Written by E. Mcgee, edited and reviewed by M. Williams, Ph.D.
Compulsive Hair Pulling
Trichotillomania (TTM, also called compulsive hair pulling), is thought to be a rare disorder, but there has not been much study to determine its overall prevalence.
One study which used a sample of college students estimated that about 0.6% of the population has diagnosable trichotillomania. This disorder is characterized by repetitive hair pulling.
Hair is most often pulled from the scalp, but it may be pulled from any area of the body; eyelashes and eyebrows are commonly pulled and in some cases, pubic hair, and hair from the extremities is pulled as well. People with trichotillomania may have large bald patches from the disorder.
Symptoms
Symptoms of trichotillomania include recurrent pulling of one's own hair resulting in a noticeable hair loss, increasing sense of tension immediately before pulling out the hair or when trying to resist the urge to pull, and gratification or a sense of relief when pulling out the hair.
Diagnosis
To be diagnosed with trichotillomania, the symptoms must not be caused by any other disorder or medical condition, and they must cause significant distress or impairment in daily functioning.
Trichotillomania can cause a number of problems for sufferers. Often people with the disorder pull so much hair that the loss is noticed by others. People with trichotillomania may have thinning hair or even lack eyebrows or eyelashes. This can lead to embarrassment and even avoidance of social situations. People with the trichotillomania often eat the hair they pull, which can cause digestive problems that can threaten health.
Classified as an impulse control disorder
Trichotillomania is a classified as an impulse control disorder because people feel unable to resist the impulse to pull hair from their bodies. It is also classified as an Obsessive Compulsive Spectrum Disorder because of its similarities to Obsessive Compulsive Disorder, including the compulsive and repetitive aspects of the behavior.
Other disorders involving body-focused repetitive behaviors include compulsive skin picking, compulsive nail-biting, eating disorders, body dysmorphic disorder, and Tourette Syndrome.
The Terminology of Repetitive Self-Mutilation
The most common behaviors performed by people suffering from superficial compulsive self-mutilation are not dangerous but can become extreme. These include hair-pulling, nail-biting, and the picking and scratching of scabs and skin.
- Hair Pulling: trichotillomania
- Hair Ingestion: trichophagia
- Skin Picking: dermatillomania
- Nail Biting: onychophagia
These behaviors are probably all different aspects of the same problem.
OCD and Trichotillomania
Trichotillomania and obsessive-compulsive disorder have definite similarities. Both disorders are characterized by the inability to resist impulses and by the performance of repetitive anxiety-reducing behaviors. There are, however, many key distinguishing differences between the disorders. OCD typically results in a greater impairment in daily functioning and is more associated with high levels of anxiety and depression. Types of compulsions associated with OCD typically vary over time whereas trichotillomania is always characterized by hair pulling (although the site of the pulling may vary).
Obsessions and rituals are associated more with OCD than with trichotillomania. In fact, patients with trichotillomania are often unaware of their hair pulling disorder, whereas OCD compulsions are usually deliberate. Additionally, patients with trichotillomania report a feeling of gratification after plucking whereas there is not typically gratification associated with OCD-related compulsions. Finally, for those with TTM, although the hair pulling disorder is a result of anxiety, it is not a conscious action done with the purpose of reducing anxiety, as is the case with OCD's compulsions.
Not surprising due to their similarities, many people who are diagnosed with OCD also have trichotillomania (and many diagnosed with trichotillomania also have OCD). One study reported that for those with a primary diagnosis of OCD, 18% also had trichotillomania; for those with a primary diagnosis of trichotillomania, 17% also had diagnosable OCD. In another study of chronic hair pullers, 83% of which were diagnosed with trichotillomania, 10% had current OCD, 5% had past OCD, and 18% had obsessions and compulsions that did not warrant a diagnosis. There are also elevated rates of OCD in relatives of people with trichotillomania.
Trichotillomania and OCD are similar symptomatically and neurologically and when one is present, there is an increased likelihood for the other to coexist or to exist in a family member. They are, however, separate disorders with unique characteristics.
Treatment for Compulsive Hair Pulling
Various psychiatric medications have been shown to help those with OCD and those with trichotillomania. Trichotillomania responds to drugs like clomipramine, typically thought to be an anti-obsessional drug. There is some evidence that people diagnosed with comorbid OCD and trichotillomania, however, do not demonstrate as much improvement and are less responsive to medications than those who have only one diagnosis.
Cognitive-behavior therapy is probably the best means of treating trichotillomania. Therapy may involve several different techniques, including habit reversal and stimulus control. These techniques help the person to resist hair pulling by providing alternative behaviors when the urge to pull strikes. People with trichotillomania are also taught to identify places and situations where pulling is likely, and take preventive measures to resist temptation. With time and persistence, the urge will fade away.
Related Reading
References:
- American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders DSM-IV-TR. Washington, DC: American Psychiatric Association.
- Christenson, G. A., Mackenzie, T. B., & Mitchell, J. E. (1991). Characteristics of 60 adult hair pullers. American Journal of Psychiatry, 148(3), 365-370.
- Christenson, G. A. Pyle, R. L., & Mitchell, J. E. (1991) Estimated lifetime prevalence of trichotillomania in college students. Journal of Clinical Psychiatry, 52(10), 415-417.
- Koran, L. M. (1999). Obsessive-compulsive and related disorders in adults: A comprehensive clinical guide. Cambridge: Cambridge University Press.
- Lenane, M. C., Swedo, S. B., Rapoport, J. L., & Leonard, H. (1992). Rates of obsessive compulsive disorder in first degree relatives of patients with trichotillomania: A research note. Journal of Child Psychology and Psychiatry, 33(5), 925-933.
- Stanley, M. A., Swann, A. C., Bowers, T. C., Davis, M. L., & Taylor, D. T. (1992). A Comparison of clinical features in trichotillomania and obsessive-compulsive disorder. Behaviour Research Therapy, 30(1), 39-44.
- Swedo, S. E. & Leonard, H. L. (1992). Trichotillomania: An obsessive compulsive spectrum disorder? Psychiatric Clinics of North America, 15(4), 777-790.
- Swedo, S. E. Leonard, H. L. & Rapoport, J. L. (1989). A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling). New England Journal of Medicine, 321(8), 497-501.
