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Trichotillomania (TTM)

Trichotillomania (Pronounced: trick-oh-till-oh-may-nee-ah) is a type of psychological disorder known as an impulse control disorder. Trichotillomania is not an Obsessive-Compulsive Disorder (OCD) as such. However, it is a disorder that involves irresistible urges which can co-exist with OCD.  There are also strong similarities with Compulsive Skin Picking.

The condition is found predominantly in females. It usually develops at an early age from adolescence to early twenties and often can stay with the sufferer throughout their life until they get treatment.

Trichotillomania may be present in infants, but the peak age of onset is 9 to 13. It may be triggered by depression or stress. Due to social implications the disorder is often unreported and it is difficult to accurately predict its prevalence; the lifetime prevalence is estimated to be about 0.6%, which, based on the 2009 UK population estimate, equates to  370,752 people possibly affected by TTM.

The symptoms of Trichotillomania range greatly in severity. However, its defining characteristic is the recurrent, compulsive pulling of the hair out at the root from places like the scalp, eyebrows, or eyelashes, sometimes causing baldness. Pulling may also occur from less common locations including the pubic area, perirectal area, or any other body region.  The most common method of hair pulling amongst sufferers is for them to use their fingers. However, some sufferers also use tweezers or other instruments.

Another issue relating to this condition is hair sucking or chewing (sometimes resulting in hair ingestion); this may lead to intestinal problems requiring surgery.

Individuals with Trichotillomania often attempt to cover up the hair loss that occurs because of the disorder. They try to prevent others from seeing the hair loss by using camouflage techniques that include the use of hats, scarves, and false eyelashes. Some may even resort to having false eyebrows permanently tattooed onto their skin.

Sufferers can be so embarrassed, ashamed, or depressed by their hair loss that they avoid social situations in an effort to prevent others from seeing it.  Although many sufferers of trichotillomania go on to lead normal lives (forming relationships, getting married etc) there are those who have avoided intimate relationships for fear of having their embarrassing Trichotillomania secret exposed. The main characteristics of TTM include:

  • Before the sufferer pulls their hair there is a high level of tension and a strong urge to pull.
  • Pleasure, gratification, or relief when pulling out the hair.

 Trichotillomania is classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as an impulse control disorder, but there are questions about how it should be classified. It may seem, at times, to resemble a habit, an addiction, a tic disorder or an obsessive–compulsive disorder. The name, coined by French dermatologist François Henri Hallopeau, derives from the Greek: trich- (hair), till(en) (to pull), and mania ("an abnormal love for a specific object, place, or action")

What treatments are available? Research into treatments for Trichotillomania has grown steadily over the past few years with medication and CBT leading the way, although no one treatment has been found to be effective for everyone. Sometimes a combination of both will be required.

Initially consult your GP, however, be aware that many GPs have little or no knowledge of Trichotillomania so you may have to be prepared to explain to them what it is and what your symptoms are. You should then ensure that they refer you to an appropriate psychologist or psychiatrist.

The primary treatment for Trichotillomania is a type of CBT called Habit Reversal Training (HRT). Habit Reversal Training was developed in the 1970’s by psychologists Nathan Azrin and Gregory Nunn for treating nervous habits which are done automatically, such as pulling, tics, stammering and skin-picking.

HRT is based on the principle that hair pulling is a conditioned response to specific situations and events, and that the individual with Trichotillomania is frequently unaware of these triggers. Therapy should focus initially on developing Habit Awareness and patients may be asked to keep records of when, where and under what circumstances they normally pull.
HRT challenges the problems of sufferers as a two-fold process. Firstly, the individual with Trichotillomania learns how to become more consciously aware of situations and events that trigger hair-pulling episodes. Secondly, the individual learns to utilise alternative behaviours in response to these situations and events. The therapist will encourage hair pullers to develop an increased awareness of the times of day, emotional states, and other factors that promote hair pulling.

However, there are a number of other therapeutic techniques that can be used in addition to Habit Reversal Training. Among these are Exposure and Response Prevention (ERP) and Stimulus Control Techniques.

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