Trichotillomania - Dr. Janet Roberts

Trichotillomania (a term coined in 1889) is the unfortunate name given to a hair loss condition characterized by the urge a person has to repeatedly pull out one's own hair. We have learned a lot about the many facets of trichotillomania in the last decade and how to help people who have it. People who have it are not "mad" or "crazy" as the term implies. One thing that we have learned through the renewed interest in research of trichotillomania is that it is a complicated problem. The environmental and emotional triggers are different in different people so that all of these must be identified and addressed to find successful treatment tailored to each individual person.

Trichotillomania is now felt to be a type of compulsive behavior pattern rather than a manifestation of a more serious mental disorder. Any hair-bearing areas can be affected. The affected areas are, in descending order of frequency, scalp, eyebrows and eyelashes, then areas remote from the head and neck.

There are two basic types of trichotillomania, one that is usually self-limiting and involves infants under the age of two in which males are more likely to be affected. It may be related to infantile stresses. More common is the second type, which often begins around or after puberty and is approximately nine times more frequent in females. In many cases, these are people who are very accomplished in school or in their profession, who on outward appearance would have no obvious reason to be pulling their hair. Often the family is unaware of the self-induced nature of the hair loss and the person may see many doctors before a correct diagnosis is made as the patient does not usually acknowledge the problem publicly. The condition tends to be chronic, lasting for years if not treated.

As more is learned about this disorder and the possible relationship to other types of compulsive habits (such as skin-picking and nail biting) or obsessive traits (such as having repetitive, intrusive thoughts), the prior stigmas attached to having trichotillomania have been lessened. More people today who experience this do seek treatment versus suffering alone and feeling that there can't be other people who have the same urges. In fact, trichotillomania is quite common, with estimates ranging as high as 4% of the population or 6-8 million affected people in the United States alone. In some families, there are members who may have hair-pulling behavior while other family members may have other symptoms of obsessive or compulsive behaviors. In other words, there may be a genetic component to trichotillomania.

The range of treatments available is increasing. There is no single treatment that is effective for all people. Often there are mental health practitioners in your community who specialize in the treatment of this and similar disorders. In some cities, there are support groups dedicated to mutual emotional support and sharing of successful strategies of treatment.

With the recent progress in understanding that the cause of trichotillomania, and other possibly related obsessive-compulsive disorders, may be a biochemical abnormality in the brain, newer treatments with medications that treat this abnormality may be of some help. Possible benefit may be obtained with classes of medications called serotonin reuptake inhibitors (SRI) as well as other medications. Other treatment approaches help the individual recognize what triggers the urge to have pulling episodes and learn methods of modifying this behavior. The trigger may be due to over-stimulation or under stimulation of the nervous system. Experts agree that a combination approach, including behavioral, biologic and self-awareness therapy, is usually the most successful in allowing individuals to achieve long-term control of this problem.

- Janet Roberts, M.D.


References:

• Robert JL, DeVillez RL: Infectious, Physical, and Inflammatory Causes of Hair and Scalp Abnormalities.

The following are frequently asked questions on trichotillomania. The information provided is not meant to be a substitute for the information obtained at an evaluation and by discussion with a physician but merely to encourage understanding of this condition. No questions regarding individual scenarios will be answered by the NAHRS. No changes in treatment should be undertaken by a patient without discussion first with the patient's physician.

• My 16 year old daughter has had persistent "alopecia areata" in spots on her scalp for 3 years now. She has been treated with intralesional steroids and the hair grows to a certain length and then falls out. We were referred to a hair specialist who said she doesn't have alopecia areata after all but rather trichotillomania. We are frustrated by this differing diagnosis and years of what now appears to be the wrong treatment. How did this diagnostic problem occur?
• My daughter has lost all her eyelashes. Her dermatologist says she is pulling them out but she denies this. Is there a way to prove this one way or the other?
• My 14 year old daughter, who is a straight A student, has lots of friends and is not a discipline problem, has been diagnosed with trichotillomania. How can she have a "mental" problem when she is so normal? And why is she mutilating herself like this? We want to help her but she refuses to go to a psychologist or psychiatrist.
• My 14 year old son has trichotillomania and the psychiatrist that he was referred to has recommended he be put on Prozac. Isn't this a dangerous drug?
• I am 21 years old and have trichotillomania. Where can I talk with others with similar problems? The psychiatrist I've seen can't seem to help me stop pulling out my hair.
• I have alopecia areata and have heard that there is new NIH sponsored research on alopecia areata. Can you tell me how I can participate?

