• Trichotillomania (hair-pulling disorder or HPD) is one of the world’s best-kept secrets.
• This condition is not a new disease, rather it is “coming out of the closet” due to recent increased publicity about the topic.
• HPD is a relatively common phenomenon and is estimated to affect 1–3.5% of late adolescents and young adults.
• Multiple factors have been identified as possible causal or contributory factors to HPD.
• There are several treatment options available, some of which have been proven to reduce hair-pulling severity.
What is trichotillomania (hair-pulling disorder, or HPD)?
Previously included under the “impulse control disorders not elsewhere classified” heading in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), HPD is now categorized with the obsessive-compulsive and related disorders in DSM-5.
HPD is characterised by recurrent pulling out of one's hair resulting in hair loss. There are repeated attempts to decrease or stop hair-pulling.
The hair-pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The hair-pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition or cancer treatment).
In the DSM, HPD is classified as a disorder by itself, i.e. not as a variant of obsessive-compulsive disorder or as symptom of another disorder. Large-scale epidemiological studies have yet to be conducted; however, HPD is estimated by smaller studies to affect 1–3.5% of late adolescents and young adults.
Read: Losing your hair, grandpa?
What are the symptoms of HPD?
People pull hair from their scalp, eyelashes, eyebrows, face, arms, legs, beard, moustache, genital area, armpits, in short: from anywhere there is hair. The majority of people pull scalp hair, or eyelashes and/or eyebrows.
The types of hair (most commonly) selected to pull are coarse, wiry and black/grey hairs. Such hair-pulling can result in thin hair, bald spots, loss of eyelashes or eyebrows, a tonsure pattern similar to "Friar Tuck," which also looks much like male pattern baldness or androgenic baldness, and even total baldness.
Some cases are quite severe, and in other cases, this condition is barely or not noticeable.
Hair-pullers may resort to wearing wigs, false eyelashes, scarves, hats, special hairstyles, and make-up to disguise their bald spots and lack of eyelashes.
Read: How to look after your hair?
Indeed, the cosmetic damage caused by HPD crosses a wide spectrum. But whether mild or severe, this cosmetic damage can be devastating to a person’s self-image, just as hair loss caused by alopecia or cancer treatment, or even normal balding, can hurt a person’s self-esteem.
With HPD, there are often additional strong feelings of shame and self-blame.
People with HPD are not trying to injure themselves or to purposefully damage their appearance. In addition, the hair-pulling often feels pleasurable rather than painful. People with HPD are not necessarily particularly anxious or troubled (except by the hair-pulling) - in fact, they are often very successful human beings.
Often, people with HPD have avoided situations where their problem might be discovered. For example, many people with trichotillomania avoid having anyone get close to their hair or make-up. Many have not been to a hairdresser in years because they are afraid of having to explain their problem!
Read: Hair-loss drug off black list
What causes HPD?
Multiple factors have been identified as possible causal or contributory factors to HPD. For example, onset may in some cases be associated with a stressful or traumatic life event such as illness or injury to self or a family member, parental divorce, or even alienation from friends.
In addition, abnormalities in several neurotransmitter systems including the serotonin, dopamine and opiate circuits may also play a role in the aetiology of TTM. Brain imaging studies have suggested that there is involvement of the cortico-striatal thalamic circuitry in HPD. At the same time, other brain regions may also play an important role. In conclusion, one would expect that HPD result from a combination of factors.
Who gets HPD?
There are factors which may render a person more vulnerable to HPD. For example, HPD is much more prevalent in females than in males. In adult recruitment studies, female participants have typically outnumbered males by at least 3 to 1 or higher.
Onset of pathological hair-pulling generally appears to be in childhood or adolescence. Although not everyone agrees, it has been suggested that HPD can be subdivided (subtyped) according to the age of onset of hair-pulling, with patients with early onset presenting with phenomenological and course differences compared to those with later onset of hair-pulling.
It seems that hair-pulling in children under the age of 5 years often remits spontaneously whereas a later age of onset (i.e. preadolescence to young adulthood) is more common and may have a more chronic and relapsing course.
Read: The end of bad hair days?
How is HPD diagnosed?
A clinician (usually a general practitioner, psychologist or psychiatrist) should do a thorough assessment, including taking an in-depth history of the patient and his/her family. The input of people close to the affected person may also be valuable. A diagnosis is made according to the criteria set out in diagnostic manuals such as DSM.
Comorbid conditions must also be diagnosed and addressed in treatment. Psychiatric comorbidity is common, with anxiety disorders (mainly generalized anxiety disorder and specific phobias), mood disorders (major depressive disorder), substance use disorders, and eating disorders, as well as personality disorders being the most prevalent in adults with HPD, whereas younger patients most often present with anxiety, disruptive behaviour disorders and other obsessive-compulsive and related disorders (particularly body focused repetitive behaviours such as nail-biting, cheek-chewing and lip-biting).
When to see a mental health professional
A mental health professional should be seen when the pulling behaviours including the avoidance and distress are significantly impacting on school, work, or social life. Early diagnosis and treatment can prevent the negative impact of the disorder on social development and general functioning.
It can also perhaps prevent the development of comorbid conditions, such as depression or other body-focused repetitive behaviours.
People with HPD should tell the doctor about when it first became a problem, the course of the disorder and previous treatment received, including what medication was prescribed, the dosage and duration, and how effective it was in relieving their symptoms.
If the person underwent psychotherapy, it is important to mention the kind of psychotherapy used (there are different types of psychotherapy – ask your therapist which she/he will use during treatment).
Read: How do we make sense of hair loss?
How is it treated?
