Abstract
The purpose of this paper was to provide a detailed discussion on trichotillomania. The main causes of trichotillomania include stress, anxiety, abnormalities in the brain, and hormonal changes. A strong urge to pull hair from various parts of the body is the main symptom of trichotillomania. Other symptoms include experiencing tension before pulling hair and feeling pleasure when engaging in the behavior. Trichotillomania can be treated through therapies such as habit reversal and comprehensive behavior treatment, as well as, acceptance and commitment therapy. Medicines can also be used to reduce the urge to pull hair.
Introduction
A detailed discussion on trichotillomania will be provided in this paper. Trichotillomania is one of the major anxiety-based disorders in the world. For instance, it affects nearly three million people in the US. The discussion will begin with an overview of the disorder. This will be followed by a discussion on the causes, diagnosis criteria, and symptoms of the disorder. The different types of trichotillomania will also be discussed. The last part of the paper will focus on treatment and management of trichotillomania.
Why the Name and Definition
Trichotillomania refers to “recurrent pulling of one’s hair from the scalp, eyebrows, eyelashes, pubic area, underarm, chest, or other parts of the body, which causes noticeable bald patches” (Woods & Miltenberger, 2006, p. 171). The name trichotillomania was derived from three Greek words namely, thrix, tillein, and mania. Thrix refers to hair, whereas tillein is the act of pulling something. Mania means madness. Nonetheless, individuals who suffer from the disorder are usually not mad or crazy. The name was chosen to emphasize obsessive compulsion to pull hair as the main symptom of the disorder. The definition also emphasizes the fact that the disorder can present itself as an addiction or a habit that may be easy or difficult to avoid.
History
The act of “hair pulling has been observed in different societies for several centuries” (Chamberlain, Menzies, & Fineberg, 2010, pp. 568-574). In ancient Egypt, Greece, and India, hair pulling was accepted and encouraged as a meaningful behavior. In 1889, the name trichotillomania was developed to refer to the act of pulling hair in tufts. The symptoms and prevalence of richotillomania have evolved since 1889. Currently, trichotillomania is classified as an impulse control disorder that often occurs in situations of stress and anxiety.
Causes
Trichotillomania has several causes. To begin with, it can be caused by mental health problems. Psychological and behavioral theories indicate that trichotillomania can be caused by stress or anxiety (Parakh & Srivastava, 2010, pp. 50-52). In this case, individuals pull their hair as a way of reducing stress and anxiety. Abnormalities in the brain can also cause trichotillomania. Abnormalities that impair regulation of behavior, habit formation, and impulse control can result into acts such as hair pulling.
Trichotillomania can also be caused by a change in a given gene in the body. In this case, the disorder is inherited from parents. Insufficient secretion of serotonin has also been linked to trichotillomania. Serotonin is a type of chemical in the brain that makes individuals feel good (Diefenbach & Williamson, 2000). Its absence can lead to recursive behaviors such as hair pulling. Trichotillomania can also be caused by hormonal changes. This perspective is based on the fact that the prevalence of the disorder is high during development stages such as puberty that are characterized by significant hormonal changes.
Symptoms
The main symptoms of trichotillomania include the following. First, the patient is expected to experience a strong urge to pull his or her hair repetitively. This results into loss of substantial amount of hair on specific parts of the body such as the scalp. Hair pulling tends to take place during sedentary activities such as using the bathroom or talking on phone. Second, people who suffer from trichotillomania normally experience tension before pulling their hair (Gershuny & Keuthen, 2006). Tension can also be experienced when the patient is trying to avoid pulling his or her hair.
Third, hair pulling is associated with a feeling of pleasure, gratification, or relief. This makes hair pulling a habit that is very difficult to overcome. Fourth, the act of hair pulling causes significant distress in one or several areas in life (Zuchner & Cope, 2006). For instance, the affected person may experience stress or feel ashamed if he is not able to conceal bald patches on his head. Finally, trichotillomania is associated with skin infections. Forceful hair pulling can cause small wounds on the skin, which are likely to be painful.
