What is Trichotillomania (trich/hair pulling)

Trichotillomania, otherwise known as ‘Trich’, or ‘TTM’, is a disorder that has been around for quite sometime but is often not discussed or acknowledged due to the shame and embarrassment that it causes people who have it. Apparently, in America it only began to appear in the media around 1989 and it has only been in recent years that Trich has begun to be more noticed by the media in Ireland. People who have Trich pull out hair from their scalp, eyelashes, eyebrows or other parts of the body. This often results in the individual having noticeable bald patches or they may have no eyelashes. This disorder is different from Alopecia although both often result in the person having noticeable bald patches. The main difference is that people with Alopecia loose their hair involuntary where as people with Trich actively pull their hair out. Also, Alopecia is usually caused by stress, but the causes of Trich are unknown at this point. Perhaps, as more research is completed in the future, there will be more understanding about what causes this disorder.

In other words this means that it affects one to two people in every 100. It does appear to affect more women than men but as more research is done in the future this picture may change since one possibility is that men are more embarrassed by the Trich and are not coming forward for help as much as women are. Also, for many people, Trich often develops in the pre- or early adolescent years. Apparently the age for many first time hair pullers is 12 years old but there are reports of it effecting people as young as one and as old as 70.

Current research estimates that 1-2% of the population has this disorder.

The first reference to Trich is in medical literature in 1889 and although there are many references to hair pulling in prior medical literature this reference is the first to look at hair pulling as a disorder on its own rather than as a symptom of grief, etc. It was a French physician, Hallopeau, derived the name from the Greek words: hair (trich), pull (tillo) and abnormal love (mania). It is easy to see how Hallopeau arrived at the name but it is unfortunate that the name has done this disorder a disservice. Trich is often associated with other unrelated disorders such as pyromania (this is defined as an impulse control disorder where an individual often fails to resist the urge to start fires) and kleptomania (this is defined as the persistent compulsion to steal, especially without economic motive). Also, the ‘mania’ derivative seems to imply that the person enjoys pulling their hair when this is not in fact accurate. As noted in the book, Help for Hair Pullers, in historical references, hair pulling has long been associated with grief and upset. The prophet, Ezra, is quoted in the Bible as stating, “And when I heard this thing, I rent my garment and my mantle, and plucked off the hair of my head and of my beard.” In addition, Agamemnon, is quoted in the Iliad was described as to groan “from the very deep of his heart” and to tear “many of lock clean forth from his head”.

Although the hair pulling may range in location on the body as well as in severity, the main symptom is the active pulling of hair from one’s body or the pulling of one’s eyelashes over a long period of time. The result is that the person has few or no eyelashes and/or may have bald patches on his/her head. Usually, the person will go to great lengths to cover up the bald patches on his/her head (i.e. wearing a wig, pulling the hair up into complicated styles over the bald spots, wearing a hat, a scarf or bandana, etc).

Called ‘Trichophagy’, it can lead to hair being lodged between the teeth and more seriously to large accumulations of retained hairs in the stomach and digestive tract called ‘Trichobezoars’ (hairballs). Symptoms of ‘Trichobezoars’ include stomach pain, nausea, vomiting, and sometimes blood and/or visible hairs in the stool. Trichobezoars can also cause foul breath, poor appetite, constipation, diarrhoea excessive gas, bowel obstruction, and even bowel perforation. Liver and pancreas functions can be adversely altered. Sometimes a physician can feel a trichobezoar by gently pushing in the mid or left upper area of a patient’s abdomen. Trichobezoars can be diagnosed by using special upper gastrointestinal X-rays, looking into the stomach with an endoscope, or using ultrasound. Surgical removal is the most common treatment.

Some researchers have found that nearly 20% of hair pullers eat their hair or chew off and swallow the root ends.

When school aged children begin to display the symptoms of Trichotillomania, this is referred to as late onset. It is important to find a professional who will provide an accurate diagnosis as well as possible treatment. Research has divided children and Trich into two categories: early onset (Baby Trich) and late onset. Baby Trich, which begins in the early years, is viewed as a habit. It is thought that a baby does this for ‘self-soothing’ rather than for the release of tension and/or anxiety that usually occurs before the hair pulling. At this time, researchers believe that this behaviour is only temporary and will disappear. It also seems, from the current research available, that it is unlikely that the baby will develop Trichotillomania in later life.

It is important for people to find appropriate treatment because Trichotillomania is manageable!! Many people with Trich lead active and fulfilling lives. Research has shown that the two typical forms of treatment are medications and/or Cognitive Behavioural Therapy (CBT). Either treatment, or in some cases a combination of the two, focus on the management of the disorder since there is no cure and there is no one proven effective treatment of Trich. It is important for the person with Trich to check out a CBT therapist’s knowledge of this disorder. Not all people who say that they use CBT are properly trained or fully understand Trich and the appropriate treatments.

Abstract: Behavior therapy has the greatest empirical support, but the number of mental health providers familiar with TTM and its treatment is quite small. This manual was written as a tool for therapists to become familiar with an effective treatment for TTM. The treatment approach described in this guide blends traditional behavior therapy elements of habit reversal training and stimulus control techniques with the more contemporary behavioral elements of Acceptance and Commitment Therapy (ACT). In the first phase of the program, clients are taught skills for stopping and preventing their unconscious pulling episodes. In the second phase, clients are introduced to ACT. Unlike traditional interventions that aim to change type or frequency of pulling-related cognitions in the hopes of reducing urges to pull hair, this innovative program uses strategies to change the function of these cognitions. Clients are taught to see urges for what they really are and to accept their pulling-related thoughts, feelings, and urges without fighting against them. This is accomplished through discussions about the function of language and defusion exercises that show the client how to respond to thoughts about pulling less literally. Over the course of 10 weeks, clients learn to be aware of their pulling and warning signals, use self-management strategies for stopping and preventing pulling, stop fighting against their pulling-related urges and thoughts, and work toward increasing their quality of life. Self-monitoring and homework assignments keep clients motivated and engaged throughout. Reference: Woods, D. W., & Twohig, M. P. (2008). Trichotillomania: An ACT-enhanced Behavior Therapy Approach Workbook. Oxford University Press.

* Tips for managing Trichotillomania (trich/hair pulling).

The document below contains a collection of ideas from people who have TTM/Trich on how to substitute the sensory stimulation and emotional soothing that the pulling provides for you. Feel free to share your tips with OCD Ireland of what works for you.