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Conservative use of drug therapy
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A psychological approach that emphasizes the present and future of the patient, rather than the past.
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Emphasis on nutrition and physical exercise
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Family participation, if appropriate
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Psychoeducation for patients and relatives
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Trichollomania
Trichollomania is characterized by the repetitive pulling on one's hair resulting in noticeable hair loss. Patients typically experience an increasing sense on tension immediately before pulling out the hair or when attempting to resist the behavior. Pleasure, gratification or relief is felt upon hair pulling.
Researchers at our Institute hypothesize that two forms of trichotillomania may exist. Individuals who experience tension before pulling and gratification upon pulling may have a form of trichotillomania thought to be a type of obsessive compulsive spectrum disorder. For others who experience no awareness or pleasure, hair pulling may be a habit. Further research will help clarify these issues.
The "obsessive-compulsive spectrum" refers to a series of major psychiatric conditions defined by the presence of obsessions and compulsions. Obsessions are intrusive ideas, thoughts, or images that cause much anxiety and distress. Compulsions are repetitive behaviors or mental acts performed to reduce the anxiety produced by obsessions. You may have one without the other.
The current psychiatric diagnostic manual (DSM-IV) provides the following definitions:
- 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.
- 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.
WHAT ARE THE SYMPTOMS OF TRICHOTILLOMANIA?
- Pulling from scalp is most frequent followed by eyebrows, eyelashes, pubic region, face, body, and legs.
- Noticeable loss of hair on the specific area of the body.
- Common behaviors include:
- Inspecting the strands of hair that are pulled
- Chewing the strands of hair that are pulled
- Twirling and playing with hair
- Trichophagia (ingestion of hair)
- Pulling the strand of hair between the teeth
CHARACTERISTICS PRESENT IN TRICHOTILLOMANIA
- Trichotillomania is often associated with difficulties in family and/or other interpersonal relationships.
- Avoidance of situations in which others might notice the hair loss, such as getting hair cuts or going swimming is common.
- Personality problems may be present, such as passive aggressiveness, dependency etc.
- Children/adolescents may begin pulling after experiencing problems with their friends.
- Immediate pleasure may be experienced but in the long run the person feels frustrated and embarrassed.
WHO SUFFERS FROM TRICHOTILLOMANIA?
Trichotillomania is found predominantly in females and tends to occur more often in children than adults. The disorder usually begins between early childhood and adolescence. Trichotillomania may affect as much as 1-2 percent of the United States population. There is no clear data on it's prevalence, but it is likely to be more common than noted. The symptoms are the same for children, adolescents, and adults.
WHAT IS THE TREATMENT OF TRICHOTILLOMANIA?
The psychological treatment found to be the most effective for trichotillomania is called "habit reversal training." Habit reversal is a type of behavioral therapy typically consisting of 13 different components. These components do incorporate traditional exposure and response prevention techniques. Furthermore, our Institute has found success in preventing a relapse of symptoms by doing in session exposure and response prevention exercises as the final component of therapy (illustrated below as #3). The addition of cognitive therapy consisting of social skills training, assertiveness training, and stress management are also found to be effective and are important components of therapy.
The following is a case example that illustrates 3 out of the 13 components of habit reversal:
Anna is a 21 year old college student who has been pulling hair on her scalp and eyebrows since she was 10 years old. She reports being aware of the pulling only after she is already engaged in the behavior. She does not experience any pleasure but does experience a decrease in anxiety after the behavior. She tends to pull while talking on the phone, reading, and watching television. Hair pulling is often accompanied by twirling and playing with her hair. She tends to first feel for the coarse hair on her scalp and is more likely to pull strands of hair that feel rough or coarse.
- Competing response training - Teaching a behavioral response which prevents the pulling.
Therapist: "An effective way to prevent hair pulling is to clench the fists together and keep your arms firmly locked against the sides of the body whenever you feel an urge to play with your hair."
- Self-monitoring techniques - Keeping daily records to help the patient become aware of the rate, frequency, and intensity of the hair pulling.
Therapist: "Anna, I want you to label 7 envelopes with the days of the week. Every time you pull you are to place your hair in the proper envelope. Every night, count up the total number of hairs you have pulled and write it down on the envelope. Also write down approximately how anxious you felt on average that day before pulling. You can express your anxiety from 0 to 100 with 0 being no anxiety and 100 being the most anxiety you can imagine experiencing."
- Display of improvement - Deliberate exposure to situations and behaviors that lead to hair pulling in order to practice not pulling. Our Institute prefers to do deliberate exposure in session as well as homework assignments after the patient has gained control of the behavior using the other techniques.
Therapist: "Now that you are doing better I want you to now touch your face and twirl your hair. Can you feel a coarse hair that you have an urge to pull?
Patient: "Yes, I can feel a few hair that I could pull"
Therapist: "Good, I want you to keep twirling your hair without pulling. I want you to practice purposely evoking the urge to pull but refrain from doing so."
WHAT IS COGNITIVE THERAPY?
Cognitive therapy involves challenging and altering faulty thinking patterns. It is believed that faulty beliefs lead to negative emotions and behaviors. In cognitive therapy, patients learn to first identify faulty thinking patterns, challenge these thoughts and finally derive more constructive beliefs. It is believed that constructive thoughts lead to more positive emotions and behaviors.
Cognitive therapy for trichotillomania consists of helping the patient cope with the embarrassment of pulling and it's interference in social interactions. Patients are also taught to change faulty thinking patterns leading to negative emotions which often trigger an episode of pulling.
WHAT MEDICATIONS ARE HELPFUL FOR TRICHOTILLOMANIA?
Current research indicates that anti-depressant medications when used in conjunction with psychological treatment may be quite helpful for trichotillomania.
Some commonly used anti-depressant medications for trichotillomania:
*Anafranil
*Prozac
*Luvox
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