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Mind Matters: The trichotillomania symptoms and its treatments

January 28, 2019

“I am so upset about what happened that I could just pull my hair out!”

She was indeed distraught, red in the face, huffing and puffing. I thought that sparks would fly from her hazel eyes any moment. We discussed the offending action that had been done by the offending person and how it had simply rocked her world. She calmed a bit as we talked.

“I didn’t really mean that, you know,” she said, now much more composed and looking almost contrite.

“What?” I asked.

“I mean, I wouldn’t really pull my hair out, my hair, my actual hair, you know,” she stammered, twirling a long tress between right thumb and index finger.

“Oh, I knew you didn’t mean that literally,” I said. We continued to process the event that had upset her so much.

Have you ever had a moment like that, something that made you so irate or sad or guilt-ridden or flummoxed that you said you might pull your own hair out? Now, let me ask that question another, slightly different way.

Have you ever actually pulled your own hair out? On purpose?

Trichotillomania, or Hair-Pulling Disorder, is a psychiatric disorder listed in the Diagnostic and Statistical Manual of Mental Disorders: DSM-5. It is characterized by the following symptoms: recurrent pulling out of one’s hair, resulting in hair loss; repeated attempts to decrease or stop hair pulling; hair pulling that causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; is not attributable to another medical condition (for example, a dermatological condition); and the hair pulling is not better explained by the symptoms of another mental disorder.

According to the DSM-5, hair pulling in trichotillomania may occur from any region of the body. I have had patients come to me after pulling hair from their arms or legs, chest or body, their head, and in the form of excessive plucking of their eyebrows. Most common sites for hair pulling are the scalp, eyebrows and eyelids. Episodes may be brief and multiple throughout the day, or may last for hours at a time. Symptoms may last for years. Obviously, folks may be nervous or even embarrassed to come in and tell their doctor that they are hair pulling, and sometimes it may not be noticeable at first glance. Some patients will pull single hairs from a wide area so that overt hair loss is hardly noticed at all. Other patients will use wigs, scarves or other coverings to mask the hair loss that results from the chronic pulling.

As you have already noticed in other columns I have written, mental health conditions not only have to manifest symptoms, but to be diagnosed they usually have to cause pain and suffering of some sort, foster an urge to stop or modify them that is not always successful and must cause some problem with functioning in several areas. This disorder is no exception. Patients may have physical pain or discomfort from the hair pulling, and they may be disfigured to such an extent that causes them to isolate, miss work, not attend family functions and even feel ashamed or embarrassed to be seen in public. The hair pulling may be extremely specific and sometimes even bizarre, with only hairs of certain color, texture or length pulled, biting or swallowing the hair, and the like.

Before hair pulling becomes a problem, other symptoms or disorders may be seen. Anxiety, depression, obsessive compulsive disorder, boredom, or even automatic behaviors may be seen. When the pulling becomes excessive, patterns of complete or near complete baldness or complete loss of eyebrows and lashes may be seen. It is not uncommon to see individuals also have other associated behaviors including skin picking, nail biting and lip chewing.

How common is trichotillomania? According to DSM-5, the twelve month prevalence in adults and adolescents is 1-2 percent. Females outnumber males 10 to 1. Onset of hair pulling usually coincides with the onset of puberty. The course of the illness tends to be chronic, getting better and worse at times especially if it is not treated. The illness may have a hereditary component, and tends to be more common in those who have obsessive-compulsive disorder and their first degree relatives. Most patients who have trichotillomania admit to hair pulling, so diagnosis is not extremely difficult.

Treatment may consist of behavioral interventions, psychotherapy and medications, sometimes in combination. As I have said in the past, if you or someone you know has any mental health disorder, including trichotillomania, please see a mental health professional for a diagnostic assessment and treatment as indicated. As always, thanks for reading and I’ll see you in two weeks.

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