days, weeks, months, or even years.[12]
Individuals with trichotillomania exhibit hair of differing lengths; some are broken hairs with blunt ends, some new growth with tapered ends, some broken mid-shaft, or some uneven stubble.
An additional psychological effect can be low
For some people, trichotillomania is a mild, if frustrating, problem. But for many, embarrassment about hair pulling causes isolation and results in a great deal of
Other medical complications include
Environment is a large factor which affects hair pulling.[20] Sedentary activities such as being in a relaxed environment are conducive to hair pulling.[20][21] A common example of a sedentary activity promoting hair pulling is lying in a bed while trying to rest or fall asleep.[20] An extreme example of automatic trichotillomania is "sleep-isolated" trichotillomania, where patients pull their hair out while asleep.[20][22]
Causes
In several
It is likely that a combination of multiple genes confers vulnerability to trichotillomania. although associations between trichotillomania and the HOXB8 gene have not been demonstrated in humans.
Diagnosis
Patients may be ashamed or actively attempt to disguise their symptoms. This can make diagnosis difficult as symptoms are not always immediately obvious, or have been deliberately hidden to avoid disclosure.[8] If the patient admits to hair pulling, diagnosis is not difficult; if patients deny hair pulling, a differential diagnosis must be pursued.[9] The differential diagnosis will include evaluation for alopecia areata, iron deficiency, hypothyroidism, tinea capitis, traction alopecia, alopecia mucinosa, thallium poisoning, and loose anagen syndrome.[3][9] In trichotillomania, a hair pull test is negative.[9]
A
Diagnostic criteria from the DSM-5 provides the following criteria for trichotillomania:[33]
- Criterion A: Recurrent pulling of hair that must result in loss of hair.[33]
- Criterion B: There must be evidence that the person has attempted to stop hair-pulled behavior.[33]
- Criterion C: General medical conditions and other disorders that may results in hair pulling must first be ruled out, and TTM can only be diagnosed if the behavior is not in response to another disorder. Examples include delusions, or body dysmorphic disorders.[33]
Classification
Trichotillomania is defined as a self-induced and recurrent loss of hair.[9] It includes the criterion of an increasing sense of tension before pulling the hair and gratification or relief when pulling the hair.[8] However, some people with trichotillomania do not endorse the inclusion of "rising tension and subsequent pleasure, gratification, or relief" as part of the criteria[8] because many individuals with trichotillomania may not realize they are pulling their hair, and patients presenting for diagnosis may deny the criteria for tension prior to hair pulling or a sense of gratification after hair is pulled.[9]
Trichotillomania may lie on the
Because trichotillomania can be present in multiple age groups, it is helpful in terms of prognosis and treatment to approach three distinct subgroups by age: preschool age children, preadolescents to young adults, and adults.[9]
In preschool age children, trichotillomania is considered benign. For these children, hair-pulling is considered either a means of exploration or something done subconsciously, similar to nail-biting and thumb-sucking, and almost never continues into further ages.[34]
The most common age of onset of trichotillomania is between ages 9 and 13. In this age range, trichotillomania is usually chronic, and continues into adulthood. Trichotillomania that begins in adulthood most commonly arises from underlying psychiatric causes.[34]
Trichotillomania is often not a focused act, but rather hair pulling occurs in a "trance-like" state;[20] hence, trichotillomania is subdivided into "automatic" versus "focused" hair pulling.[9] Children are more often in the automatic, or unconscious, subtype and may not consciously remember pulling their hair. Other individuals may have focused, or conscious, rituals associated with hair pulling, including seeking specific types of hairs to pull, pulling until the hair feels "just right", or pulling in response to a specific sensation.[9] Knowledge of the subtype is helpful in determining treatment strategies.[9]
Treatment
Treatment is based on a person's age. Most pre-school age children outgrow the condition if it is managed conservatively. In young adults, establishing the diagnosis and raising awareness of the condition is an important reassurance for the family and patient. Non-pharmacological interventions, including behavior modification programs, may be considered; referrals to psychologists or psychiatrists may be considered when other interventions fail. When trichotillomania begins in adulthood, it is often associated with other mental disorders, and referral to a psychologist or psychiatrist for evaluation or treatment is considered best. The hair pulling may resolve when other conditions are treated.[9]