A variety of treatments are currently available for alleviating the symptoms of HPD in patients of all ages. However, finding a cure for HPD remains a challenge.
Treatment options include habit reversal therapy (HRT), medications and a combination of these approaches.
More randomised placebo-controlled trials are required to assess the effects of these types of treatments, and treatment combinations, in larger samples of HPD patients of all ages.
HRT, a type of behavioural therapy technique that has been used over the years in the treatment of “nervous” habits like nail-biting and thumb-sucking, has been found to be beneficial in HPD.
It basically involves three primary components i.e., awareness training, competing response training, and social support. Indeed, there is research data which suggest that HRT is superior to waiting-list-control conditions.
Hypnotherapy has also been tried in some patients with HPD; however, there is an absence of randomised placebo-controlled trials to support whether this type of therapy is efficacious in HPD.
In terms of pharmacotherapy, a number of different agents have been tried over the years. Clomipramine was found to be superior to the tricyclic desipramine in reducing hair-pulling symptoms. In another randomised placebo-controlled trial clomipramine was compared with placebo, and CBT (including HRT) and here it was found that behavioural therapy was superior to clomipramine and placebo in reducing HPD symptoms.
Read: Do hair disorders exist?
Regarding the antidepressants, 2 studies assessed the efficacy of fluoxetine in the treatment of patients with HPD. Neither study found evidence for superiority of fluoxetine over placebo.
Moreover, fluoxetine and behavioural therapy were also compared and behavioural therapy, including stimulus control and stimulus response management techniques, was found to render better results than fluoxetine. In another study a medicine called sertraline, which was used in combination with HRT, in a group of patients who had not responded to sertraline on its own, showed superior outcomes.
There was one randomised placebo-controlled trial which suggested that olanzapine may be effective in HPD. Other pharmacological agents may also be efficacious (e.g. venlafaxine and topiramate); however, none of these have yet been tested in the context of randomized placebo-controlled trials.
Read: Hair indicates heart attacks
N-acetyl cysteine or NAC is another agent that has also been tried in the treatment of HPD. NAC, a precursor to the amino acid cysteine, has a role as a modulator of the glutamatergic system. Recently, NAC was found efficacious in a randomized placebo-controlled trial.
NAC can be obtained from pharmacies or health shops and does not require a prescription from your doctor.
Special care should however be taken with the dosage thereof though.
Joining a support group may also be beneficial. In South Africa, there are no official support/treatment groups for individuals with HPD or their significant others. However, non-official, small groups have been initiated at times over the years, some of which may still be active.
Psychoeducation remains an important aspect of treatment. In South Africa, information can be obtained from the MRC Unit on Anxiety & Stress Disorders (021 – 938 9179) or the Mental Health Information Centre of South Africa (021 – 938 9229; www.mentalhealthsa.org.za).
In the USA, the Trichotillomania Learning Centre is a very active consumer advocacy group for individuals with HPD (and other body-focused repetitive behaviours): www.trich.org
Read: What triggers hair loss?
How can hair dressers help a client with this disorder?
• Do NOT call attention to hair loss by calling other stylists or clients over to examine a bald spot. (This happens frequently and can be terribly embarrassing.)
• Don’t advise your client to stop pulling. Your client really would stop pulling if he or she could. (It is unhelpful to say, “It is getting bad – you really ought to stop.”)
• Refer clients to a professional resource such as the MRC Unit on Anxiety & Stress Disorders (or the Mental Health Information Centre of South Africa.
What HPD research is being done in South Africa?
There is an ongoing HPD research project conducted at the MRC Research Unit on Anxiety & Stress Disorders (Departments of Psychiatry, Universities of Stellenbosch & Cape Town).
The HPD project at the MRC Unit primarily focuses on investigation of the phenomenology (including level of awareness while pulling, illness course, severity, extent of urge/drive to pull hair, the extent of gratification/pleasure while pulling etc.) as well as the role of genetic factors in the development of this condition.
Other factors that are also evaluated include age of onset of pulling, response to medication treatment (if any), comorbidity, personality features, and family history of HPD and other psychiatric disorders. Our focus now include investigation of brain structure and functioning in patients with HPD and the assessment thus includes both neuropsychological testing as well as brain imaging.
Participation entails a once-off consultation (and referral for treatment if required), is cost-free and takes approximately two to three hours. If scanning and neuropsychological testing are involved (in addition to the initial comprehensive diagnostic interview), one additional session will be needed.
Read: Hair extensions could lead to permanent hair loss
Blood (or a saliva sample) will be drawn from participants and their parents (if possible) to get to the genetic material (also known as DNA). The MRC Unit is situated in the Western Cape.
Participation does not have to interfere with a patient’s current treatment regime, and feedback can be provided to his/her treating clinician if requested. Appropriate referral for treatment can be discussed and organised however.
For more information on this research, to arrange research participation or for information on local support groups, contact Prof Christine Lochner at the MRC Unit on Anxiety Disorders on 021 938 9179 (email: email@example.com).
Do you suffer from hair-pulling disorder?
Stellenbosch University invites you to take part in an exciting research study to help researchers further understand this disorder. Click here to read more or, if you want more information or want to participate, please contact: Prof Christine Lochner 021 – 938 9179, e-mail: firstname.lastname@example.org or Ms Elsie Breet 021 – 938 9654, e-mail: email@example.com for more information.
Reviewed by Prof Christine Lochner, Clinical psychologist & Co-Director: MRC Unit on Anxiety and Stress Disorders, Department of Psychiatry, University of Stellenbosch.
Tel. 021 - 938 9179; Fax. 021 - 933 5790; email: firstname.lastname@example.org
Image: Robodoc, Wikimedia Commons
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