zondag 31 augustus 2008

Introduction

The essential feature of trichotillomania (often shortened to trich or TTM) is the recurrent pulling out of one’s own hair that often results in noticeable hair loss. The areas of hair pulling may vary but include any region of the body where hair grows. The most common sites to pull out hair are scalp, eyebrows and eyelashes.

Hair pulling may occur in brief periods scattered throughout the day or in less frequent but more prolonged periods that can continue for hours. Stress frequently increases the hair-pulling behavior as does being in a state of relaxation and distraction. This gives rise to the idea that trichotillomania is an impulse-control disorder (ICD) much like nail biting (onychophagia), skin picking (dermatillomania) and thumb sucking but it also seems to be related to habits like smoking and even anorexia nervosa.

I do not agree with current the psychological consensus that trichotillomania is also (part of) an Obsessive-Compulsive Disorder (OCD). Psychologists tend to forget that one of the main characteristics of an OCD is that the repetitive behaviors do not serve any real purpose. There is no immediate gain if you check if your backdoor is locked for the tenth consecutive time or if you wash your hands five times, while with trichotillomania there is an immediate reward: you get a feeling of well-being.

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Trichotillomania usually begins in childhood or adolescence, frequently coinciding with the onset of puberty. Patients with trichotillomania are often embarrassed or ashamed about their behavior, leading them to try to hide it from others and to start pulling, for instance, their pubic hairs. Because of all this, low self-esteem is very common among patients. The bald patches on the scalp or eyebrows further contribute to the feelings of embarrassment and depression.

Half of the patients with trichotillomania also engage in oral behaviors—running hair across the lips or through the teeth, biting off the root (trichophagy) or eating hair (trichophagia). Eating of hairs may eventually result in the forming of a bezoar, a hairball of swallowed hair that collects in the stomach and fails to pass through the intestines. Surgery may sometimes even be needed to remove such a bezoar.

Causes

There is no known scientific cause of trichotillomania, but one could argue that, because it is an impulse-control disorder, it is by definition also an acquired habit. Any habit starts when you gain pleasure or gratification by an action. Pulling ones own hair results in a mild feeling of pain or tingling that could release endorphins, and they resemble opiates in their abilities to produce a sense of well-being. And, as is the case with all opiates, these endorphins are addictive.

Prevalence

No systematic data is available about the prevalence of trichotillomania. Although trichotillomania was previously thought to be an uncommon condition, it is now believed to occur more frequently, affecting 1–4% of people in the general population. Trichotillomania occurs in adult females (3.4%) more often than adult males (1.5%). Among children, both genders seem to be affected equally.

Diagnosis

The ‘Diagnostic and Statistical Manual for Mental Disorders - Fourth Edition – Text Revision (DSM-IV-TR)’, published in 2000, is generally used by psychologists the world over and gives for every known psychological disorder a series of criteria. A patient must display several or all of these criteria to get a diagnosis of a particular disorder.

It is important to understand that the DSM is only a tool to reach a correct diagnosis and has to do nothing whatsoever with (advising a type of) medication or any other other form of treatment.

According to the DSM a patient should display the following diagnostic features in order to receive the diagnosis for trichotillomania:
A. Recurrent pulling out of one’s hair resulting in noticeable hair loss.
B. An increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior.
C. Pleasure, gratification, or relief when pulling out the hair.
D. The disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (eg. a dermatological condition).
E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Treatment

Any treatment starts with the realization that a patient has a habit that is socially unacceptable. Compare trichotillomania with possibly related habits like smoking, nail biting or anorexia nervosa and you will understand that such a realization doesn’t come easy. You have to be really strong to be able to resist a possible lifetime habit. Yes, you could go to a therapist or you could take drugs, but I would suggest you talk with some trusted friends first. Explain to them that you have a problem that you can’t beat on your own and ask them to correct you if you display any sign of hair pulling.

As with any other habit you want to quit you also need to make some changes in the way you live your life. If you should want to quit smoking and you were used to having a cigarette after dinner you should change the routine by supplementing it with another. Thus you could decide to go for a walk after dinner or do the washing up manually. The same applies to trichotillomania.

Breaking the habit of trichotillomania means you also have to occupy yourself with (new) activities that aren’t too stressful nor overly relaxing. Try to be as much as possibly in the company of your trusted friends and never be angry if they say ‘stop’ or gently place a hand on your arm to resist you from hair-pulling.

Prognosis

Studies show low success rates with medications and traditional psychoanalysis.

Behavioral therapy has reported long-term success rates of 90% or better. What is described in the previous section is the same as behavioral treatment only it is free and you are performing it yourself and that make the result so much more gratifying.

Professionals may not recognize or know how to treat trichotillomania effectively. Conversely, individuals with the disorder may be too embarrassed to address their symptoms.

Overal, the prognosis is good if you accept the fact that you have a problem that can’t be remedied alone.