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Trichotillomania is defined as recurrent pulling out of one's hair, resulting in noticeable hair loss, which is not due to another medical condition.
There is an increasing sense of tension immediately before pulling out the hair, or when attempting to resist the behavior, and there is pleasure, gratification or relief when pulling out the hair.
The true prevalence of Trichotillomania is unknown, since people are often ashamed of their behavior and are consequently reluctant to discuss it, even with their doctor. So it is difficult to get reliable statistics.
Historically it was thought to be rare, but the condition is now better understood and more people are seeking help. More recent estimates range from 0.5 to 3.5% of the population, depending on the definition used, and the nature of the study.
Sufferers as a group pull hair from a wide range of body sites including the scalp, eyebrows, eyelashes, beard, pubic areas; and, less commonly, underarms, chest, ears, nose and general body hair. The sites pulled by particular people vary widely, and may be restricted to one or two sites.
Associated behaviors include searching for hairs that stand out in some way; repetitive drawing of hair through the fingers, or over the lips, before or after pulling; picking of associated skin; careful examination of the hair or roots; compulsively playing with, or splitting the hair; biting off the roots, or the hair itself into segments.
The behaviors are also specific to the particular person; some just pull eyebrows with tweezers, for example, and others just pull from their scalp. Some pull intensively from particular sites; others try to manage their appearance by pulling less intensively, but from a wider range of sites.
Some people eat the roots or the whole hair. Since hair is not digested, but remains in the stomach, this condition is potentially dangerous and medical examination should be sought.
There is no known single or obvious cause, and there may be several contributing factors, such as genetic predisposition, diet and stress. It is now commonly regarded as a medical illness, and it may be caused by a disruption in the system for communication between cells in the brain.
People frequently start compulsive pulling at 12 to 13 years of age, although commonly at a much younger or older age. The onset may be associated with hormonal changes at puberty, although many people recall a significantly stressful event associated with the onset.
During hair pulling episodes, the sufferer frequently pulls from zones of heightened sensitivity. It is generally not painful to pull from these areas, or the pain is mild and the pulling causes great relief, or even comfort.
The pulling can quickly become compulsive, causing relief and comfort on the one hand, but anxiety and distress at the increasing hair loss on the other. Sufferers can quickly become greatly distressed at an apparent inability to control their own behavior, and the continual increase in damage to both their hair and self-esteem.
Is it any surprise if some sufferers feel they might be going crazy, even though they are not?
There are apparent similarities with the symptoms of Obsessive Compulsive Disorder (OCD), but only a low minority of Trichotillomania sufferers have OCD as well; 15% in one study.
Depression has been reported to occur in a majority of people. However it is not known if this is due to a direct biological link between the two conditions, or whether the depression is a consequence of the severe loss of morale and self-esteem brought on by the hair pulling.
Other behaviors believed to be common include nail biting and skin picking.
Procrastination has been reported as a symptom. This behavior of putting off tasks is very frustrating to family and friends, and may be disruptive of personal relationships.
Medications are easy to use, but, used in isolation, are reported to have limited long term effectiveness for the treatment of Trichotillomania itself. They have been reported as a useful adjunct to other treatments, and are often used to reduce the symptoms of associated depression.
Behavior Therapy attempts to stop or control specific undesirable behaviors, or to replace them with new ones. Cognitive Therapy usually involves identifying the thoughts that make pulling more likely, and working on replacing them with new thought patterns.
These are often combined and / or used in conjunction with specific medications. The treatments might include Group Therapy; training in life skills such as Assertion, Anger and Stress Management, Goal Setting and Problem Solving; and Relaxation Training. Programs are usually tailored to the needs of the individual and, where practicable, involve the family and supporting persons.
Psychotherapy and Hypnosis have also had some reported success.
Diet control has been widely claimed to contribute to easing or eliminating pulling behavior. It is recommended that all sufferers carefully consider the impact of diet, since some people have reported benefits from even simple changes.
