A Project of the Scientific Advisory Board of the Trichotillomania Learning Center, Inc.
Charles Mansueto, Ph.D., Chair

Authors:
Charles S. Mansueto, Ph.D.
Director, Behavior Therapy Center of Greater Washington, D.C.
Silver Spring, MD

Philip T. Ninan, M.D.
Associate Professor of Psychiatry and Behavioral Sciences
Director, Mood & Anxiety Disorders Program
Emory University School of Medicine
Atlanta, GA

Barbara O. Rothbaum, Ph.D.
Associate Professor in Psychiatry
Director, Trauma & Anxiety Recovery Program
Emory University School of Medicine
Atlanta, GA

Elizabeth Reeve, M.D.
Regions Hospital
Department of Psychiatry
St. Paul, MN


What is trichotillomania?

Trichotillomania is a disorder characterized by the non-cosmetic pulling of hair, resulting in significant hair loss. The name is derived from the Greek terms for hair (trich), pulling (tillo) and morbid impulse (mania). Trichotillomania is commonly associated with considerable distress.

The majority of individuals start pulling hair during childhood or adolescence, though hairpulling can begin at any age. Current estimates are that roughly 1.5% of males and 3.5% of females in the U.S. engage in clinically significant non-cosmetic hair pulling in their lifetime. While most adults with trichotillomania are women, among children hair pulling seems to be about as common in boys as it is with girls.


Hair is most commonly pulled from the scalp, eyelashes, eyebrows, beard, and pubic area, though hair from any part of the body may be pulled. Individuals may start pulling from one site, for example eyelashes, and later start pulling hair from another region, such as the top of the head. Some individuals, especially children, may also pull hair from other people, or from pets. It is not uncommon for persons with trichotillomania to play with or nibble the pulled hairs. Individuals with trichotillomania often engage in other damaging body-focussed behaviors such as skin-picking or nail-biting.

For children as with adults, hair pulling may be transient, episodic or continuous and its intensity can fluctuate. Weeks and months may pass with a person being nearly or completely free of hair pulling, only to have a sudden and unexplained recurrence. Like any condition, there is a range of severity. For some, hair loss may be minimal, for others, cosmetic damage may be extensive, even to the point of total baldness.


How early can hair pulling begin?

There appears to be a subset of very young children who pull hair as infants or pre-schoolers. It has been suggested that perhaps the majority of very young hair pullers have a more benign and time-limited condition, called early onset trichotillomania, that does not progress through older childhood. Hairpulling in children under the age of five may be associated with self-exploration and self-quieting, similar to other behaviors such as thumb-sucking, and may be outgrown. Some children who begin pulling out their hair early do progress to adult forms of trichotillomania, however.


How is a person's life affected by trichotillomania?

Many persons with trichotillomania report considerable time lost to hair pulling and in efforts to cover up cosmetic damage. The repeated, and sometimes awkward, motions involved in hair pulling occasionally result in repetitive motion injuries.

Individuals, particularly adults and older children, with trichotillomania are often embarrassed and ashamed of their behavior and resulting appearance. It is not uncommon for children with trichotillomania to hide or deny the behavior to parents, friends and clinicians. Children and adolescents often resort to elaborate hairstyles, hats, or use make-up such as mascara or even crayons and magic markers to camouflage bald patches. In adolescents and adults, shame and embarrassment can seriously impair self-esteem, and impede social, academic, and career functioning. Some individuals may resist proper medical care for fear of having their cosmetic damage discovered or scrutinized.

Young children with trichotillomania are typically less self-conscious about their hairpulling than older children and adults who pull. The secondary effects of shame and diminished self-esteem may be absent in the very young. However adult and peer reactions to the behavior and its cosmetic effects may lead even young children to feel different or strange. If these feelings are left unaddressed, they might develop into more serious emotional problems.


How can a child's trichotillomania impact the family?

Trichotillomania can have serious repercussions for the family of the hairpuller. Parents are typically frustrated and demoralized by their child's pulling. They are frequently upset because they have received multiple, and often conflicting, opinions about the disorder from many different sources. For example, they may have been told it is their fault, or that they have not done the previous recommended therapies correctly.

