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Trichotillomania (TTM)

Trichotillomania (TTM) is one of a group of impulse control disorders. The name is comprised by the Greek terms for hair (trich), added to the Greek word for pulling (tillo) and for impulse (mania). It is characterized by a compulsion to pull hair from the scalp, eyelashes, eyebrows, ears, beard, pubic area or body, and it may relate to obsessive-compulsive disorder. Some doctors consider this condition a mental disorder and others consider it a form of ‘self harm’ or ‘self-injury’. This disorder does not involve the cosmetic removal of hair. Rather the patient is compelled to physically pull on the hair until it breaks free. Hair pulling is exacerbated by stress, but can sometimes be worsened by relaxing activities like reading a book or watching television. The patient begins to feel anxious or tense prior to the hair-pulling episode and this anxiety is relieved after the hair-pulling episode is finished. Hair pulling can be transient, occur in episodes or be continuous and its intensity can vary. Weeks or months may pass with a patient nearly or completely free of symptoms, followed by a sudden recurrence of behavior. There is a wide range of severity in this disorder and for some hair loss may be minimal, while others may experience significant cosmetic damage, even to the point of baldness. Patients often start pulling hair from one site, perhaps the scalp or eyelashes, and later graduate to pulling hair from another area, as well. Some patients, especially children, also pull hair from other people, or from their pets. Patients with trichotillomania often play with or eat the hair they pull (called Trichophagia), and may also engage in other body-based behaviors like skin picking or nail biting. When patients also suffer from Trichophagia (eating the hair they pull) they may encounter significant issues with intestinal blockages (the Rapunzel Syndrome). Most patients start pulling hair during childhood or adolescence, though this disorder can appear at any age.

Some children with trichotillomania show complete remission of symptoms, whereas adults often have a chronic or episodic recurrence of symptoms. Most TTM sufferers live otherwise normal lives at work and in social situations, though some are deeply ashamed of their disorder and avoid social and intimate relationships where their illness may be discovered. Many patients spend considerable time in hair pulling and in their efforts to cover up the cosmetic damage, and the repeated motion involved in hair pulling can result in repetitive motion injuries. But, for most patients, the greatest shame they feel about their disorder relates to biting or swallowing the hair (Trichophagia). The cause of trichotillomania is unclear, but there is a theory that the disorder has a biological basis, whereby abnormal brain chemistry causes disrupted or muddled communication between the brain and the body. Genetic predisposition or traumatic events may also contribute to the onset of TTM. And, many patients also suffer from other mental disorders like anxiety and depression.

What are the symptoms?

The severity and frequency of episodes of Trichotillomania varies from patient to patient and not all symptoms will be evident in all individuals.

• Recurrent hair pulling, noticeable hair loss
• Increased anxiety or tension prior to hair pulling, followed by relief of anxiety after hair pulling
• Disorder causes significant distress or impairment at work, home or in social situations
• Compulsive need to pull hair, patient is unable to control behavior
• Attempts to cover cosmetic damage, wearing wigs, bandanas, long sleeves or pants in summer, avoiding physical intimacy

How is it diagnosed and treated?

Doctors must first rule out other medical or mental disorders including all other possible causes of hair loss, e.g. dermatological disease. The doctor will also look at the possibility of coincident disorders like obsessive-compulsive disorder, depression or anxiety disorders. To diagnose Trichotillomania (TTM) doctors will look for the following signs:

• Signs of hair removal, redness, scars on scalp or other areas of the body
• Patient describes compulsion and anxiety
• Patient attempts to hide hair pulling and associated hair loss
• No other disorder or medical problem has been diagnosed to explain these signs
• Patient may have tried, unsuccessfully, to stop behavior

Treatment(s) can include:

• Cognitive Behavioral Therapy
• Medications if appropriate: venlafaxine (antidepressant), lithium (prevents mania), neuroleptics (antipsychotic medications)
• Group Therapy or Self-Help Groups
• Habit Reversal Therapy
• Biofeedback, Hypnotherapy
• Psychotherapy if appropriate for associated disorders
• Stimulus Control Strategies
• Family Groups if appropriate

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