A project of the Scientific Advisory Board of the Trichotillomania Learning Center, Inc. (TLC)

Authors:

Charles Mansueto, Ph.D.
TLC Scientific Advisory Board Chair
Director, Behavior Therapy Center of Greater Washington, D.C.
Silver Spring, MD

Philip T. Ninan, M.D.
TLC Scientific Advisory Board Vice-Chair
Associate Professor of Psychiatry and Behavioral Sciences
Director, Mood and Anxiety Disorders Program
Emory University School of Medicine
Atlanta, GA

Barbara O. Rothbaum, Ph.D.
TLC Scientific Advisory Board Member
Associate Professor in Psychiatry
Director, Trauma and Anxiety Recovery Program
Emory University School of Medicine
Atlanta GA


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 occurs more frequently in women and is commonly associated with considerable distress.

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. 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 with one site of hair pulling, 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 common for persons with trichotillomania to play with and/or ingest the pulled hairs. Individuals with trichotillomania often engage in other damaging body-focussed behaviors such as skin-picking or nail-biting.

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.

The majority of individuals start pulling hair during childhood or adolescence, though hair pulling can start at any age. 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 very young hair pullers have a more benign and time-limited condition that does not progress through older childhood.


How does trichotillomania impact lives?
Individuals with trichotillomania are often embarrassed and ashamed of their behavior and resulting appearance. They may hide the problem from even their closest friends and family, or deny the behavior entirely. They often resort to elaborate hairstyles and make-up to camouflage bald patches, or wear wigs. Shame and embarrassment can have grave repercussions for self-esteem, social and career functioning, and may even lead individuals to avoid proper medical care. 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 can result in repetitive motion injuries.

For many, the most shameful aspect of trichotillomania involves the biting or ingesting of parts of the hair, such as roots, or entire hairs. Doctors treating trichotillomania should be aware that the ingestion of significant amounts of hair can lead to development of trichobezoars, or clumps of hair trapped in the stomach or intestines, a relatively rare, but potentially dangerous medical condition.


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. It is likely that more than one mechanism is responsible for the occurrence of the disorder.

Trichotillomania is currently 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. Trichotillomania has been considered a habit, like nail-biting, that can have both a soothing function and potentially distressing consequences. 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. 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.

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.


What prompts individuals with trichotillomania to pull out their hair?
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. Hair pulling typically occurs during sedentary and contemplative activities during which the hands are free and the mind is otherwise occupied. Hair is often pulled absentmindedly, while involved in another activity like reading, talking on the telephone, driving or watching television. There may also be times of the day when the risk of pulling is greater. Many people pull in the evening and late at night when they are alone, tired, or trying to fall asleep.

Many persons who pull hair describe their behavior as a habit, much like biting nails or cracking knuckles. Some have more intense feelings associated with the behavior. These individuals 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.

While many individuals pull out hair without being fully conscious of their activity, others pull with a great degree of attention to their behavior. These may involve efforts 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. Many individuals pull the stubbier new growth, only the longer hairs, or hair of a certain texture or color, such as coarse or gray hairs. 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.


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. Stress can cause a change in many behaviors such as overeating, nail biting, sleeping, or cigarette smoking. Similarly, it is not uncommon for persons with trichotillomania to note that their hair pulling worsens in response to stressors like final exams, work deadlines, and income tax preparation. Thus, learning to handle stressful situations as optimally as possible is recommended, though this in itself, is not likely to end the hair pulling.


Don't individuals who pull their hair bring their problems on themselves?
While trichotillomania certainly does involve self-destructive behavior patterns, persons with trichotillomania typically try to help themselves in a variety of ways. Most individuals make personal attempts to stop pulling their hair, with varying degrees of success. However, despite even heroic efforts, most individuals return to hair pulling, even if they have achieved a period of abstinence.

Blaming an individual for hair pulling is like blaming a person with asthma for having difficulty breathing. Criticism, anger and accusations are unlikely to diminish the hair pulling, and may increase the shame, depression, anxiety and low self-esteem that often accompany trichotillomania. It is more appropriate to provide individuals with support for acknowledging the problem and seeking treatments that can help them gain control over hair pulling. Because hair pullers often hide their behavior from others, out of fear that their hair pulling will be discovered, they may avoid many social encounters, including even medical appointments. Thus, professionals, in particular, should be sensitive to such issues when interacting with an individual with trichotillomania.


What treatments are available for trichotillomania?
Because trichotillomania is not yet fully understood, the search is still underway for reliable and effective treatment. At this time, management of trichotillomania should begin with education about the disorder and consideration of treatment options (discussed below). Treatment should also address any additional conditions, such as anxiety and depression, that often accompany trichotillomania. The special considerations and approaches for treating children and adolescents with trichotillomania are discussed in detail in another publication.

Two treatments are currently known to have potential benefits for reducing hair pulling: a form of psychological therapy called behavior therapy (sometimes called cognitive behavior therapy), and pharmacotherapy. Many professionals believe that the combination of both behavior therapy and medications is most likely to provide optimal short- and long-term treatment benefits. Which approach to use, or if both are to be used, whether they should be started simultaneously or sequentially, depends on a number of considerations. These include availability of professionals competent to provide these treatments, and individual characteristics and preferences of the hair puller.

Other forms of treatment have not been evaluated systematically enough for any confident conclusion about their degree of success. There are reports that alternative forms of treatment, such as hypnosis and biofeedback, have been used successfully to treat hair pulling, however, such approaches have yet to be subjected to rigorous scientific scrutiny. Diet is believed by some
individuals to play a role in inducing hair pulling and thus dietary manipulations could potentially aid in its control or cessation. Unfortunately, these beliefs have yet to be systematically tested. A healthy and balanced diet has general benefits for the individual.


