Trichotillomania, hair-pulling disorder or hair-pulling disorder is the irresistible or compulsive urge to pull out your hair. Everyone pulls their hair or wraps it around their finger sometimes. Women also love to pluck out annoying facial hair. This in itself is not unusual, but there are also people who compulsively pull out their hair every day, sometimes even for hours, until bald spots appear or it even bleeds. This is known as trichotillomania or hair pulling disorder. In this case, those affected pull out their own hair, not only on the head, but on all hairy parts of the body. However, the most noticeable and visible from the outside are only bald spots on the head. Those affected do not seem to feel any pain when pulling out their hair and are often absent-minded or absent-minded. Those affected chew the hair, split the hair, bite off the root and find this satisfying and enjoyable.
- What is trichotillomania?
- Prevalence
- Causes of compulsive hair pulling
- No cause known yet
- Triggering factors
- DSM-5 classification criteria and symptoms
- Criteria
- Diagnostic features
- Examination and diagnosis
- Discussion with a doctor or psychiatrist
- Dermatological examination
- Comorbidity
- Complications
- Treatment of hair pulling disorder
- Prognosis
- Prevention
A pattern of incomplete hair loss in a trichotillomania sufferer / Source: Robodoc (original uploader), Wikimedia Commons (Public domain)
What is trichotillomania?
Trichotillomania belongs to the spectrum of obsessive-compulsive and related disorders within the DSM-5 (the abbreviation of Diagnostic and Statistical Manual of Mental Disorders). Typical symptoms include an inability to resist the impulse to pull out one’s own hair, resulting in hair loss, and having made repeated attempts to stop the hair pulling.
Prevalence
In about two-thirds of those affected, the condition begins during puberty. However, it can also start in early childhood or later in adulthood. The life-time prevalence (where a cross-sectional study examines whether an individual ever had or still has the condition in question) is 0.6 to 2 percent. In childhood, trichotillomania occurs approximately equally in boys and girls. In adulthood, more women than men will be affected, at a ratio of approximately 10:1.
Causes of compulsive hair pulling
No cause known yet
The causes of hair pulling disorder remain largely unexplained in 2023. A genetic influence or vulnerability is suspected. Neurobiological research has so far not produced consistent results.
Triggering factors
The triggering factors must be determined on a case-by-case basis. It is believed that a hereditary predisposition linked to certain triggers in the brain leads to imbalances in the neurotransmitters that cause the compulsive act.
Other reasons include traumatic events, such as the death of a close relative, family problems, divorce, sexual abuse, (chronic) stress, stressful childhood events, or events that reduce self-esteem. More than two-thirds of those affected have had at least one traumatic experience in their lives. In some cases, post-traumatic stress disorder (PTSD) has already been diagnosed. Recognizing your own triggers can be helpful in finding ways and strategies to deal with these difficult situations.
Manual for the Classification of Mental Disorders (DSM-5) / Source: DSM-5
DSM-5 classification criteria and symptoms
Criteria
The classification criteria according to DSM-5 are:
- A Recurrent pulling out of your own hair, resulting in hair loss.
- B Repeated attempts to stop hair pulling.
- C Hair pulling causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
- D Hair pulling or hair loss cannot be attributed to a general medical condition (e.g. a dermatological condition).
- E The hair pulling is not better explained by the symptoms of another mental disorder (such as the attempts to correct a perceived deformity or defect in appearance in a morphodysphoric disorder).
Diagnostic features
Trichotillomania is mainly noticeable by compulsive pulling out of the hair on the head. In some cases, the hair is pulled from other parts of the body. This causes bald spots to appear on the affected body parts. These spots can be camouflaged by those affected with a scarf or make-up. You can also always draw in a different area, so that it is not so noticeable. Preferred places are:
- scalp
- eyebrows
- eyelids
The least commonly affected are the following areas:
- armpit hair
- hairs from the genital and perianal area
Those affected usually feel no pain or it is simply ignored. The actions are often not even consciously experienced, although the urge to pull out the hair is usually felt strongly. Trichotillomania can in principle occur at any age. However, it often occurs during puberty.
Examination and diagnosis
Discussion with a doctor or psychiatrist
The disorder is usually easily recognized by the bald spots that appear after compulsive hair pulling. Usually the disorder only lasts a few months. However, in some cases it also takes several years. This condition is almost always accompanied by inner unrest or restlessness or a feeling of tension. The process of pulling out the hair usually leads to the desired relaxation in the short term.
However, the feelings of anger, shame and fear that often follow increase the inner tension , which in turn leads to the compulsive impulse. A vicious circle is created that is difficult to break. The experience of not being able to control oneself leads to feelings of frustration and inferiority. In some cases there is comorbidity, such as anxiety disorders or depression. Many people do not want the disorder to be discovered. As a result, in some cases there is social isolation.
Dermatological examination
If a person does not admit to suffering from trichotillomania, dermatological examination may be necessary. By means of a skin biopsy and dermatoscopy (skin examination) or trichoscopy (hair examination), it is possible to distinguish the disorder from other causes of alopecia (patchy baldness). During the examination, several typical features can be observed:
- reduced hair density
- the presence of short downy hair
- broken hairs with different shaft lengths
Comorbidity
Trichotillomania often co-occurs with other conditions. Up to 63 percent of those affected also suffer from mood disorders (depressive disorder), up to 57 percent from anxiety disorders, up to 22 percent from substance abuse and up to 22 percent from obsessive-compulsive disorders (for example, skin picking disorder or other body-oriented repetitive actions, such as nail biting).
Complications
Compulsive pulling of hair from the head leads to hair loss. Trichotillomania mainly occurs during puberty. Some affected people may be bullied about their behavior, which often makes symptoms worse. Because of the bald spots, those affected often no longer feel beautiful and they can develop an inferiority complex or have reduced self-confidence. In addition, thoughts of suicide may arise. Many people with trichotillomania also suffer from anxiety disorders or (severe) depression. Maintaining social contacts is often also difficult. The disorder affects school or work performance, but family relationships can also suffer.
Therapy for compulsive hair pulling / Source: Wavebreakmedia/Shutterstock.com
Treatment of hair pulling disorder
Trichotillomania can be treated. Psychotherapeutic treatment plays an important role, especially if the course is severe. Cognitive-behavioral therapy supports those affected in recognizing the behavior and symptoms and especially the triggers and subsequently changing their behavior. During therapy, the affected person must learn to gradually cope with the disorder and its consequences.
However, it takes time for old behavior patterns to be unlearned and replaced by new ones. Complementary drug therapy can also help suppress the compulsive impulse and counteract accompanying symptoms such as depression or anxiety, which also often occur. Many patients respond positively to antidepressants. The use of medication alone is not recommended, because when it is stopped, the urge to pull out the hair often arises again. It is therefore advisable to follow cognitive-behavioral therapy at the same time. Relaxation techniques can help reduce stress.
Prognosis
Most people end up pulling out their own hair within 12 months. In some people it lasts longer and sometimes trichotillomania is a lifelong disorder. However, treatment often improves the situation, allowing you to better control your behavior and often reduces feelings of depression, anxiety or poor self-image.
Prevention
As a preventive measure, it has been helpful to make a plan to save yourself from compulsive urges. This means that when the urge to pull out your own hair is noticed, replace this impulse with positive thoughts or apply relaxation techniques at that moment. In these situations it is advisable to take a few minutes for yourself to clear your head, so to speak. The stress must be reduced. However, this does not only apply in these situations, it is fundamental to eliminate all triggers of (too much) stress as much as possible in order to find a good balance between tension and relaxation.
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