Friday, June 2, 2017

How to Diagnose Trichotillomania (TTM) Hair Pulling

trichotillomania hair pulling
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trichotillomania eyelash pulling

Signs & Symptoms

Trichotillomania is currently classified as an “Obsessive Compulsive and Related Disorder” in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
The DSM-5 diagnostic criteria include:
  • Recurrent hair pulling, resulting in hair loss
  • Repeated attempts to decrease or stop the behavior
  • Clinically significant distress or impairment in social, occupational, or other area of functioning
  • Not due to substance abuse or a medical condition (e.g., dermatological condition)
  • Not better accounted for by another psychiatric disorder
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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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What is Trichotillomania (Hair Pulling)?

Trichotillomania is a body-focused repetitive behavior classified as an impulse control disorder (along the lines of pyromania, kleptomania, and pathologic gambling) which involves pulling out one's hair. Hair pulling may occur in any region of the body in which hair grows but the most common sites are the scalp, eyebrows, and eyelids.
Occurring more frequently in females, it is estimated that 1%-2% of adults and adolescents suffer from trichotillomania. In general, trichotillomania is a chronic condition that will come and go throughout an individual’s life if the disorder is not treated. For some individuals, the disorder may come and go for weeks, months, or years at a time. [1]


  • Recurrent pulling out of one’s hair resulting in noticeable hair loss
  • An increasing sense of tension immediately before pulling out the hair or when resisting the behavior
  • Pleasure, gratification, or relief when pulling out the hair
  • The disturbance is not accounted for by another mental disorder and is not due to a general medical condition (i.e., dermatological condition)
  • Repeated attempts have been made to decrease or stop hair pulling
  • The disturbance causes significant distress or impairment in social, occupational, or other important areas of functioning. Distress may include feeling a loss of control, embarrassment, or shame and impairment may occur due to avoidance of work, school, or other public situations.
  • Hair pulling may be accompanied by a range of behaviors or rituals involving hair. For example, individuals may search for a particular kind of hair to pull or they may try to pull out hair in a specific way. Individuals might also visually examine or tactilely or orally manipulate the hair after it has been pulled (e.g., rolling the hair between the fingers, pulling the strand between the teeth, biting the hair into pieces, or swallowing the hair).

How and when does it start?

The most common age of onset is in preadolescents to young adults. On average, it is typically between 9 and 13 years, with a peak between 12 and 13 years. [2][3] It is possible that hair pulling may be seen in infants, but this behavior typically resolves during early development. The onset of this disorder may be preceded or accompanied by various emotional states, such as feelings of anxiety or boredom. A stressful event such as abuse, family conflict, or death may also trigger trichotillomania. 

Does Trichotillomania lead to other problems?

During adolescence, which is an especially crucial time for developing self-esteem, body image, comfort with sexuality, and relationships with peers of both sexes, teens may endure ridicule from family, friends, or classmates, in addition to feeling shame over their inability to control the habit. Therefore, even a small bald patch can cause devastating problems with development that can last life-long.  Although many people with trichotillomania get married and carry on with their lives in a "normal" fashion; there are those who avoid intimate relationships for fear of having their shameful secret exposed, leading to the conclusion that the shame associated with this behavior is the greatest debilitating effect of trichotillomania. [4]


There is no certain cause of trichotillomania, but the current way of looking at trichotillomania is as a medical illness.  One theory on a biological level is that there is some disruption in the system involving one of the chemical messengers between the nerve cells in parts of the brain.  There may be also a combination of factors such as a genetic predisposition and an aggravating stress or circumstance; as with many other illnesses.  Further, trichotillomania could be a symptom caused by different factors in different individuals just as a cough can be produced by a multitude of different medical problems.  Finding the cause(s) will take more research.

Co-occurring Illnesses

Trichotillomania is on the obsessive-compulsive spectrum, which means that it shares many symptoms of obsessive-compulsive disorder (OCD), such as compulsive counting, checking, or washing. These two disorders commonly run in the same families and medications used to treat OCD can be helpful in treating trichotillomania.
Depression also frequently occurs in individuals with this illness, along with excoriation (skin-picking) disorder. Other body-focused repetitive behaviors, such as nail biting, thumb sucking, head banging, or compulsive scratching are also common.


The two methods of treatment that have been scientifically researched and found to be effective are behavioral therapy and medications, which are generally used in combination.
  • Therapy. In behavioral therapy, people learn a structured method of keeping track of the symptoms and associated behaviors, increasing awareness of pulling, substituting incompatible behaviors and several other techniques aimed at reversing the “habit” of pulling.
  • Medications. Although medications clearly help some people temporarily, symptoms are likely to return when the medication is stopped unless behavioral therapy is incorporated into treatment.  Medications may help to reduce the depression and any obsessive-compulsive symptoms the person may be experiencing.
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People with trichotillomania pull hair out at the root from places like the scalp, eyebrows, eyelashes, or pubic area.
Some people with the condition pull large handfuls of hair, which can leave bald patches on the scalp or eyebrows. Other people pull out their hair one strand at a time. They might inspect or play with the strand after pulling it out. About half of people with trichotillomania put the hair in their mouths after pulling it.
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