There is no evidence that family dynamics or specific personality types cause hair pulling. It is very clear that family issues may affect the way in which a child or adolescent reacts to, or deals with, the hair pulling, however. It can be very difficult for friends and family to understand that a child can't simply stop pulling hair. Many families become stuck in very unhealthy behavioral patterns around the issue of pulling, and the relationship between the parent and child can become negative and punitive. Parents often feel frustrated or angry when children attempt to hide hair pulling and cosmetic damage or deny that they are pulling despite evidence to the contrary. Criticism, anger and punishments are unlikely to diminish the hair pulling, and may increase the shame, depression, anxiety and low self-esteem that often accompany trichotillomania.

Even in supportive environments, family patterns may be disrupted by the attention and energy being directed toward trichotillomania. Parents may relax the structure and discipline their child is accustomed to, or appear to favor the child over siblings, because of fear of exacerbating the hairpulling with additional stressors. Siblings of school-age children with trichotillomania may be teased for their sister or brother's problem.


What causes trichotillomania?

The cause of trichotillomania is not known. Because hair has prominent symbolic importance in most cultures and has been equated with beauty in women and power in men, it is not surprising that various psychological interpretations of hair pulling have been proposed. Some emphasize principles of learning and conditioning as critical mechanisms in the genesis and development of trichotillomania. Other explanations suggest that biological factors play significant roles. So far, the validity of these explanations has not been established using systematic scientific methods.

While it is likely that a variety of factors is responsible for the occurrence of trichotillomania, various perspectives have been offered regarding the proper manner of conceptualizing the disorder. Trichotillomania has been considered a habit, like nail-biting, that can have both a soothing function and potentially distressing consequences. Trichotillomania also has been viewed as a form of obsessive compulsive disorder (OCD) because of the repetitive and seeming compulsive nature of hair pulling, though significant differences between trichotillomania and OCD have been noted. The possibility that trichotillomania is associated with neurological conditions marked by motor tics, such as Tourette's disorder, has been suggested since hair pulling, like tics, can be viewed as an uncontrollable response to an irresistible sensation. In the current diagnostic system, trichotillomania is categorized as an impulse control disorder in which the urge to pull hair is associated with an increasing sense of tension. The act of pulling itself is presumed to relieve that tension.

Many individuals who pull out their hair also suffer from other disorders, the most common being anxiety and depression. Professional care of individuals with trichotillomania should therefore include a diagnostic assessment that addresses the broader impact of the disorder on the individual as well as any additional chronic conditions coexisting with trichotillomania.


What triggers hair pulling episodes in young persons with trichotillomania?

There are many specific experiences that can lead to individual episodes of hair pulling. Troublesome emotions like anxiety, tension, anger and sadness may increase the tendency to pull hair. However, hair pulling more frequently occurs during sedentary and contemplative activities, in the absence of notable emotions. Hair can be pulled absentmindedly, while involved in another activity like reading, talking on the telephone, doing homework, or watching television. Many children pull in the evening when they are settling down and trying to fall asleep.

While hair pullers often describe their behavior as a habit, some describe the build-up of an urge or a feeling of tension that seems to be relieved by the pulling of hair. The tension or urge returns again and again, resulting in the repeated pattern of pulling.

For some individuals, particular thoughts about hair may contribute to pulling episodes. It may feel necessary to achieve symmetry in hair growth, to change or even up the hairline, or to round out a bald spot, for example. The physical quality of the hairs targeted for pulling may also be important. Individuals may pull only the stubbier new growth, the longer hairs, or hairs of a certain texture or color, such as coarse or gray ones. Some hair pullers acknowledge an interest in the removed hair, or in the root, and may play with, bite, or ingest the root or even the entire hair.

In children, it appears that tactile stimulation, oral stimulation, or eating or sucking on the hair are especially important components of the hair-pulling ritual. While it is relatively rare, some individuals ingest enough hair to develop a potentially serious medical condition in which a trichobezoar (hairball) forms in the digestive system. It is important to either rule this out or to pursue prompt medical intervention if it is suspected.


Does stress play a role in trichotillomania?