What is behavior therapy?
Behavior therapy is a form of treatment that targets specific behaviors, feelings, and thinking (cognitive) patterns 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 means of a competing response. 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 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 control the urge to pull. The competing response is one that is incompatible with hair-pulling, such as clenching both hands into fists. 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 relaxation training.

Other behavior therapy strategies employ "stimulus control" procedures. Hair pulling often occurs in certain discrete situations but not in others. For example, most individuals pull only when alone. Activities typically associated with hair pulling include 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 regulate 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 behavior treatment.

When control of hair pulling has been achieved, the issue of "relapse" should be addressed. In relapse prevention, the individual is taught how to handle the recurrence of hair pulling by limiting damage and getting back on track.

What medications are effective for trichotillomania?
Individuals with hair pulling should be evaluated to rule out other potential medical disorders including skin conditions.

While research has been limited, several medications have been evaluated in controlled studies and found useful for trichotillomania. The first medication shown to be effective was clomipramine (trade name Anafranil) which has the capacity to block the reuptake of serotonin and norepinephrine, two key neurotransmitters in the brain. However, problems with side-effects have limited the clinical use of clomipramine. Venlafaxine (Effexor) shares similar
chemical properties as clomipramine, has documented benefits in trichotillomania and is generally well tolerated. Several studies were performed with antidepressant medications that block the reuptake of serotonin alone (SSRI's), with mixed results. Such results suggest that these SSRI's, fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), and others, should also be considered as potentially useful medications.

Though individuals often have a reduction in hair pulling in response to the above medications, improvement is often modest and rarely complete. Some individuals experience initial improvement but find that the effect wears off with time. Still, many individuals who do not experience much improvement in their hair pulling, report improvement in other areas such as reduction of anxiety and improvement in mood.

A variety of other medications are being considered as potentially useful agents for trichotillomania. Because scientific evidence to support the use of these medications is currently lacking, it is too early to make global recommendations about their use. Among medications currently receiving attention are dopamine-blocking neuroleptics. The rationale for their use is a potential link between trichotillomania and tic disorders such as Tourette's disorder. Similarities have been noted between the sensations that, for some individuals, trigger the seemingly irresistible urge to pull, and the impulse that often precedes a motor tic. If employed, neuroleptics should be used at very low doses to minimize potential side-effects. These include extrapyramidal side-effects (parkinsonian like tremor, rigidity and bradykinesia), akathisia, dysphoria, emotional blunting, sedation, tardive dyskinesia, and so on. The use of 'atypical' neuroleptics can reduce these potential side-effects. Thus risperidone (Risperidal) or olanzapine (Zyprexa) at low doses might be appropriate alternatives for some individuals.

A reasonable medication strategy at this time would employ a systematic trial of a specific medication while monitoring the severity of symptoms. Rating scales can be used to assess the degree of hair pulling as well as a global measure of improvement (see the appendix in the book 'Trichotillomania' mentioned below for details). The dose should be built up until complete benefit is obtained, or to the maximum recommended, or best tolerated dose. An appropriate period of time should be allowed (6-12 weeks, or longer) before deciding whether maximum benefit has been achieved. If the degree of benefit is negligible, the medication should be discontinued. Medication from another class may then be tried.

If the benefit from a medication is partial, augmentation strategies should be considered. These include medications in other classes or behavior therapy, if it had not yet been employed. If trials of all medications are ineffective, they should be discontinued unless they are providing benefits for associated conditions like depression or anxiety.

There is evidence suggesting that the best outcome occurs in individuals who receive a combination of both medications and behavior therapy. If no benefit is derived from medications and behavior therapy, the focus should shift to a rehabilitative model where goals of treatment include learning to cope with the effects of the disorder - in other words, focussing on improving self-image and the quality of life.


Are support groups useful for people with trichotillomania?
Prior to seeking treatment, individuals with trichotillomania have often spent years coping with the disorder alone. Many report that participation in either therapist-facilitated or peer support groups helps to improve self-image and sometimes even helps to reduce hair pulling. 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 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 on the internet.


How should hair pulling be treated in children and adolescents?
Treating hair pulling in children and adolescents can involve a number of important components: education of the child and the family, assessment and therapy for problematic relationships in the family, reduction of environmental stressors, and providing a targeted behavioral program for reducing the child's hair pulling.

The benefits of medications in children and adolescents have not been systematically evaluated. Clinicians generally prefer to use behavioral techniques as the treatment of first choice and only try medications if that fails.

A more complete consideration of treatment of trichotillomania in children and adolescents can be found in a separate publication, "Trichotillomania and its Treatment in Children and Adolescents: A Guide for Clinicians," available from the Trichotillomania Learning Center.


What other services does the Trichotillomania Learning Center provide?
The Trichotillomania Learning Center (TLC) 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 provides its members with contact Information for local treatment providers, support groups, and other services, such as hairdressers, familiar with trichotillomania. The organization publishes a quarterly newsletter, "In Touch", and a website, "www.trich.org", and distributes videos, books, pamphlets, and selected bibliographies of publications about trichotillomania and other body-focussed behaviors.

TLC sponsors an annual national conference devoted to trichotillomania and a four-day retreat for hairpullers of all ages. The media frequently seeks TLC's assistance in reaching clinicians and persons with trichotillomania to interview for stories and broadcasts. Requests for assistance in finding individuals to participate in research studies are reviewed by TLC's Scientific Advisory Board.


Suggested reading:
Trichotillomania. Edited by Drs. Stein, Christenson and Hollander.
Publisher, Washington, DC: American Psychiatric Press, 1999.