Skin care has been shown to be important for control of the condition in some people. A variety of effective and readily available products has been identified to relieve intense itching or other associated problems which are present with some people.
Religion may become a powerful motivating force for healing in some people, particularly as an adjunct to other treatments. It can contribute to a sense of community; improved self-esteem; a strong sense of purpose, and focus on goals; and an easing of depression.
A sense of community is a powerful force for healing with many people - to know that you are not alone; to discover after years, or even decades, that your condition is known to medicine; to share your thoughts and feelings; to feel understood and accepted; to see people, who share the same affliction, caring for one another.
There are reports from sufferers that aspects of hygiene may be important for some people. Specifically, those who pull from eyebrows or lashes may benefit from avoiding furry pets and frequent washing of the hands and eye area with soap and water.
We should also consider what we regard as success, as so eloquently stated
by a parent,
"Improvement tends to be incremental rather than total or complete, and
must be viewed in a broad perspective [rather] than simply the reduction or
cessation of the hair pulling behavior itself. Rarely can a given course
or therapy be viewed in such absolutes as success or failure, but rather as
a process of continuous improvement in all aspects of the child's overall
quality of life" M.J.Grant, TTM mailer, 5 August 1999.
There are two broad ways to interact with fellow sufferers: via support groups in your own locality, and via the various internet networks.
There should be a Mental Health organization in your own area who can put you in contact with local support groups. In any case, the Trichotillomania Learning Center attempts to maintain a comprehensive listing of support groups.
For those who have an internet connection, there are support groups using email which are knowledgeable, helpful and provide a safe environment for interaction and learning.
Options for contacts include email networks (e.g. the TTM mailer); the Fairlight Bulletin board; online chat groups; private email with users met via these groups; and private web pages featuring contacts and links.
Some groups organize or facilitate activities, such as retreats, picnics, an International Day, and a bracelet symbolic of unity within the trich community.
The best way to help sufferers with Trichotillomania is to care about them, to try to understand them, and to help them to learn more about their condition, and how to manage it.
Sufferers commonly express enormous relief to discover that they are not alone; to find that the condition has a name; and to be reassured that they are not weird or mad. It can be a profound experience for a sufferer to describe their behavior and associated feelings to others people, and for this to be accepted.
Parents of sufferers have often sought guidance about what is a helpful approach toward their children, and specific information and contacts are available for parents.
Please note that this is not intended to be a comprehensive list of information sources. Readers are referred to the pages below with the comment "resources and links".
Dan Stein, Gary Christenson, Eric Hollander, Trichotillomania
(American Psychiatric Press, 1999) 344 p.
ISBN: 0880487593
Price: US$45
Publisher phone (US): 1 (202) 682-6262
Jeffrey L. Anders, James W. Jefferson, Trichotillomania: A Guide
(Madison Institute of Medicine, 1998) 49 p.
ISBN: 189080214X
Price: US$4.95
Publisher phone (US): 1 (608) 827-2470
Publisher fax (US): 1 (608) 827-2479
Publisher address:
Information Centers
Madison Institute of Medicine
P O Box 628365
Middleton, WI 53562-8365
U.S.A.
Reprinted online: http://www.trichotillomania.ab.ca/rwpeta/Aguide.html
Cheryn Salazar, You Are Not Alone: Compulsive Hair Pulling, the Enemy
Within (Cheryn Intl, 1995) 262 p.
ISBN: 0965067009
Price: US$14.95
Web: http://www.cheryn.com/book.html
Jack M. Gorman, M.D., The Essential Guide to Psychiatric Drugs,
revised edition December 1998
(St Martins Mass Market Paper, 1998) 416 p.
ISBN: 0312954581
Price: US$6.99
[Comment: Expert but non-technical information on psychiatric drugs]
The list of English-language web sites has been moved.
Next revision due: January 2001