1. My 16 year old daughter has had persistent "alopecia areata" in spots on her scalp for 3 years now. She has been treated with intralesional steroids and the hair grows to a certain length and then falls out. We were referred to a hair specialist who said she doesn't have alopecia areata after all but rather trichotillomania. We are frustrated by this differing diagnosis and years of what now appears to be the wrong treatment. How did this diagnostic problem occur?
   Trichotillomania can be difficult to diagnose and is often confused initially with alopecia areata, a different type of hair loss. Also, if the individual with trichotillomania is being secretive about the habit, it obviously can delay the diagnosis. Trichotillomania and alopecia areata can be confused because they both can present as patches of hair loss and both can even have short stubby hairs in the affected areas. However, there are some differences between the two conditions that a trained hair specialist can recognize. One is that the patches of hair loss in trichotillomania are often irregular, geometric patterns where in alopecia areata the patches are smooth-bare and perfectly round. If there is doubt in the mind of the hair specialist, a biopsy can be done to confirm the suspected diagnosis. The biopsy findings of trichotillomania under the microscope are quite specific.
   
   
2. My daughter has lost all her eyelashes. Her dermatologist says she is pulling them out but she denies this. Is there a way to prove this one way or the other?
   This can be a difficult diagnosis to make if the person denies the real reason for the hair loss. Sometimes in trichotillomania, only eyelashes may be pulled out. It can be easily confused with alopecia areata in which the eyelashes may be lost as well. In trichotillomania, there is a cycle of continual regrowth and loss in an uneven pattern. There is often the stubble of hairs either regrowing or broken off. Biopsies of the eyelid to provide definitive information are generally not done.
   
   
3. My 14 year old daughter, who is a straight A student, has lots of friends and is not a discipline problem, has been diagnosed with trichotillomania. How can she have a "mental" problem when she is so normal? And why is she mutilating herself like this? We want to help her but she refuses to go to a psychologist or psychiatrist.
   Your daughter has a disorder characterized by the irrational compulsion to pull out her hair. It is undoubtedly confusing to her and a painful admission for her to make, even to her parents and close friends. Certainly, she doesn't want to "mutilate" herself. You can be sure, that if she could choose, she would love to have hair like her friends. People with trichotillomania are not "crazy". They simply have this irresistible urge to pull at their hair, which can be as puzzling to them as it is to you. People with trichotillomania, like people with other compulsions or obsessions, are often very successful in school and work. With gentle offers of help and support without accusations or ridicule, your daughter may eventually see the benefit of getting professional help. The teen years are difficult enough without the added burden of struggling with strange compulsions, especially one that is as visible as having patches of hair loss.
   
   
4. My 14 year old son has trichotillomania and the psychiatrist that he was referred to has recommended he be put on Prozac. Isn't this a dangerous drug?
   Trichotillomania is felt to be related to other disorders characterized by compulsions (such as nail biting and skin picking) or obsessions (characterized by intrusive unwelcome repetitive thoughts) that may be in part caused by alterations in brain chemistry. One thought is that there may be changes in serotonin metabolism. The group of drugs called serotonin reuptake inhibitors, of which Prozac is one type, can have a beneficial effect in treatment of these disorders. Prozac has been FDA approved for 14 years and has a good safety profile, though like all medications, it can have unwanted side effects. A health professional, experienced in use of these medications, should monitor such treatment.
   
   
5. I am 21 years old and have trichotillomania. Where can I talk with others with similar problems? The psychiatrist I've seen can't seem to help me stop pulling out my hair.
   In some cities, there are support groups for people with trichotillomania, dedicated to mutual emotional support and sharing successful treatment strategies. There are also specialists in various areas of the country who are especially interested in treating trichotillomania and may have group therapy session in which you could talk with others having the same issues. You can learn more about support groups and specialists in your area by contacting the Trichotillomania Learning Center, a national trichotillomania support organization, dedicated to supporting individuals with educational materials, outreach and networking. The email address is trichster@aol.com. They also have two yearly national meetings, focusing on various aspects of trichotillomania. There are internet message boards and chat rooms, another way of finding and "talking" with people who are experiencing problems like yours