Diagnosis Criteria
There is no specific medical test for trichotillomania. Thus, diagnosis is based on observed signs and symptoms. Doctors usually refer “patients with the symptoms of trichotillomania to psychiatrists or psychologists to determine if they have an impulsive disorder” (Grant & Stein, 2012, p. 89). Generally, the patient is expected to exhibit all the main symptoms of trichotillomania. A person is considered to be suffering from trichotillomania if the urge to pull hair cannot be better explained by any other mental disorder or medical condition. This criterion ensures that the symptoms are not confused with those of other mental disorders such as schizophrenia, which might also result into hair pulling.
Recent studies show that some people might not experience all the major symptoms of trichotillomania (Grant & Stein, 2012). For example, some individuals do not experience tension before they start pulling their hair. Moreover, some hair pullers hardly experience pleasure or gratification during the act. This means that clinicians must explore all the possible causes of hair pulling before diagnosing an individual with trichotillomania.
Types
There are three main types of trichotillomania namely, transient, focused, and automatic. Transient trichotillomania is prevalent among infants and children aged below 9 years. Among infants, the disorder is normally caused by infantile stress. Children with the disorder are likely to pull hair from their bodies, other people, pets, or dolls. Focused and automatic trichotillomania are common among adults (Zuchner & Cope, 2006). In focused trichotillomania, an individual pulls his or her hair intentionally to achieve a particular outcome such as releasing tension. Automatic trichotillomania, on the other hand, is habitual. It occurs without much thought or planning.
Prevention
Trichotillomania can be prevented through stimulus control. This strategy involves eliminating environmental factors that encourage hair pulling and increasing those that discourage the act. For instance, mirrors can be removed from areas such as bathrooms and bedrooms because they can prompt an individual to pull his or her hair. The urge to pull hair is likely to reduce if the unwanted hair cannot be seen frequently or easily. Stress management is another effective way of preventing trichotillomania (Gershuny & Keuthen, 2006). This strategy is based on the fact that releasing stress is one of the factors that cause the disorder. In this respect, avoiding stress can prevent the urge to pull hair. Stress can be managed effectively by identifying and avoiding its causes.
Treatment
Medication can be used to reduce the urge to pull one’s hair. Selective serotonin reuptake inhibitor (SSRI) is one of the main antidepressants that have been used successfully to suppress the urge to pull hair. Atypical “antipsychotics such as olanzapine and aripiprazole can also be used to reduce compulsive behaviors such as hair pulling” (Diefenbach & Williamson, 2000). The effectiveness of these medicines varies from individual to individual. In some cases, temporary medication can effectively treat trichotillomania. However, some individuals must take medication daily in order to overcome the disorder.
Tips on How to Overcome Trichotillomania
Several strategies can be used to overcome the disorder. To begin with, the affected person can wet his or her hair to avoid pulling. Wet hair tends to be slippery, which makes pulling very difficult. Learning the needs of the body at the time when the urge to pull hair is high is also an important strategy (Diefenbach & Williamson, 2000). The desire to engage in hair pulling can be triggered when a person is tired, bored, sleepy, or exited. Appropriate action should be taken to satisfy the identified need immediately to avoid pulling hair. For instance, talking to a friend when one is bored can shift attention away from pulling hair. Moreover, avoiding caffeine before going to bed can significantly reduce the severity of the disorder. Avoiding caffeine allows individuals to fall asleep easily, thereby overcoming the temptation to pull their hair. Another strategy for overcoming the disorder involves finding alternative activities that involve intensive use of hands. These include knitting, holding a toy while watching TV, and exercising. Keeping hands engaged reduces the chances of using them to pull hair.
