Trichotillomania

[trik-uh-til-uh-mey-nee-uh]

Trichotillomania (TTM), or "trich" as it is commonly known, is an impulse control disorder or form of self-injury characterized by the repeated urge to pull out scalp hair, eyelashes, facial hair, nose hair, pubic hair, eyebrows or other body hair, sometimes resulting in noticeable bald patches. Trichotillomania is classified in the DSM-IV as an impulse control disorder, but there are still 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. Trichototillomania often begins during the individual's teenage years. Depression or stress can trigger the trich. Due to social implications the disorder is often unreported and it is difficult to predict accurately prevalence of trichotillomania; 2.5 million in the U.S. may have TTM, with a 1% prevalence rate.

The name derives from Greek: tricho- (hair), till(en) (to pull), and mania.

Characteristics

Individuals with trichotillomania live relatively normal lives; however, they may have bald spots on their head, among their eyelashes, pubic hair, or brows. An additional psychological effect can be low self-esteem, often associated with being shunned by peers and the fear of socializing due to appearance and negative attention they may receive. Some people with TTM wear hats, wigs, eyebrow pencil, or style their hair in an effort to avoid such attention. There seems to be a strong stress-related component. In low-stress environments, some exhibit no symptoms (known as 'pulling') whatsoever. This 'pulling' often resumes upon leaving this environment.

Many clinicians classify TTM as a habit behavior, in the same family as nail biting (onychophagia) or compulsive skin picking (dermatillomania). These disorders are a cross between mental disorders, such as obsessive compulsive disorder (OCD) because the sight or feel of a body part causes the individual anxiety, and physical disorders such as stereotypic movement disorder because the person performs repetitive movements without being bothered by or completely aware of them. The current classification of trich as an impulse disorder with pyromania, pathological gambling and kleptomania, has been called into question as inadequate and in need of revision. One study showed that individuals with TTM have decreased cerebellar volume. Anxiety, depression and OCD are more frequently encountered in people with TTM. People with TTM may also eat/chew the roots of the hair that they pull, referred to as trichophagia. In extreme cases this can lead to Rapunzel syndrome, and even death. Some individuals with TTM may feel they are the only person with this problem due to low rates of reportage.

Treatment

Habit Reversal Training or HRT, has been shown to be a successful adjunct to medication as a way to treat TTM. With Habit Reversal Training, doctors train the individual to learn to recognize their impulse to pull and also teach them to redirect this impulse. As a part of the behavioral record-keeping component of HRT, patients are often instructed to keep a journal of their hair-pulling episodes. They may be asked to record the date, time, location, and number of hairs pulled, as well what they are thinking or feeling at the time. This can help the patient learn to identify situations where they commonly pull out their hair and develop strategies for avoiding episodes.

Treatment with Clomipramine, a tricyclic antidepressant, was shown in a small double-blind study to significantly improve symptoms.

Fluoxetine (Prozac) and other similar SSRI drugs have limited usefulness in treating TTM, and can often have significant side effects. According to F. Penzel, antidepressants can even increase the severity of the TTM.

Epidemiology

TTM is diagnosed in all age groups; it is more common during the first two decades of life, with mean age of onset usually reported between 9 and 13 years of age. Among preschool children the genders are equally represented; there appears to be a female predominance among preadolescents to young adults, with between 70% and 93% of patients being female. Evidence now points to a genetic predisposition.

The number of reported trichotillomania cases has increased throughout the years, possibly due to a reduced stigma associated with the condition. Estimates of the number of persons with TTM range from 1–3% up to 5% of the world's population.

Genetics

When genes that were suspected to cause trichotillomania were injected into laboratory mice in one study, the mice obsessively pulled out their fur and the fur of other mice in the cage.