Trichotillomania is characterized by the compulsive pull out of an individual’s hair or body hair. It leads to alopecia on the concerned body area. Mental disorder literature classifies it as a habit and impulse disorder.
The word comes from Greek, meaning depilating hair. The French dermatologist François Henri Hallopeau first used this word in a case study in 1889.
Trichotillomania epidemy is very complex to estimate. First, very few people suffering from trichotillomania seek medical assistance for this disorder. The ones who go to the doctor mostly consult dermatologists or psychiatrists. Moreover, trichotillomania is often a symptom of other psychiatric conditions and rarely the disorder itself. Trichotillomania definition and its symptoms are not always clear.
All this leads to trichotillomania epidemiology dramatically varies from one study to another depending on the used criteria.
Until the 1990s, this disorder was quite rare. The statistics went up after the media got interested in this phenomenon, as many people had sought medical attention. Some doctors who wrote on this subject believe 1 of 200 adults older than 18 suffers from trichotillomania. 3.5% of women and 1.5% of men would have suffered from a trichotillomania episode in their life. The condition starts in childhood or teenagehood for most people suffering from trichotillomania, but it may also begin later in life. Globally, trichotillomania would concern 1 to 2% of people.
In 2008, Flessner and al. wrote about 0.6% of the world population suffered from trichotillomania. Those figures rise to 13 to 15% for less severe cases of trichotillomania which do not lead to alopecia. More women (90%) than men suffer from trichotillomania; however, it is more accessible for men to hide this condition while women seek medical assistance.
Despite studies on the topic, doctors are still unsure about the causes of trichotillomania. A genetic mutation involved in trichotillomania would have been identified, but they still have to explore this hypothesis. Trichotillomania often happens after trauma. The patient pulls out his hair on a designated spot to distract himself from stressful thoughts. However, in some cases, the condition appears without explanation (automatic pulling out).
There are many psychodynamic explanations for trichotillomania as hair is associated with feminity, and this disorder is more present in women.
Trichotillomania may be episodic or continuous, and its intensity varies. This condition is impulsive; patients cannot prevent touching and pulling out their hair (or body hair). They may experience a period without feeling those impulses and feeling them again without explanation. Stress, post-traumatic syndrome, anxiety, or boredom may trigger crisis: the patient cannot prevent himself from pulling out their hair for several minutes to several hours. He is feeling in a daze. It is very hard for someone suffering from trichotillomania to end a crisis.
Usually, patients pull out their hair, lashes, brows, and beard hair. However, it may happen with all body hair. Some people, primarily children, may pull out someone else’s or pets’. Frequently, people suffering from trichotillomania play or eat the hair they pulled out. Trichotillomania is sometimes considered an Obsessive-Compulsive Disorder (OCD), but this behavior, even if it is compulsive, gives pleasure (which makes it addictive), so it is not precisely OCD. Many doctors agree that people suffering from trichotillomania have all the criteria of behavioral addiction (persistence of a behavior despite its psychological and social consequences).
Hair loss may be minimal for some patients, while for others, trichotillomania may lead to severe corporal damages such as total baldness, which comes with mental distress. Some patients suffering from this condition do not have a job anymore and are reluctant to leave home. However, in most cases, patients who suffer from trichotillomania are afraid people would know (they avoid going to the pool, take up to several hours to do their hair, and use many elements (scarves, makeup) to hide the damage.
Trichotillomania is linked with poor self-esteem, conflictual relationships with one’s body, anxiety, frustration, depression, and the feeling of being unattractive. 80% of the people suffering from this condition would have body image issues, and more than 20% would suffer from a dysmorphic disorder. According to studies, 17 to 75% of people suffering from trichotillomania hide this disorder from their friends and family.
Many patients face doctors’ incomprehension as this disorder is poorly known. Some believe this condition is not severe and do not see the emotional and psychosocial implications. Those reactions make the patient feel shame and worsen his condition.
Trichotillomania often comes with other psychological disorders such as anxiety, depression, histrionic personality, narcissism, and borderline disorder.
Treatment depends on the patients’ age. Most kids under 10 suffer from this disorder when they do not feel good. In young adults, a diagnosis and preventive measures are comforting for the patient and his family. Psychologists and psychiatrists consider non-pharmaceutical interventions, such as behavioral modification programs, fallible. When trichotillomania appears in adults, it goes with other mental disorders. Since 2011, we have known sugar would trigger trichotillomania.
Some antidepressants may give good results, such as clomipramine, sertraline, and selective inhibitors of serotonin recapture (SISR) based antidepressants.
Cognitive-behavioral psychotherapy is a therapy based on behaviors, sentiments, and thoughts. It helps the patient suffering from trichotillomania acknowledge his moves to control them better. Studies proved the most effective treatment is behavioral therapy and antidepressant. It has better efficacity than support therapy.
Tools from cognitive-behavioral therapy (CBT) are:
- Self-monitoring collecting pulled-out hair: it is a task only for trichotillomania. The patients collect all the hair he pulled out in a day and put it in a dated envelop. It helps the patient figure out how severe his condition is and how much hair he pulls out daily. To disclose how much hair he pulls out is shameful for the patient, reducing the pleasure he feels doing it.
- Coping strategy development: helping the patient identify and face risky situations when he feels the impulse to pull out hair. Then, the therapist helps the patient to determine cognitive-behavioral strategies to avoid pulling out hair. The patient develops auto-efficiency.
- Automatic thoughts identification is the patient acknowledging his intern monologue, especially when he feels the impulse of pulling out his hair. He may think: “I will just pull out a few ones, it won’t be visible, it is so good, I can do it after such a day at work…”). Therapists sensibilize the patient to those thoughts during risky situations.
- Motivational meeting: Miller and Rollnick developed it for addiction in 1991. In the case of trichotillomania, it is another argument proving this condition is an addiction. During those meetings, the professional invites the patient to openly and without judgment check up on his situation and the trichotillomania’s consequences on his life (family, social life, wellness). The patient then thinks about the cost and benefice of stopping pulling out his hair. The therapist asks the patient to imagine his future life and consider the potential consequences with or without hair pulling.
- Relaxation training: for patients who pull hair because of stress, learning relaxation techniques may help to prevent pulling out behavior. Most classical relaxation technics used in cognitive-behavioral therapy (Jacobson, Schultz, abdominal breathing) may be used, depending on the patient’s will.
- Self-affirmation: according to Marcks, Woods, and Ridosko’s research in 2005, trying to hide trichotillomania from friends and family is socially not accepted; being comfortable with this condition would give the patient better social consequences. To help the patient be comfortable with this disorder and stop hiding the affected area, especially teaching him social abilities to help him face criticism. It is interesting to develop type-sessions of self-affirmation adapted to trichotillomania, based on triggering situations the patient may encounter. Moreover, not hiding trichotillomania may help with social support research and affiliation, improving coping strategies.
- Acknowledging training: The purpose of this technique is to prevent automatic pulling out with acknowledging it. The patient has to focus on his hand when it touches the hair and the pulling out area and focus on the tactile sensations. Concentrating on pulling out increases its cognitive cost, decreasing the pleasure.
- Response control: when the patient feels the urge to pull out hair, he must create an antagonist behavioral response incompatible with doing it. It may be, for example, to clench fists as hard as he can for three minutes. The purpose is to manage to pull out urges.
For some people suffering from trichotillomania, hypnotherapy would be efficient. However, there is no documented study proving it.