Parenting Skills
Parents should focus on observing their children to determine when they pull their hair and the behaviors that accompany the act. Once the pattern of pulling hair is determined, parents should encourage children to engage in alternative behaviors. This includes buying dolls with hair to enable children to enjoy the same sensation that they would experience by pulling their hair. The alternative behavior should be implemented before pulling begins to achieve the best outcome (Grant & Stein, 2012).
Parents should also avoid punishing or warning children when they pull their hair. Research shows that admonition can reinforce rather than discourage hair pulling (Grant & Stein, 2012). In this respect, parents should ignore the behavior and encourage children to engage in alternative activities. Providing appropriate rewards can motivate children to shift their attention to alternative behaviors.
Evidence-based Therapies
Habit Reversal Training (HRT)
HRT consists of three components namely, awareness training, social support, and competing response training. Awareness training involves helping the affected individual to focus on the circumstances that lead to hair pulling. This allows the patient to know when pulling is likely to occur in order to take appropriate actions (Zuchner & Cope, 2006). Competing response training involves teaching the patient to substitute hair pulling with an alternative behavior. Providing social support involves collaborating with family members and friends to provide positive feedback that encourages the patient to engage in alternative activities.
Comprehensive Behavioral Treatment (CBT)
In CBT, treatment is provided through five stages. The first stage involves assessment and self-monitoring of symptoms. The patient works “with the therapist to assess thoughts, feelings, and behaviors that are associated with hair pulling” (Woods & Miltenberger, 2006, p. 112). In the second stage, the therapist chooses a sensory substitute to enable the patient to respond to the urge to pull hair from a particular part of his body. The third stage involves examining the environment in which hair pulling occurs in a bid to make it unsuitable for the behavior. In the fourth stage, the therapist helps the patient to deal with the feelings associated with trichotillomania in a positive way. The last stage involves addressing the thoughts that promote the disorder.
Acceptance and Commitment Therapy (ACT)
ACT involves encouraging the patient to experience and accept the urge to pull hair rather than to avoid it. The patient is also encouraged to experience negative emotions that normally accompany hair pulling. The emotions are accepted as events that should be observed rather than addressed (Zuchner & Cope, 2006). The purpose of this strategy is to allow the patient to accept his or her condition, thereby achieving freedom or relief. However, HRT and stimulus control should be used as interventions if the patient does not value hair pulling.
Conclusion
Trichotillomania is a disorder characterized by pulling hair from various parts of the body. It is caused by several factors that include stress, anxiety, abnormalities in the brain, and hormonal changes. The main symptoms of the disorder include repeated pulling of hair, experiencing tension before pulling, and feeling pleasure when engaging in the behavior. Trichotillomania can be treated through therapies that focus on behavior change. These include habit reversal and comprehensive behavior treatment, as well as, acceptance and commitment therapy. Antidepressants can also be used to reduce the urge to pull hair.
References
Chamberlain, S., Menzies, L., & Fineberg, N. (2010). Lifting the veil on trichotillomania. American Journal of Psychiatry, 164(4), 568-574.
Diefenbach, J., & Williamson, A. (2000). Trichotillomania: A challenge to research and practice. Clinical Psychology Review, 20(1), 289-309.
Gershuny, S., & Keuthen, J. (2006). Current posttraumatic stress disorder and history of trauma in trichotillomania. Journal of Clinical Psychology, 62(1), 1521-1529.
Grant, J., & Stein, D. (2012). Trichotillomania, skin picking, and other body-focused repetitive behaviors. Arlington, VA: American Psychiatric Publishing.
Parakh, P., & Srivastava, M. (2010). The many faces of trichotillomania. International Journal of Trichology, 2(1), 50-52.
Woods, D., & Miltenberger, R. (2006). Tic disorders, trichotillomania, and other repetitive behavioral disorders. New York, NY: Springer.
Zuchner, S., & Cope, H. (2006). Mutations in trichotillomania. Molecular Psychiatry, 11(2), 887-889.