Although some individuals report stressful events preceding the first occurrence of hair pulling, it is overly simplistic to conclude that hair pulling is inevitably a reaction to stress. There is no evidence that trichotillomania is symptomatic of a "deep-seated" problem or emotionaldisturbance either.

Hairpulling may increase if the individual is experiencing stress, whether of a positive or negative variety. For instance, participating in a school play may be viewed as a positive event, but still may cause an increase in pulling. It is important to identify both positive and negative stressors that may be impacting the rate of hair pulling. Learning to handle stressful situations as optimally as possible may reduce episodes of hairpulling, but is not in itself likely to end hairpulling completely.


What treatments are available for trichotillomania?

Because trichotillomania is not yet fully understood, the search is still underway for reliable and effective treatment. However, there is evidence that early intervention can be successful in reducing or eliminating hair pulling and its emotional side effects in many, and perhaps, most children.

When the patient is an infant or pre-schooler, hair pulling may very well be temporary in nature. Family education and casual monitoring of the condition may be preferable to direct treatment in these cases.

Management of trichotillomania should begin with education about the disorder and consideration of treatment options. For most children and adolescents with trichotillomania, medications should not be used as a treatment of first choice (see below.) Pharmacotherapy can be considered, however, to alleviate additional conditions, such as anxiety and depression, that often accompany trichotillomania, and for which medication may be effective. Individuals with hair pulling should be evaluated to rule out other potential medical disorders including skin conditions that may be related to the pulling of hair.

Treating hair pulling in children and adolescents involves a number of components including: education of the patient and the family, decreasing stressors, assessing the relationships in the family and the child's motivation and ability to participate in treatment, and providing a behavioral program (i.e. behavior therapy) for the person pulling hair.

Many persons receive a significant benefit from education. Knowing that they have a defined disorder, which other people share, and that can be treated is a huge relief and decreases shame and embarrassment. Frequently teachers, other relatives and counselors need to be included in the educational process.


What is behavior therapy?

Behavior therapy (also known as cognitive behavior therapy) is a form of treatment that targets specific behaviors, feelings, and thoughts with goals of changing them. It is usually provided for a specified period of time during which individuals are taught various techniques to gain control of their problem. In behavior therapy, the emphasis is placed on changing problems directly rather than seeking explanations of why they began.

A common behavior therapy approach for trichotillomania is called "habit reversal". It involves increasing the person's awareness of each occurrence of hair pulling and interrupting it by performing a response that competes with that behavior. Techniques to increase awareness of hair pulling include identifying triggers and sequences of events associated with hair-pulling. In addition, the individuals usually monitor and may record each occurrence of pulling, noting Information such as the date and time, location, thoughts, feelings, number of hairs pulled, etc. that can be of use in treatment.

A crucial element of habit reversal training involves the utilization of a competing response to help contain the urge to pull. The competing response is one that is incompatible with hair-pulling, such as clenching both hands into fists. Typically, the individual is instructed to use and maintain the competing response for brief periods on entering high-risk situations, at the very first urge to pull, or after hairs are actually pulled. Other elements of habit reversal training address preparation of individuals for treatment, maintenance of motivation during treatment, and sometimes training in relaxation techniques.


Other behavior therapy strategies called "stimulus control" procedures capitalize on the fact that hair pulling often occurs in certain discrete situations but not in others. For example, most individuals pull only when alone and engaged in such activities as watching television, talking on the phone, reading, and driving. Stimulus control techniques are used in situations where pulling is likely and are designed to interfere with hair pulling. Typical stimulus control techniques include wearing impediments to pulling, such as hats, scarves, gloves, rubber fingertip protectors, keeping hands occupied, and keeping fingers away from hair except when grooming.

Because hair pulling often occurs, increases, or re-appears in conjunction with stress, behavior therapy techniques can also focus on teaching effective ways to handle stress. Stress management techniques include breathing control, deep muscle relaxation and cognitive techniques to help minimize distress.

Some behavior therapists apply these and other techniques in a comprehensive approach geared specifically to the needs of the individual hair puller as assessed at the outset of treatment. Although all behavior therapists do not use identical approaches, some, if not all of the approaches mentioned above, constitute the core of behavioral treatment.