Psychotherapy
Habit reversal training (HRT) has the highest rate of success in treating trichotillomania.[9] HRT has also been shown to be a successful adjunct to medication as a way to treat trichotillomania.[8][35] With HRT, the individual is trained to learn to recognize their impulse to pull and also teach them to redirect this impulse. In comparisons of behavioral versus pharmacologic treatment, cognitive behavioral therapy (including HRT) have shown significant improvement over medication alone.[8][9] It has also proven effective in treating children.[9] Biofeedback, cognitive-behavioral methods, and hypnosis may improve symptoms.[36] Acceptance and commitment therapy (ACT) is also demonstrating promise in trichotillomania treatment.[37] A systematic review from 2012 found tentative evidence for "movement decoupling".[38]
Medication
The United States Food and Drug Administration (FDA) has not approved any medications for trichotillomania treatment.[39]
However, some medications have been used to treat trichotillomania, with mixed results. Treatment with
A study published in March 2023 studied the application of memantine, a drug typically used to treat symptoms of Alzheimer's disease, to treat patients with trichotillomania. Similar to NAC mentioned above, memantine acts to regulate glutamate levels.[44]
Different medications, depending on the individual, may increase hair pulling.[39]
Devices
Technology can be used to augment habit reversal training or behavioral therapy. Several mobile apps exist to help log behavior and focus on treatment strategies.[45] There are also wearable devices that track the position of a user's hands. They produce sound or vibrating notifications so that users can track rates of these events over time.[46]
Prognosis
When it occurs in early childhood (before five years of age), the condition is typically self-limiting and intervention is not required.[8] In adults, the onset of trichotillomania may be secondary to underlying psychiatric disturbances, and symptoms are generally more long-term.[9]
Secondary infections may occur due to picking and scratching, but other complications are rare.[9] Individuals with trichotillomania often find that support groups are helpful in living with and overcoming the disorder.[9]
Epidemiology
Although no broad-based population epidemiologic studies had been conducted as of 2009, the lifetime prevalence of trichotillomania is estimated to be between 0.6% and 4.0% of the overall population.[3] With a 1% prevalence rate, 2.5 million people in the U.S. may have trichotillomania at some time during their lifetimes.[47]
Trichotillomania is diagnosed in all age groups; onset is more common during preadolescence and young adulthood, with mean age of onset between 9 and 13 years of age,[9] and a notable peak at 12–13.[8] Among preschool children the genders are equally represented; there appears to be a female predominance among preadolescents to young adults, with between 70% and 93% of patients being female.[9] Among adults, females typically outnumber males by 3 to 1.[8]
"Automatic" pulling occurs in approximately three-quarters of adult patients with trichotillomania.[9]
History
Hair pulling was first mentioned by Aristotle in the fourth century B.C.,[48] was first described in modern literature in 1885,[49] and the term trichotillomania was coined by the French dermatologist François Henri Hallopeau in 1889.[3][8]
In 1987, trichotillomania was recognized in the Diagnostic and Statistical Manual of the American Psychiatric Association, third edition-revised (DSM-III-R).[50]
Society and culture
Support groups and internet sites can provide recommended educational material and help persons with trichotillomania in maintaining a positive attitude and overcoming the fear of being alone with the disorder.[8][9]
Media
A documentary film exploring trichotillomania, Bad Hair Life, was the 2003 winner of the International Health & Medical Media Award for best film in psychiatry and the winner of the 2004 Superfest Film Festival Merit Award.[51][52][53]
Trichster is a 2016 documentary that follows seven individuals living with trichotillomania, as they navigate the complicated emotions surrounding the disorder, and the effect it has on their daily lives.[54]
Fiction
The trichotillomania of a prominent character is a key plot element in the 1999 novel Whatever Love Means by David Baddiel.[citation needed]
Ashley Barret, a character portrayed by Colby Minifie in the superhero fiction series The Boys, is shown suffering from it.
Music
On the 2017 album, 20s a Difficult Age by Marcus Orelias, there is a song called "Trichotillomania".[55]
See also
- Feather-plucking
- Noncicatricial alopecia
- Psychogenic alopecia, a form of baldness that is caused by excessive grooming in cats
- Self-harm
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