Trichotillomania: And That Is?

Trichotillomania (TTM), what I’ll call “trich,” is a fascinating, albeit brutal, mind variance (my stigma-reducing term for “mental illness”). Now, if you’ve elected to read an article addressing treatment you more than likely have a pretty good idea as to just what trich is. But to make sure no one’s left in the dark I’m going to offer some details.

The DSM-IV-TR, the book of formal psychiatric diagnoses, categorizes trichotillomania as an impulse control disorder. That would make it akin to pathological nail-biting, fire-setting, stealing, gambling, skin-picking, and explosive behavior. But some would categorize trich as an anxiety disorder, similar to obsessive-compulsive disorder (OCD). Others believe trich is a tic disorder, even an addiction. It’s interesting that trichotillomania has been recognized as a “disorder” for only about twenty years.

Okay - hair is where it’s at for those dealing with trich. And that means hair – anywhere. The preferred sites are the scalp, eyebrows, and eyelashes. But hair on the face, nose, pubic and perirectal areas, chest, arms, and legs are fair game. At its worst, pulling behavior can become so intense and chronic that it leads to very noticeable bald spots. And in some ten percent of trich cases the pulled hair is eaten (trichophagia) causing what’s called a bezoar; a fancy medical term for, in this case, a hairball. These may require some pretty heavy medical intervention. Most often used in the act of pulling are fingers, tweezers, pins, and other creative “pullers.”

A trich episode is often induced by a stressful event or mood situation. However, an episode may also emerge in the midst of calm. No matter how you slice it, the end result is an “urge.” And quite often a sense of relief is realized after the urge has been acted upon. Though trich behaviors can be conscious acts, they’re very frequently performed unconsciously, almost as though the individual is in a trance. In most cases, trich doesn’t result in a significant compromise in mental and emotional functioning; however, the social ramifications may be severe. I mean, we’re dealing with bald spots and, perhaps, wigs, funky hairstyles, and some very creative make-up schemes. Needless to say, peers and friends may run from a trich sufferer, resulting in a head full of very low self-esteem. And for the record, because of stigma and the potential for alienation cases of trich are highly under-reported.

Trich’s average age of onset is between the ages of nine and fourteen and it’s much more prevalent in the first twenty years of life. It presents 75-95% of the time in females. Though, again, reporting of trich is a dicey proposition it’s thought that up to 5% of the world’s population is affected. As with many mind variances, heredity is a major factor.

So, now that we have a pretty good understanding as to what trich is, how ‘bout we take a look at some management strategies and techniques. The psychotherapy of choice for trich is a form of Cognitive Behavioral Therapy (CBT) known as Habit Reversal Training (HRT). Foundational in HRT is helping the sufferer “connect-the-dots” in terms of awareness so they’ll come to understand their hair-pulling is a conditioned response to an event or situation. This is super important because all too often, as was said earlier, the individual may be in what appears to be a trance in the midst of a hair-pulling episode, totally unaware of what it is they’re doing. So, indeed, the individual needs to come to grips with his/her behavior and the environmental circumstances at the time. Pivotal in this endeavor is a detailed behavior/circumstances journal that can reviewed by both the sufferer and his/her therapist.

The next order of business is some body work. First up is learning progressive muscle relaxation techniques, which are to be practiced on a daily basis. And then the sufferer learns techniques of diaphragmatic breathing, breathing at or below the diaphragm instead of up in the chest or collarbones. A muscle tensing activity known as “competing response” is introduced. This is a very cool and precise movement protocol that is the reverse of hair-pulling and considered to be physically incompatible with it. Finally, when the individual is ready all of the body techniques are pulled together to form what’s called a “full habit reversal response.” And it’s all about establishing a life-theme of relaxation to prevent trich behaviors, as well as developing a coping strategy should the urge to pull present.

So much of what we’ve just discussed is related to the Buddhist phenomenon known as “mindfulness,” a clear-minded, in-the-present-moment, self-observational technique that emphasizes viewing self without criticism or judgment. And as we’re talking about the impact of mindfulness on urges, here’s a neat quotation from Buddhist nun and Tibetan Buddhism teacher and author, Pema Chodron. “The root (of mindfulness practice) is experiencing the itch as well as the urge to scratch, and then not acting it out.”

Now, one can incorporate other techniques to supplement HRT, one of these being Stimulus Control (SC). This is a behavioral technique that helps individuals identify, avoid, or change the activities, environments, routines, and circumstances they’ve associated with their hair-pulling episodes. This is a matter of awareness and management, deleting old associations and replacing them with freshly learned connections between urges to pull and non-destructive behaviors. By the way, this paragraph is based in “neuroplasticity,” the neurobiological concept that posits neurons that consistently work together form long-lasting functional bonds. And it’s important to know that neuroplasticity also says not-so-healthy neural bonds can willfully be broken and, indeed, replaced with new and healthier connections.

To add a bit of frosting on the HRT/SC cake, learn and practice techniques of positive self-talk, guided imagery, and visualization. And let’s not forget about medication. The selective serotonin reuptake inhibitor (SSRI) antidepressants paroxetine (Paxil), sertraline (Zoloft), fluvoxemine (Luvox), citalopram (Celexa), and fluoxetine (Prozac) have provided relief for trich sufferers. As with any mind variance, the combination of psychotherapy and meds provides the greatest knockout punch.

So there you have it, the scoop on trichotillomania – what it is and how to manage it. As you leave this article please engrain in your minds the importance of awareness, daily practice of your management techniques, and coming to the understanding that the reality of life suggests the occasional pulling “oops” will occur. All is not lost!