When control of hair pulling has been achieved, the issue of "relapse" should be addressed. This is essential because of the strong likelihood that episodes of increased hair pulling will recur after treatment has been completed. In relapse prevention, the individual is taught how to handle the recurrence of hair pulling by limiting damage and getting back on track with therapy booster sessions if necessary.


What role does the child's family play in treatment and recovery?

Finding a proper role for the family in treatment and recovery can be one of the most difficult aspects of treating children with trichotillomania. As discussed above, trichotillomania often causes great disruption in a family, and parents can become strongly enmeshed in their child's symptoms.

The role of the parent should be carefully considered in consultation with the therapist providing behavioral treatment. With younger children, the parent may need to be directly involved in the implementation of treatment strategies. With older children and adolescents, it is generally advisable to help the parents distance themselves from the problem and from the childs therapy. If so, parents may need guidance and support in finding their proper role in the therapeutic effort These relationships can be complicated and need to be evaluated carefully and addressed on a family-by-family basis.


Should medication be used to treat trichotillomania in children?

As stated above, medication is not a treatment of first choice for children and adolescents. There is little scientific evidence to suggest that medication is beneficial in the treatment of school-age children with trichotillomania. If other therapies have failed, it may be appropriate to use medication with older or adolescent children, either alone or, preferably, in combination with behavior therapy. Use of medication is of particular concern in children because few controlled studies on trichotillomania have been done testing the efficacy of drugs in younger hair pullers. While medications can be utilized to address conditions concurrent with trichotillomania (e.g. tic disorders, depression, social anxiety, attention deficit disorder, etc.), stimulant medications should be used with care because of anecdotal reports that they may worsen hair pulling in some individuals. When treating children and adolescents with medication, consideration should be given to the potential effects of drugs on the developing nervous system.


Are support groups a useful part of treatment?

Individuals with trichotillomania often feel very much alone with their problem. Though trichotillomania is much more common than previously thought, it is also hidden and seldom discussed.

Many report that participation in either therapist-facilitated or peer support groups helps to improve self-image and may help to reduce hair pulling in some cases. Parents and loved ones of hair pullers may also experience feelings of frustration or guilt about the disorder and may benefit from communication with others who share their experience. The Trichotillomania Learning Center (TLC) provides Information about local support groups and will assist individuals to start new groups. There are also "bulletin boards," "chats," and other support resources available onthe internet.


What other services does TLC provide?

The Trichotillomania Learning Center helps its members to learn about trichotillomania, find treatment resources, and keep up-to-date on the latest research and treatment developments. TLC's Scientific Advisory Board works to advance understanding of trichotillomania and its treatment.

TLC sponsors an annual national conference devoted to trichotillomania and a four-day retreat for hairpullers of all ages. Both of these events include complete programs designed for children and teens, as well workshops addressing the special concerns of parents. The organization provides contacts for children and parents who are interested in talking with others with trichotillomania, as well as Information about local treatment providers, support groups, and other services, such as hairdressers familiar with trichotillomania. TLC publishes a quarterly newsletter, In Touch, and a website, "www.trich.org" with a section devoted to children & teens, and distributes videos, books, pamphlets, and selected bibliographies of publications about trichotillomania and related body-focused behaviors.

The organization frequently assists the media in preparing stories and broadcasts to increase awareness and educate the public about trichotillomania. TLC also helps advance the scientific understanding of trichotillomania through its Scientific Advisory Board, a panel of experts who are actively engaged in research, writing for general and professional audiences, and public and professional education.


Suggested reading:

Trichotillomania edited by Dan Stein, Gary Christenson and Eric Hollander.
Published by American Psychiatric Press, Washington DC, 1999. The Hair Pulling Habit & You by Ruth Goldfinger Golumb & Sherrie Mansfield Vavrichek.
Published by Writers' Cooperative of Greater Washington, Silver Spring, MD, 1999.

Persons wishing to read further about trichotillomania may contact the Trichotillomania Learning Center. Selected reading lists are available both for professionals, and nonprofessionals.

Trichotillomania Learning Center, Inc. (TLC)
1215 Mission Street
Santa Cruz, CA 95060-5863
831-457-1004
Website: www.trich.org



Copyright 2001 Trichotillomania Learning Center, Inc.